Sunday, February 28, 2010

Blow out fracture of orbit endoscopic repair


Blow out fracture is one of the common injuries of orbit. This is commonly caused due to frontal blunt injury to orbit causing fracture of the floor of the orbit. Orbital fat / extraocular muscles may be entrapped within the fracture fragments. Commonly entrapped extraocular muscle is inferior oblique muscle. Usually entrapment of these muscles causes diplopia when the patient attempts to look down. Blow out fracture also creates enophtholmos since prolapse of orbital contents into the maxillary sinus through the fractured floor causes reduction in the volume of orbital contents.

Clinical features of blow out fracture orbit:

1. Orbital swelling immediately

2. Ecchymosis

3. Step deformity of infraorbital rim and crepitus on palpation

4. Entrapment of infraorbital nerve will cause anesthesia over the chin on that side

5. Positive forced duction test - in patients with entrapment of inferior oblique muscle

6. Diplopia on looking down


Should ideally be performed after reduction of orbital oedema.

Caldwell Luc procedure should be performed. Through the opening in the anterior wall of maxillary sinus the fractured floor of orbit is elevated. The fractured fragments can be held in position by placing plate and screws via a subciliary incision. Two incisions are necessary for successful reduction of blow out fracture conventionally. The first one is the sublabial incision to perform caldwell luc procedure, and the second one is the subciliary incision to stabilize the fractured fragments.

Endoscopic reduction of blow out fracture:

Advent of endoscopes have helped in the management of blow out fracture under vision.
Step 1: A caldwell luc procedure is first performed by creating an opening in the anterior wall of maxilla. An endoscope is introduced through the opening and the fracture is reduced under vision

Step 2: Inferior meatal antrostomy is performed using Miles retrograde gouge.

Step 3: Foley's catheter is introduced into the maxillary antrum through the inferior meatal antrostomy and its bulb is inflated with air. The inflated bulb holds the reduced fractured fragments in position and it should be retained for atleast 6 weeks.

Monday, February 22, 2010

Malignant growth tongue Role of surgery

Malignant lesions involving tongue are very difficult to treat.  This is partly due to the fact that tongue is richly endowed with lymphatics.  Even small lesions can involve regional lymph nodes.  The proximity of this organ to mandible makes irradiation a difficult task.  Mandible responds to irradiation rather poorly causing osteo radionecrosis leading on to troublesome fistula formation after irradiation.  Irradiation of these patients need to be planned carefully and is fraught with irritable side effects like dryness of mouth, halitosis etc.

Clinical details of the patient who was treated with hemiglossectomy:

65 years old female patient - C/O ulcerating mass in the left lateral border of tongue anteriorly - 6 months duration.
H/O Tobacco chewing ++
On examination:
Tongue protrusion and mouth opening were normal.
Slough covered ulcero proliferative mass measuring 3 cms in its largest dimension, could be seen occupying the lateral portion of anterior 1/3 of tongue.  On palpation mass was found to be indurated.  Clinically there was no evidence of Nodal metastasis.  CT scan of neck also showed no evidence of nodal metastasis.

Biopsy was reported as well differentiated squamous cell carcinoma.

Since the mass was involving the anterior portion of the left side of tongue the patient was taken up for surgical resection of the mass - Hemiglossectomy.
This patient underwent hemiglossectomy via intra oral route - without splitting the mandible as there was no ankyloglossia / trismus.  Due to full mouth opening surgical exposure was good and the posterior border of the mass was clearly found not involving the posterior 1/3 of tongue. 

Clinical photograph of the patient

After surgery the patient was submitted for a course of post op radiotherapy to take care of micro nodal metastasis.

Friday, February 19, 2010

Pediatric Laryngoscopes

     This article is relevant in the present day scenario as more and more children under go endolaryngeal surgeries.  With efficient neonatal intensive care units, large number of premature / low birth weight babies thrive these days.  As the old adage goes "A child is not a miniature adult" it is imperative that equipment design should keep pace with the advancing science.  Pediatric larynx is unique in many ways.  It is placed high up in the neck, the overhanging omega shaped epiglottis makes visualization of larynx nearly impossible.  It is important to design laryngoscopes that could overcome these anatomical variations.  This article discusses the various laryngoscopes available for use in pediatric age group of patients.

