Sunday, May 30, 2010

Nasal mucosal congestion index and how to measure it.


Nasal mucosal congestion is an important determinant in deciding whether the patient needs medical / surgical therapy. It goes without saying that if the nasal mucosa is thickened due to mucosal oedema than it would respond better to nasal decongestants, while if the thickening is due to underlying submucosal fibrosis then it doesn't respond to decongestants and needs to be surgically removed to improve nasal airway patency. Nasal mucosal compliance cannot be estimated by CT scans alone.

It has been demonstrated that tissue remodelling which is the repair response of nasal mucosa to insults is characterised by decrease in vascular density, and an increase in fibrosis causing the nasal mucosa to thicken irreversibly. This thickened mucosa reduces drug permeability through osmosis causing a reduction in the effectiveness of the drug.

Nasal mucosa congestion index:

This measurement helps in identifying mucosal oedema from mucosal thickening due to fibrosis involving submucosa. This can be measured by performing acoustic rhinomanometry before and after decongesting the nose with epinephrine. If the nasal mucosal congestion index is large then medical management is preferred and if the index is small then surgery should be resorted to in the management of chronic rhinosinusitis. For sake of objectivity congestion index of the nasal mucosa can be classified as normal, mild, moderate, severe and very severe.

Acoustic rhinometry:

This procedure was first introduced by Hilberg as an objective method in assessing the nasal cavity. This procedure is based on the principle that sound waves traveling through the nasal cavity is reflected by local changes in acoustic impedance. Four areas of the nasal cavity have been shown to be the cause of nasal resistance. They are:

1.Nasal valve area (internal nasal valve)
2.Nasal vestibule
3.Head of inferior turbinate
4.Head of middle turbinate

Nasal resistance caused contributed by these areas can be clearly assessed by acoustic rhinomanometry. This method is very accurate in studying the nasal resistance at the level of nasal valve area. The accuracy progressively reduces for nasal resistance contributed by posterior structures like head of the middle turbinate.

Tuesday, May 25, 2010

Presentation widget

Hi everybody

I have uploaded some interesting power point presentations. I have created a widget for you to view all of them in a single page.

Monday, May 24, 2010

Minimally invasive surgery in the nasal valve area to treat nasal obstruction


Mink defined nasal valve area to be the narrowest portion of the whole of the nasal cavity. He anatomically characterized this area anatomically as a two dimensional slit like opening lying between the caudal edge of the upper lateral cartilage and the corresponding area of the nasal septum. Deformities involving this area cause troublesome nasal stuffiness and obstruction. Surgical procedure involving this area is fraught with dangers of stenosis in this vital area and deformities involving the contour of the nose. This article describes what could be considered to be a simple surgical procedure that could relieve obstruction in this area.

This procedure can be performed under local anesthesia. Nasal cavity is first packed with ribbon gauze dipped in 4% xylocaine with 1 in 100,000 units adrenaline. Xylocaine in 1% concentration

mixed with 1 in 100,000 units adrenaline is infiltrated over the prominence formed by the caudal portion of the upper lateral cartilage. Parallel incisions are made on either side of the caudal portion of the upper lateral cartilage. The caudal portion of the upper lateral cartilage is exposed after removing a strip of mucosa with the underlying fibrous tissue. A 2 mm cuff of mucosa along with overlying fibrous tissue is also removed to prevent redundant tissue formation. About 1-2 mm of the terminal portion of the upper lateral cartilage should be resected and removed. The wound is closed with absorbable suture like catgut. This procedure is safe to perform bilaterally also if necessary.

This type of minimally invasive surgical procedure releaves the fixed nasal obstruction which is caused by excessive cartilage in this area.

Figure showing the steps of minimally invasive surgery involving the nasal valve area

This technique was first described by Gray in 1970. It was left to Kern (1978) to popularize this procedure. According to Kern goal of this surgery is to reconstruct the normal anatomy of the nasal valve area without increasing the rigidity / collapsibility of the nasal valve area.

This surgical procedure is really helpful in relieving nasal obstruction due to abnormalities in the nasal valve area.

Sunday, May 23, 2010

Can the presence of Biofilms be identified under routine H&E staining?

