Peritonsillar abscess [quinsy]

Aetiology

often mixed infection : Strep pyogenes, Staph aureus, anaerobes
H/O denovo / acute tonsillitis
Infection & blockage of 1 crypt[C.magna] &larr intratonsillar abscess &larr bursts capsule causing peritonsillitis & abscess.

CFs : mostly in adults; usually unilateral pus in peritonsillar space [capsule &harr superior constrictor ms]

1. local :
   • unilateral severe throat pain
   • odynophagia [ ∴ no swallowing & dehydration]
   • ipsilateral earache [CN9 to tonsil & ear]
   • muffled thick voice
   • foul breath [sepsis]
   • trismus [pterygoid near sup constr]
2. general : septicaemia [104Ffever-chills-rigor, malaise, headache, bodyache, nausea, constipation

Signs:

• unilateral congested & swollen - tonsils, pillars, soft palate
• mucoid pus
• uvula pushed to opposite side
• torticollis - neck tilted towards abscess side
• jugulodigastric lymphadenopathy

Complications:

1. parapharyngeal abscess
2. laryngeal edema &rarr tracheostomy
3. septicaemia &rarr endocarditis, nephritis, brain abscess
4. aspirated pus &rarr pulmonitis, abscess
5. carotid artery & jugular venous thrombosis & spontaneous hmrrg

Rx : Hospitalization

• peritonsillitis -
  1. IV fluids &rarr dehydration
  2. IV antibiotics -high dose
  3. strong analgesics [pethidine] [not aspirin - bleeding]
  4. H2O2, saline, mouth washes &rarr oral hygiene
• abscess -
  1. incise[guarded knife, sinus forceps -drain] at max bulge at upper pole/lateral to junction of uvula base & ant pillar
     4-6wks later – interval tonsillectomy
  2. abscess tonsillectomy -less preferred since abscess rupture & bleeding.

Juvenile nasopharyngeal angiofibroma

Rare but commonest benign nasopharyngeal tumor.

Aetiology

probably testestorone appearance in an adolescent male [10-20 age] causes the hamartomatous nidus of vascular tissue in postnasal cavity near sphenopalatine foramen, to activate into angiofibroma which is fibrovascular pink-purple sessile firm locally-invasive mass without muscle coat, hence bleeding can’t be controlled by vasoconstrictors/adrenaline.

CFs :

1. nasal cavity obstruction [1 or both choana] -
   • recurrent profuse epistaxis [marked anaemia]
   • discharge
   • denasal speech
2. ET obstr – conductive deafness, serous otitis media
3. invasive destruction of PNS [max, sph, eth] – swelled cheek
4. pterygomax & infratemporal fossa – broad nasal bridge
5. enters inf/sup orbital fissure & destroys orbit apex – proptosis, frog face deformity
6. thr sphoid sinus into middle cranial cavity, thr ethmoid roof into anterior cranial cavity – involvement of CN 2,3,4,5

Δ : only from CFs, palpation should be done only during surgery since profuse bleeding[2l]

Biopsy [for D/D: teratoma, hemartoma, pleomorphic adenoma, chordoma, choristoma, paraganglioma] only under general anaesthesia with bleeding control arrangements & blood transfusion.

• Xray -
  • lateral nasopharynx – soft tissue mass
  • PNS – opaque sinuses, deviated nasal septum, anterior bowing/destruction of posterior max sinus wall.
  • Skull base – erosion of sphenoid Gwing & pterygoid plates, widenned lower lateral margin of superior orbital fissure
• CT scan – esp intracranial extensions
• Carotid angiography – extensions & feeding vessels

Rx : Surgical resection :
preoperative ↓ vascularity – stilbEsterol, radiation, cryotherapy, embolise feeding bv.

• transpalatal type – for nasopharyngeal tumor
• lateral rhinotomy type – for extended tumor

Nasopharyngeal cancer

Uncommon in India except in north-east[mongoloid origin]
Common in S.China, Indonesia, Taiwan.

Commonest origin : Rosenmuller fossa in lateral nasopharynx.
Metastases involves : nearly all Cranial nerves & Cervical lymph nodes.

Aetiology	genetic succeptibility in chineese Epstein-Barr virus environ - air pollution, smoking (tobacco, opium), dry salted fish(nitrosamines), incense & wood smoke
Pathological types
most common 85%	SqCC [variants: transitionalCC, lymphoepitheloima
10%	lymphomas
5%	rhabdomyosarcoma, malignant mixed salivary tumor, malignant chordoma
3 morphological types
proliferative	causes obstructive symptoms
ulcerative	epistaxis
infiltrative	invades sub-mucosa

CFs:

1. nasal obstruction:
   • discharge
   • denasal speech (rhinolalia clausa)
   • epistaxis
2. Eusthacian tube obstruction :
   • conductive deafness
   • unilateral serous/suppurative otitis media
3. Ophthalmo-neuralgic :
   • into orbit apex & CN2 - exophthalmos, blindness
   • 5 - facial pain, ↓ corneal reflex
   • CN6 - squint, diplopia
   • 3,4,6 - ophthalmoplegia
   • 9,10,11 - Jugular foramen syndrome
   • into hypoglossal canal - CN12
   • cervical sympathetic chain - Horner's syndrome
4. Cervical nodal metastases - in 75% , can be the only manifestation
5. Distant metastases to organs

Δ

• Ex postnasal space - NPmirror/nasopharyngoscope
• Xray,CTscan - extension, skull base erosion
• Biopsy - histology
• no lesion - histology by transpalatal approach for a strip of mucosa&submucosa from rosenmuller fossa

Rx

1. Irradiation for primary tumor - 6000rads
2. Radical neck dissection for persisting nodes
3. recurrent tumor -
   • external radiation
   • Brachytherapy [intracavitary implants]
   • Cryosurgery thr palatal fenestration
4. Palliative Systemic chemo – radiation failure, distant metastases

otitis externa =inflm of EAC.

acute2 types:

infective -

• bacterial -localised acute furuncle, diffuse, malignant/necrotising.
• fungal =otomycosis.
• viral - herpes zoster oticus, otitis externa haemorrhagica.

reactive -

• eczema
• seborrhoea
• neurodermatitis

localised acute oitis externa =FURUNCLE [1/(many)]

• staph inf of hair follicle[cartilagenous part]
• severe pain,tender -jaw,pinna movts.
• at post mestal wall -mastoid edema,oblit retro auricular groove,(enlarged preauricular Lnodes).

Rx:

• early stage -sys antibiotics,analgesics,local heat, splinttage -ear pack[10% ichthammol(antiseptic)glycerine(hygroscopic)]
• abscess -incise+drain.
• recurrent -treat DM,staph inf of skin/nasal vestibuli.

diffuse otitis externa + [pinna,TM]:

pinna

CONGENITAL DISORDERS:

bat ear/lop ear - protruding,large concha,poor antihelix & scapha.

• Rx: surgical correction after 6yrs.

preauricular appendages- skin covered cartilaginous tags between tragus & mouth angle.

preauricular pit/sinus at helix root- incomplete tubercles fusion–>repeated inf–>purulent discharge.

anotia- first arch syndrome.

macrotia

microtia- major dev anomaly of EAM,Mear,Iear[deaf].

TRAUMATIC CONDITIONS:

haematoma- blood between cartilage & perichondrium from blunt trauma[boxers,wrestlers,rugby].

• clot organizes-CAULIFLOWER EAR
• infection–>perichondritis.

Rx

• aspiration,
• pressure dressing,
• incise+drain+pressure w/ dental rolls thr sutures,
• prophylactic antibiotics

lacerations- Rx:

• absorbable sutures-perichondrium[no stripping-avscular necrosis]
• nonabsorbable sutures-skin
• broad spectrum antibiotics-1wk

avulsion:

• w/ pedicle  Rx:reatteach
• complete  Rx:micrvascular surgical reimplantation, implant deskinned cartilage under postauricular skin for later reconstruction.

frost bite=erythema/edema/bullae/necrosis.

Rx:

• rewarm w/ moist 38-42 ~c cotton pledgets [causes pain from rapid heating :analgesics]
• superficial inf -0.5%AgNO3 , deep inf -sys antibiotics.
• protection to stop bullae rupture.
• after several mos[dead & living demarcated]- surgical debridgement.

keloid =from trauma/pierce of lobule/helix.

Rx:

• surgical excision+pre,post operative 600-800rads/local steroid inj to prevent recurrence.

INFLM DISORDERS:

perichondritis:

• mixed flora,psudomonas inf from-
  • sec to lacerations/haematoma/surgery.
  • extended  from otitis externa.
• early red,burn,pain,stiff.
• late- abscess between perichondrium[bv] & cartilage –>cartilage necrosis.

Rx:

• sys antibiotics, 4%Al Acetate compresses.
• drain absces + culture sensitivity , remove devitalised cartilage/antibiotic catheter drip for 7-10days.

autoimmune relapsing polychondritis [ear,septal,larynx,tracea,costal] =inflam,tender,stenotic.

