|
INTRODUCTION |
Otolaryngology
has advanced in a dramatic and rapid manner in the last decade. The
advent of the operating microscope has facilitated the refinement of
microsurgical techniques.
A new era was started by functional endoscopic sinus surgery, skull
base surgery, and phonological surgery. The surgical advances proceeded
hand in hand alongwith diagnostic audiovestibular and radiological investigations. |
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DIAGNOSTIC
ADVANCES |
Laryngeal
photography : Photographic documentation has become more and more
important in the upper respiratory tract. Documentation is necessary
for recording
| • |
Natural
history of the illness. |
| • |
Effect
of treatment on the disease. |
| • |
Medicolegal purposes. |
The modern method of photography is done with a 35 mm single frame,
single lens reflex camera with Hopkins telescopes fibreglass light conducting
cable provides continuous light for visualisation.1,2
Otoscopic photography : This is required to record the status
of the eardrum and the middle ear contents, binocular microscope makes
it easier for a clinical photograph.4 |
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Techniques
for visualisation of the vocal cords |
| • |
Stroboscopy
: It enables us to see slowed sequence of the vocal cord movements.
Modern stroboscope is an extremely essential part of the voice
clinic. Xenon light source is usually preferred. The most important
advantage of the stroboscope is that it shows mucosal as well
as ground movements of the vocal cords.9 |
| • |
Fibre
optic laryngoscopy : It is often used in the out patient
department. The larynx can be visualised under good magnification.
The cord movements can be recorded and local anaesthesia is
used.8 |
|
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Advances
in Imaging Techniques |
| • |
Contrast
enhancement CT Scan : This procedure is useful in imaging
metastatic nodal disease and high resonance scanning of the
temporal bone. Gadolinium enhancement is very useful for temporal
bone lesions such as tumours like neuromas, paragangliomas,
carcinomas and inflammatory lesions and carcinomas. |
| • |
Magnetic
resonance imaging : This is the investigation of choice
for retrocochlear pathology. Gadolinium enhancement helps to
distinguish between tumours of the sinuses. Soft tissue masses
are better seen on MRI. The efficacy of magnetic resonance angiography
is fast increasing and is fast replacing the conventional catheter
angiography.
Newer advances in MRI like fast spin-echo very well demonstrate
the normal anatomy in Otolaryngology.5 |
|
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SURGICAL
ADVANCES |
Reconstructive
prosthesis in the ear |
There
have been great advances in the surgical techniques of tympanoplasty,
mastoidectomy and stapedectomy. Various implants have been used after
these surgeries to give the patient a good hearing.
Metallic : These implants are bio-inert and have One of the
major problems in this surgery is the cost. A multi-channel implant
does cost several lakhs. Thus a reduction in cost in India will surely
make a light visible at the end of the tunnel and enable more people
to have access to this surgery.18 |
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Lasers
in ENT |
The
introduction of laser into routine ear, nose and throat surgery has
gradually given way to a more balanced and realistic attitude to its
uses and limitations. The major advantage of laser is its precise incision,
haemostasis achieved and reduced post operative fibrosis and scarring.
The Carbon dioxide and Neodymium - YAG laser offer the Otolaryngologist
a new perspective in the management of difficult tracheal and oesophageal
problems.
The CO2 laser is used extensively in most ENT lesions. The spot size
has been reduced to less than 1 mm diameter, which greatly reduces any
damage to the surrounding areas. The Neodymium - YAG laser offers a
vehicle for the treatment of endotracheal lesions including tracheal
stenosis. This laser is of vital importance for the management of urgent
respirator obstruction. The laser emission can be targeted even by a
flexible endoscope. The Argon laser has shown to be extremely useful
in making the footplate opening in stapedotomy. It is especially useful
in revision cases, which require safe removal of scar tissue over the
oval window.
Laser surgery for the oral cavity and the larynx has an extremely good
precision because of the facility for the attachment of the laser beam
to the microscope in ENT disease. |
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Common
indications for laser in ENT |
| 1 |
Oral
leucoplakia : Leucoplakia is strikingly responsive to the
CO2 laser. Recurrence of new patches of leucoplakia after laser
treatment are also less likely. The operating microscope enables
one to see much more of the targeted field. The reduced ground
tissue reaction adds to the advantage of laser. |
| 2 |
Oral
Verrucous carcinoma : Lesions, which are 2 cms or less,
are amenable to laser treatment. The results of treating small-circumscribed
oral verrucous carcinomas are excellent, especially if adjacent
epithelial dysplasia is limited. |
| 3 |
Oral
carcinomas : Removal of intra-oral carcinomas by CO2 laser
is much preferred these days due to the more rapid and less
painful process. Some surgeons do advocate leaving the wound
open to facilitate better healing and reduced pain. |
Other conditions
where laser has been advocated in diseases of the Oral cavity are.
| • |
Oral
and Oropharyngeal haemangiomas. |
| • |
Pleomorphic
adenomas. |
| • |
Tonsillectomy |
| • |
Uvulo-palato-pharyngoplasty. |
Nasal indications : Listed are some of the commonly encountered
indications in the nose which can be dealt very effectively with laser.
