Velopharyngeal insufficiency and its management

Velopharyngeal insufficiency and its management

Blow out fracture orbit current management concepts

Lingual thyroid

Respiratory medicine for nurses and paramedics

Foundation otolaryngology for nurses

Lingual thyroid and its management

Orbital disorders

Eosinophilic otitis media a literature review

Abstract:

Eosinophilic otitis media is actually a recent introduction. These patients may manifest with sudden hearing loss. There may be associated bronchial asthma and allergic rhinitis. Diagnostic criteria of this condition are rather vague. A review of literature shows that demonstration of eosinophils in the middle ear secretion of these patients could be considered to be pathognomonic of this condition.

Introduction:

Eosinophils are considered to be effectors for allergic reactions. Eosinophilic otitis media ¹ is a newly recognised entity causing intractable middle ear pathology. This condition is characterised by excessive accumulation of eosinophils in the middle ear cavity and is associated with persistent middle ear effusion. These patients usually suffer from bronchial asthma. The first description of this condition should be credited to Koch ² who first reported some patients with middle ear effusion which contained lots of eosinophils. He also added that these secretions were highly viscous and the middle ear mucosa was pinkish in color. The term eosinophilic otitis media was coined by Tomioka et al ³ in 1993.

Pathophysiology:

Pathophysiology of this condition is obviously allergy. These patients commonly had associated allergic rhinitis and branchial asthma. Eosinophils could have been probably attracted to the middle ear cavity by the presence of IL 5 ⁴ inside the middle ear cavity.

Features of Eosinophilic otitis media ⁵:

1. Sudden deterioration of hearing
2. Bronchial asthma
3. Allergic rhinitis
4. Intractable otitis media
5. Persistent otorrhoea

Incidence:

Incidence of eosinophlic otitis media is not clearly known. Literature search puts it to be rather common cause of otitis media with effusion.

Managment:

Patients diagnosed with this condition should be warned of the possibility of sudden deterioration of hearing.

Administration of systemic / topical steroids ⁶ could be of benefit in these patients.

Antihistamines and leukotreine receptor antogonists can also be used with benefit.

Grommet insertion is indicated in patients with acute sudden hearing loss.

References:

1. Iino Y, Kakizaki K, Katano H, Saigusa H, Kanegasaki S. Eosinophil chemoattractant in middle ear patients with eosinophilic otitis media. Clin Exp Allergy 2005;35:1370–6.
2. Koch H. Allergical investigations of chronic otitis. Acta Otolaryngol 1947;62(Suppl.):1–201.
3. Tomioka S, Yuasa R, Iino Y. Intractable otitis media in cases with bronchial asthma. Recent advances in otitis media. In: Mogi G, HonjoI, Ishii T, Takasaka T, editors. Proceedings of the second extraordinary international symposium on recent advances in otitis media. Amsterdam, New York: Kugler Publications; 1993. p. 183–186.
4. NonakaM, Fukumoto A, Ozu C, Mokuno E, Baba S, pawankar R, et al. IL-5 and eotaxin levels in middle ear effusion and blood from asthmaticswith otitis media with effusion. Acta Otolaryngol 2003;123:383–7.
5. Suzuki H, Matsutani S, Kawase T, Iino Y, Kawauchi H, Gyo K, et al. Epidemiologic surveillance of ‘‘eosinophilic otitis media’’ in Japan. Otol Jpn 2004;14:112–7 (In Japanese).
6. Iino Y, Nagamine H, Kakizaki K, Komiya T, Katano H, Saruya S, et al. Effectiveness of instillation of triamcinolone acetonide into middle ear for eosinophilic otitis media associated with bronchial asthma. Ann Allergy Asthma Immunol 2006;97:761–6.

VOL 1, NO 1 (2011) ONLINE JOURNAL OF OTOLARYNGOLOGY ISSN 2250- 0359

First volume of Online journal of otolaryngology (JORL) is given here. VOL 1, NO 1 (2011) ONLINE JOURNAL OF OTOLARYNGOLOGY ISSN 2250- 0359

Online journal of otolaryngology (JORL) First issue

First issue of online journal of otolaryngology (JORL) is available.  This free to access and free to publish e journal will be published 4 times a year.  You can start submitting  your work to the next issue right now following author submission guidelines mentioned in the website.

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Maxillectomy a review

Maxillectomy a review

View more presentations from Balasubramanian Thiagarajan

Retrotympanic Recesses

Introduction:

The posterior wall of middle ear cavity (Tympanum) is also known as retrotympanum. Important anatomic structures are lodged in this area. This area has assumed significance because of the difficulties encountered in clearing cholesteatoma from this area. This area is so narrow and has lot of crevises, it is very difficult to clear disease from this area.

