LAPT-Laser assisted partial turbinectomy being done under Local anesthesia using Co2 Laser, in ENT OPD, SUT Speciality hospital, Trivandrum, Kerala, South India.

Peritonsillar abscess (Quinsy)is a complication of acute tonsillitis. In peritonsillar abscess, there is pus trapped between the tonsillar capsule and the lateral pharyngeal wall.

Complaints
• Severe throat pain which may become unilateral
• Fever
• Drooling of saliva
• Foul smelling breath
• Swallowing may be painful
• Difficulty opening the mouth
• Altered voice quality (’hot potato voice’) due to pharyngeal oedema and trismus
• Earache on the affected side
• Neck stiffness symptoms
• Headache and general malaise
Findings
• Examination may be difficult as trismus may make it difficult to open the mouth in up to two thirds of cases.
• Breath is fetid.
• There may be drooling and salivation.
• Look for a temperature.
• Tender, enlarged ipsilateral cervical lymph nodes.
• Torticollis may be present.
• There is unilateral bulging usually above and lateral to one of the tonsils; occasionally the bulging is inferiorly.
• There is medial or anterior shift of the affected tonsil and the tonsil may be erythematous, enlarged and covered in exudate.
• The uvula is displaced away from the lesion.
• Examine for signs of dehydration.
• Compromise of the airway is rare.
• Spontaneous rupture of the abscess into the pharynx can rarely occur and can lead to aspiration.
Medical Management
• Intravenous fluids may be required to correct dehydration.
• Analgesia should be prescribed.
• Intravenous antibiotics give higher blood levels than oral therapy and are usually used.
• intravenous steroids

Surgical Management
• Needle aspiration: Needle aspiration can be therapeutic in itself; in some studies, up to 85% of patients were effectively treated with outpatient needle aspiration and oral antibiotics. Aspiration can also be used to confirm the diagnosis and localize the Quinsy for incision and drainage.
• Incision and drainage under Local anesthesia(see picture)
• Quinsy tonsillectomy-rarely advocated

Complications
• The abscess can spread to the deeper neck tissues and can result in necrotizing fasciitis. Infection can spread from the parapharyngeal space through the anatomical planes to cause mediastinitis, pericarditis and pleural effusions.
• Airway compromise is rare.
• Recurrence of peritonsillar abscess can occur.
• Haemorrhage may follow tonsillectomy.
• Death can occur from aspiration, airway obstruction, erosion into major blood vessels or extension to the mediastinum.
• The rate of recurrence is around 10 to 15%.

Tympanoplasty is a surgical procedure to reconstruct a perforated tympanic membrane (eardrum) or the small bones of the middle ear. Eardrum perforation may result from chronic infection or, less commonly, from trauma to the eardrum. Mastoid exploration may or may not be combined with this operation.

Ear Drum
The tympanic membrane(Ear Drum) of the ear is a three-layer structure. The outer and inner layers consist of epithelium cells. Perforations occur as a result of defects in the middle layer, which contains elastic collagen fibers. Small perforations usually heal spontaneously. However, if the defect is relatively large, or if there is a poor blood supply or an infection during the healing process, spontaneous repair may be hindered. Eardrums may also be perforated as a result of trauma, such as an object in the ear, a slap on the ear, or an explosion.
The purpose of tympanoplasty is to repair the perforated eardrum, and sometimes the middle ear bones (ossicles) that consist of the incus, malleus, and stapes. Tympanic membrane grafting may be required. If needed, grafts are usually taken from tragus or temporalis fascia
Types
There are five basic types of tympanoplasty procedures:
• Type I tympanoplasty is called myringoplasty, and only involves the restoration of the perforated eardrum by grafting.
• Type II tympanoplasty is used for tympanic membrane perforations with erosion of the malleus. It involves grafting onto the incus or the remains of the malleus.
• Type III tympanoplasty is indicated for destruction of two ossicles, with the stapes still intact and mobile. It involves placing a graft onto the stapes, and providing protection for the assembly.
• Type IV tympanoplasty is used for ossicular destruction, which includes all or part of the stapes arch. It involves placing a graft onto or around a mobile stapes footplate.
• Type V tympanoplasty is used when the footplate of the stapes is fixed.

