Tonsillar Fossa Research Articles

Haemostasis and analgesia with autologous platelet-rich plasma in tonsillectomy.

A single-centre, single-blinded prospective experimental study was conducted to determine the effectiveness of autologous platelet-rich plasma applied to the tonsillar bed post-operatively in reducing post-operative pain and haemorrhage. Platelet-rich plasma, prepared prior to surgery, was applied with calcium gluconate to one randomly chosen tonsillar fossa. Pain and haemorrhage were analysed, using a visual analogue scale and a pre-defined grading scale respectively, four times on the day of surgery at 2-hourly intervals, and thrice on the following day. The pain score and haemorrhage grade on the test side were lower than on the control side. These findings were statistically significant. This pilot study, conducted in India, revealed valid positive results for a promising new technology. The manual preparation of platelet-rich plasma could be automated in the future to allow a larger sample size.

Functional reconstruction of soft palate and tonsillar fossa is still a challenge?

Background: Purpose: to show the results obtained with a new technique for soft palate and tonsillar fossa reconstruction developed to improve the function restoring concept in reconstructive surgery.

Could digital photography be an alternative to postoperative physical examination for pediatric tonsillectomy patients?

ObjectiveTo evaluate and compare the efficacy of postoperative control with digital photographs and physical examination for children who underwent tonsillectomy? MethodsIn this prospective study, 86 children (46 boys (53.5%) and 40 girls (46.5%) were enrolled for postoperative clinical visit and for obtaining photographs of the tonsillar bed with a digital camera at clinic control. ResultsNo difference in tonsillar fossa healing was observed between the two methods 2 weeks after surgery. ConclusionsDigital photographs proved to be a safe method for postoperative control of pediatric patients who underwent tonsillectomy. Adding control with outpatient follow-up will be useful for minimizing postoperative complications.

Effect on postoperative pain after topical application of local anesthetics in the tonsillar fossa after tonsillectomy

BackgroundTonsillectomy is one of the most commonly performed surgeries in ENT practice. Despite improvements in anesthetic and surgical techniques, post-tonsillectomy morbidities continue to be a significant clinical concern. Pain is the cause of most of the postoperative morbidity after tonsillectomy. An effective pain therapy to block or modify the physiological responses to stress has become an essential component of modern pediatric anesthesia and surgical practice.AimThe present study compares the results between the effect of lidocaine 2% infiltration, lidocaine 10 % spray, and bupivacaine 0.5% spray in the tonsillar bed after tonsillectomy on postoperative pain.Materials and methodsThe study included a total of 120 patients aged 5–18 years who were candidates for tonsillectomy at the Otorhinolaryngology Department of Alexandria Main University Hospital. The patients were randomly divided into three groups of 40 patients each. Group A received lidocaine 2% (Xylocaine) peritonsillar infiltration 2ml in one tonsillar bed and posterior pillar; group B received lidocaine 10% (Xylocaine) spray 2 puff in one tonsillar bed; group C received bupivacaine 0.5% (Marcaine) solution 2ml in one tonsillar bed spray by syringe and the other tonsillar bed in each group receives pack with similar amounts of normal saline for 5 min as a control group after tonsillectomy before recovery from anesthesia.ResultsThere was no statistical difference between the three studied groups as regards age and sex. There is significant statistical difference according to the frequency of throat pain and ear pain by comparing cases and controls of each group within the first 24 h after surgery. It appears that increased frequency of postoperative throat pain and ear pain is present with the control side (saline).ConclusionTopical application of the tonsillar bed with a local anesthetic after tonsillectomy results in significant reduction of postoperative throat pain and referred otalgia and should be used during surgery for tonsillectomy.

Perioperative interdisciplinary approach for reduction of opioid use in pediatric tonsillectomy: Protocol using dexmedetomidine and bupivicaine as adjunct agents.

