Tonsillolith

Tonsillolith is a rare condition. Small areas of calcification are commonly seen while sectioning a tonsillectomy

specimen. Large calcified mass within the tonsil (tonsillolith) is a relatively rare phenomenon.

Pathogenesis of tonsillolith is still unknown. It has been attributed to recurrent infections of tonsillar tissue
and accumulation of infected material within the crypta magna. This accumulated material initiates foreign body reaction and dystrophic calcification. Tonsillolith may also arise due to stasis in the ducts of accessory salivary glands. This could commonly be caused due to obstruction to the ducts of accessory salivary glands due to post tonsillectomy scar tissue or infection.
Usually deposition of calcium salts (Calcium phosphate) occurs normally in the skeleton. When calcification occurs in soft tissues in an unorganized fashion it is known as heterotopic calcification. This heterotopic calcification can be further subdivided into three categories:

Metastatic calcification: This calcification occurs in normal tissues due to deposition of calcium. This is the result of higher than normal levels of serum calcium as in the case of hyperparathyroidism or higher levels of serum phosphate as in patients with chronic renal failure. Metastatic calcification usually occurs bilaterally and symmetrically.

Idiopathic calcification: This condition refers to deposition of calcium in normal tissue despite normal serum levels of calcium and phosphate. Examples include chondrocalcinosis and phleboliths.

Dystrophic calcification: Is pathologic and usually occurs in degenerative and dead tissues. This calcification occurs despite normal serum calcium and phosphate levels.

Tonsillolith is usually an incidental finding. Patients may report

1. Foul breath

2. Pain in the thorat

3. Cervical lymphadenopathy (involving upper deep cervical lymph node)



Microscopy: Microscopic examination of the tonsillolith shows necrotic debris, ghost cells, calcifications and
inflammatory cells.
Tonsillolith may occur in any age group. Tonsilloliths are usually hard in consistency, may be single or multiple, may be round or oval, cylinderical or irregular pyramidal shape.

Usually tonsillolith contains minerals like carbonates and phosphonates of calcium. Other minerals like magnesium, sodium, silica, potassium, ammonia have been reported.

Image showing an intratonsillar tonsillolith

Video clipping showing tonsillolith being removed

An interesting case report of mucoepidermoid carcinoma of parotid gland

Mucoepidermoid carcinoma as an entity was first described by Stewart in 1945. He considered this tumor to arise from the pluri-potent reserve cells of salivary gland ducts. These reserve cells have the potential to develop into squamous, columnar and mucoid cells.
This tumor constitutes about 5% of all malignant salivary gland tumors. It is more common in the parotid gland. Usually these tumors are asymptomatic, but may cause pain when they become aggressive. These tumors usually donot involve the facial nerve and commonly is confined to the superfical lobe of parotid gland.
Causative factors of this tumor is not known. Exposure to radiation has always been suspected.
This tumor commonly arises in children and young adults and is rare in elderly. This case is being reported because it is a rarity in this age group. Mucoepidermoid carcinoma may become cystic because of the presence of mucoid cells which secrete mucous. There are two malignant lesions that are known to cause cystic lesions in the parotid gland. They are mucoepidermoid carcinoma and adenocystic carcinoma.

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Heuwieser forceps

As a surgeon you would have faced tremendous difficulty during endoscopic sinus surgery while attempting to remove a polyp from maxillary antrum through the natural ostium you have widened. In fact it will be virtually impossible to remove polyp from the roof and anterior wall of maxillary antrum via the natural ostium.
With the introduction of Heuwieser forceps this job has become simple.
The jaw of this forceps is highly versatile that it opens backwards up to 120 degrees. It has a working length of 130mm.

History of Mastoidectomy

Introduction: “One who ignores history would do so at his peril, to be condemned to repeat the same mistakes”. A study of history of mastoid surgery and its instrumentation is important in a sense that they are the tombstones to our success today. Eighteenth century is characterized by advancement in instrument designs and sterilization techniques. Heat resistant metals were used to manufacture surgical instruments as they had to withstand extremely high sterilization temperatures. Our forefathers of 18th century were great innovators and to their credit even now majority of mastoid instruments in use were conceived and designed by them.

