Throat and Head and Neck Surgeries

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This picture depicts examination of voice box with a mirror in the ENT clinic.

Let’s see how voice is produced:

During inspiration (breathing in), the vocal cords move apart and allow air to enter the lungs.

During expiration (breathing out), the vocal cords move close to each other. When we want to make a sound, the vocal cords come together and vibrate to produce the sound.

The oral cavity, tongue, teeth and lips improve the quality of that sound which we perceive as ‘voice’.

Voice changes may occur due to various conditions in the vocal cords. 

  1.  Infections 
  2. Cancers
  3. Paralysis of the vocal cord/cords. 
  4. Nodule formation due to voice abuse and misuse
  5. Smoking -

     If the voice change persists for more than two weeks, the throat should be examined. Only an ENT surgeon can do a proper vocal cord assessment. With a good light beam directed to the patient’s mouth the doctor holds the patient’s tongue and passes the mirror into the patient’s mouth (which is held behind the tongue). This gives a mirror image of the larynx. If this procedure is causing any difficulty to the patient it can be avoided by anaesthetising the oral cavity using an anaesthetic spray.
     
    Vocal cords also can be examine using endoscopes passed through the nose or mouth.
     
    If detected early, cancers of vocal cords can be completely cured. Hoarseness of more than two weeks, therefore, should not be neglected.
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Our voice is generated in the voice box (vocal cords) in the neck at the mid level of the adams apple. This cannot be seen with a torch by an ordinary doctor. ENT surgeons visualise the vocal cords in the clinic using a warmed mirror through mouth or a flexible camera through the nose. Patient is very comfortable with the camera as there is no induction of gag.(common problem with the mirror through mouth)Patient can talk while doctor is looking through the camera. This is a basic test in the modern ENT clinic.
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This picture shows a magnified view of the voice box(vocal cords)taken during microlaryngoscopy. Triangular gap between the vocal cords allows air to pass through to lungs.There are two white nodules seen on the vocal cords. These nodules are formed due to excessive use of voice.(common problem among teachers and preachers) Microlaryngoscopy is the examination of the larynx (voice box)with the microscope under a general anaesthetic to find out causes for hoarseness. short metal tube ( a laryngoscope) is inserted through the mouth into find what the problem is. If needed, surgery of voice box can also be done through the laryngoscope, while the surgeon is looking through the microscope to get a better view. Microlaryngoscopy is quite a short operation and usually takes less than 30 minutes. If there is a leision, a small part of the lining of the voice box is taken away for tissue diagnosis. If any biopsies were taken, these normally take a few days to process in a laboratory. Results are available in a week. After laryngoscopy, voice may sound worse, especially if any biopsies have been taken. This should be temporary until the lining of the voice box heals. patient can go home the same day as the operation. Patient is advised to stay off work for a few days of voice rest depending on the job.
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Tonsillitis is seen mostly among children. Tonsils help fight germs that invade our bodies. Tonsils in children are bigger and become smaller in size with age. ‘Viral’ infections can also cause throat pain but tonsillitis is caused by a bacterium called Streptococcus. Symptoms of tonsillitis are fever, difficulty in swallowing, change of voice and earache. Examination will show multiple yellow spots on the tonsil. The entire throat looks inflamed. Pain killers and antibiotics are administered under medical supervision. Washing the throat with an anti-septic liquid and consuming hot liquids may be helpful. The diagnosis of tonsillitis is mainly clinical. Blood investigations and bacterial cultures are not always necessary. However, a full blood count report will help the doctor differentiate between viral and bacteria infections. Tonsillitis can lead to kidney infections, rheumatic fever, arthritis and diseases of the heart valves. Tonsillitis should not be ignored. If you have a sore throat, consult your family doctor to establish tonsillitis. If it occurs 5-6 times per a year for about two consecutive years, get a referral from your family doctor to an ENT surgeon. Tonsils can be removed surgically if frequent attacks interfere with your day to day activities (job or education). The surgical procedure does not leave a scar. The tonsils are removed through the mouth, without an external incision. As there is risk of post-operative bleeding, the patient must stay in hospital for a day under medical supervision. Meals should not be avoided due to pain. Take pain-killers 30 minutes before mealtime. Since healing may take about one week, stay at home and avoid crowded places.
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Tonsillar infections can spread to surrounding tissues causing an abscess called peri tonsillar abscess.Patient presents with severe pain, difficulty in opening mouth,ear ache,muffled speech,dysphagia and drooling.On examination, throat shows swollen displaced uvula. Patient may or may not have recurrent tonsillitis.Causative organisms are different from acute tonsillitis. This abscess has to be drained by an incision or aspiration with a wide bore needle after spraying local anesthetic. This will immediately relieve of symptoms.Pus can be sent for culture and antibiotic sensitivity. Oral or intravenous antibiotics given dipending on the severity.Sometimes abscess tonsillectomy is done as method of treatment. There is a risk of spread of peritonsillar infection to surrounding vital structures like blood vessels and chest cavity endangering life. therefore it is very important to drain this abscess as early as possible.