Pediatric tonsillectomy is a common procedure now being performed most often for patients with obstructive sleep apnea, which has been associated with increased sensitivity to the respiratory side effects of opioid medications. This study investigates a strategy to decrease the use of opiate medications in a particularly vulnerable population. Describe an interdisciplinary approach between Otolaryngologists and Anesthesiologists to decrease opiate use in tonsillectomy patients. Demonstrate safety of this protocol. Evaluate the effect of the protocol on intraoperative need for opiate medications and inhaled anesthetic use. Perform cost analysis of the protocol. Retrospective case-control study with cost analysis. Tertiary Care Hospital. Pediatric patients undergoing tonsillectomy at a tertiary care hospital. Preoperative and intraoperative dexmedetomidine with local bupivacaine injection into the tonsillar fossa. Intraoperative need for sevoflurane, opiate, and propofol. Post-operative pain scores, and utilization of post-operative opiate, acetaminophen, and ibuprofen pain medications. Post-operative adverse events. Cost analysis of protocol. This protocol led to a decrease in intraoperative opiate use by 49.6%, a decrease in intraoperative sevofluorane use by 18%, and a lower reported maximum post-operative pain score without any increase in adverse events. The protocol added a small increase in medication cost of $4.07 to each procedure. The use of dexmedetomidine and local anesthetic in pediatric tonsillectomy is a safe and effective protocol that allows for the reduction of opiate use and improved post-operative pain control. Question: Can the combination of dexmedetomidine and infiltration of local anesthetic reduce overall opioid use for peediatric patients undergoing tonsillectomy? In this case-control study, use of dexmedetomidine and local anesthetic injected into the tonsillar fossa led to a decrease in intraoperative opiate use by 49.6%, a decrease in intraoperative sevofluorane use by 18%, and a lower reported maximum pain score without an increase in adverse events. Meaning: Use of dexmedetomidine and local anesthetic as anesthetic adjuncts may help reduce need for intraoperative opiates and decrease the use of volatile anesthetic agents in pediatric tonsillectomy patients, which are undesirable medications in the pediatric population for their respective respiratory depression and potentially neurotoxic side effects.

Aberrant carotid bulb in bilateral tonsillar fossae: An exceptional discovery during tonsillectomy

Tonsillectomy, though a popular surgery, has now downsized to limited indications. Although rare, this surgery may cause trauma to the great vessels leading to life-threatening hemorrhage. The congenitally tortuous internal carotid artery (ICA) is an unusual but important anomaly, especially when it is situated in the tonsillar fossae. About 1%–16% of patients have a surgically vulnerable ICA manifested clinically. Here, we present the first reported case of carotid bulb in the right tonsillar fossa. A 7-year-old female child underwent tonsillectomy for obstructive sleep apnea syndrome. Intraoperatively, she was found to have a carotid bulb in both tonsillar fossae, right more prominent than left one. Computed tomography angiogram confirmed the presence of a prominent carotid bulb in the right tonsillar fossa at the C2level. This case report highlights the importance of a heightened awareness of the anatomic variations of carotid artery, in particular, the carotid bulb. This is of critical significance for a safe tonsillectomy as well as any procedure performed in the oropharyngeal region.

Subcutanious emphysema and pneunomediastinum - the rare complication of tonsillectomy

Tonsillectomy is one of the most common surgical interventions in the practice of ENT hospitals. As a rule, complications of tonsillectomy are early and late postoperative bleeding. However, in extremely rare cases tonsillectomy can be complicated by subcutaneous emphysema and pneumomediastinum. The mechanism by which these complications develop are poorly understood. The article describes the case of a rare complication of tonsillectomy - the intraoperative development of subcutaneous emphysema and pneumomediastinum. Such complications are most likely caused by deep trauma of the pharyngobasilar fascia of the tonsillar fossa, which causes the penetration of the air into the parapharyngeal space and its subsequent spread to the mediastinum.

Lingual Tonsillectomy Likely Does Not Improve Outcomes for Squamous Cell Carcinoma of the Head and Neck From an Unknown Primary Site.

