Sialendoscopy

Introduction:

Common disorders of salivary glands involve obstruction involving their ductal system. Salivary gland calculi comprises the most common cause of enlargement of salivary glands. Obstructions could be caused by the presence of calculi, strictures of the duct etc. Sialoendoscopy is the most preferred mode of treating obstructions involving major salivary glands. Major advantage of this procedure is that it can be performed under local anesthesia as an office procedure.

History:

It was Konigsberger and his colleagues first used sialoendoscopy and lithotripsy to treat salivary gland calculi in 1990. During the year 1991 Gundlach and colleagues published their experience of doing sialoendoscopic procedures. Katz in 1991 used a 0.8 mm flexible endoscope to diagnose sialolithiasis and to remove them from major salivary glands. It was Kongisberger and colleagues who successfully used a flexible mini endoscope and intracorporeal lithotriptor to fragment major salivary gland calculi, thus opening up new vistas.
In 1994 Arzoz and his colleagues first introduced a 2.1 mm rigid endoscope which had a 1mm working channel as sialendoscope. This was indeed a mini urethroscope. They also used a Pneumoballistic lithotriptor along with this endoscope to hit the calculus and break it. This work was followed by Nahlieli who published his three years experience with rigid sialendoscope in the year 2000.


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Pseudocyst of Pinna

This condition involves the Pinna and can frequently recur even after successful treatment. It goes by various names i.e. intercartilagenous cyst, endochondral Pseudocyst and idiopathic cystic chondromalacia. This condition was first described by Engel in 1966.

Clinical features:

1.Presents as painless, spontaneous dome shaped cystic swelling on the anterior surface of auricle.
2.This condition is predominantly seen in adult males
3.It is uncommon before 20 and after 60 years of age.
4.Majority of these cysts are found in the scaphoid and triangular fossae of the pinna
5.Majority of these cysts have been reported in Chinese. Chinese have attributed this problem due to the firm pillow they use to sleep. Studies have not demonstrated any racial differences.
6.Right ear is more commonly affected than the left. This has been attributed to the habit of majority of individuals to sleep on their right side.

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Congenital Epulis

Introduction:
“Epulis” is a Greek term meaning Gums. This term is used to denote a wide variety of lesions involving the gums regardless of their pathology.
This is a rare congenital growth affecting the gingival mucosa of neonates. It is also known as Neumann’s tumor. It is truly a benign condition affecting predominantly female infants. It may even be multiple. This tumor was first described in 1871 by Neumann and hence the name.

These tumors are commonly present at birth arising from the gingival mucosa of maxilla / mandible. These infants may have feeding and breathing difficulties because of the mass effect. Ultrasound studies have shown that this tumor can arise as early as 26th week of gestation.

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Rhinitis medicamentosa

Introduction:

Rhinitis medicamentosa is a condition characterised by nasal congestion without rhinorrohea or sneezing. This condition is caused by the use of topical nasal decongestants for a prolonged period of time. Use of these topical decongestants for more than a week is sufficient to cause this problem. This condition should be differentiated from rhinitis caused by use of drugs like oral contraceptives, antihypertensives and psychotrophic drugs.

History:

The term rhinitis medicamentosa was coined by Lake in 1946.

Synonyms:

Rebound rhinitis / chemical rhinitis

Pathophysiology:

The nasal mucous membrane is rich in resistance blood vessels draining into capacitance venous sinusoids. These resistance blood vessels include small arteries, arterioles and arteriovenous anastomosis. The capacitance vessels (venous sinusoids) are innervated by sympathetic fibers. Sympathetic stimulation causes activation of alpha 1 and alpha 2 receptors present in the walls of the capacitance vessels which leads to decreased blood flow and constriction of venous sinusoids causing nasal decongestion. Parasympathetic stimulation causes release of acetyl choline which increases nasal secretions. Parasympathetic stimulation also causes release of VIP (vasoactive intestinal polypeptides) causing vasodilatation of the resistance blood vessels leading on to dilatation of sinusoids there by causing nasal congestion. In addition to sympathetic and parasympathetic innervation the nasal mucosa is richly endowed with sencory type c fibers. These sensory fibers on stimulation releases neurokinin A, calcitonin gene related peptide and substance P. These substances cause down regulation of sympathetic vasoconstriction causing nasal congestion. The exact pathophysiology of rhinitis medicamentosa is still not clear. Various hypothesis exist. Almost all of them focus on dysregulation of sympathetic / parasympathetic tone by exogenous vasoconstriction molecules.