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This picture shows a picture of the throat after drainage of the abscess around the tonsil. Drainage can be done with a sharp blade under local anesthetic spray while in the ward. Aspiration of abscess with a wide bore needle also adequate to ease pain and discomfort in opening the mouth. Pus can be sent to laboratory for bacterial analysis.
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When there is unilateral tonsillar enlargement,a cancerous (malignant)lesion has to be suspected. Palpation with a gloved finger is helpful to compare the texture of tonsils.Malignant lesions are firm in consistency. There may be ulceration of the surface. Draining lymph nodes are usually enlarged. To obtain tissue diagnosis, tonsillectomy has to be done under general anesthesia.If the tonsil is ulcerated, small piece can be taken from the ulcer crater. Pathologist's report will be available in a weeks time.If the lesion is cancerous, Oncologists help is required.
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This indicates a harmless nodule. This is a fluid-filled mass. It will rupture by itself and the fluid can be swallowed. The cause of this nodule is a blockage of a gland opening, causing a cyst. This can become quite large with time. If it causes no pain, no treatment is required. Stop putting your tongue out and examining your throat each time you get hold of a mirror. Formation of more than one cyst can lead to swollen tonsils that require surgical removal.
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This picture depicts a cancerous ulcer of the tonsillar area with raised edges and a crater.Presenting symptoms are throat pain, ear ache, foreign body sensation of throat, blood stained saliva, difficulty in swallowing and a lump in the neck due to enlargement of lymph nodes. Smokers and alcoholics are prone to get this cancer.Diagnosis is usually late due to late onset of symptoms. A small piece of tissue is taken from the edge of the ulcer and sent for tissue diagnosis.If it is a small cancerous leision, radiotherapy to burn the ulcer has to be started by a doctor who treats cancer.(oncologist) It the cancer is advanced,patient may need major surgery to remove the growth and nodes of the neck. Prevention is always better than cure. Therefore smoking and alcohol consumption should be minimised or completely stopped.
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Tonsillectomy is a common operation done in ENT units. Under general anesthesia mouth is kept open by a gag. Tonsil is dissected from its bed with sharp instruments. Bleeding is completely arrested by sutures or electric burning. Patient is kept in ward for 24 hours to observe for bleeding.Patient can go home with pain killers. A normal diet is encouraged for quick healing of wounds.
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Plaque is caused by fungi called yeast. These fungi live on our body (e.g. mouth, vagina, anal canal…) but only in healthy amounts because harmless bacteria living in the mouth control their growth. Sometimes, however, when body immunity is low, fungi growth can increase. Immunity becomes low in the following cases: 1. Infants and elderly people. 2. People suffering from diabetics 3. People suffering from AIDS 4. People suffering from cancers This condition may also be seen among people who have taken oral antibiotics over long periods for certain conditions. The antibiotics destroy the healthy bacteria (which controls the growth of the fungi) leading to an over growth of the fungi. People who wear dentures can also have fungi growth on their palate. Treatment If this condition occurs in an infant, cleaning with glycerine will be effective. But if the condition occurs in an adult, the reason should be investigated as this excessive fungi growth can be a warning signal of dangerous diseases like cancer or AIDS. This condition may make the intake of food difficult. Anti-fungal gels are given as a remedy. A toffee containing nistatine (an anti-fungal medicine) is administered, to be sucked three times a day for about two weeks to control the situation. If this condition is observed in a person with dentures, it should be examined for loose connections. The denture should be stored in an anti-germ solution during the night. A denture that is swallowed may even threaten life and this has been discussed separately.
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This picture shows major aphthous ulcers of tongue.They are different from the common minor ulcers as they are larger and takes a longer time to heal.Sometimes these cannot be differentiated with cancers. In situations like these, the ulcer is removed surgically and sent for investigations. The prevalence is high among young females. The cause is not yet known. This condition can get exaggerated during times of depression and menstruation (of females). A slight association with congenital transfer cannot be excluded. Treatment: Heals spontaneously. Healing may be accelerated while reducing the pain with medication. a. Tetracycline dust (contained in a capsule) dissolved in water can be kept in the mouth b. Application of pain killing gels c. Steroid ointment can be applied during the night to accelerate the healing process d. If many ulcers are present, steroid tablets will be given. But they have more adverse side-effects. There is no permanent treatment / cure for frequent ulcers. The occurrence of ulcers decreases with age.