Patients with mucosal squamous cell carcinoma (SCC) of the head and neck almost always have a primary site in the base of tongue or tonsillar fossa. Lingual tonsillectomy has recently been advocated as part of the diagnostic evaluation as opposed to directed biopsies of the base of tongue and thought to possibly result in an increased likelihood or cure. The purpose of this project is to determine whether this is probable. We reviewed the medical records of patients treated with primary radiotherapy (RT) between January 1983 and March 2013. The outcomes were compared following RT in consecutively treated patients with either T1-2 base of tongue or unknown primary (cancer of unknown primary) SCC with predominantly level 2 adenopathy. At 10 years, there were no clinically significant differences in the 2 groups, in local control, regional control, freedom from distant metastases, disease-specific, or cause-specific survival. Overall survival at 10 years was improved with T1-2 base of tongue cancers but not for those with T0 N3 disease. The reasons for this are unclear. Tongue base biopsy (or lingual tonsillectomy) likely increases the probability of identifying an unknown primary in the base of tongue, but it does not improve outcome following RT for patients with cancer of unknown primary SCC with predominantly level 2 adenopathy.

Branchial Fistula : A Case Report

We report a case of complete branchial fistula in a 13-year-old boy which could be evaluated by a contrast study. The tract was completely excised and the patient had an uneventful recovery. Branchial fistulae are formed due to the persistence of the embryonic second branchial cleft. Complete fistulae with the internal opening in the region of the tonsillar fossa are not common and should be properly evaluated before going to surgical exploration.TAJ 2011; 24(2): 145-147

Lethal manifestations of angioedema

An 86-year-old woman with a history of angioedema was found dead at her home address. She had recently complained of a swollen tongue. At autopsy the tongue was grossly edematous, protruding from the mouth. There was also marked edema of the tonsillar fossae, epiglottis and glottic inlet, causing critical obstruction. Histology of the tongue and upper airway demonstrated marked submucosal edema. Death was attributed to upper airway obstruction due to angioedema of the tongue, oropharynx and glottic inlet. Angioedema is characterized by localized non-pitting edema of the deep dermis and subcutaneous/submucosal tissues. It may be acute or chronic, acquired or inherited. Sudden death may result from critical airway occlusion, although both stroke and ischemic heart disease are known to occur. Post mortem genetic testing for hereditary variants can be conducted for SERPING1 gene and F12 gene/THR328 mutations.

Stylalgia Revisited: Clinical Profile and Management.

Eagle's syndrome is a constellation of signs secondary to an elongated styloid process or due to mineralization of the stylohyoid or stylomandibular ligament or the posterior belly of the digastric muscle. The syndrome includes symptoms ranging from stylalgia (i.e. pain in the tonsillar fossa, pharyngeal or hyoid region) to foreign-body sensation in the throat, cervicofacial pain, otalgia, or even increased salivation or giddiness. We describe a clinical study of 12 patients with Eagle's syndrome, along with their clinical profile and the treatment offered. Patients were diagnosed based on history and clinical examination, as well as the Xylocaine 2% tonsillar fossa injection test. A visual analog scale (VAS) was used for comparison of pain before and up to 3 months after treatment. Radiology (orthopantomogram or three-dimensional computed tomography) was used for further exploration. Nine patients underwent tonsillo-styloidectomy surgery and three underwent medical treatment with pregabalin (75 mg/day). The majority of surgically-managed cases (88%) achieved a definitive benefit by tonsillo-styloidectomy surgery, whereas all medically managed cases achieved only short-term pain relief. Besides the common throat diseases, the symptoms associated with Eagle's syndrome may be similar to those due to cervicofacial neuralgias, dental, or temporo-mandibular joint diseases. Diagnosis is primarily based on symptomatology, physical examination and radiographic investigations, and should not be missed. Treatment by tonsillo-styloidectomy produces satisfactory results in stylalgia.