Depending on its type, Tympanoplasty can be performed under local or general anesthesia. In small perforations of the eardrum, Type I tympanoplasty can be easily performed under local anesthesia with intravenous sedation. An incision is made into the ear canal and the remaining eardrum is elevated away from the bony ear canal, and lifted forward. The surgeon uses an operating microscope to enlarge the view of the ear structures. If the perforation is very large or the hole is far forward and away from the view of the surgeon, it may be necessary to perform an incision behind the ear. This elevates the entire outer ear forward, providing access to the perforation. Once the hole is fully exposed, the perforated remnant is rotated forward, and the bones of hearing are inspected. If scar tissue is present, it is removed either with micro hooks or laser.
Tissue is then taken either from the back of the ear-Temporalis fascia graft, the tragus (small cartilaginous lobe of skin in front the ear).. The tissues are thinned and dried. An absorbable gelfoam sponge is placed under the eardrum to support the graft. The graft is then inserted underneath the remaining eardrum remnant, which is folded back onto the perforation to provide closure. Very thin sheeting is usually placed against the top of the graft to prevent it from sliding out of the ear when the patient sneezes.

Diagnosis
The examining physician performs a complete physical with diagnostic testing of the ear, which includes an audiogram and history of the hearing loss, as well as any vertigo or facial weakness. A microscopic exam is also performed. Otoscopy is used to assess the mobility of the tympanic membrane and the malleus.
CT Scan is routinely performed before tympaoplasty.

Postoperative care

Once the mastoid bandage is and drain, if any removed, the neat day, patient can go home.
Antibiotics are given, along with a mild pain reliever. After 10 days, the packing is removed and the ear is evaluated to see if the graft was successful. Water is kept away from the ear, and nose blowing is discouraged. If there are allegies or a cold, antibiotics and a decongestant are usually prescribed. Most patients can return to work after five or six days, or two to three weeks if they perform heavy physical labor. After three weeks, all packing is completely removed under the operating microscope. It is then determined whether or not the graft has fully taken.
Complications
Possible complications include failure of the graft to heal, causing recurrent eardrum perforation; narrowing (stenosis) of the ear canal; scarring or adhesions in the middle ear; perilymph fistula and hearing loss; erosion or extrusion of the prosthesis; dislocation of the prosthesis; and facial nerve injury. Other problems such as recurrence of cholesteatoma, may or may not result from the surgery.
Tinnitus (noises in the ear), particularly echo-type noises, may be present as a result of the perforation itself. Usually, with improvement in hearing and closure of the eardrum, the tinnitus resolves. In some cases, however, it may worsen after the operation. It is rare for the tinnitus to be permanent after surgery.

Results
Tympanoplasty is successful in over 90% of cases. In most cases, the operation relieves pain and infection symptoms completely. Hearing loss is minor.

Congenital Pre auricular sinuses are malformations that result from incomplete fusion of 2 of the 6 hillocks that arise from the first and second branchial arches.
Once infection occurs, the likelihood of recurrent acute exacerbations is high, and the sinus tract should be surgically removed. Surgery should take place once the infection has been treated with antibiotics and the inflammation has had time to subside.

The sinus tract should be surgically extirpated in patients who are asymptomatic because the onset of symptoms and subsequent infection cause scarring, which may lead to incomplete removal of the sinus tract and postoperative recurrences. The recurrence rate after surgery is 20-30% , if the track is incompletely excised.
Most postoperative recurrences occur because of incomplete removal of the sinus tract. One way to prevent incomplete removal is to properly delineate the tract during surgery. Some surgeons cannulate the orifice and inject methylene blue dye into the tract.
During surgery, some surgeons use either a probe or an injection of methylene blue dye for cannulation of the orifice. The most successful method is to use both modalities to delineate the entire tract.

The standard technique for extirpation of the sinus tract involves an incision around the sinus and subsequent dissection of the tract to the cyst near the helix.
A portion of the auricular cartilage, which is attached to the tract, is also removed, decreasing the incidence of recurrence to 5%.

External (open)Rhinoplasty is a very popular procedure that can make profound differences not only in the balance of facial features, but also in a person’s self-esteem. The aesthetic improvements that a Rhinoplasty surgeon can make include decreasing or increasing the size of the nose, altering the tip or bridge of the nose, and narrowing or changing the shape of the nostrils.The nasal septal deformities also can be dealt with an open approach.