Centers for disease control and prevention estimate that about 65% of human bacterial infectious processes involve biofilms. Biofilm is a group of bacteria seen over surface epithelium like mucous membrane, enclosed within a matrix of extracellular polysaccharide material. The presence of this biofilm has been implicated in the following chronic infections:

  1. Chronic rhinosinusitis
  2. Chronic bronchitis
  3. Atrophic rhinitis
  4. Lung infections following prolonged intubation
  5. Urinary catheter related infections
  6. How biofilms protect the bacteria from host defenses?

    Biofilm contains multiple types of bacteria. Bacteria from biofilms are difficult to culture & hence difficult to identify. These multiple organisms coexist with each other conferring drug resistance. Antibiotics don't penetrate biofilms in adequate concentrations thus the organisms within are well entrenched and protected. These biofilms surround the microbes with extracellular polymeric substance which constitute a physical non cellular barrier against host defense mechanisms.

    Staphylococcus and pseudomonas organisms have been implicated in chronic sinonasal disease associated biofilms.

    How to identify Biofilms?

    Biofilms have been identified by scanning electron microscopy. Recently Fluorescence insitu hybridization techniques have been used to identify biofilms (FISH technique).

    Christian J. Hochstim in his original work has shown that the presence of Biofilms can be identified with reasonable degree of accuracy using H & E stains.

    Histologically under H & E staining, biofilms appear as clusters of basophilic bacteria and host cells entrapped in a layer of extracellular polymeric substance.

    It is really worthwhile looking for the presence of biofilms in all mucosal specimen sent for biopsy.




Wednesday, May 19, 2010

Nasal stents are they really useful ?


Formation of synechiae constitute one of the common complications following ESS. Conservative estimates place about 10 % of all patients who have undergone ESS as prone for synechiae. Dissection in the frontal sinus area is more prone for synechiae formation because of the difficult access. Dissection in this area is troublesome due to the difficult angle involved. True cutting instruments which cause little tissue damage have difficulty in reaching this area. Using powered shavers and debriders in this area has also not managed to reduce the risk of synechiae. Stents have been used with varying degree of success in preventing postop complications following ESS.

Functions of Stents following ESS:

1.The primary function of stent is to separate two edges of raw wound thus preventing the formation of fibrous band / synechiae. This is classically seen when there is lateralization of middle turbinate following ESS. Lateralization of middle turbinate can potentially obstruct middle meatus drainage. This can effectively be prevented by placing a stent between the middle turbinate and the lateral nasal wall.
2.Stents can potentially take up space which would otherwise be occupied by mucous/ clot. Presence of clot can lead to epithelial migration and synechiae formation.
3.Patients in whom stents have been placed have very little crust formation, hence frequent wound debridement is not needed.
4.Stents also serve as occlusal dressing facilitating better & faster wound healing. Occlusal dressings have known to reduce tissue necrosis.

Types of nasal stents:

1.Middle meatal stent
2.Frontal sinus stent
3.Drug containing stents

Middle meatal stents:

Role of middle meatal stents include:

1.Decrease synechiae formation
2.To prevent lateralization of middle turbinate
3.Since it fills up the ethmoid sinuses it effectively prevents clots, mucous or fibrin.

Stents of middle meatus is also known as spacers. Common spacers of middle meatus are made of glove fingers filled with polyvinyl acetyl sponge which are sutured together and tied with silk. Since this spacer is smooth it does not adhere to the surrounding tissue, thus serves as an occlusive dressing.

Foam made of biodegradable synthetic material like polyurethane can also be used to stent the middle meatus after surgery. This material is suitable for patients who does not tolerate other types of middle meatal stents.

               Image showing Freemann stent

You can access the complete e book from here.

Saturday, May 15, 2010

Torus palatinus excision


The word “tori” is derived from the latin word torus which means “to stand out” / “lump”.

Synonyms: Exostosis of oral cavity, Buccal exostosis.


Torus palatinus is a sessile nodule of bone occuring commonly in midline of hard palate. It can also occur over the lingual surface of the maxilla (torus mandibularis). Torus mandibularis is a bony protruberance located on the lingual aspect of the mandible (commonly between the canine and premolar areas). These are bony masses, begining their development during early teens and gradually progresses to adult hood. These masses are slow growing and painless.