Posterior pillar mucosal suspension technique for posttonsillectomy pain and wound healing: a prospective, randomized, controlled trial.

To investigate the efficacy of a simple and feasible suturing technique on posttonsillectomy pain control and wound healing. A prospective, randomized, controlled trial was conducted on a sample of 121 children between 3 and 10years of age. Group A comprised children undergoing surgery with bipolar cautery and the posterior pillar mucosal suspension technique. Bipolar alone (Group B) and cold dissection tonsillectomy (Group C) were used as control groups. Pain was assessed at 1, 3, 5, 7, and 10days postoperatively via visual analog scale scores. Peritonsillar edema, erythema, and granulation tissue in the tonsillar fossa were evaluated by direct visual examination for wound healing on days 1, 3, 5, 7, and 10. There were consecutive 121 patients which were included, with mean ages being 6.2 ± 2.5, 6.1 ± 2.4, and 6.1 ± 2.6 in groups A, B, and C, respectively. Postoperative pain scores on days 1 and 3 were significantly lower in Group A than Group B and C (P < .001) and scores were 0.87 ± 1.1, 3.83 ± 2.29, and 4.29 ± 2.48 on day 1 and 0.38 ± 0.88, 2.25 ± 2.13, and 2.76 ± 2.12 on day 3 respectively. The wound-healing scores on postoperative 1st, 3rd, 5th, and 7th days were significantly lower in Group A than control groups (P < .001). The wound-healing score on postoperative day 10 was only different than Group C (P = .020). The posterior pillar mucosal suspension technique is an effective and comparable method in terms of wound healing, maintains the preoperative anatomical structures, and enables a better pain control with reduced analgesic/opioid usage.

Transcervical styloidectomy in Eagle's syndrome

Eagle's syndrome is a rare disease responsible for polymorphic head and neck symptoms, often resulting in delayed diagnosis. The diagnosis of Eagle's syndrome is based on the presence of suggestive clinical signs associated with pain on palpation of the styloid process in the tonsillar fossa, a positive lidocaine test and elongation of the styloid process on 3D CT scan. The most commonly proposed curative treatment is styloidectomy, which allows complete resolution of symptoms in the great majority of cases. This procedure can be performed via a transoral approach or a transcervical approach. After briefly reviewing the embryology and anatomy of the styloid diaphragm region, the authors describe the transcervical styloidectomy technique performed in their department. This simple technique is based on anatomical imperatives designed to limit the operating time and avoid damage to neurovascular structures.

A Second Branchial Cleft Cyst Presenting as a Dumbbell -Shaped Anterior Neck Mass

A Second Branchial Cleft Cyst Presenting as a Dumbbell -Shaped Anterior Neck Mass

Síndrome de Eagle hacia la delimitación clínica

ObjectivesOrofacial and cervical pain are a frequent reason for neurology consultations and may be due to multiple pathological processes. These include Eagle syndrome (ES), a very rare entity whose origin is attributed to calcification of the stylohyoid ligament or elongation of the temporal styloid process. We present a series of five patients diagnosed with ES. Material and methodsWe describe the demographic and clinical characteristics and response to treatment of 5 patients who attended the headache units of two tertiary hospitals for symptoms compatible with Eagle syndrome. ResultsThe patients were three men and two women aged between 24 and 51, presenting dull, intense pain, predominantly in the inner ear and the ipsilateral tonsillar fossa. All patients had chronic, continuous pain in the temporal region, with exacerbations triggered by swallowing. Four patients had previously consulted several specialists at otorhinolaryngology departments; one had been prescribed antibiotics for suspected Eustachian tube inflammation. In all cases, the palpation of the tonsillar fossa was painful. Computed tomography scans revealed an elongation of the styloid process and/or calcification of the stylohyoid ligament in three patients. Four patients improved with neuromodulatory therapy (duloxetine, gabapentin, pregabalin) and only one required surgical excision of the styloid process. ConclusionsEagle syndrome is a rare and possibly underdiagnosed cause of craniofacial pain. We present five new cases that exemplify both the symptoms and the potential treatments of this entity.