Mastoidectomy during different eras:

The art and craft of Mastoidectomy has evolved during the past 200 years. The process of this evolution can be studied under three different eras i.e.:

1. Era of trepan (18th century)

2. Era of chisel & gouge (Early 19th century)

3. Era of electrical drill (20th century)



Era of Trepan:

Trephination was performed to let out pus. This was extensively practiced during the 18th century to let out pus from skull bones. The first successful trephination of mastoid cavity was performed by Ambroise Pare during 16th century. Younger during 17th century devised a hand Trepan which he used extensively to perform this procedure. A hand held trepan was commonly used during this period. The cutting head of trepan used could be circular (to cut a circular piece of bone), exfoliative head (to shed the superficial layer of bone), and perforative head (used to make a hole in the bone). In 1736 Jean Louis Petit performed the first mastoid opening for a patient with mastoid abscess. Pus His main aim was to create a hole through which pus from the mastoid cavity can drain. While using a Trepan it should be dipped in cold water often to reduce heat generated during the procedure.

In 1776 Jasser used a trocar to open up the mastoid cavity. He used the nozzle of a syringe to aspirate the contents from the mastoid cavity. This surgical procedure hence was aptly named as “Jasser procedure”. The term “trocar” has its origin in French language. “Toris – quarts” is a French word to describe an instrument with three cutting sides used to make a hole. American otologist Fredreik White described this era of mastoid surgery as an experimental one. This experimental era proved that the concept of opening up the mastoid cavity and draining the secretions is a possibility. The instrumentation was of course woefully inadequate. The first catalogue of surgical instruments published in 1860’s mentioned the various surgical and dental instruments in use. Mastoid instrumentation of course did not find a place in that catalogue.



Chisel & Gouge period: This period was characterized by the introduction of general anesthesia which facilitated a surgeon to operate leisurely on a patient. It was Amedee Forget a French surgeon who used a mallet and gouge to open the mastoid cavity and drain the accumulated pus. He performed this surgery during 1860.

Modern mastoid surgery was pioneered by the German otologist Scwartze during 1873. He and his assistant Adolf Eysell abandoned the use of Trepan in favour of chisel and gouge. He popularized Chisel and gouge as he was convinced that it was the safest way to open up the mastoid antrum. His assistant had drawn up detailed illustrations of the various types of chisel and gouges used in this procedure. Buck introduced the small curette that could be used to widen the aditus. He also advocated continuous chiseling of the hard mastoid cortex till the soft bone is reached which could be curetted out rather easily using curettes of varying sizes.

Initially Volkmann sharp edged spoons were used as curette. Samuel Kopetzky, American otologist advised that one should become dexterous and elegant with the use of a set of instruments. Newer instruments (design wise) should be introduced only when they have distinct advantages over the tried out older ones. This observation holds good even today.



Electrically driven drill period: “Modern era Mastoidectomy”

Electrically driven drills were used to manage dental caries even way back in 1882. It was William McEwen who drew the attention of the world to this unique device. He believed that the safest instrument that can be used to drill the mastoid antrum is the rotating burr. It had better control and uniform rotator cutting ability. The size of the burr bits can vary according to the area of surgery. It was Julius Lempert in 1922 who really popularized the use of electrically driven drill in ear surgeries. William House introduced the suction irrigation system and retractors in mastoid surgery. He observed that while performing ear surgeries a surgeon needs to keep both hands useful.

Holmgren introduced the operating microscope which really made Mastoidectomy totally a safe procedure.

An interesting videolaryngoscopy

You will be seeing here an interesting videolaryngoscopy.  This 75 years old female patient came with complaints of breathlessness - 1 year.  On examination she was found to be in mild stridor.

Given below is the videolaryngoscopy movie.

Role of microdebriders in nasal endoscopic sinus surgery

History: Microdebrider surgical technique was first introduced by Urban in 1968 for removing large acoustic neuromas. This instrument became a fancied tool for orthopedic surgeons who specialised in joint surgeries. Later on plastic surgeons started using this technique for performing liposuction procedures. Otolaryngologists did not lag behind in adapting this equipment for nasal surgeries.

Components of microdebrider:
A debrider contains three components.

1. The console which helps in controlling the speed of rotation/direction of rotation. These parameters can easily be changed with the help of a attached foot pedal.
2. The blade: This is a tubular metal structure with serrated edge / smooth edge. The cutting edge is present only on one side only, while the smooth opposite surface does not cut. It is usually connected to a suction tube. These blades come in various sizes and configurations. This blade allows for simultaneous cutting and removal of cut tissue by suction.
3. Handpiece: Which is a portable micromotor. It derives its power supply from the console. The blade is attached to the shaft of the hand piece.

Advantages of microdebrider:
1. It cuts and removes tissue
2. Suction applied holds the tissue to the blade facilitating their cutting
3. Microdebrider is useful in performing polypectomy surgeries in the nose. It causes minimal trauma to normal turbinate tissue. Since it cuts on one side only, the opposite side is not traumatized. Since there is no raw area on the opposite side the incidence of post op synechiae formation is minimized.

Image showing the console

You can see a video of debrider in action:

You will be viewing a online photo show of various radiological findings in otolaryngology.

Total Laryngectomy

History credits Patrick Watson for having performed total Laryngectomy. This happened way back in 1866. Careful study of Patrick Watson’s description of the case has revealed that he performed a tracheostomy on a live patient and performed an autopsy Laryngectomy on the same patient. Ironically the patient died of syphilitic laryngitis. It was Billroth from Vienna who performed the first total Laryngectomy on a patient with growth larynx. This happened on December 31 1873.
Bottini of Turin documented a long surviving patient following total Laryngectomy (10 years).
Gluck critically evaluated total Laryngectomy patients and found that there were significantly high mortality rates (about 50%) during early post operative phases. This prompted him to perform total Laryngectomy in two stages. In the first stage he performed tracheal separation, followed by total Laryngectomy surgery two weeks later. This staging of procedure allowed for healing of tracheocutaneous fistula before the actual Laryngectomy procedure.
In 1890’s Sorenson one of the students of Gluck developed a single staged Laryngectomy procedure. He also envisaged the current popular incision Gluck Sorenson’s incision for total Laryngectomy.

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Role of ultrasound in recurrent thyroid disease

Introduction:
Number of patients undergo total thyroidectomy for malignant lesions of thyroid. Recurrences can be identified easily and accurately by performing ultrasound examination of the thyroid bed area in the neck. The widespread availability of ultrasound guided fine needle aspiration cytology has added to the diagnostic armamentorium. Even after performing total thryroidectomy, recurrences are common in thyroid malignancies.

Role of ultrasound neck in post operative evaluation of thyroid cancer patients:
1. To identify tumor recurrence
2. To perform fine needle aspiration cytology

Usually sonographic evaluation is performed in post thyroidectomy patients using a high frequency probe 10 - 15 MHz. Since thyroid is absent in these patients, a valuable landmark in the neck is lost to the sonologist. Moreover the normal anatomy is also distorted. Hence it is imperative that in the absence of thyroid tissue, imaging should be performed in two planes i.e. transverse and longitudinal. Any visible mass in the thyroid bed should be considered to be a recurrent mass unless proved otherwise.
In the postthyroidectomy patient, the carotid artery and jugular vien slide medially into the space previously occupied by thyroid gland. The right carotid artery ideally is pulled medially and lies immediatly adjacent to the trachea, whereas the left carotid is at the lateral edge of oesophagus.

Recurrence in thyroid bed is typically seen as:
1. Round and hypoechoic mass situated between carotid and trachea
2. May have well defined margins
3. Microcalcifications may be seen within the mass
4. Abnormal vascularity
5. Loss of normal echogenic hilum seen in normal lymph nodes

Abnormal internal jugular chain of nodes should be searched on both sides.

Tooth inside nasal cavity

I am reporting an interesting case of tooth inside the nasal cavity.

This 35 years old female patient came with c/o obstruction to left nasal cavity
lasting for 1 year. She also gave history of bleeding from left nasal cavity.

On examination a whitish mass hard in consistency could be seen in the
floor of left nasal cavity. This mass was surrounded by granulation tissue which
bled on touch.

CT scan showed radio opaque mass in the floor of left nasal cavity.




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Frequently asked questions on Tonsil surgery (Tonsillectomy)

1. Is tonsillectomy an emergency surgery?

No. Tonsillectomy is not an emergency surgery. It is an elective surgical procedure done at a time convenient to the patient.

2. My child is 3 years old & suffering from tonsillar infection. Is surgery a solution?

No tonsillectomy is usually not performed in a child under the age of 5 because the blood loss (about 100ml) will harm the patient.

3. What are the indications of tonsil surgery?

a. Repeated tonsillar infections about 5-6 attacks in a year

b. Frequent tonsillar infections causing the child to miss school

c. In a child breathing through the mouth (nasal obstruction due to enlarged adenoid tissue). Adenoid tissue if enlarged is removed along with tonsil. If adenoid tissue is not removed along with tonsil, it will undergo compensatory enlargement in size causing nasal obstruction.
d. Frequent attacks of ear pain / ear discharge. (i.e. Ear pain and discharge will recur if the root cause is not addressed "Tonsillar infection").
e. In patients with severe dental malformations before orthodontic treatment.
f. If culture from throat / tonsil shows Beta hemolytic streptococci infection and ASO test shows four fold increase in values. This is done to prevent the patient from developing Acute rheumatic fever and acute glomerular nephritis.
4. How long must my child stay in the hospital?

Tonsillectomy is a day care surgical procedure. One day hospitalization is enough.

5. Will there be any scar in the neck?

No. Tonsil removal is performed through the mouth. No suture is necessary.

6. After surgery how long will it take for my child to regain consciousness?

Your child will be fully conscious when being shifted out of the operation theatre.

7. How long will it take for my child to eat normally?

You must encourage your child to eat ice cream 3 hours after surgery. Your child may refuse because of pain. If you make your child eat as early as 3 hours after surgery pain will reduce dramatically. You will find the act of swallowing will help your child to tolerate pain better.
During the first 3 days after surgery your child should eat soft bland diet. Normal diet can be gradually restored after the 4th day of surgery.

8. How many days leave my child need to apply?

4 days would suffice. It is always better to schedule this surgery during your child's vacation.

9. My child has blood stained sputum 3 days after surgery. Is it normal?

Yes it is quite normal for your child to have this problem during the first week.

10. What must I fear after tonsillectomy?

You must fear bleeding. If your child has bleeding from the mouth / vomits brown colored fluid you must seek immediate medical attention.

11. The area of surgery appears white on the first day Is it normal?

Yes it is normal. White patch in the tonsil area will last for at least a week.

12. After surgery will my child have voice change?
Quite unlikely. The surgery is not performed over the vocal cord. Any change in voice could be due to placement of anesthesia tube into your child's voice box during surgery. This voice change will be transient. If your child would have had adenoid enlargement then in all probability will have improvement in voice following adenotonsillectomy.

13. How much blood loss will my child suffer during tonsil surgical procedure?

Roughly about 100 ml.

Can I see the surgical procedure?



Yes

Acute frontal sinusitis

Acute frontal sinusitis is defined as inflammation of mucosal lining of frontal sinus and it’s out flow tract of less than 3 weeks duration. The incidence of acute frontal sinusitis is considerably lower when compared with that of maxillary sinusitis in adults and ethmoidal sinusitis in children. Early diagnosis and management of acute frontal sinusitis will go a long way in preventing development of complications.

Acute sinusitis commonly affects 20% of population. Acute frontal sinusitis affects about 4% of these individuals. Acute frontal sinusitis commonly affects adolescent males and young men. The age predilection is due to the fact that frontal sinuses become vascular and enlarge rapidly during 7 – 15 years of life. Male predilection largely remains unexplained.

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Embryology of nose and paranasal sinuses

Anatomically nose and paranasal sinuses are highly variable. Developmentally nose and paranasal sinuses are interlinked. They are always considered together developmentally. Developmentally the various sinuses may follow different calenders, their orgin is the same.

Development of head and neck along with face, nose and paranasal sinuses takes place simultaneously in a short window span. At the end of 4th week of development branchial arches, branchial pouches and primitive gut makes their appearance. This is when the embryo gets its first identifiable head and face with an orifice in its middle known as the stomodeum.
The stomodeum (primitive mouth) is surrounded by mandibular and maxillary prominences bilaterally. These prominences are derivatives of first arch. This arch will give rise to all vascular and neural supply of this area. The stomodeum is limited superiorly by the presence of frontonasal eminence and inferiorly by the mandibular arch.
The frontonasal process inferiorly differentiates into two projections known as “Nasal Placodes”. These nasal placodes will be ultimately invaded by growing ectoderm and mesenchyme. These structures later fuse to become the nasal cavity and primitive choana, separated from the stomodeum by the oronasal membrane. The primitive choana forms the point of development of posterior pharyngeal wall and the various paranasal sinuses.
The oronasal membrane is fully formed by the end of 5th week of development. It gives rise to the floor of the nose (palate develops from this membrane).

