Adenoids & tonsils are lymphoid tissue in the throat which have a protective role & act as a sentinal. Surgery is done in cases of recurrent episodes of tonsillar / adenoid infection when
- it is the focus of infection
- tonsillar / adenoid enlargement cause difficulty in eating or breathing or
- snoring or altered speech is present. It is a day care surgery done under general anaesthesia.
Conventional method causes less post operative pain & discomfort versus laser method
There are 4 pairs of sinuses ie air cavities in the facial bones to impart resonance to our voice. These get infected and the inflammation is called sinusitis.
- Chronic headache sometimes associated with pain on eye movements.
- Repeated attacks of cold
- Uncomfortable feel of phlegm running down the throat
- Clearing the throat – hawking sensation
- These indicate that your sinuses are affected.
Sinusitis requires surgical treatment if :
- Patients do not respond to oral medications
- Infection is prolonged causing irreversible changes
- Basic cause of sinusitis is a mechanical obstruction like septal deflection
- Presence of polyp, cyst, mucocoele or
- Fungal infection
Patient is first subjected to Diagnostic Nasal Endoscopy (DNE) which is done as an OP procedure. This is followed by CT scan of the sinuses if necessary.
Earlier, antral puncture used to be done through an artificial opening. The ciliary beat cannot drain the secretions of the sinuses by this method. Moreover any additional obstruction present at the opening of the sinuses was not tackled. Even repeated attempts never brought relief. This is now replaced by the currently popular FESS, a boon to the patient.
Surgery is done under general / local anaesthesia as a day care procedure. Can walk back home the same evening. Done endoscopically with the most sophisticated equipments & instruments. The natural opening of all sinuses are identified & widened & complete disease clearance assured. One day nasal packing is done. Nasal obstruction is expected in the first 3-4 days Post operative suction clearance done 1 week after the surgery relieves any residual nasal block.
Reluctance of patients to opt for surgery can lead to superadded fungal infection which is often a recurring problem.
The repair of ear drum is called myringoplasty. Ear drum can be perforated due to trauma or infection. A non discharging ear is ideal for repair. Patient may present with hard of hearing or buzzing sound within ear . Pre operatively audiogram is done. Surgery is done with the endoscope through the ear canal.
No external scars except for a 3cm incision within the hairline. No post operative swelling as in conventional method. It is a day care surgery done under local anaesthesia Suture is removed after 1 week.
Endoscopic mastoidectomy & tympanoplasty:
- cases of chronically discharging ear with hearing loss
- cases of unsafe ear ( cholesteatoma) or
- when bones in the middle ear are eroded or absent
Patient is subjected to general ENT examination with preoperative audiogram to assess the degree & type of hearing loss. Surgery is done using nasal endoscope. Complete disease clearance achieved due to clarity of field & end on view. Endoscopic view is right on the target. All hidden areas which escape are picked out using angled endoscopes. Burring is done if required. No postoperative hollow cavity in the ear bone as in conventional microscopic method. Adequate drainage is assured to avoid any recurrence. Post operative edema is ruled out as there is no retraction. Any deficiency in ossicular chain is managed by reinserting the re -shapened ossicles or using cartilage graft from pinna [part of outer ear] Hearing improvement & disease clearance is achieved with minimal post operative discomfort.
It is done in cases of oto sclerosis a disease where one of the middle ear bones (stapes) get fixed & impede the normal sound conduction. Patient present with hearing loss or tinnitus. A thorough clinical examination along with pure tone audiogram & Impedence audiometry clinches the diagnosis. It is totally rectifiable surgically with the patient having normal hearing post operatively. Endoscopic method offers a magnified & close up view for accurate placement of stapes piston. This is also a day care surgery. Patient is advised strict bed rest for one week for permanent benefit.
Endoscopic Grommet Insertion:
A bobbin like material is inserted into the ear drum.
It is done:
- When fluid is present in middle ear.
- Due to acute middle ear infection
- In cases of ear drum adhesion with decreased middle ear space.
It is done in theatre under local anaesthesia & patient can walk out within 15 minutes of the procedure. Endoscopic insertion of grommet keeps the vital middle ear structures uninjured.
Endoscopic Removal of Tumors of Sinuses
Tumors of sinuses are treated as per its type & stage. Tumors extending into the cheek, skin or extensive intracranial extension have to be managed with external approach requiring an incision on the face. Others are dealt endoscopically with complete removal of tumor & its extensions. Endoscopic removal of tumor is precise & often saves the eyeball from being removed totally as endoscopically offered magnified view helps us remove the tumor alone. All these cases may require post operative chemotherapy or radiotherapy or both. The quality of life of the patient is better. The results and life expectancy are the same when compared with open methods.