This area is supposed to contain 4 important recesses. Each of these four recesses could hide cholesteatoma causing the surgeon to leave residual disease which could later recur. Precise knowledge of anatomy of this region is vital for the surgeon who wants to clear disease from this area. The recesses present in the retrotympanic area are:

1. Sinus tympani
2. Lateral tympanic sinus
3. Posterior tympanic sinus
4. Facial recess

Pyramidal eminence is the most prominent anatomical landmark of this area. This eminence hold the pyramidalis muscle. There are other prominences arising from this area projecting in various directions. They include:

1. External: Chordal ridge
2. Inferior: Pyramidal ridge
3. Superior: Suprapyramidal ridge
4. Internal: Ponticulus

The 4 types of retrotympanic recesses are found under these eminences.

Sinus tympani:

This is the most common and constant depression present in the retrotympanic area. Anatomically this sinus is located at the junction of the lateral and posterior walls of the tympanic cavity. Phylogentically this recess is considered to ba analogue of bulla tympanica seen in mammals. It lies between ponticulus superiorly and subiculum inferiorly. This recess is bounded by pyramidal ridge externally and promontory internally. Visualization of this area during middle ear surgery proves to be a challenge. During yester years small angled mirrors known as zinne mirrors were used. Now angled telescopes serves this function rather brilliantly. The sinus tympani is known to extend posteriorly up to the round window niche.

Types of sinus tympani:

Sinus tympani has been classified into three types depending on its depth. Note in type III it extends up to the level of lateral semicircular canal.

Lateral tympanic sinus:

Proctor described this sinus in 1969. This sinus lies between three eminences of styloid prominence. These eminences include:

Pyramidal eminence

Styloid eminence

Chordal eminence

Posterior tympanic sinus:

Posterior sinus of middle ear cavity is one of the recently identified anatomical sinus inside the middle ear cavity.
Serial temporal bone dissections have shown that it is present in nearly 90% of dissected bones.

Position: It lies just posterior to the oval window.

Depth: 1mm or less
Width: 1.5 mm or less

In nearly 60% of dissected specimen a ridge of bone arising from the floor of middle ear cavity separates it from sinus tympani.

In 8% of dissected specimen, the sinus tympani and posterior sinus merged together to form one confluent sinus.

It has been demonstrated that cholesteatoma / granulation tissue may lie within this sinus making removal difficult leading on to residual disease.
Retraction pockets may also occur close to this area.

Facial recess:

This recess lies between the promontory and tympanic annulus. It is bounded medially by the facial nerve and laterally by tympanic annulus. Running between these two structures at varying angulations is the chorda tympani nerve. Chorda tympani nerve always runs medial to the ear drum. Drilling in this area between the facial nerve, annulus and the angle formed by the chorda tympani nerve will lead into the middle ear cavity without causing a breach in the ear drum. This approach is used in cochlear implant surgery to place the electrode in the round window area. Hypotympanum can also be approached through this approach.

Subiculum:

This is the posterior extension of promontory separating oval and round windows.

Ponticulus:

Rarely a spicule of bone arises from the promontory above the subiculum and runs to the pyramid on the posterior wall of the middle ear cavity. This spicule of bone is known as the ponticulus.

Submission of articles to online journal of otolaryngology

Introduction:

Online journal of otolaryngology has been started.  It is free to access and free to publish.  You can read / submit articles to this journal by going through a simple registration process which is free.  Articles submitted will be peer reviewed before publication.  Publication of selected articles is absolutely free.

Click on the image below to read a short tutorial on article submission to this journal.

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Effect of altered core body temperature on glottal closure force. Can it explain SIDS (Sudden Infant death syndrome?)

Introduction:

The important basic function of larynx is to provide sphincteric protection to the lower airway. This is achieved by adduction of vocal folds in response to stimulation from the internal division of superior laryngeal nerves. This mechanism is initiated by complex brain stem response which is polysynaptic in nature. This reflex is sensitive to variations in body core temperature. In febrile neonates, a hypersensitive glottal closure reflex have been known to cause sudden infant death syndrome.

Role of animal studies in verifying this hypothesis:

Haraguchi etal in their canine experiments demonstrated that hyperthemia enhances the glottal closure reflex by decreasing the latency of nerve stumulation thereby aumenting their conduction. In hypothermic conditions they also demonstrated depression of glottal closure reflex. The following are the inferences of this study:

1. When the core body temperature raises axonal body temperature also raises.
2. Conduction of sodium and potassium ions increase nearly 3 times with every 10 ° C increase in body temperature.
3. Temperature drop caused delay in the release of neurotransmitters at the neuronal junctions.