These masses are usually self limiting, rarely they may cause periodontal diseases. Periodontal disease is usually caused by the mass forcing food towards the teeth while being chewed instead of away from it. Too large torus may interfere with dentures.


1.Masticatory hyperfunction
2.Genetic factors (common in females)
3.Environmental factors

Age of occurrence:

It is very rare during the first decade of life. Its increase in size occur during the second and third decades of life. According to Bruce etal the average age of presentation of tori is 34. Since there is very little literature available on this subject very little knowledge regarding age of occurrence is available.

Rate of growth:

The rate of growth of these bony masses is very slow and gradual. Studies have shown that maximum increase in size occurs during the second and third decades of life.

Role of imaging:

CT scan is virtually diagnostic.


Oral exostosis was first classified by Haugen. He classified oral cavity exostosis according to their sizes as small, medium and large.

  1. Less than 2 mm in their largest diameter – small
  2. 2 – 4 mm in their largest diameter – medium
  3. More than 4 mm in their largest diameter

According to Haugen majority of oral cavity exostosis belonged to the small and medium categories.

Reichart in his modification of Haugen's classification suggested few changes:

Grade I – Tori up to 3 mm in their largest dimension

Grade II – Tori up to 6 mm in their largest dimension
Grade III – Tori above 6 mm belong to this group


Torus palatinus occur in varying shapes. It can be flat, nodular, lobular or spindle shaped. Small tori are invariable nodular and they are the most common variety encountered. Lobular shapes are pretty rare.

Indications for surgical removal:

  1. The mucosa over torus is ulcerated
  2. When it interferes with placement of dentures
  3. When there is associated periodontal disorder
  4. Where torus can be used as graft material
  5. Phonatory disturbances
  6. Sensitivity of the overlying mucosal layer
  7. Disturbances involving masticatory apparatus
  8. Esthetic reasons

Surgical removal:

Torus palatinus can be removed either under local / general anesthesia. If the surgery is tobe performed under local anesthesia the following nerves should be anesthetised using 2 % xylocaine mixed with 1 in 100,000 units adrenaline.

  1. Nasopalatine nerve should be anesthetised as it exits through the anterior palatine foramen
  2. Anterior palatine nerves should be anesthetised through posterior palatine foramen
  3. Anesthetic solution should also be infiltrated over the mass to detach the oral mucosa from the mass

To surgically remove torus mandibularis infiltration anesthesia is used over the mass. Nerve block anesthesia blocking inferior alveolar, mental and lingual nerves can also be used.


To remove torus palatinus a double Y incision is preferred. This incision prevents damage to the nasopalatine and anterior palatine blocks of the hard palate. The incision should involve the full thickness of the muco periosteal lining.

Surgery to remove torus mandibularis involve incision over the mandibular ridge. If the incision is made above the torus it provides a good operating field. In rare cases scalloped inter dental incisons can be used.

Fissure burr is used to remove the bony torus. After removal of torus the flap could be found to be redundant and the same may also be trimmed. The flaps may be sutured back in place using absorbable suture material.

Surgical complications of torus palatinus:

  1. Perforation into the nasal cavity
  2. Secondary anesthesia due to damage to palatine nerve
  3. Palatine artery hemorrhage
  4. Laceration of palatine mucosa
  5. Fracture of palatine bone

Surgical complications of torus mandibularis:

  1. Mandibular fracture
  2. Devitalisation of teeth
  3. Injury to salivary ducts
  4. Injury to lingual nerve
  5. Flap laceration

Post op complications:

  1. Hematoma
  2. Wound infection
  3. Flap necrosis


Prosper Meniere an apostle of humility

Prosper Meniere:

Prosper Meniere described clearly the symptoms of Meniere's disease. Even now the description of Meniere's of this disorder holds good. Very little has been added to the description of Meniere's disease.

Prosper Meniere was born in Angers a French town in 1799. He underwent basic education at Lycee. Later he joined the university of Angers. He completed his medical studies at the Hotel-Dieu in Paris which was one of the most prestigious hospitals of Europe those days. He received gold medal for excellence in medicine in 1826. He received his doctorate in medicine in 1828.

