Saturday, July 25, 2009

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.

Get the full story from here

Saturday, July 18, 2009

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?


Thursday, July 16, 2009

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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Wednesday, July 15, 2009

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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Thursday, July 09, 2009

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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Tuesday, July 07, 2009

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.