Velopharyngeal insufficiency and its management

velopharyngeal_insuff

Mandibular swing approach a step by step guide

Mandibular Swing

Grommet insertion Current conceptsIntroduction: Myringotomy with grommet insertion was introduced by Poltizer of Vienna in 1868. He used this procedure to manage “Otitis media catarrhalis”. Soon it became the common surgical procedure performed in children. Indications: Bluestone and Klein (2004) came out with revised indications for grommet insertion which took into consideration the prevailing antibiotic spectrum. 1. chronic otis media with effusion not responding to antibiotic medication and has persisted for more than 3 months when bilateral or 6 months when unilateral. 2. Recurrent acute otitis media especially when antibiotic prophylaxis fails. The minimum episode frequency should be 3/4 during previous 6 months / 4 or more attacks during previous year. 3. Recurrent episodes of otitis media with effusion in which duration of each episode does not meet the criteria given for chronic otitis media but the cumulative duration is considered to be excessive (6 episodes in the previous year) 4. Suppurative complication is present / suspected. It can be identified if myringotomy is performed. 5. Eustachean tube dysfunction even if the patient doesnt have middle ear effusion. Symptoms are usually fluctuating (dysequilibrium, tinnitus, vertigo, autophony and severe retraction pocket). 6. Otitis barotrauma inorder to prevent recurrent episodes. Problems with Grommet insertion: This procedure is not without its attendant problems. Common problems include: 1. Segmental atrophy of tympanic membrane 2. Tympanosclerosis 3. Persistent perforation sydrome (rare) Before treating patients with otitis media with effusion the following factors should be borne in mind. Pneumatic otoscopy should be used to differentiate otitis media with effusion from acute otitis media. Duration of symptoms should be carefully documented. Children with risk for learning / speech problems should be carefully identified. Hearing should be evaluated in all children who have persistent effusion for more than 3 months. Grommet insertion can be performed under local anesthesia. Incision is made in the antero inferior quadrant of ear drum. The incision is given along the direction of radial fibers of the middle layer of ear drum. This causes minimal damage to the radial fibers. It also enables these fibers to hug the grommet in position.

Introduction:

Myringotomy with grommet insertion was introduced by Poltizer of Vienna in 1868. He used this procedure to manage “Otitis media catarrhalis”. Soon it became the common surgical procedure performed in children.

Indications:

Bluestone and Klein (2004) came out with revised indications for grommet insertion which took into consideration the prevailing antibiotic spectrum.

1. chronic otis media with effusion not responding to antibiotic medication and has persisted for more than 3 months when bilateral or 6 months when unilateral.
2. Recurrent acute otitis media especially when antibiotic prophylaxis fails. The minimum episode frequency should be 3/4 during previous 6 months / 4 or more attacks during previous year.
3. Recurrent episodes of otitis media with effusion in which duration of each episode does not meet the criteria given for chronic otitis media but the cumulative duration is considered to be excessive (6 episodes in the previous year)
4. Suppurative complication is present / suspected. It can be identified if myringotomy is performed.
5. Eustachean tube dysfunction even if the patient doesnt have middle ear effusion. Symptoms are usually fluctuating (dysequilibrium, tinnitus, vertigo, autophony and severe retraction pocket).
6. Otitis barotrauma inorder to prevent recurrent episodes.

Problems with Grommet insertion:

This procedure is not without its attendant problems. Common problems include:

1. Segmental atrophy of tympanic membrane
2. Tympanosclerosis
3. Persistent perforation sydrome (rare)
   Before treating patients with otitis media with effusion the following factors should be borne in mind.

Pneumatic otoscopy should be used to differentiate otitis media with effusion from acute otitis media.

Duration of symptoms should be carefully documented.

Children with risk for learning / speech problems should be carefully identified.

Hearing should be evaluated in all children who have persistent effusion for more than 3 months.

Grommet insertion can be performed under local anesthesia.

Incision is made in the antero inferior quadrant of ear drum. The incision is given along the direction of radial fibers of the middle layer of ear drum. This causes minimal damage to the radial fibers. It also enables these fibers to hug the grommet in position.

Management of vestibular schwannomas current trends

Introduction:

Management of vestibular schwannomas has undergone lots of changes during the past decade.  Review of published literature exemplifies this fact.  Various currently available management modalities to treat this condition are:

1      Observation

2     Stereotactic radiosurgery

3     Microsurgery

Among these three modalities stereotactic radiosurgery is evincing keen interest because of the precision of the procedure and lesser incidence of side effects.  Advances in imaging technology have enabled early diagnosis of these lesions.  About a decade back the sensitivity of imaging techniques used to identify lesions measuring 30 mm.  Recent imaging modalities are accurate enough to identify even lesions measuring less than 10 mm.  A stage has reached when surgeons are managing more intracanalicular lesions than ever before.