He was really popular with the ruling elite. He attended to Duchess Caroline Louise, the widow of the second son of Charles X who was pregnant while imprisoned at Blaye. His popularity with the ruling elite alienated him from main stream academic medicine.

In 1835 epidemic of cholera swept over Europe. Meniere organized regional health care against cholera epidemic. He introduced the concept of barrier nursing while treating these patients. He was awarded the Chevalier of the Legion d'Honneur for this work. During this very period juniors superseded him to professorial chair at the Hotel – Dieu.

1838 happened to be a turning point year in the life of Meniere. It was during this year that Jean Marc Gespard (one of the fathers of otology) died while serving as director of the Institute of Deaf – Mutes in Paris. Meniere who had no formal otological training was appointed to the post. His marriage to the daughter of Becqauerel, an influential member of the Institute of Deaf – Mutes in Paris helped his cause. From now on he dedicated the rest of his life to the care of deaf mutes.

His greatest contribution to medical science came in 1861. It was during this year he presented a paper at the Imperial Academy of Medicine in Paris. In that paper he questioned the then existing theory that vertigo was a form of cerebral apoplexy or epilepsy. He argued in favor of inner ear dynamics. This paper was heavily criticized those days. This paper was based on some astute observations made by him while treating deaf patients who had associated giddiness. He also heavily borrowed from the work of Pierre Flourence who proved by his methodical dissection of pigeon's labyrinth that ablation of various portions of labyrinth caused loss of balance in these birds. He also precisely recognised that vertigo of central origin was not associated with hearing loss. He also observed that patients with aural vertigo did not lose consciousness during attacks of vertigo.

He died at the ripe age of 62 following an attack of pneumonia in 1862. The triad of tinnitus, vertigo and deafness became recognized as “Maladie de Meniere”. This term was coined by Charcot in 1874.

Menier's was a man of great humility. One of his famous quotes runs like this:

I am certain that the best works have been burned, that
the sweetest verses have never been printed . . . whereas
the shameless, the impertinent, the pre-eminent show off
with insolence in the sun of publicity without any right to
do so.”

Sunday, May 09, 2010

Eagle's syndrome

The styloid process shows lot of variations in its length. In majority of patients it is about 20 – 30 mm long. Technically speaking when the length of styloid process exceeds 30 mm then it is considered to be elongated. The clinical signs and symptoms associated with elongated styloid process was first described by Eagle in 1937. Later this condition became known as Eagle's syndrome / Elongated styoid process. The signs and symptoms of elongated styloid process are pretty vague and often at best misleading. These patients usually go medical shopping visiting neurologists, dental surgeons, psychiatrists and surgeons. The diagnosis of this condition requires awareness and vigilance. This condition can be confirmed by palpating the tonsillar fossa, infiltration of local anesthetic agents and imaging studies.


Historically the ossification of stylohyoid apparatus can be divided into three periods.
This division is purely for better understanding.
Era of anatomists: Anatomists belonging to 17th century described ossification of stylohyoid apparatus they encountered during dissection as normal variants as they were not privy to the clinical details and patient history.
Era of diagnostic radiologists: This period includes the early 20th century. Due to advances in radiological anatomy, radiologists were able to identify ossification of stylohyoid apparatus and correlate this condition with that of the symptoms expressed by the patient. Eagle under whom this syndrome is named belonged to this era.
Era of panoromic radiology: This period includes the mid 20th century. Routine study of panoromic radiographs by dental surgeons threw up more such cases of ossification of the stylohyoid apparatus.


Gossman's classification of types of elongated styoid processes: Gossman studies about 4000 patients with elongated styoid process and classified it into three types.

4.Very elongated

Correll's classification of elongated styloid process:

Type I: Elongated styloid process
Type II: Pseudoarticulated styloid process
Type III: Segmental styloid process

Common symptoms associated with elongated styloid process include:

1.Vague pain in the neck
2.Foreign body sensation in the throat
3.Pain in the throat
4.Painful swallowing
5.Pain while changing head position
6.Pain in the ear
7.Pain over temporomandibular joint
8.Pain radiating to upper limb

You can download the full e book from here