Nasopharyngeal Angiofibromas : These are extremely aggressive
and vascular tumours of the nose and paranasal sinuses. The CO2 laser
attains markedly reduced blood loss and precise incision.
Familial haemorrhagic telangiectasia : This disease has lesions
which cause bleeding in the nose due to capillary dilatations. Ablation
of the mucosa by laser is extremely useful to control the bleeding.
However, there have been some cases of recurrence after laser.
Choanal atresia : The major advantage of the CO2 laser in these
conditions in infants is the minimal tissue trauma and the bleeding.
The laser beam is directed along the axis close to the floor of the
nose using the inferior turbinate as a landmark. The bleeding is usually
minimal and an indwelling elastic or polyvinylchloride tube can be used
to prevent contraction of the new orifice.The surgery may need to be
repeated at times.12
Nasal polyposis : Polyps in the nose are usually avascular
and have a restricted area of the disease. Ethmoidal polyps have a high
recurrence rate and laser surgery is very useful to reduce it.10 |
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Common
Laryngeal indications for laser |
Juvenile
laryngeal papillomatosis : The major advantage of laser in these
conditions is a very low recurrence rate and an acceptable voice after
surgery. If the papillomas are beyond the larynx, then a bronchoscopic
coupler is used to deflect the laser beam.
Laryngeal polyps and granulomas : Polyps or granulomas of the
vocal cords can be excised by laser or can even be vapourised. The precise
incision and good post-operative voice are the main reasons why laser
is mostly used in these conditions.
Congenital subglottic haemangioma : Formerly, excision of the
subglottic haemangioma had a high operative mortality and likelihood
of recurrence. Laser surgery has brought a totally new perspective to
treatment of this condition. It provides a simple endoscopic one stage
removal, minimal bleeding and may avert a tracheostomy. The absence
of post-surgical laryngeal oedema facilitates early extubation.
Carcinoma in situ of the vocal cords : Laser is a satisfactory
method of local control of carcinoma with a good post-operative voice
and provides a quick treatment to the patient.
Invasive carcinoma of the vocal cords : The technique of CO2
laser helps in excision of the lesion for frozen section. The results
of this method are comparable to radiation therapy. However, a proper
case selection is required.11
Bilateral Abductor cord palsy : The surgery of cordectomy achieved
a big milestone after the introduction of laser. One can do a simple
cordectomy (partial or total) or an arytenoidectomy depending on the
airway available between the two vocal cords. The procedure is extremely
precise and with relatively minimal blood loss
.
Other laryngeal indications of laser are:
Reinke’s Oedema.
Congenital subglottic stenosis.
Laryngeal stenosis.
|
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Bronchoscopic
applications of CO2 laser
|
Lesions
further down the trachea require the use of a bronchoscope. Special
bronchoscopic couplers have been designed for projecting the laser beam.
The coupler contains mirrors for altering the angle of the beam from
the laser arm. Ventilation is maintained via the sidearm of the bronchoscope
and trachea viewed through the eyepiece coupler. The newer neodymium
- YAG laser is excellent especially for bronchial granulomas, papilomas,
web-stenosis, and for palliative purposes in endotracheal neoplasm.13 |
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Lasers
in ear surgery
|
Laser
in ear surgery was tried in 1979. Escuderol was first to describe the
use of laser in seven cases of tympanoplasty. In 1980, Perkias performed
laser surgery in 11 cases of otosclerosis. Laser surgery especially
for otosclerosis provides pinpoint accuracy and instantaneous cauterisation
minimising tissue trauma.14
The Argon laser has been more commonly used in stapedectomy as compared
to the other lasers as it
| 1. |
Has
a visible wavelength. |
| 2. |
Accuracy
of the argon laser helps to prevent inner ear damage and also
causes photocoagulation. |
| 3. |
A
large stapedial artery transversing the oval window can be encountered
with an argon laser. |
Uses of laser in Ear surgery are
| • |
Perilymphatic
gusher. |
| • |
Revision
stapedectomy. |
|
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Functional
Endoscopic Sinus Surgery (FESS) |
Functional
endoscopic sinus surgery (FESS) is considered one of the most exciting
development in Otolaryngology since the introduction of the operating
microscope. Nasal endoscopy allows the accurate assessment of diseases
and anatomical abnormalities. Endoscopes may be used to perform a wide
variety of nasal surgeries like nasal polypectomy, frontoethmoidectomy,
orbital decompression, hypophysectomy and surgery of the choanal atresia.