The current management modality of these tumors focusses on:

Preservation of hearing

Preservation of facial nerve functions.

Observation / Watchful waiting:  This modality is preferred in managing patients with small asymptomatic / minimally symptomatic intracanalicular tumors.  Since tumor doubling time of these lesions is prolonged (1-2 mm / year) this method warrants a trial.  Advantages of this method are preservation of hearing and facial nerve function in these patients.  Studies have also revealed that growth rates between intracanalicular and extracanalicular tumors are not significantly different.  It is ideal to perform imaging at least twice a year within the first year of diagnosis and once a year from there on.

Positive features that could warrant this management modality include:

1      Excellent speech discrimination scores

2     Growth rate of less than 2.5 mm / year

Microscopic surgery:

This is indicated for small intracanalicular lesions with vestibular symptoms.  Amount of tumor growth also is one important factor that could force the hands of a surgeon.  Growth rate of more than 3mm / year is an indication for surgical intervention.  Hearing can be conserved by using retrosigmoid / middle cranial fossa approach.

Stereotactic radiosurgery:

This is indicated in residual lesions after microscopic excision or rapidly enlarging canalicular lesions.  Advantages of radiosurgery include:

1      Hearing preservation

2    Conservation of facial nerve function

Susac syndrome

Introduction:

Susac syndrome was first described by Susac etal in 1979. This syndrome is characterised by rapidly progressing encephalopathy, blindness and hearing loss.

Pathophysiology:

This is actually an endotheliopathy affecting precapillary arterioles. This endotheliopathy could probably be immune mediated. This causes rapid tissue infarction which leads to these problems.

Women are commonly affected than men. Typical vulnerable age group is between 20 – 40.

Clinical features:

1. Severe head ache
2. Rapid dementia
3. Micro infarcts seen in corpus callosum demonstrable in MRI scans
4. Photopsia and black spots due to retinal artery occlusion
5. Scintillating scotoma
6. Rapidly progressive sensori neural hearing loss on both sides
7. Vertigo
8. Nystagmus

Management:

High dose steroid therapy is the main treatment modality.

Intravenous administration of immunoglobulin.

Cyclophosphamide administration.

Rituximab is the currently used drug in the management. This is a monclonal antibody against CD20 protein. This receptor protein is found on the surface of B lymphocytes.

Recent management concepts in the management of Atrophic rhinitis and empty nose syndrome

Introduction:

The presence of normal sized nasal turbinates covered by normal moist mucosa is vital for the normal function of the nose.  It should also be remembered that the receptors for initiating nasobronchial / nasal cardiac reflexes are found embedded in the mucosal lining of the nasal turbinates.  Surgical augmentation of atrophied turbinates and nasal mucosa will help in the restoration of nasal function and regeneration of nasal mucosa.  Usually various types of implant materials are considered for this purpose.

Commonly used implant materials:

1. Bone
2. Cartilage
3. skin
4. Fat
5. Plastic
6. Calcium hydroxyapatite


Role of Hyaluronic acid as an implant:

Hyaluronic acid is a naturally found polysaccharide consisting of a linear chain of fragments of D-glucoronic acid and N-acetlyglucosamine that alternate in the structure.  In its pure form it is not an allerge and does not stimulate immunogenic rejection process.  In view of its negative struture it absorbs large quantities of water.  On absorption of water hyaluronic acid forms a gel like structure.  It is extensively being used in plastic and reconstructive surgical procedures.  Its important unique property is that it maintains its liquid form when it is under pressure, the moment the pressure reduces it solidifies.  Hence it can be injected through a small needle.    It has another important property i.e. Isovolumetric degradation, which indicates single molecules of this substance undergoes periodic degradation while the remaining molecules absorb large amounts of water thereby enabling it to maintain its volume.  The overall volume of the gel maintains a constancy.



Hyaluronic acid can be injected submucosally thereby enlarging the size of the turbinates.  It can also be injected under the septal mucosa.  This not only cause narrowing of the nasal cavity but also promotes regeneration of nasal mucosal lining.  If a cannula is used to inject hyaluronic acid instead of needle it causes less mucosal trauma thereby minimizing the risk of accidental intravascular injection.  It would be better if the quantity of hyaluronic acid injected is the same on both sides.  Studies conducted by Marek Modrzynski, M.D.
 showed promising results.