• Rx: high dose sys steroid.

myringoplasty + ossicular reconstruction = tympanoplasty.

pars tensa perforation closure w/ graft-temporal fascia, tragus perichondrium/cartilage,vein.

indications:

• deafness,tinnitus
• ascending nasopharyn inf.
• aeroallergens.

contraindications:

• otitis externa
• discharge
• nasal allergy
• SqE invasion.
• age<3

underlay technique:[ADR- ant perforation, Mear narrowing, adheres to promontory]

• harvest graft
• incise along perforation edge
• raise tympanomeatal flap
• check ossicles & for SqE – then pack Mear w/ gel-foam antibiotic.
• insert graft under TM perforation edges & post ear canal.

overlay technique: [ADR- ant sulcus blunting, epithelial pearls/cysts, lateralisation of graft]

• harvest graft
• incise to raise meatal skin w/ TM epethelium
• graft on TM. [ant under annulus, tuck under malleous handle]. replace skin.

post operative: stiches,ear pack removed after 5-6 days.

complete epithelisation of graft takes 6-8 wks.

myringotomy

TM incision + drain effusion/aerate Etube.

indications:

• ASOM,
• glue ear -grommet,
• otitic barotrauma -unlock Etube.

contraindications: glomus tomour risk bleeding.

local anaesth [gen anaesth in children & inflamed TM].

steps:

• clean ear canal.
• operating microscope – myringotome – ASOM-circumferential incise, glue ear-radial incise.[pitfalls - thick TM, inflammed TM duped post meatus].
• suction/grommet insertion.
• post operative -  daily mop, dry ear precautions.

complications:

• injure incudostapedial joint, high jugular bulb.
• Mear inf.

tubercular otitis media

secondary inf usually in young people thr Etube/blood from focus in lungs/tonsils/lymph nodes.

pathology:

insidious pale tubercles in Mear cleft submucosa –>necrosis of TM,ossicles.

CF:

• foul discharge.
• multiple TM perforations.
• severe deafness.
• sudden facial paralysis.

diagnosis: culture sensitivity for discharge.

Rx:

• ATB
• aural toilet
• mastoid surgery for complications.

otitic hydrocephalus

raised ICP during Mear infs in children–>

• lateral sinus thrombosis–>obstr venous return.
• supsagittal thrombosis–>CSF not absorbed thr arach villi.

CF:

• severe headache, vomiting,nystagmus =CSF pressure>300mm.
• 6th CN -diplopia.
• pailledema,optic atrophy-blurring vision.

Rx: to prevent optic atrophy

• repeated lumbar puncture
• shunt operation CSF into a vein.
• Mear inf -antibiotics
• mastoidectomy -to expose lateral sinus & drain abscess.

lateral sinus thrombophlebitis / sigmoid sinus thrombosis.

inflm, thrombus in lateral venous sinus.

pyogens-proteus, Ecoli, pseudo, staph.

cause: CSOMcholesteat,mastoiditis –>bone erosion-thrombophlebitis.

pathology:

outer dura abscess[perisinus] –>endophlebitis + thrombus –>obliteratn + inf –>

• thrombus extension[ to supsagittal,cavernus,jugular vein,mastoid emissary vein],
• septicaemia,
• septic emboli.

CF:

• headache, irregular high fever + chills,rigor,sweating.
• anaemia,emaciation
• GRIESINGER’s sign- mastoid edema
• PAPILLEDEMA-blurred margins,dilated/haemrrhg.
• TOBEY AYER test- jugular compr causes no rise in CSF[thrombosis]
• CROWE BECK test- jugular compr dilates retinal,supraorb veins.
• tender lymphadenopahty, torticollis[tiltc neck].

diagnosis:

• blood- no malaria, culture-inf.
• ICP rised.
• xray mastoid- clouding,erosion.
• ear swab culture.
• CTscan.

complications:

• jugular thrombosis- CN 9,10,11.
• cav sinus thrombosis- chemosis,proptosis,fixed eye, papilledma.
• supsagittal thrombosis- ottitic hydrocephalus.
• septicaemia.
• meningitis, abscess-subdural,cerebellar,lung,joints,bone,subcutaneous.

Rx:

• surgical mastoidectomy[expose sinus & drain abscess] + 7days sys antibiotics.
• ligate int jugular vein to control thrombosis.
• raely- anticagulants for cav sinus thrombosis.
• blood transfuse for anaemia.