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Role of leptin in the pathophysiology of nasal polyposis

Leptin which is an antiobesity protein is also suspected to play a role in the pathophysiology of nasal polyposis. The term leptin is derived from the Greek work leptos which means thin. Molecularly speaking it is a 16 kilodalton protein molecule which is playing a key role in regulating energy expenditure which includes appetite and metabolism. This protein molecule is coded by the Ob(Lep) gene located in chromosome 7 in humans.
Leptin was first discovered by Friedmann in 1994.He identified that white adipose tissue is the main source of synthesis of Leptin. He also postulated that leptin could be an important biomarker for body fat. Patients who are fasting or on very low calorie diet have low levels of serum leptin.

Studies have shown that serum levels of Leptin is found to be elevated in patients with nasal polyposis.

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Tonsillectomy New Vistas

Introduction: History of tonsillectomy dates back to nearly 2000 years. It was Celsius who first described the procedure in the first century A.D. The potentials for complications after this surgical procedure are still very high despite the advancements in technology. There is still no consensus between the otolaryngologists regarding the safest operating technique which is not attended by any of the classic post operative complications described after tonsillectomy.
None of the evaluated procedures has clearly shown that post operative pain could be minimized. The cause for post operative pain following tonsillectomy is due to disruption with exposure of underlying nerve endings (glossopharyngeal and vagus), and pharyngeal constrictor muscle fibres. Postoperatively exposed to external elements the exposed muscle fibres undergo spasm causing pain while swallowing. Any newer surgical technique should address this aspect of inflammation involving the pharyngeal constrictor muscles.

Subtotal intracapsular tonsillectomy:

This concept is based on minimal tissue injury. The pharyngeal constrictor muscles are not exposed. The raw nerve endings are also not exposed to the environment. The post operative pain after this procedure is very minimal and the patient undergoes a stress free convalescence period. In this procedure radio frequency probe is used. This technique is also known as “Temperature controlled radiofrequency tonsil reduction”. In this technique a RF probe is introduced into the tonsillar tissue and heated up to 40 - 70° C. A plasma field containing highly ionized particles is formed at the probe’s surface causing tissue destruction. This probe can thus be used to create small channels in the tonsil with dissipation of the energy released by ionizing radiations. This causes tissue destruction during the following days / weeks of surgery leading on to a gradual reduction in the size of tonsillar tissue. Initially there is an increase in the size of tonsil due to soft tissue oedema. Tonsil shrinkage usually occurs between the first and third weeks. The main advantage of this procedure is that since the tonsillar bed structures are minimally damaged, these patients are absolutely pain free even on the first post operative day.

Advantages of radiofrequency probe versus conventional diathermy / electrocautery:

1. Radiofrequency generators operate at lower frequencies than conventional electrocautery units. The cutting action of R.F. cautery occurs at 70° C. This is much lower than the cutting temperature of conventional electro cautery units which ranges between 400 – 500 º C.
2. The high current density which is released by the electrode causes a rapid increase in the local temperature ranging from 50 – 80 ° C. This raise in temperature causes coagulation, protein denaturation and irreversible tissue destruction. When the tissue temperature reaches the critical level of 100 º C boiling occurs at the electrode tissue interface. This boiling causes the tissue coagulum to adhere to the electrodes disrupting the current flow through the prongs.
3. Radiofrequency ablation uses frictional heating that is caused when the ions in the tissue attempts to follow the changing directions of alternating current.
4. These devises have sensors close to their tip which are capable of monitoring tissue temperatures. When the local tissue temperature reaches 100 º C the sensor automatically shuts off the current to the generator ensuring that the tissue temperature does not exceed 100 ° C.

During RF tonsillectomy the cutting mode should be paused for 10 seconds for every 10 seconds of tissue cutting.