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This patient has presented with a advanced fungating ulcerative growth of the throat. This is an advanced cancer with blocked air passage. He would have presented with hoarseness, difficulty in breathing and swallowing. A breathing tube is seen coming out through the growth. For early diagnose one should not ignore hoarseness.
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This picture shows a patient after major head and neck surgery for cancer of the voice box.There is a nasal tube to feed a liquid diet until the wounds are healed. Patient cannot talk hence a bystander is necessary in the immediate post operative period.
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Malignant tumour or lumps on the voice box (Larynx) frequently occur in middle aged people, who have a history of smoking and drinking alcohol. Lesions develop on the vocal cords (Glottis) and the upper part of the larynx, which is located above the vocal cords (Supraglottis). Cancerous cells grow from flat cells that are located on the surface of the throat / larynx (Squamous Cell Carcinoma). This is the most common type of malignant growth in the head and neck. Treatment Radiotherapy is used to kill small malignant tumours in the voice box (Larynx) in many cases although some surgeons are advising the use of the laser to remove small tumours, there is still some debate regarding this form of treatment. If radiotherapy is unsuccessful or the cancer is recurrent, then surgery is recommended to remove some or all for the voice box (Partial or Total Laryngectomy). Many patients undergoing laryngectomy will retain voice , either through developing oesophageal speech or the use of a small ‘valve’ that is placed at the time of surgery.
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Malignant tumour or lumps on the voice box (Larynx) frequently occur in middle aged people, who have a history of smoking and drinking alcohol. Lesions develop on the vocal cords (Glottis) and the upper part of the larynx, which is located above the vocal cords (Supraglottis). Radiotherapy can be given for early lesions.Then it is possible to retain patients voice. If radiotherapy is unsuccessful or the cancer is advanced in the begining or there is a recurrence of tumour after radiotherapy, then surgery is recommended to remove some or all for the voice box (Partial or Total Laryngectomy). Many patients undergoing laryngectomy will need a electronic voice generator called electrolarynx. This generates vibrations of a diaphragm on the upper part of the machine. Patient has to touch the skin under the chin with the vibrator. When the muscles of the floor of the mouth vibrates, patient can generate a robot type voice.There is a rechargeable battery as power supply. When an electrolarynx is purchased,voice production has practiced under a speech and language therapist.
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Malignant tumour or lumps on the voice box (Larynx) frequently occur in middle aged people, who have a history of smoking and drinking alcohol. Lesions develop on the vocal cords (Glottis) and the upper part of the larynx, which is located above the vocal cords (Supraglottis). Radiotherapy can be given for early lesions.Then it is possible to retain patients voice. If radiotherapy is unsuccessful or the cancer is advanced in the begining or there is a recurrence of tumour after radiotherapy, then surgery is recommended to remove some or all for the voice box (Partial or Total Laryngectomy). Many patients undergoing laryngectomy will need a electronic voice generator called electrolarynx. This generates vibrations of a diaphragm on the upper part of the machine. Patient has to touch the skin under the chin with the vibrator. When the muscles of the floor of the mouth vibrates, patient can generate a robot type voice.There is a rechargeable battery as power supply. When an electrolarynx is purchased,voice production has practiced under a speech and language therapist. This picture shows a patient who underwent laryngectomy using a elecrolarynx.

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Malignant tumour or lumps on the voice box (Larynx) frequently occur in middle aged people, who have a history of smoking and drinking alcohol. Lesions develop on the vocal cords (Glottis) and the upper part of the larynx, which is located above the vocal cords (Supraglottis). Radiotherapy can be given for early lesions.Then it is possible to retain patients voice. If radiotherapy is unsuccessful or the cancer is advanced in the begining or there is a recurrence of tumour after radiotherapy, then surgery is recommended to remove some or all of the voice box (Partial or Total Laryngectomy). Many patients undergoing laryngectomy will need an artificial valve to allow air to pass through the wind pipe to the gullet. Air in the gullet vibrates the muscular walls generating voice. This is a one way valve allowing only air. This will not allow food particles to pass from gullet to wind pipe. This valve can be inserted at the time of operation or at a later date when the wounds are healed.One way function of this valve ceases after about two years. Then it has to be replaced with a new one.Voice generated from this method is more natural than from electrolarynx.
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Lymph nodes belong to the lymphoid system which produces antibodies and special cells that fight germs. These lymph nodes can be found in our body especially in neck, armpits and groin regions. When an infection occurs in a certain part of our body, the lymph nodes nearby are activated. For instance, a wound in a finger causes the lymph nodes in the armpits to get activated (making them larger). When there is a wound in the throat region, the nodes in that area will swell/become activated. •Tuberculosis (TB) enlarges the lymph nodes in the neck region. •When cancers spread, the cells enter the lymphatic (system) and blood vessels. As a result, the lymph nodes may swell. The lymph nodes in the throat region swell when a cancer occurs in the ear, nose or throat region. Cancers can originate from the lymphatic cells itself. The whole system will then swell. Liver and spleen, which are also components of the lymphatic system, may become inflamed. When your doctor examines you, he will consider all these aspects in reaching a diagnosis. He will thoroughly examine the ear, nose and throat for any inflamed wounds or cancers. You may be investigated under general anaesthesia. Blood investigations may also be done (WBC/ DC, ESR, blood picture). You may be referred to a pathologist who will do an aspiration biopsy of the lymph node (which involves taking a small portion/cells from the nodes.) A diagnosis will be done based on the reports, a diagnosis will be done. If it indicates a cancer, the patient may be referred to an oncologist. If it is an infection, relevant medical treatments will be administered. E.g.: TB, tonsillitis
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This young female has a lump of left parotid salivary gland. Lump has displaced the ear lobe. Common causes for parotid swelling are viral and bacterial infection, tumours and outflow obstruction due to a stone in the tube of gland. When a patient presents with painful parotid swelling, infection or obstruction is suspected. Examination is not complete until mouth cavity throat and facial nerve is examined. Fine needle aspiration cytology of the gland is performed to have an idea about the pathology of swelling. As this test is not very specific it is wise to operate and remove the gland. Specimen should be sent to the lab to have definite diagnosis.
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Thyroid enlargement is very common among females of child bearing age. Thyroid is exposed to hormonal changes during puberty, pregnancy and lactation. There can be irregular growth of gland with nodule formation due to increased demand of thyroxine during these periods of high demand. It is rare to get thyroid enlargement among males. When a male has a goiter, we have to exclude malignancy as early as possible. Thyroid profile, ultra sound scan of thyroid and fine needle aspiration cytology of lump is done in any patient with a goiter. If the profile shows decreased production of thyroxine, hormone replacement therapy will reduce the size. Ultra sound scan reveals whether the enlargement is smooth or nodular, whether the nodule is hard or fluid filled, whether there is an extension of goiter in to the chest cavity. If the goiter is compressing the air way, surgery has to be done immediately to relieve the wind pipe. . If the fine needle aspiration cells reveals cancer cells ,whole thyroid gland has to be removed along with the enlarged lymph nodes if any. During post operative period , radio iodine treatment has to be given to ablate the residual thyroid tissue. Patient need life long follow up by a cancer specialist . If the aspiration is harmless we can plan the operation for cosmetic reasons. The thyroid gland is related to few important structures. Nerve supply to our voice box is underneath the thyroid gland. Extra precautions has to be taken to protect the nerve during surgery. Parathyroid glands which are responsible for bone remodeling and calcium metabolism are also under the thyroid gland. These glands are four in number. We have to Preserve at least two of them during surgery. If the nerve to voice box is damaged, patient's voice is hoarse. To correct the voice, speech therapy exercises are given for a long period. If the voice is not better with these exercises,another operation is required to correct the voice. If all four parathyroid glands are removed, patient will have serious consequences . Due to all these reasons, surgeons are reluctant to remove thyroid gland for cosmetic reasons.
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Branchial cystS are developmental abnormality due to trapped tissues in the neck. These anomalies appear as a soft lump. They can appear in any age group yet are very common in the first decade of life. Because these anomalies develop in the growing embryo, any tract that forms in combination with a cyst follows a fairly predictable pattern. The tracts connect the cyst to the inside of the throat at a specific area. It is important to understand this relationship so that the entire tract can be excised and will not recur.An ultra sound scan of the neck and fine needle aspiration cytology will help to establish the diagnosis. Treatment is complete removal of the cyst before it has a chance to get infected and become an abscess. Surgery is performed under general anesthesia by making an incision over the cyst or draining area. Every effort is made to place the incision in an existing skin crease so that cosmetically the child's scar will be minimal. These operations usually last between one and two hours. Ear, nose and throat specialists have extensive training in surgery of the neck, making them the most qualified doctors for this type of surgery. If the cyst has become infected (or formed an abscess) prior to removal, incision and drainage of the abscess may be necessary first, followed by treatment with antibiotics. The cyst and tract can then be safely removed at a later date.

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This picture shows a inflammed lymph node in the neck.There are multiple nodes towards the lower part of the neck. The commenst cause for this problem is tuberculosis. Tuberculous infection of neck can occur without involvement of lungs. Young people are affected more than elderly. Patient is not ill. Symptoms like fever,cough and weight loss are not common. For the diagnosis, fine needle aspiration cytology of a lymph node is done by a pathologist.(The node is pierced with a small needle to take some cells. A thin film is made on a glass slide and immediately dipped in an alcohol solution to fix the cells. Cells are examined under the microscope.) If the pathologist suspects tuberculosis, he/she will inform the surgeon to remove one node surgically and send for further examination.If the diagnosis is confirmed, antiTB drugs are started for a period of six months under the supervision of a chest physician. This condition is not infectious to others. Patient can continue normal activity at home and workplace. Once the treatment is over, the condition is completely cured.
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The thyroid gland, which is shaped like a butterfly, is in the front part of our throat. This is located around the larynx and the trachea (wind pipe). The larynx moves up and down when swallowing and the thyroid follows. A lump in the thyroid gland can occur on the side of the neck. This lump could be a cancer or a harmless lump. Further investigations are imperative. a) A pathologist will do an aspiration biopsy (which involves taking a cell sample from the lump). If it is diagnosed as a cancer, the thyroid gland will be removed surgically. The removal of the lump alone is not enough. b) An ultra sound scan of the neck to check whether the lump is solid or cystic.(filled with fluid) It also indicates whether the gland has a single lump or multiple lumps. If there are multiple lumps, it is unlikely to be cancerous. c) T 99 thyroid scan is done to investigate activities inside the gland. If it is under-functioning, it will be removed surgically. d) The level of thyroid hormones in the blood must be investigated. The removed gland is sent to a pathologist. If it is a cancer, the patient will be referred to an oncologist for further management. Oral Radioiodine therapy is given to destroy the remaining disease. A Large dose of thyroxine is given to keep the activity of the remaining thyroid tissue suppressed. Early diagnosis of thyroid gland cancers has a better prognosis.One can lead a normal life after the disease is fully controlled. Patient has to attend to clinic according to the instructions given by the oncologist.
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This picture shows an elderly lady with a huge goitre. She has ignored it until it caused pressure effects on gullet and wind pipe. She may get dysphagia and noisy breathing. There can be cancer formation within the long standing goitres.Goitre can enlarge in to the chest cavity causing blockage of large blood vessels and wind pipe. After the preliminary investigations like FNAC.thyroid hormone assay and ultra sound scan of neck to establisn the diagnosis,patient has to be prepared for anesthesia and surgical excision. An intensive care unit bed has to be arranged for the immediate post operative period. There can be significant blood loss during surgery. Therefore blood has to be crossmatched before surgery. Sometimes patient needs a tracheostomy breathing tube in the neck. All these problems during surgery can be avoided if the patient had consulted a doctor when the goitre was small.

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The thyroid gland, which is shaped like a butterfly, is in the front part of our throat. This is located around the larynx and the trachea (wind pipe). The larynx moves up and down when swallowing and the thyroid follows. When a doctor examines the thyroid gland,he/she has to stand behind the patient and palpate with the fingers of both hands. Neck has to be relaxed by bending forwards. When the patient is swallowing a sip of water,the doctor has to confirm the mobility of the gland. The position of the wind pipe,enlargement of the lymph nodes of the neck,and the pulse of the major vessels in the neck and enlargement of gland in to the chest cavity has to be noted.
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This picture shows a midline neck lump in a child.The most likely diangnosis is thyroglossal cyst.As it is attached to the hyoid bone of the neck,this lump moves up and down with swallowing. This is a developmental deformity of the thyroid gland. Thyroglossal duct cysts are cysts that are left over when the thyroid migrates from the base of the tongue into the neck before birth. The cyst is connected to the back of the tongue by a small tract. The cyst usually lies in the middle of the neck in front of the "Adam's Apple"Although it is present at birth, it rarely enlarges during infancy.These cysts usually show up in the first ten years of life, but may be found in older children or even adults. It is a benign cyst that usually contains mucous or even pus-like fluid. Many times, these cysts will not be evident until child has an upper respiratory infection (cold). After which, the cyst will suddenly appear in the front of the neck. The sudden appearance or rapid enlargement of these cysts can be alarming. If a cyst is infected, many times antibiotics and/or drainage may be necessary to control the infection prior to definitive removal. However, if the cyst appears without infection, and you wish to avoid further problems with infection, surgical removal is best performed before the cyst is ever infected. Because thyroid tissue may be inside the cyst, it is important to make sure that the thyroid gland has developed normally (and that not all the thyroid tissue is within the cyst). An ultrasound and/or a thyroid scan is necessary to make sure the "cyst" is not the only functioning thyroid gland. Once these tests have been completed, excision of the cyst may be performed This operation usually takes 45 minutes to an hour. The cyst is excised along with the tract and the middle one centimeter of the hyoid bone. A tube drain is inserted for drainage of accumulated blood. Wound is sutured with absorbable suture material. The patient can go home on the following day.
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Parotid salivary gland is situated at the root of the ear lobe. The facial nerve which supplies the muscles of facial expression is under the gland. Among all the salivary glands, Parotid has the highest incidence of tumours. To diagnose parotid swellings, ultra sound scanning and fine needle aspiration biopsy helps. Sometimes CT and MRI scans are done to decide the depth of tumour and the spread to the surrounding tissue. All parotid tumours should be operated to know the exact nature of it. Since the facial nerve is underneath the gland, a special type of incision which goes round the ear is used to protect all the branches of the nerve. The facial nerve is carefully dissected before we remove the gland with the tumour. When the wound is healed, scar is also invisible.
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Small children swallow coins and it is very common all over the world. Although coins are stuck in the food passage,child may get breathing difficulty due to compression of the air way. Therefore it is necessary to take the child to hospital as soon as possible. In the hospital, coin will be removed under anesthesia.
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Tongue-tie is a minor defect of the mouth that decreases the mobility of the tongue. If you raise your tongue to the roof of the mouth, you will see a band of tissue underneath your tongue called the frenulum. This band helps anchor your tongue to the floor of your mouth. If this string of tissue is too short or tight, you cannot move your tongue well enough to touch the roof of your mouth and may result in speech problems. Tongue-tie is present at birth. If the newborn child has a tight frenulum, feeding may be difficult. Tongue tie has to be released immediately.If there are no feeding problems,tongue tie has to be released when child is around two years to prevent speech problems. Treatment is surgical and consists of separating the band of tissue (frenulum) in a very quick and completely painless procedure called FRENULOPLASTY.