Pediatric laryngoscopes can be classified into:

1. General purpose laryngoscopes

2. Laryngoscopes designed for special purposes

General purpose laryngoscopes:

These are designed with the intention of providing a good view of

oropharynx, laryngeal inlet and laryngopharynx of an infant.There are two

varieties of general purpose laryngoscopes:

Karl storz


Karl storz - The general purpose laryngoscope designed by karl storz can be used

for both diagnostic and intubation purposes.These are available in 4 sizes:

1. 8 cms for premature and newborns

2. 9.5 cms for infants

3. 11 cms for children

4. 13.5 cms for adolescents

These differing sizes will enable proper placement of the beak of laryngoscope

either in vallecula or behind the epiglottis. Proper placement of the beak of

laryngoscope will ensure better field of vision of oropharynx and laryngopharynx.

Illumination is provided by proximal prismatic deflector. Light is transmitted to the

prismatic deflector via a thin fibre optic cable which passes via the handle of the


Parsons laryngoscopes are a variety of paediatric laryngoscopes.

It is usually available in three sizes.

1. 8 cms for premature babies / new borns

1. 9.5 cms for infants

2. 11 cms for toddlers and older children

on being positioned over the posterior 1/3 of tongue a wide view of

laryngopharynx can be seen. It can be connected to suspension apparatus

helping the surgeon in laryngeal examination and surgeries leaving both

hands free. Another important advantage is the presence of a side port

on the left side through which a cannula can be introduced to pass anesthetic

gases. It has another port on the right side though which fibre optic

attachement can be passed for illumination purposes.

It is very useful in laser endolaryngeal surgeries.

Telescopes can also be passed through the left port for complete

examination of larynx and laryngopharynx.

Special purpose laryngoscopes: These are usually operating laryngoscopes used during surgical procedures

involving larynx. These include:

1.Benjamin Lindholm laryngoscope

2.Holinger Benjamin laryngoscope

3.Benjamin operating laryngoscope

Benjamin Lindholm laryngoscope: is available in two sizes.

9.5cms for premature babies and 11 cms for children from 18 months - 8 years of age

When the beak is placed a wide view of laryngopharnx is available. Since it is provided

with suspension system both arms are free for manipulation. It has a special cannula which

is fixed to the left side of the laryngoscope. Through this cannula anesthetic gases can

be insufflated. The laryngoscope provides a wide exposure for microlaryngeal and laser


Holinger Benjamin laryngoscopes:is manufactured in three sizes:

1. 9.5 cms with a very narrow distal end for very low birth weight new born babies

2. 9.5 cms with a larger distal end for new born babies

3. 11 cms for older children

By virtue of their design these laryngoscopes help in full visualization of anterior commissure,

posterior glottic space and subglottic area. This laryngoscope can be used for difficult intubation

scenarios. Since the blade of these laryngoscopes are slim and slightly upturned, it is helpful in

intubating patients with difficult mouth opening like Pierre Robin syndrome. This scope is very

useful in diagnosing congenital webs involving larynx.

Benjamin operating laryngoscopes:

These are available in two sizes. These scopes allow binocular vision during microlaryngeal / laser

surgeries. These scopes are provided with portal for anesthetic gas insufflation.

This image shows a Parson's laryngoscope

Lindholm's laryngoscope

Thursday, February 04, 2010

History of frontal sinus surgery

The first frontal sinus surgical procedure was first described in 1750. Despite more than 2 centuries since the description of the procedure on frontal sinus, the optimal procedure is still not clear. Frontal sinus disease could be highly morbid with the danger of life threatening complications, because of its anatomic proximity to anterior skull base and orbit.
“Surgical treatment of chronic frontal sinusitis is difficult, often unsatisfactory and sometimes disastrous” Ellis 1954.

A brief history of frontal sinus surgery can be accessed from here: