Interesting case of fibroma sphenoid sinus

Clinical details:

18 years old boy came with c/o blocking sensation both nasal cavity - 1 year duration

Decreased sensation of smell - 6 months duration

He gave h/o repeated attacks of upper respiratory infection

He gave no h/o bleeding from nose

No h/o head ache

On examination:

Anterior rhinoscopy:

A pale mass could be seen occupying the posterior portion of right nasal cavity.

Post nasal examination:

The same mass could be seen occupying the nasopharynx occluding both choana.

CT scan nose and paranasal sinuses plain / contrast were taken.

It showed non enhancing mass arising from sphenoid sinus entering the post nasal space and the posterior portion of right nasal cavity.

Management:

This patient was taken up for endoscopic sinus surgery and the mass was removed completely in toto.

Histopathology report - fibroma

Fibroma involving sphenoid sinus and post nasal space are commonly vascular (angiofibroma). In this case the fibrous elements

predominated and hence the mass was not enhancing in contrast CT. There was no abnormal bleeding during surgery.

The Tamilnadu Dr MGR Medical University MS (ENT) Basic sciences march 2009 question paper with solution

In my continuing effort to help out post graduate students of otolaryngology I have uploaded the MS (ENT) Basic sciences question paper with solutions of Tamilnadu Dr MGR Medical university.

Basic sciences post graduate question papers have always been dicey.  Unless you prepare diligently for the same you may encounter pit falls.  The whole question paper has been broken down into sub topics i.e. anatomy, physiology, pathology and biochemistry.  Since each of these sections will be evaluated by different examiners belonging to basic sciences department you need to concentrate equally on all these sections.

You can access the question paper with solutions from here.

Lingual thyroid and its management

Clinical details:

6 years old female patient came with complaints of:

1. Difficulty in swallowing - 6 months

2. Occasional episodes of bleeding from mouth - 2 months

On examination:

Oral cavity: Pinkish globular mass could be seen in the posterior 1/3 of tongue. The mass was firm on palpation. The posterior border of the mass was not visible on oral examination.

Both tonsils were found to be enlarged grade III.

Radiology:

X ray soft tissue neck lateral view:

X ray soft tissue neck lateral view showing mass in the suprahyoid region occupying posterior 1/3 of tongue.

Axial CT scan of neck showing mass involving the posterior 1/3 of tongue.

Contrast CT axial view showing absent thyroid gland in the neck

Ultrasound neck: Absent thyroid gland in the neck

Thyroid profile:

Pt was euthyroid with normal serum T3 T4 and TSH levels

Management:

Patient was taken up for surgery.

supra hyoid midline approach was preferred.

Skin crease incision is made just below the hyoid bone in the neck.

Skin flap elevated in the subplatysmal plane. Hyoid bone was exposed.

Supra hyoid muscles were resected from the superior border of hyoid bone

Mylohyoid muscle fibers are resected and retracted. Lingual thyroid mass removed in toto and the wound closed in layers.

Discussion:

Lingual thyroid is a rare embryonic aberration with an incidence rate of 1 in 100,000 individuals.

This condition is invariably due to failure of descent of thyroid gland. Parathyroid glands in these patients will

be found in the neck in their normal positions because of their separate origin embryologically.

Symptoms are invariably caused due to the mass effect of the lesion. It has also been pointed out that these

ectopic thyroid gland may not be in a position to cater to the increasing demands of thyroxine during menarche / pregnancy and

may undergo enlargement causing increasing symptoms. Incidence of malignancy is also more in ectopic thyroid glands hence

it is always better to resect the gland and place the patient under supplemental thyroid hormones.

Surgical approaches:

1. Removal via the oral cavity: This is the commonly practiced approach. This approach has the advantage of avoiding neck incisions.

The mouth of the patient is kept open by using Boyle's Davis mouth gag. Using either diathermy / laser / cobalator the dissection is

started from the anterior border of the mass and it is removed totally by encircling incision. Bleeders if any can be cauterized using

a bipolar cautery. This approach is advisable if the posterior border of the lesion is visible on opening the mouth.

2. Suprahyoid midline approach: This is another commonly used approach which has been described already. This lesion is useful

in patients with large lingual thyroid mass.

3. Lateral pharyngotomy approach: This approach is useful in removing big mass with a predominant vascular supply from the lingual

artery. This approach will also facilitate repositioning of ectopic thyroid mass in the neck.

4. Midline mandible and tongue splitting approach: Useful in adults with a huge lingual thyroid mass. The mandible is slit in the midline

by performing a midline osteotomy. The tongue is slit right in the middle till the foramen cecum portion is reached. The lingual

thyroid mass is removed in an encircling manner.

Fibrous dysplasia posterior ethmoid with blindness

Complaints:

48 years old male patient came with complaints of loss of vision left eye - 6 months duration.
Persistent left nasal block - 4 years
Discharge from left nose - 4 years
Head ache more on the left side - 5 years (Deep boring in nature)

Past history:

No history of epistaxis
No history of loss of smell

On examination:

Anterior rhinoscopy was unremarkable.
Post nasal examination normal.
Vision was absent in the left eye.

Imaging:

 

 

 

 

 

  

 

CT scan plain axial cut paranasal sinuses show heterodense mass arising from left posterior ethmoid air cells extending up to the anterior face of sphenoid. The mass could be seen compressing the left optic nerve. Diagnosis (Fibrous dysplasia)

 

MRI showing mass arising from posterior ethmoidal air cells on the left side compressing the left optic nerve.

 

Management:

This patient was taken up for endoscopic surgery. The mass from the left side of the nasal cavity was progressively drilled out under endoscopic vision.

Discussion:

The term fibrous dysplasia was first introduced by Litchtenstein in 1938. Usually fibrous dysplasias affect children commonly
in their teens (during the growth phase).
In any fibrous dysplasia involving the nasal cavity and paranasal sinuses the clinical presentation
is initially related to sinus obstruction, visual disturbance, facial asymmetry and nasal blockage.
In fibrous dysplasia the normal woven bone is replaced by isomorphous fibrous tissue and poorly
formed woven bone.

Classification:

Fibrous dysplasias have been classified into:
Monostotic - Involves single bone
Polyostotic - Involves multiple bones
Albright's syndrome - Endocrine hyperfunction, Unilateral Café-au-lait spots, and polyostotic fibrous dysplasia

Among these types the monostotic fibrous dysplasia is more common accounting for 70% of all fibrous dysplasias.

Rarely fibrous dysplasia may become more aggressive and dedifferentiate causing (desmoplastic fibroma). Sometimes the tissue may undergo sarcomatous transformation.

Excision of these mases makes sense because of their propensity to undergo malignant transformation.

Risk factors for malignant transformation include:
1. Polyostotic form
2. Post radiation sequelae
3. Facial bone involvement
4. Albright's syndrome

 

 

Fibrous dysplasia posterior ethmoid with blindness

This is an interesting case report of a patient with fibrous dysplasia of posterior ethmoid with blindness.

Complaints:

48 years old male patient came with complaints of loss of vision left eye - 6 months duration.
Persistent left nasal block - 4 years
Discharge from left nose - 4 years
Head ache more on the left side - 5 years (Deep boring in nature)

Past history:

No history of epistaxis
No history of loss of smell

On examination:

Anterior rhinoscopy was unremarkable.
Post nasal examination normal.
Vision was absent in the left eye.

Imaging:

 

 

<>












CT scan plain axial cut paranasal sinuses show heterodense mass arising from left posterior ethmoid air cells extending up to the anterior face of sphenoid. The mass could be seen compressing the left optic nerve. Diagnosis (Fibrous dysplasia).

MRI showing mass arising from posterior ethmoidal air cells on the left side compressing the left optic nerve.

Management:
This patient was taken up for endoscopic surgery. The mass from the left side of the nasal cavitywas progressively drilled out under endoscopic vision.

Discussion:

The term fibrous dysplasia was first introduced by Litchtenstein in 1938. Usually fibrous dysplasias affect children commonly
in their teens (during the growth phase).
In any fibrous dysplasia involving the nasal cavity and paranasal sinuses the clinical presentation
is initially related to sinus obstruction, visual disturbance, facial asymmetry and nasal blockage.
In fibrous dysplasia the normal woven bone is replaced by isomorphous fibrous tissue and poorly
formed woven bone.

Classification:

Fibrous dysplasias have been classified into:
Monostotic - Involves single bone
Polyostotic - Involves multiple bones
Albright's syndrome - Endocrine hyperfunction, Unilateral Café-au-lait spots, and polyostotic fibrous dysplasia
Among these types the monostotic fibrous dysplasia is more common accounting for 70% of all fibrous dysplasias.
Rarely fibrous dysplasia may become more aggressive and dedifferentiate causing (desmoplastic fibroma). Sometimes the tissue may undergo sarcomatous transformation.
Excision of these mases makes sense because of their propensity to undergo malignant transformation.
Risk factors for malignant transformation include:
1. Polyostotic form
2. Post radiation sequelae
3. Facial bone involvement
4. Albright's syndrome

The Tamilnadu Dr MGR Medical University MBBS Prefinal Otolaryngology March 2010 question paper with solution

The Tamilnadu Dr MGR Medical University MBBS Prefinal Otolaryngology March 2010 question paper with solution has been uploaded.

Get it from here.

Interesting case report of invasive mucor mycosis causing palatal destruction

Clinical details:
38 years old female
Diabetic on poor glycemic control
Complaints:

Ulcerative lesion of right side of hard palate - 2 years
Devitalization of upper premolars - 6 months
On examination:

Nasal cavity - Whitish mass seen inside the right nasal cavity. The mass was insensitive to touch and cheesy.
Floor of right nasal cavity found to be eroded.

Oral cavity - Slough covered lesion seen in the right side of hard palate. On probing there was no bone palpable
through the slough.

Investigations:
Biopsy from the lesion was reported as mucormycosis.
These fungi can be seen as large number of aseptate ribbon like hyphae with right / obtuse angle branching in necrotic tissue.

Imaging:

Ct scan showing heterodense mass occupying the right maxillary sinus with destruction of its medial wall.
The mass could be seen extending to the right nasal cavity with destruction of the floor of right nasal cavity.

Discussion:

Synonyms include - zygomycosis / phycomycosis
Two main types of mucor mycosis infections occur in humans. They are superficial and visceral.
Superficial mucormycosis involves external ear, fingers and skin commonly.
The visceral form could be Gastrointestinal, rhinocerebral, pulmonary or disseminated.
Visceral forms of mucor infections are common in diabetics and immune compromised individuals.
Among these visceral types the rhinocerebral type is the most common. This is due to the fact that the
nasal mucosa is normally colonized by mucor. Rhinocerebral mucor mycosis can be subclassified into two types.
They include:
Type I - Rhino orbito cerebral. This form is highly fatal
Type II - Rhinomaxillary form. This form is not fatal. This case belongs to type II category.
Mucor infections has a strong prediliction to involve blood vessels, nerves and lymphatics. Invasion of arteries causes
avascular necrosis of the infected area.
Mucor is known to thrive in acidic and glucose rich medium, which is common in a diabetic. Hyperglycemia also impairs
neutrophil chemotaxis thereby reducing immunity.
In addition increased availability of micronutrients like iron in diabetics increase the pathogenecity of the organism.

Management:

Is by wound debridment.
Control of diabetes.
Administration of amphoteracin B.

Tamilnadu Dr MGR Medical Univeristy MBBS Prefinal otolaryngology september 2010 question paper with solution has been upped

The Tamilnadu Dr MGR Medical University Prefinal MBBS otolaryngology September 2010 question paper with solution has been released. Access it from here.

drtbalu's otolaryngology resources: Laryngomalacia

drtbalu's otolaryngology resources: Laryngomalacia: "Introduction: The term Malakia in Greek means softening. The term indicates softening of larynx. This is a disease of infants and children..."

Laryngomalacia

Introduction:

The term Malakia in Greek means softening. The term indicates softening of larynx.
This is a disease of infants and children. This disease is characterised by the presence of stridor which is caused due to excessive redundancy of supraglottic tissues which gets sucked into the glottis due to the negative pressure caused during inspiration. The stridor in these patients are inspiratory in nature.

Age of onset:
This condition gets manifested within first two weeks after birth and usually resolves when the child reaches the age of 2.

Pathophysiology:

1.Excessive redundancy of supraglottic soft tissues
2.Immaturity of neuromuscular system
3.Immaturity of cartilages of larynx
4.GERD
5.Submucosal gland hyperplasia

Possible mechanisms causing stridor in these patients include:

1.Indrawing of cuneiform cartilages on inspiration
2.Omega shaped epiglottis of infants curls upon itself
3.The arytenoids collapse inwards
4.The epiglottis gets displaced against the posterior pharyngeal wall
5.Short aryepiglottic folds
6.Overtly acute angle of epiglottis at the laryngeal inlet

Get the full article from here.

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.

Read the full article from here

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.

Carotid blow out syndrome

This is an extremely high risk condition associated with significant degrees of morbidity and mortality. This condition commonly results from invasion and destruction of cervical carotid vasculature from head and neck squamous cell carcinomas. Prompt diagnosis of this condition and active intervention will help in saving lives of these patients.


Causes of carotid blow out syndrome:


1.Aneurysms
2.Infections – cause vasovasorum thrombosis leading on to necrosis of carotid walls.
3.Secondary carcinomatous deposits in cervical lymph nodes
4 Following irradiation for secondary carcinomatous deposits in the neck – Free radicals caused during irradiation causes thrombosis of vasovasorum leading on to breakdown of carotid artery wall. Patients develop fibrosis and thinning of the cartotid arterial wall leading on to blow out.


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Avoiding pitfalls in endoscopic skull base surgery

Introduction:

The advantages of endoscopic approach to skull base are many. They include:

1. It is the most direct route to anterior skull base. This approach provides access to the following areas Sella, Cribriform plate, Planum sphenoidale, suprasellar cistern, Clivus, Pterygopalatine fossa and adjacent parasellar areas.
2. In this approach there is decreased retraction of brain and cranial nerves when compared to that of conventional neurosurgical apporaches.
3. Endoscope offers excellent visualization of the tumor and the surrounding neurovascular structures
4. Post operative recovery time is short when compared to that of conventional neurosurgical approaches
   

As with any other procedure this method also has its flip side, which includes a steep learning curve, and need to collaborate with neurosurgeon. A cohesive collaboration with neurosurgeon is a must for successful endoscopic skull base surgical procedures.The complicated anatomy of skull base has managed to bridge these two specialities. In a nut shell an otolaryngologist navigates the pathway to the intracranial lesion while the neurosurgeon removes the tumor.

Dangers of endoscopic skull base surgery:

Since the skull base has many vital structures it should be performed with the highest degree of deligence and skill. The potential complications of any endoscopic skull base surgery include:

1. CSF rhinorrhoea
2. Injury to great vessels (internal carotid artery and its branches inside the skull)
3. Injury to optic nerve
4. Injury to other cranial nerves
   
5. Bleeding from cavernous sinus
6. Meningitis
   
   
   
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Gradenigo's syndrome E module

In continuation with my effort in creating learning modules I have come out with a module titled "Gradenigo's syndrome".

Nasal topical therapeutics

Intranasal drug delivery systems for the management of local and systemic
ailments have caught up recently. Initially this route of drug administration
was attempted for the management of allergic rhinosinusitis. Now inflammatory sinusitis is also managed by intranasally administered drugs. The reasons for interest in this route of drug administration because of its high vascularity, porous endothelial basement membrane and a high total blood flow per volume of tissue. Since first pass metabolism is avoided in this drug delivery method the drug is metabolized slowly thus helping in reducing the dosage of the drug. This also goes a long way in reducing the potential toxicity of the administered drug even if it has a very low therapeutic index. The complex nasal anatomy and the varying dynamics of nasal air flow make this drug delivery modality a little bit unpredictable. This is more so especially in patients with nasal cold which is associated with congestion of nasal mucosa and turbinates.







You can read the complete e book by clicking  the link below:

http://www.drtbalu.co.in/nasal_thera.html

Unique e module on chronic tonsillitis by drtbalu

I have given a unique e learning module on chronic tonsillitis.

This will be very useful for exam going students of otolaryngology.

You can expect more such modules in future:

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.


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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.



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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.