Micro Laryngeal Examination/ Excision
This is the method of choice in cases of diseases of voice box & upper airway problems. Vocal nodule is a condition presenting with hoarse voice particularly in teachers, singers, call center workers or rather in people with voice exploitation. Voice abuse strains the vocal cords & in the long run, patient develop nodules that does not respond to voice rest, thereby threatening their career. Under general anesthesia, a tube is inserted into the throat. Endoscope is insinuated into it & the extra tissue alone is precisely removed. Speech therapy is required following this & patient regains her/his normal voice. The same procedure holds good for early cancers of the larynx. These patients may require post operative radiotherapy. The quality of life is excellent compared to open techniques requiring tracheotomy (artificial hole in the neck).
Parotid is one of the 3 pairs of salivary glands. They are present on either side of the cheek in front of both ears. Removal of parotid is required in benign tumors which may be potentially malignant as well as for malignant tumors affecting the parotid gland. Rarely stones may form & block the parotid duct causing its infection, swelling & increase in size on eating. Parotid gland is very much in relation to the facial nerve. Microsurgery helps in better identification of the facial nerve. Hence trauma to the this vital nerve is minimized.
Elongated Styloid Process:
It can cause neuralgic pain in the throat particularly on one side while the patient swallows. Pain can radiate to the same side of the ear. This can be diagnosed clinically & confirmed by a CT scan. This condition can be treated surgically through an intra oral [ through the mouth ]approach after doing a tonsillectomy. The elongated portion of the styloid process is visualized fully up to base of the skull & removed easily without much problem.
Endoscopic Management of Allergic Fungal Rhinosinusitis [ AFRS ] :
Allergic rhinitis if not treated properly can turn into fungal infection involving the sinuses.
The symptoms are:
- Nasal block
- Reduced sensation of smell
- Eye ball pain
- Protrusion of eye ball when it invades the orbit
- Loss of vision when it compresses the optic nerve
- Neurological symptoms like severe headache when there is intra cranial spread, though this is rare.
AFRS can be treated nowadays successfully with the help of the endoscopic sinus surgery & by the latest addition, namely the micro debrider. It can give complete clearance. Some of the cases have to be followed up with newer anti-fungal medications.
Endoscopic Management of Invasive Fungal Sinusitis:
In immunocompromised individuals with diabetes or on immunosuppressants for renal transplant, this condition may develop. This is a very morbid condition, The mortality is also very high. Though medical treatment is the main stay, we have to endoscopically debride the disease for confirmation of diagnosis as well as to facilitate drainage to a certain extent. Gone are the days of opening of the skull[ craniotomy] and removal of the eyeball [exenteration]
Endoscopic Removal of Parapharyngeal Tumors:
The parapharynegeal space is present in the neck. Tumors within it may present with swelling in oral cavity pushing the tonsils inwards. If the cranial nerves get affected, neuralgic pain is evident. Patients may also present with nerve paralysis. They can also present as swelling in neck. Earlier, these cases were operated by opening the neck.
Currently, endoscopic method saves the patient from all post operative inconveniences with entire tumor removal.
Endoscopic Submandibular Gland Excision:
This gland is a salivary gland notorious for stone formation. Stones in the gland or any tumor of the gland necessitates removal of the total gland. It is done by making an incision in the neck along the skin crease.
In cases of cancer of larynx with extensive spread removal of larynx is required. Part of the airway along with voice box, needs to be removed. The extent of surgery is decided by the degree of tumor spread. So, laryngectomy can be total, subtotal or even laryngeal conservation surgeries. A preliminary tracheostomy is done followed by surgery. Artificial speech prosthesis & special training will help them communicate. This is an extensive surgery requiring good post operative rehabilitation.
Thyroid gland enlarges due to hormonal changes or tumors may arise out of it. Depending on the increased or decresed activity of the gland, patient may present with palpitation, anxiety, increased pulse rate, heat intolerance, loss of weight despite good appetite and intake or with weight gain, coarse skin, dull feeling or lethargy, sleepiness, swelling of feet, cold intolerance and increased menstrual flow. When the hormonal activity is normal the patient may present with just swelling in neck or difficulty in swallowing. The gland is removed by making a skin crease incision giving very good cosmesis. Depending on the involvement of the gland, it is removed fully or partially once the hormone levels are brought to normal.
Endoscopic JNA Removal:
Juvenile nasopharyngeal angiofibroma is a tumour occurring in young males. Patients present with spontaneous bleeding through the nose. In earlier days, it was a terror for surgeons as JNA is notorious for torrential bleeding. Now, with the advances in radio imaging, the exact extent is studied & surgery is planned accordingly. With the advent of endoscope, this surgery is simplified in skilled hands without disfiguring the patient. Blood loss & recurrence have come down a lot with this approach.