Possible mechanisms of rhinitis medicamentosa include:

1. Secondary decrease in the production of endogenous norepinephrine through a negative feed back mechanism
2. Sympathomimetic amines used as topical decongestants have effects on both alpha and beta receptors. Their alpha effects predominate over beta effects causing nasal decongestion. This beneficial alpha effect is short lived while beta effect is more prolonged. After cessation of alpha stimulation the sympathomimetic amines still keep stimulating beta receptors causing rebound nasal congestion.
3. Rebound increase in parasympathetic activity causing increased nasal secretion and nasal mucosal congestion
   
   
   
   
   
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Primary itching of external auditory canal and its management

Introduction:

Patients with itchy ear are said to be suffering from “itchy ear syndrome”. Sometimes the itching in the external auditory canal may be so severe that it may even disrupt sleep.

Classification of itchy ear:

Itchy ears has been classified into primary and secondary types.

Secondary itching: of the external auditory canal may be caused by:

1.Dermatitis – contact / seborrhoeic
/ dermatomycosis
2.Systemic disorders causing itching include – jaundice, diabetes, and renal pathology


Primary itching:

In patients with primary itching there is no evidence of dermatitis or systemic disorders which have been attributed to be the causative factors of secondary itching. These patients may at the most have pathogenic colonization of the external auditory canal.
These patients are commonly middle aged or elderly women.

Predisposing features of primary itching include:

1.Excess moisture in the external auditory canal
2.Changes in pH of cerumen
3.Obstruction to external auditory canal due to presence of wax


Management:

These patients can be managed by

1.Topical application of 2% acetic acid
2.Appication of soothing agents like coconut oil
3.Application of topical steroids like triamcinalone
4.Application of silver nitrate gel
5.Oral antihistamines

Long term application of topical steroids is frought with a lot of complications. This includes thinning of epidermis, decreased microvasculature and a reduction in the number of keratinocytes.

Current therapy:

Pimecrolimus
a new topical immunosuppressive agent has shown immense promise in the management of this disorder. This is an immunomodulating agent which has been successfully used in the management of atopic dermatitis. This drug is a macrolactum derivative and is known to inhibit calcineurin which is known to cause itching in these patients.

Role of sphenoplatine ganglion block in managing cluster headaches

Introduction:
Cluster head ache (suicide headache) is one of the most painful of all headache syndromes. It is characterized by very severe orbital / temporal pain occuring usually on the same side lasting between 15-150 minutes if not treated. Cluster headache attacks are usually associated with rhinorrohea, lacrimation, conjunctival injection, perspiration and psychomotor agitation. These clusters usually occurs during “cluster periods” which range between 6-12 weeks with painless intervel inbetween.

Pathophysiology:

Current views suggest that cluster headaches are caused by central mechanisms which are triggered by reflex arc involving the sphenopalatine ganglion. Hypothalamus has been suspected to play an important role in the pathophysiology of cluster headaches. That is the reason for using deep brain stimulation of the posterior nucleus of hypothalamus in managing drug resistant cases of cluster headaches.

Role of sphenopalatine ganglion block:

Recent studies have shown promising results when sphenopalatine ganglion is blocked. This can be carried out transnasally with minimal intervention under endoscopic vision. This can easily be achieved by a mixture of local anesthetics and steroids. These drugs should be delivered as close to sphenopalatine ganglion as possible. After decongesting and anesthetizing the nasal cavity a solution of triamcinolone acetonide (40 mg), 1% bupivacaine (4 mL), and 2% mepivacaine with 1/100,000 adrenaline (2 mL) in an average of three (range 2– 4) weekly sessions Injection is usually administered with a 20 gauge needle close to the tail of the middle turbinate (this is the approximate location of sphenopalatine ganglion). Care is taken not to damage the sphenopalatine artery. Two to three injections may be adminstered in a space of 4 – 6 weeks.