LAUP is performed under local or general anaesthetic and is considered to be a safer, more economical and a more comfortable alternative to UPPP. It involves vaporising the free edge of the soft palate and uvula using a laser. Unlike UPPP, LAUP may have to be repeated in order to obtain the desired effect. The tonsils are removed if needed along with this procedure. Although laser surgery is associated with fewer complications than UPPP, post-operative pain is still reported as being mild to moderate
Post-operative pain peaked anywhere from 3 to 9 days after surgery and usually resolved within 2 weeks
The results are encouraging 70-80% cure OSA and 80-90% cure for snoring.
LAPT is also done at the same time. Any septal deviation can also be corrected with Laser.

Allergic fungal sinusitis is very common in the tropical countries.20-30% of patients I see in my clinic come under this category.
Fungal sinusitis may occur in patients with chronic sinusitis, who usually have a predisposing cause such as uncontrolled diabetes or are immunosuppressed. It is of utmost importance that surgeon suspect the possibility of fungal sinusitis in theses patients if they do not respond to medical treatment or have any complication of sinusitis.
A variety of different causative organisms could be responsible for fungal sinusitis. Aspergillus and mucor mycosis are the commonest. Non-invasive fungal sinusitis is usually due to aspergillosis. It mimics sinusitis but there is no response to antibiotics.

Surgical clearance is of fungus is required with medical treatment. In invasive fungal sinusitis, patients will complain of fever, local pain, swelling, discharge and foul smell. Fungal sinusitis is often detected after the onset of an orbital complication or cranial nerve palsy and the sinus involvement seen on CT scan. While imaging will undoubtedly help in the diagnosis and assessment of the extent of fungal involvement, nasal swabs or tissue must be sent for fungal culture in all patients with the slightest doubt of fungal infection to confirm the diagnosis. Early diagnosis, correction of any underlying cause and aggressive treatment is the key to a successful outcome.

Surgical treatment by Caldwe Luc and Fess is required .This is followed by corticosteroid, Itraconazole , antihistamines treatment.

Mastoidectomy is often indicated for other diseases that spread to the mastoid bone, such as cholesteatoma. Cholesteatoma is an abnormal skin growth in the middle ear behind the eardrum . Repeated infections and/or and a tear or retraction of the eardrum can cause the skin to form an expanding sac.

Cholesteatomas often devolop as cysts or pouches that shed layers of old skin, which build up inside the middle ear. Over time, the cholesteatoma can increase in size and destroy the surrounding delicate bones of the middle ear. Hearing loss, dizziness, and facial nerve paralysis rarely, also continued cholesteatoma growth may result in intracranial complications..

A mastoidectomy is also helpful in preventing further complications of mastoiditis. These include meningitis (infection in the fluid surrounding the brain), brain abscess (pocket of infection in the brain), or blood clots in the veins of the brain.
This procedure allows complete removal of these benign yet destructive growths.

Hearing tests and CT scan are also obtained prior to surgery.
A mastoidectomy is performed with the patient fully asleep (under general anesthesia). A surgical cut (incision) is made behind the ear. The mastoid bone is then exposed and opened with a surgical drill. The infection is then removed. The incision is closed with stitches under the skin. A drainage tube may also be placed.

Depending on the amount of infection or cholesteatoma present, various degrees of mastoidectomies can be performed.
In a simple mastoidectomy, the surgeon opens the bone and removes any infection. A tube may be placed in the eardrum to drain any pus or secretions present in the middle ear.
A modified radical mastoidectomy means that some middle ear bones are left in place and the eardrum is repaired-Tympanoplasty.
A radical mastoidectomy removes the most bone and is indicated for extensive spread of a cholesteatoma. The eardrum and middle ear structures may or may not be completely removed. Usually the stapes bone is spared if possible to help preserve some hearing.
Bleeding and/or infection of the wound area are possible complications with any incision. Antibiotics and good surgical technique help prevent this. Some blood-tinged drainage is common in the first two days.
Complications can include injury to the balance system, hearing loss, or facial nerve. Dizziness or a ringing in the ear (tinnitus) could also result.