E book of the week : Role of Debriders in Otolaryngology

E book of the week:


"Role of Microdebriders in Otolaryngological surgery"


This freely downloadable e book discusses the current role of
Microdebriders in Otolaryngology.

 

Role of Microdebrider in Otolaryngological surgery

E book of the week "Tuberculosis of tonsil a review of literature"

E book of the week:


"Tuberculosis of tonsil a review of literature"

A rare case of tuberculosis tonsil

Introduction:

Tuberculosis involving the tonsil is very rare. These days it is still rare because of better milk processing techniques like pasteurization which eradicates the bovine strain of tuberculosis. Even though tonsils are situated in an exposed area where infected material like sputum and food stuffs come into contact this lesion is rare because of the following features:

1. Antiseptic and cleansing action of saliva (first and foremost)

2. Presence of saprophytic organisms in the oral cavity which prevents growth of tubercle bacilli

3. The stratified squamous epithelial lining of the tonsil also offers some degree of protection

Tuberculosis of tonsils may be:

Primary - Due to ingestion of infected milk (Bovine strain)

Secondary - Due to pulmonary infection. The coughed out infected sputum finds its way to the throat to involve the tonsils.

Diagnosis of tuberculosis of tonsil is not straight forward. It needs high degree of suspicion.

Pointers for the diagnosis of tuberculosis tonsil:

1. Asymmetric enlargement of tonsil

2. Tonsillar enlargement without exudate

3. Obliteration of crypts

4. Painful deglutition

5. Presence of enlarged mobile jugulodigastric nodes

Clinical photograph of a patient with Tuberculosis tonsil


View the full case details from here.

Vocal cord paralysis

Definition: Vocal cord paralysis is caused by paralysis of intrinsic muscles of larynx. This is a symptom of an underlying disorder and not a disease by itself. The intrinsic muscles of the vocal cord are supplied by the vagus nerve. The term vagus means "wanderer" which is the apt term to describe this nerve becuase of its long anatomical course.

Unilateral vocal fold paralysis occurs due to dysfunction of recurrent laryngeal or vagus nerve causes a breathy voice. The breathiness of voice is caused by glottic chink which allows air to escape when the patient attempts to speak. Normal voice production is dependent on proper glottal closure resulting from bilateral adduction of the vocal cords. This adduction of vocal folds combined with subglottic air pressure causes the vocal folds to vibrate causing phonation.

you can read the full e book from here.

Surgical management of puberphonia recent concepts

Introduction:


Mutational falsetto is also commonly known as Puberphonia. This condition is caused due to the failure of the voice to drop in its pitch from the higher levels after puberty. These patients hence suffer from lack of resonance in voice, breathiness of voice and lack of pitch variations. These patients have easy fatigability of voice and are unable to raise their voice in noisy environments.

This condition is caused due psychological problems in the patient which prevents lowering of the pitch of the voice of an adolesecent to that of a adult range. Puberphonia is more common in adolescent males and may also occur rarely in females.


The following are the probable psychological factors that could lead to the developement of puberphonia:


1. Over identification of the affected boy with his mother
2. Failure of the boy to accept his adult male role
3. Social immaturity
4. Anxiety to maintain a Soprano voice
5. Incordination of muscles of vocalization

Surgical management of Puberphonia:


When all the above conservative methods fail then surgery will have to be resorted to. Isshiki type III relaxation thyroplasty has shown promise in managing these patients. This surgical procedure lowered the pitch of voice in these patients by shortening the length of the vocal folds. In the classic Isshiki type III thyroplasty 2 – 3 mm of vertical strips of cartilage were excised on each side of midline of thyroid cartilage. This procedure caused retrusion of the middle portion of the thyroid cartilage causing a reduction in the length of the vocal folds.

Various modifications of Type III Ishikki thyroplasty have been proposed.


View the full article from here.

Anatomical changes that occur in ethmoid sinuses following FESS

Introduction:


The bony walls of paranasal sinuses demonstrate excellent degree of plasticity. This feature allows alterations in the size and dimensions of paranasal sinuses during growth phase. The process of pneumatization of paranasal sinuses begins in utero and continues through teenage years.

Causes of pathological expansile alterations of paranasal sinuses include:


1. Allergic fungal sinusitis
2. Extensive sinonasal polyposis
3. Mucocele formation
4 Benign tumors


While performing endoscopic sinus surgery it should be borne in mind that it is being performed in a setting of bony changes, with an intention to halt the expansile / contractile changes that are likely to take place.


View the full article from here.