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Facial Nerve Injuries and Paralysis There are actually two facial nerves, one on each side of the head. The facial nerve or 7th cranial nerve is known as a "cranial nerve" since it starts in the brain. It then sends branches out to the face, neck, salivary glands (secrete saliva into the mouth), and the outer ear. A normal functioning facial nerve allows us to move our face and neck (smile, frown, wrinkle our nose and forehead), secrete saliva, lets the front of the tongue "taste" food, and makes us cough when something is placed in the ear. Problems with the facial nerve result in weakness or paralysis of the face muscles and possibly, a loss of taste on the affected side. This nerve loss is one of the most disfiguring since it involves facial movement. Without the nerve connection (innervation) intact, the eye does not close, there is loss of facial muscle tone, and movement on the affected side is reduced or lost. Causes of paralysis It is important to understand the location or pathway the facial nerve takes in the head and face. This understanding makes it easier to see how the nerve is damaged and how this damage may affect function. The facial nerve starts in the brain, and then tracks through a narrow space located inside the ear (internal auditory canal). The nerve then passes through the middle ear (behind the ear drum) and leaves through another narrow passage located under the ear area (stylomastoid foramen). It then branches out to provide muscle movement and sensation to various parts of the face and neck. The branches start inside the parotid gland (in front of the ear) and travel to the forehead, cheek,nose, mouth and neck. Anything that may cause swelling or pressure on the nerve can result abnormal function. Some of the general causes of problems along the pathway of the facial nerve include; congenital (birth) abnormalities, infections of the middle ear (OTITIS MEDIA), or CHOLESTEATOMA, infections or tumors of the PAROTID GLAND, FACIAL AND NECK TRAUMA, and uncommonly, as a complication after an operation in the ear area (for example, after a MASTOIDECTOMY). One of the most common causes of facial nerve paralysis a viral infection called Bell's Palsy. How is facial paralysis evaluated? Evaluation begins with thorough history to help determine the cause. A physical examination will help to determine whether the nerve damage is at the brain level (central) or closer to the ear and face area (peripheral). Usually various tests are performed as part of the evaluation. The nerve (8th cranial nerve) that allows us to hear is located close to the facial nerve, so it may also be affected (sensorineural hearing loss) when the facial nerve is paralyzed. In addition, problems with the middle ear may also be associated with a hearing loss similar to having the sensation of earplugs in the ears (conductive hearing loss). The type of hearing loss, if present, helps with diagnosis and treatment of the condition. A thorough examination is performed to determine the level of the paralysis. The extent of facial nerve paralysis can involve all of the nerve (complete) or just a part of the nerve (incomplete). An x-ray is usually performed after the history and physical examination of the patient. A computed tomography (CT) scan or magnetic resonance imaging (MRI) scan is very useful in making the diagnosis. It can help to determine exactly where swelling, infection, trauma, or tumor may be that is causing the facial nerve abnormality. More specialized tests involve the use of electrical impulses. A commonly used technique called electromyography (EMG) sends electrical impulses to muscle (as a nerve would do). This is a painless technique that helps to determine whether the problem is with the nerve or the muscle itself. Another study is known as the nerve excitability test (NET). This study uses electrical impulses to compare the normal facial nerve on one side of the face with the abnormal one on the other. Electroneurobility testing (ENoG) goes further than NET, by giving actual numbers to help with the comparison. Finally, a group of tests checking tear production, saliva production, taste sensation and small ear muscle movement can help to determine if only a small branch of the facial nerve is damaged. This is known as topographic localization. When would an otolaryngologist be consulted to help manage facial paralysis? An otolaryngologist is consulted to help surgically treat many causes of facial nerve paralysis that will not resolve on their own. These conditions include a trapped nerve that needs to be released to function normally, which can be seen with FACIAL TRAUMA, tumors, or severe OTITIS MEDIA. The otolaryngologist is also skilled in surgically connecting a facial nerve that has been divided by trauma. In these instances, the facial nerve will continue to die until a surgical procedure is undertaken. This underscores the urgency in which facial nerve paralysis should be evaluated.
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A ranula is a swelling found on the floor of the mouth. They present as a swelling of collected mucin from a ruptured salivary gland duct, which is usually caused by local trauma. The latin rana means frog, and a ranula is so named because its appearance is sometimes compared to a frog's underbelly.The gland that most likely causes a ranula is the sublingual gland.Rarely submandibular gland may be involved. Treatment of ranula is excision of both the gland and the lesion through the mouth. Ranulas are likely to reccur if the sublingual gland or other gland causing them is not also removed with the lesion.
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A peritonsillar abscess forms in the tissues of the throat next to the tonsils.