A Rare Cause of Recurrent Cerebral Ischemia and Syncope: Eagle Syndrome

Eagle syndrome is defined as symptomatic elongation of the styloid process or calcification of the stylohyoid and stilomandibular ligament. The syndrome was described by WW Eagle in 1937. The styloid process is located between the internal and external carotid arteries and laterally in the tonsillar fossa. Patients with cerebrovascular ischemia causing syncope or hemiparesia due to Eagle syndrome are rarely published in the literature. The authors presented a patient with recurrent cerebrovascular attacks due to long styloid process.

Reducing the exposure of the tonsillar fossa does not impact postoperative pain levels in children undergoing tonsillectomy: A double-blind randomized controlled trial

BackgroundIt is not established whether reducing the exposure of the tonsillar fossa would be an effective strategy for postoperative pain relief among the pediatric population submitted to tonsillectomy. We assessed the impact of closing this region using absorbable sutures on pain, on the resumption of normal diet and on the healing process until seven days after surgery. MethodsRandomized, double-blind, controlled trial comparing postoperative pain in 132 children between the ages of 5 and 12 years undergoing tonsillectomy having bilateral closure, unilateral closure or non-closure of the tonsillar fossa. ResultsNo differences in pain levels were reported both at discharge and on postoperative day 7. The day of resumption of normal diet was similar in all patients. Less granuloma and edema of the uvula were noted in patients with non-closure of the tonsillar fossa. ConclusionThese results showed that reducing the exposure of the tonsillar fossa after the removal of the palatine tonsils was not an effective method for postoperative pain relief in children. Moreover, its closure was associated with slower healing.

Pulsed Radiofrequency Ablation for the Treatment of Glossopharyngeal Neuralgia Secondary to Oropharyngeal Carcinoma

Background: The management of glossopharyngeal neuralgia due to oropharyngeal carcinoma is particularly difficult because of rich innervations of the area, erosive nature of neoplasm and dynamic pain evoked by the functional movements like swallowing and chewing. Few case reports have shown the efficacy of pulsed radiofrequency (PRF) treatment in primary and secondary glossopharyngeal neuralgia in non-cancer patients. However, the efficacy of PRF ablation of the glossopharyngeal nerve in oral cancer patients is not known. Objectives: This study was conducted to evaluate the efficacy and safety of PRF ablation of the glossopharyngeal nerve for the management of oropharyngeal cancer pain involving the base of the tongue, tonsillar fossa, and oropharynx. Study Design: Prospective interventional clinical trial. Setting: Tertiary care hospital and medical education and research institute. Methods: A total of 25 adult patients suffering from oropharyngeal carcinoma, complaining of severe pain in the area mainly supplied by glossopharyngeal nerve, were included. The patients underwent fluoroscopy-guided PRF ablation of the glossopharyngeal nerve of the affected site 3 times at 42°C temperature for 120 seconds with 22-gauge, 10 cm long, 5 mm active tip radiofrequency needle. They were followed up for one year for pain relief, nausea-vomiting and sleep disturbances. The treatment was considered effective if there was 50% reduction in pain score at 2 weeks. Results: There was significant reduction in the overall pain score including site specific pain, odynophagia and ear pain after radiofrequency ablation (P &lt; 0.0001) in all the patients. This was associated with decreased opioid consumption (P &lt; 0.001), lesser nausea/vomiting, and improved sleep. The treatment was effective in 23 out of 25 patients (92%) for more than 3 months. No major complication was observed in any patient. The average duration of effective pain relief was 5 to 9 months. Limitations: Patients having bilateral glossopharyngeal neuralgia or an advanced stage of oral cancer with large lymph nodes at the angle of mandible were not included. This study was a singlecenter observational clinical trial and further multi-center, randomized, controlled trails are needed to obtain higher level of evidence. Conclusion: Our results showed that PRF ablation can be used effectively and safely for the treatment of glossopharyngeal neuralgia secondary to oropharyngeal carcinoma. Key words: Glossopharyngeal neuralgia, ear pain, odynophagia, oral cancer pain, pulsed radiofrequency ablation, side effects