Dysontogenic cysts of floor of mouth

Introduction:

Dysontogenic cysts are otherwise known as dermoid cysts. These cysts develop due to defective embryonic development. This cyst includes any cyst which are filled with sebum like material with evidence of presence of specialized skin derivatives.

Meyer's classification of Dysontogenic cysts of floor of mouth:

Meyer classified dysontogenic cysts of floor of mouth into 3 types, namely

Epidermoid

Dermoid

Teratoid

Epidermoid cyst: is usually lined with stratified squamous epithelium without adnexal structures.

Dermoid cyst: is lined with stratified squamous epithelium with the presence of adnexal structures. These adnexal structures include sebaceous cysts, hair follicles and sweat glands.

Teratoid cyst: Features of teratoid cysts include the presence of lining squamous epithelium, respiratory epithelium, dermal appendages and distinct mesodermal components.

Eventhough dysontogenic cysts can occur anywhere in the body, about 10% of them occur in the floor of the oral cavity. Congenital cysts occuring in the infancy have also been reported.

Clinical features:

These include:

1. Dysphagia
2. Dysphonia
3. Stridor

Pathophysiology:

These cysts can be congenital / acquired in nature.

Congenital cysts are derived from ectodermal differentiation of multipotential cells that could have been pinched off during the closure of the anterior neuropore. Commonly accepted theory explaining congenital cysts is that it is caused due to entrapment of midline ectodermal tissue during fusion of first and second branchial arches during the third week of gestation. Lateral dysontogenic cysts are said to arise from the first pharyngeal pouch or first branchial cleft.

Acquired dysontogenic cysts can be explaine by Baker's theory. According to Baker trauma is the commonest cause of acquired dysontogenic cysts. Trauma causes implantation of epithelial cells into deep tissues. These implanted tissues results in formation of cystic cavities filled with keratin.

Differential diagnosis:

These cysts should be differentiated from:

1. Ranula
2. Obstructed wharton's duct
3. Thyroglossal tract cyst
4. Branchial cleft cyst
5. Lymphatic malformation
6. Pleomorphic adenoma
7. Enlarged submental glands
8. Prominent submental fat mass

Investigations:

Ultrasound examination will help in differentiating cystic from solid lesions. It ofcourse has the advantage of being easily available, cost effective and rapidly performed investigation.

MRI: Provides excellent soft tissue detail. It helps in differentiating mass from surrounding soft tissues. T2 weighted images of dysontogenic cysts shows hyperintense areas due to high proteinaceous content.

Treatment:

Complete excision of the mass is the ideal treatment modality. Almost all dysontogenic cysts of floor of the mouth can be approached through intraoral approach. All submental cysts should be approached through the neck. A cyst that has breached the floor of mouth musculature should ideally be approached through the neck.

Inverted papilloma of nose and its management

Introduction: Inverted papilloma is a benign lesion occuring in the nasal cavity and paranasal sinuses. Eventhough these tumors are classified as benign they are known to cause local destruction, known to recur and also can under go malignant transformation to squamous cell carcinoma.

History: Ward in 1854 described the macroscopic features of papilloma of nose. He used the term papillomatous neoplasm to describe this lesion. Billroth in 1855 used the term villous carcinoma to describe inverted papilloma because of its propensity to destroy local tissues and recurrence after surgery. Hopmann in 1883 used the terms hard and soft papilloma to ascertain the stoma : epithelium ratio. This classification ofcourse was not useful because the number of epithelial layers varied within the various areas of the same specimen.
Ringertz in 1938 coined the term inverted papilloma after recognizing the characteristic endophytic growth pattern demonstrated by this type of papilloma. Kramer and Som in 1935 used the term genuine papilloma of the nasal cavity. Berendes in 1966 after taking congnizance of the destructive properties of this lesion used the term Malignant papilloma to indicate this mass. Hyams in 1971 classified nasal papillomas as inverted papilloma (to indicate papillomas with endophytic growth) and fungiform papilloma. He also included a third group cylinderical papilloma to accomodate the variantions seen in these papillomas. Batsakis in 1987 used the term inverted Schneiderian papilloma indicating its origin from the Schneiderian membrane (nasal mucosa). Michaels in 1996 regarded the three types of nasal papilloma as three completely distinct entities whereas Eggers in 2005 considered these three types of nasal papillomas as hybrid lesions.

Synonyms: As indicated above various synonyms have been used to indicate inverted papilloma of nose. They include:

1.Schneiderian papilloma
2.Inverted papilloma
3.Benign papilloma of nose
4.Cylindroma
5.Malignant papilloma of nose




Definition: The mucosal lining of nose and paranasal sinuses is known as Schneiderian membrane in memory of Victor conrod Schnider who described its histology. Papillomas arising from this membrane is very unique in that they are found to be growing inwards and hence the term inverted papilloma. These papillomas are unique in their history, biology and location. Papillomas involving the vestibule is not included in this group because histologically, biologically and behavior wise it is different.



You can download the e book by clicking at the image below.

 

Inverted papilloma nose

Rhinosporidiosis still an enigma

Introduction:

Rhinosporidiosis has been defined as a chronic granulomatous disease characterized by production of polyps and other manifestations of hyperplasia of nasal mucosa. The etiological agent is Rhinosporidium seeberi.

Theories of mode of spread:

1. Demellow's theory of direct transmission
2. Autoinoculation theory of Karunarathnae (responsible for satellite lesions)
3. Haematogenous spread - to distant sites
4. Lymphatic spread - causing lymphadenitis (rarity)
   
   
   
   
   
   
   Reasons for endemicity of Rhinosporidiosis:
   It has to be explained why this disease is endemic in certain parts of South India and in the dry zone of Srilanka. If stagnant water could be the reason then the chemical and physical characteristics of the water needs to be defined. In addition other aquatic organisms may also be playing an important synergistic reaction. This aspect need to be elucidated. Text book of microbilogy is repleate with examples of such synergism i.e. lactobacillus with trichomonas, and Wolbachia with filarial nematodes.
   
   
   
   
   
   These studies prompted Prof Ahluwallia et al to conclude that:
   
   
   
   1. Chronic inflammation almost always precedes rhinosporidiosis
   2. During this period if the patient consumes dry / fried tapioca and is malnourished it invariably leads to granulomatous polyp in the nose.
   3. Dirty pond water in which the patient takes bath causes inflammation of the nasal mucosa
      
      
      
      The following are the reasons making the study of this disease rather difficult:
      
      
      1. Till date no pure extract containing rhinosporidial trophozoite / spores / sporangium is available
      2. Attempts made to culture these organsim have not been successful
      3. The role of electron dense bodies in disease propagation is yet to be studied. Studies have shown that these electron dense bodies stain positively to Feulgen staining indicating that it contains nucleic acids
      4. The absence of good animal model for studying this disease is one major drawback.
         
         
         
         
         
         Rhinosporidiosis still an enigma
         
         
       
      
      
    
   
    
   
   

 

OSCE Notes in otolaryngology

What exactly is OSCE: Objective structured clinical & Practical examination.

This system of examination consists of 15 - 20 stations. A student appearing for the exam is expected to spend 4 - 5 minutes inside a station. These stations can be simultaneously run and hence about 15 - 20 students could be examined within 1 hour. The students are expected to complete the task within the station and fill it up in the response sheet provided.

These stations should be carefully planned so that the clinical acumen of the student can be comprehensively tested. All these stations should have observers armed with check lists to assess the student's performance. Some stations are called procedure stations where in the student is expected to perform an examination technique on the patient. These procedure stations should be so designed to test the examination skill of the student.

Testing protocol for procedure stations:

1. Does the student greet the patient on entering the cubicle ?
2. Does the student explain to the patient what he is going to do in simple terms ?
3. Does the student seek permission of the patient before examining him / her ?
4. Does the student provide a screen to maintain privacy of examination ?
This system of examination consists of 15 - 20 stations. A student appearing for the exam is expected to spend 4 - 5 minutes inside a station. These stations can be simultaneously run and hence about 15 - 20 students could be examined within 1 hour. The students are expected to complete the task within the station and fill it up in the response sheet provided.
These stations should be carefully planned so that the clinical acumen of the student can be comprehensively tested. All these stations should have observers armed with check lists to assess the student's performance. Some stations are called procedure stations where in the student is expected to perform an examination technique on the patient. These procedure stations should be so designed to test the examination skill of the student.

Testing protocol for procedure stations:

1. Does the student greet the patient on entering the cubicle ?
2. Does the student explain to the patient what he is going to do in simple terms ?
3. Does the student seek permission of the patient before examining him / her ?
4. Does the student provide a screen to maintain privacy of examination ?


I have released an e book titled "OSCE notes in Otolaryngology" to cater to the needs of students who need to be trained in this particular facet of clinical examination.  You can download it by clicking at the picture below.

Preauricular sinus and its management

Introduction:

This condition was first described by Van Heusinger in 1864. He also rightly postulated it to be congenital in nature. Most of these patients are symptomatic. Common symptoms include infections, cellulitis, and abscess formation infront of the pinna. Some of these patients may have recurrent infections leading on to embarassing discharge from the sinus. In most patients this condition is identified during routine examination involving ear, nose and throat.