 An abscess is a collection of pus that forms near an area of infected skin or other soft tissue.The clinical picture is that of a rapidly increasing difficulty in swallowing that occurs after a streptococcal tonsillitis (strep throat). The tonsillitis may seem to be improving for a day or two, but then, one side of the throat becomes increasingly painful. The pain is severe and radiates to the ear. Opening the mouth is difficult and so painful that the patient refuses to eat or swallow. There is drooling of saliva and bad breath. The voice is indistinct and muffled It is referred to as "hot potato speech".

On examination, there is a tense swelling of the soft palate and anterior pillar above the tonsil. The uvula may be displaced to the opposite side. It is often difficult to know at first whether the swelling is an abscess or a peritonsillar cellulitis.

The doctor has several options for treating you:

  • Needle aspiration involves slowly putting a needle into the abscess and withdrawing the pus into a syringe.
  • Incision and drainage involves using a scalpel to make a small cut in the abscess so pus can drain.
  • Acute tonsillectomy (having a surgeon remove your tonsils) may be needed if, for some reason, you cannot tolerate a drainage procedure, or if you have a history of frequent tonsillitis.

    You will receive an antibiotic. The first dose may be given through an IV. Penicillin is the best drug for this type of infection, but if you are allergic, tell the doctor so another antibiotic can be used (other choices may be erythromycin or clindamycin). If you are healthy and the abscess drains well, you can go home.
     
    If you are very ill, cannot swallow, or have complicating medical problems (such as diabetes), you may be admitted to the hospital.

    Occasionally, the abscess ruptures spontaneously and foul-smelling thick pus drains through a crater in the anterior pillar.Antibiotics will help to expedite the recovery.
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An oral mucocele, is a swelling consisting of collected mucin from a ruptured salivary gland duct, which is usually caused by local trauma. It has a bluish translucent color, and is more commonly found in children and young adults.The size of oral mucoceles vary from 1 mm to several centimeters. Their duration lasts from days to years, and may have recurrent swelling with occasional rupturing of its contents.Some mucoceles spontaneously resolve on their own after a short time. Others are chronic and require surgical removal. Recurrence may occur, and thus the adjacent salivary gland is excised as a preventive measure.
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The tongue is divided into 2 separate anatomical areas, the oral tongue is the part that can be moved. The base of tongue is the part which cannot be seen during examination of the mouth.The cancer of tongue is usually located on the side border, of the oral tongue. It is usually ulcerated and is grayish-pink to red in color. It will often bleed easily if bitten or touched. Small cancers of the oral tongue can be quickly and successfully treated by surgical removal leaving behind little cosmetic or functional change. Larger cancers may indeed have some effect on speech and on swallowing, but one must remember that not treating this problem would cause far more significant problems, up to, and including death. As the size of the primary tumor increases the possibility of some cancer cells spreading through lymphatic vessels to the lymph nodes of the neck increases. The site and pattern of the involved lymph nodes is pretty much constant. When the presence of enlarged lymph nodes in the neck is detected , then an operation called a neck dissection is performed to remove these "secondary" deposits of cancer. Following removal of the tumor,there may sometimes be the need to perform plastic surgery and reconstruction.Radiation treatments may have to be given after the surgery to try to minimize the possibility of recurrence.