Prospective in silico study of the feasibility and dosimetric advantages of MRI-guided dose adaptation for human papillomavirus positive oropharyngeal cancer patients compared with standard IMRT

PurposeWe aim to determine the feasibility and dosimetric benefits of a novel MRI-guided IMRT dose-adaption strategy for human papillomavirus positive (HPV+) oropharyngeal squamous cell carcinoma (OPC). Materials/methodsPatients with locally advanced HPV+ OPC underwent pre-treatment and in-treatment MRIs every two weeks using RT immobilization setup. For each patient, two IMRT plans were created (i.e. standard and adaptive). The prescription dose for the standard plans was 2.12 Gy/fx for 33 fractions to the initial PTV. For adaptive plans, a new PTVadaptive was generated based on serial MRIs in case of detectable tumor shrinkage. Prescription dose to PTVadaptive was 2.12 Gy/fx to allow for maximum dose to the residual disease. Any previously involved volumes received minimally a floor dose of 50.16 Gy. Uninvolved elective nodal volumes were prescribed 50.16 Gy in 1.52 Gy/fx. Dosimetric parameters of organs at risk (OARs) were recorded for standard vs. adaptive plans. Normal tissue complication probability (NTCP) for toxicity endpoints was calculated using literature-derived multivariate logistic regression models. ResultsFive patients were included in this pilot study, 3 men and 2 women. Median age was 58 years (range 45–69). Three tumors originated at the tonsillar fossa and two at the base of tongue. The average dose to 95% of initial PTV volume was 70.7 Gy (SD,0.3) for standard plans vs. 58.5 Gy (SD,2.0) for adaptive plans. The majority of OARs showed decrease in dosimetric parameters using adaptive plans vs. standard plans, particularly swallowing related structures. The average reduction in the probability of developing dysphagia ≥ grade2, feeding tube persistence at 6-month post-treatment and hypothyroidism at 1-year post-treatment was 11%, 4%, and 5%, respectively. The probability of xerostomia at 6-month was only reduced by 1% for adaptive plans vs. standard IMRT. ConclusionThese in silico results showed that the proposed MRI-guided adaptive approach is technically feasible and advantageous in reducing dose to OARs, especially swallowing musculature.

Coblation versus dissection tonsillectomy in children

Background and objective: Tonsillectomy is the surgical procedure of removing the tonsils. Various methods of tonsillectomy have been practiced aimed at decreasing or eliminating intraoperative and postoperative morbidity. This study was conducted to determine the different outcomes of tonsillectomy surgery in both coblation and dissection techniques. Methods: A prospective control study was conducted with a total sample size of 66 patients. Each patient underwent tonsillectomy by using ArthroCare Coblator on the right side and dissection method on the left side. Children between the age of 3-12 years old were selected with indications of recurrent tonsillitis and/or kissing tonsil causing snoring and/or sleep apnea. Children with peritonsillar abscess, malignancy, bleeding disorder were excluded. Operative time and blood loss, postoperative pain, bleeding and healing process were compared between two methods. Operations performed by the same surgeon. Results: The intraoperative time was significantly shorter (P <0.001) and intraoperative blood loss was significantly lesser (P <00.01) in coblation as compared to dissection tonsillectomy, while there were no significant differences in the postoperative pain scores on 1st, 2nd, 7th and 14th postoperative days. There was a significant healing process in tonsillar fossa in favor of coblation rather than dissection. No primary or secondary postoperative bleeding was reported. Conclusion: Coblation tonsillectomy is a safe procedure with significantly less intraoperative time and less blood loss and better surgical wound healing with similar postoperative pain in comparison with dissection tonsillectomy.