You can view the e book from here.

Thyroid nodules Management dilemma

Introduction:
Thyroid nodule is a common occurrence. Majority of these nodules may be present without clinical evidence of thyroid disease. Statistics reveal that the incidence of palpable thyroid nodule is about 5%. Ultrasound neck is very sensitive in picking up thyroid nodules. Ultrasound can diagnose thyroid nodules even as small as ½ cm. Studies have shown that only 3-5% of thyroid nodules show malignant transformation.

Causes of thyroid nodules include:

Benign causes:

1.Goitre
2.Hashimoto's thyroiditis
3.Simple / hemorrhagic cysts
4.Follicular adenoma
5.Subacute thyroiditis

Malignant causes:

1.Papillary carcinoma
2.Follicular carcinoma
3.Hurthle cell carcinoma
4.Medullary carcinoma
5.Anaplastic carcinoma
6.Primary thyroid lymphoma
7.Metastatic malignant lesion

Tools of diagnosis as far as these thyroid nodules include:

1.Ultrasound neck
2.FNAC
3.Molecular / genetic marker analysis of fine needle aspiration biopsies

Image showing ultrasound of a benign looking thyroid nodule





You can download the full  e book from here.

Odiosoft rhino

Introduction:

Odiosoft rhino is an equipment used to measure the sound produced by nasal airflow. Measurement of nasal airflow sounds helps us to indirectly assess the presence / absence of nasal block as well as accurately identifying the site of the block. Normal nasal airflow in humans is neither laminar nor turbulent, but a mixture of both. Hence the term transitional is used to describe nasal airflow. Simple mathematical formulae cannot be used to study nasal air flow dynamics. At higer velocities of nasal airflow turbulence also increases. This turbulence creates sound which can be recorded by recording devices such as odisoft rhino.

Airflow within the nasal cavity is regulated by 4 valves:

1. External nasal valve
2. Internal nasal valve
3. Nasal turbiantes
4. Nasal septum

Role of Fourier analysis in the study of nasal airflow:

According to Fourier the French scientist any complicated wave form can be expressed as a series of two or more simple sine waves and cosine waves.

Sound generated by air passing through nasal cavity can be recorded by placing probes containing microphone in the anterior nasal cavity. These recorded sounds are subjected to fast fourier transformation using the software called Odisoft rhino.

The recorded frequency spectrum could be classified into:

1. Low frequency (500 – 1000Hz)
   
2. Medium frequency (1-2KHz)
   
3. High frequency (3-6 Khz)
   

Procedure:
Before emarking on recording nasal sounds, the following things should be ensured:

1. The patient should be completely relaxed
   
2. Crusts and mucous secretions from the nasal cavity should be removed
   
3. While testing the right nasal cavity the probe is held in the right hand and parallel to the right nasal cavity, while the left hand is used to close the left nasal cavity.
   
4. The probe should not be inserted into the nasal cavity and atleast 1 cm space should be there between the probe and the nares.
   
5. Recording usually starts during non forced expiration.
   
6. Recording should ideally be performed in quiet environment and acoustic artifacts like noise caused by rubbing of wires should be avoided.
   

Nasal sound analysis:



The frequency and amplitude of the recorded sounds should be taken into consideration. Nasal sound frequency and amplitude increases as the turbulence inside the nasal cavity increases. Nasal sound recordings in patients with deviated nasal septum have shown that the intensity of sound in lower and mid frequencies are not raised that much while the intensity of sound in high frequency was significanty elevated.
Obstruction in nasal valve area can be assessed by performing the Cottles Maneuver. Before cottle's maneuver the intensitey of sound in high frequency is elevated, while recordings performed during cottle's maneuver shows a reduction in the intensity of sound at high frequencies as the nasal air flow assumes a laminar pattern.



This whole system can also be used as a web based diagnostic service, where a patient can be asked to use the probe and the recorded sound is transmitted through internet to the diagnostic server where these sounds can be analysed and diagnosis can be made.

Nasal mucosal congestion index and how to measure it.

Introduction:

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.

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

Introduction:

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.


Procedure:
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.

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

Introduction:
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.
    
   
   
   
   
   
   
   
    
   
    
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   

 

Nasal stents are they really useful ?

Introduction:

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.

Torus palatinus excision

Introduction:

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


Synonyms: Exostosis of oral cavity, Buccal exostosis.


Definition:


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.


Etiology:


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


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.

Classification:

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

Shapes:

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.

Incision:

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.”