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Torus palatinus is a bony growth on the palate, usually present on the midline of the hard palate. Palatal tori are more common in Asian and Inuit populations, and twice more common in females. Palatal tori are usually a clinical finding with no treatment necessary.[2] It is possible for ulcers to form on the area of the tori due to repeated trauma. Also, the tori may complicate the fabrication of dentures. If removal of the tori is needed, surgery can be done to reduce the amount of bone present.
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This picture depicts a polyp of one vocal cord with normal opposite cord. Injury or chronic irritation causes changes in the vocal cords that can lead to polyps or nodules. The main cause is chronic voice abuse (yelling, shouting, singing loudly, or using an unnaturally low frequency). Polyps may have several other causes, including gastric reflux, untreated hypothyroid states, chronic laryngeal allergic reactions, or chronic inhalation of irritants, such as industrial fumes or cigarette smoke. Polyps may occur at the mid third of the membranous cords and are more often unilateral. Symptoms are hoarseness and a breathy voice.If these symptom persists for more than three weeks, visualization of the vocal cords with a mirror or camera is a must. Diagnosis is based on biopsy to rule out cancer. Surgical removal with the help of an operating microscope restores the voice,but removal of the irritating source is essential to prevent recurrence. Correction of the underlying voice abuse cures most nodules and prevents recurrence. Removal of the offending irritants allows healing, and voice therapy with a speech therapist reduces the trauma to the vocal cords from improper singing or protracted loud speaking. In microlaryngoscopy, an operating microscope is used to examine, biopsy, and operate on the larynx. Images can be recorded on video as well. The patient is anesthetized, and the airway is secured.The microscope allows observation with magnification.Tissue can be removed precisely and accurately, minimizing damage to the vocal mechanism. Laser surgery can be done through the optical system of the microscope to allow for precise cuts.
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This picture depicts a swollen red epiglottis , an endotracheal tube under the epiglottis.(which was inserted to secure the airway)Causative organism is a bacterium called Haemophilus influenzae. Before the widespread use of the Haemophilus influenzae type b vaccine, epiglottitis occurred mainly in young children. Recently, the incidence has decreased among children and increased among adults. Adult epiglottitis is different.Organism identification is less common and the mortality is higher. 15% to 21% of patients require either endotracheal intubation or emergency tracheostomy to secure the airway. The remaining cases can be safely treated with antibiotics. In certain cases intravenous corticosteroid therapy may be of benefit. The most common symptoms are sore throat, odynophagia and muffled voice. Soft-tissue lateral neck radiography shows swollen epiglottis as a thumb.Laryngoscopy under anaesthesia is the most accurate investigation to establish a diagnosis. Prompt recognition of the condition and early airway intervention by intubation or tracheostomy in cases of airway compromise are crucial to avoid a possible fatal outcome.
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Two stones are seen in an x ray of the floor of the mouth. These stones are lodged in the ducts(drainage tube) of a salivary gland situated at the floor of the mouth. Patient has severe pain during meals associated with swelling under the lower jaw. Pain is due to saliva accumulation in the gland as the stones are not allowing the flow.
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When a person gets ear ache without a ear problem doctor has to suspect problems in teeth. Commonest dental problem causing earache is impacted wisdom teeth. This X Ray shows impaction of all four wisdom teeth. This is a special X ray of all 32 teeth in one film. It is called orthopantomogram. X rays are sent panoramically to take picture of all the teeth. So it is very convenient for the doctor to diagnose and treat dental problems.
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There is a visible lump below the jaw. This swelling is due to enlargement of submandibular salivary gland. There are six salivary glands in the body. Parotid glands are situated behind the ear. Submandibular salivary glands are situated under the mandible. Sub lingual salivary glands are situated under the tongue. Sub mandibular gland has a tortuous long duct which opens at the floor of the mouth. When saliva flows slowly along this duct there can be sediment formation. These stones can block the saliva flow during meals. Patient gets a painful swelling of gland during meals. Gland returns to normal size some time after meal. when the stone is removed surgically pain and swelling disappears. Other reason for swelling of the gland is tumour. There will be painless enlargement of the gland .Best treatment is excision of the gland. Gland will be sent to the lab for further evaluation . If the report shows malignancy, further treatment is given by cancer specialists.
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Iron Defeciency anaemia,difficulty in swallowing due oesophageal web , smooth tongue (glossitis) and spoon shaped nails are associated together as a syndrome called Plummer Vinson Syndrome. Patients are post menapausal women.They present with dysphagia and burning sensation of mouth. Barium swallow shows the web. Treated by correction of anaemia with iron supplements and dilatation of the web by passing a rigid tube oesophagoscope.THis condition is pre malignant. Patients need life long follow up for oesophageal cancer.