Messerklinger in 1978, was one of the pioneers of this surgery and explained
the aim of the surgery as restoring the natural mechanism and maintaining
as much normal anatomy as possible.15
In the past decade FESS has been performed with greater accuracy in
a minimally invasive fashion, also attempting to restore normal function
with very encouraging results.
|
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Indications |
FESS
is indicated in the management of those patients with a circumscribed
pathology causing obstruction of the osteomeatal complex. The disease
may be in the maxillary, ethmoid, frontal or sphenoid sinuses or any
area beyond the sinuses, which can be used as an approach. The common
indications are:
| 1. |
Nasal polyposis. |
| 2. |
Chronic
sinusitis. |
| 3. |
Removal
of impacted foreign bodies |
| 4. |
Dacryocystorhinostomy. |
| 5. |
Closure of CSF leak. |
| 6. |
Vidian
neurectomy. |
| 7. |
Optic
nerve decompression. |
| 8. |
Biopsy
of nasal masses.. |
| 9. |
Cauterization of bleeding points in epistaxis. |
The major advantage of the endoscope is the different angulations (30
and 70 degrees) enabling the visualisation of the different parts of
the complex nasal anatomy. 0 degree Hopkins rod telescope is used in
a majority of the surgery.
Diagnostic endoscopy is increasing popular procedure in the out patient
department.16
|
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Soft
tissue shavers in endoscopy |
Powered
instrumentation (soft tissue shavers and microdebrides) represent the
newest advances in endoscopic surgery. These instruments offer precision
in soft tissue resection.
The advantage exists not only for routine sinus surgery but also removal
of nasal polyps, scar tissue, septal spurs, choanal atresia and obstructive
adenoids in the nose.17 |
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Voice
conservation techniques in Carcinoma of the larynx |
Carcinoma
of the larynx is one of the commonest cancers seen in Otolaryngology.
Numerous procedures have been described by Oncologists all over the
world.
Recent advances towards voice conservation surgeries without compromising
on oncological safety are greatly appreciated. A wide range of partial
laryngectomy procedures have been introduced depending on the site,
extent, and staging of the disease. Partial laryngectomy can be done
in glottic, supraglottic and transglottic cancers.
Glottic cancers : These malignancies are resected in a vertical
plane across the glottis. The voice conservation procedures for glottic
carcinomas include:
| 1. |
Laryngo
fissure with cordectomy. |
| 2. |
Vertical
partial laryngectomy. |
| 3. |
Crico-hyoido-epiglottopexy
(CHEP). |
| 4. |
Supracricoid
laryngectomy |
Supraglottic cancers : They are resected in a horizontal plane
above the vocal cords without disturbing the latter part of the valeculae,
pyriform fossae or arytenoids are resected depending on the extent of
the disease.
Transventricular (Transglottic) cancers : These lesions are
more advanced and often extend into supraglottic region or vice-versa.
A wide resection is often necessary. The most commonly done procedures
are
| 1. |
Supra-cricoid
laryngectomy with crico-hyoidopexy. |
| 2. |
Three-fourths
laryngectomy. |
It must be remembered that prior to any voice conservation procedure,
accurate clinical assessment of the disease is most important. A CT
scan or an MRI surely helps in the assessment. |
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CONCLUSION |
Thus
several milestones have been achieved in treating otolaryngology patients.
Application of physics and biology in surgery has been responsible for
dawning of a new era. Finally one must remember ‘Every great advance
in science is issued from a new audacity of imagination’. (John
Dewey). |
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ACKNOWLEDGEMENT |
I
sincerely thank Dr. Lalit Mehta, Dean, KJ Somaiya Medical College and
Hospital, Dr. RV Juvekar, Professor and Head, and Dr. DS Vaidya Asso.
Prof. department of Otolaryngology KJ Somaiya Medical College and Hospital,
for their valuable guidance and support. |
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| 2. |
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HH. Optical principles of endoscope In: Berci F ed Endoscopy,
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RT, et al. Longitudinal evaluation of communication skills of
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|
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WHEEZE
IN CHILDREN
Efficacy of a short course of oral prednisolone for preschool
viral wheeze, a 5-day course of oral prednisolone given by parents
at the start of wheezing did not have any effect on lower respiratory
tract symptom score, need for inhaled salbutamol, or need for
admission. Furthermore, they did not note any benefit of prednisolone
in children with increased systemic eosinophil priming.
Lancet Infect Dis 2003; 3 : 1433 |
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