Iatrogenic Septal Perforation

Septal perforation is a possible complication of septal surgery. Commonly such patients complaints of dryness of nose and occasional whistling sound (very small perforation).

Various factors play a role in formation of these perforation. Most important is handling of flaps on both sides of cartilage. Ideally one septal flap should be lifted intact. (But that is no guarantee that septal perforation will not happen). next even if accidental tears happen on both side of nasal septum then they ideally should not be at same location. Even if that happens then make it sure that a good piece of septal cartilage or bone lies in between the tear.

Try to give quilting suture to hold both flaps in contact so that no dead space forms and do a soft packing so that by pressure blood supply of flap is not hampered with.

Give good broadspectrum antibiotic cover and keep both flaps lubricated or moist with saline spray.

Pigmented lesion just under the ear lobule skin (Epithelial inlusion cyst)

A pigmented lesion just beneath the skin is seen with a hole on skin surface noticed for last few weeks.

Excised specimen

Epidermal inclusion cyst on Histopathological examination.

PUBERPHONIA (Female voice in a male)

          Dr. Ajay Jain, MS (PGI, Chandigarh), DNB, Sr. ENT Consultant

Himani Tyagi, MASLP (AIISH, Mysore) Audiologist, Chacha Nehru Baal Chikitsalya

Bindu, MASLP (AIISH, Mysore)

The persistence of adolescent voice even after puberty in the absence of organic cause is known as puberphonia. The condition is commonly seen in males. Normally adolescent males undergo voice changes due to sudden increase in length of vocal cords due to enlargement of thyroid prominence (Adam’s apple). This is uncommon in females because their vocal cords do not show sudden increase in length. This sudden increase in length of vocal cords is due to sudden increase in testosterone levels found in pubescent males. Children reach puberty around 12 years of age when their hormone levels begin to become elevated. In males, this is also the age when their larynx has a rapid increase in size. The vocal cords become longer and begin to vibrate at a lower pitch (or frequency). This explains why most males go through the period of voice breaks. The vocal cords are trying to adjust to their new dimensions. No such laryngeal changes take place in females who continue using a high pitched voice. The incidence of puberphonia in India is about 1 in 9,00,000 population. Even though the incidence is low, for an individual it causes social and psychological embarrassment.

In infants laryngotracheal complex lies at a higher level. It gradually descends. During puberty in males the descent is rapid, the larynx becoming larger and unstable and on top of it the brain is more accustomed to infant voice. The boy may hence continue using high pitched voice even after puberty or it may break into higher and lower pitches

Case Report:

21 years old male came to ENT OPD Yashoda Super specialty  hospital with complaints of persistence of adolescent voice since childhood. There was an inability to raise his voice with frequent pitch breaks. And he complained of voice fatigue. He was psychologically depressed due to social embarrassment.

On examination his Adam’s apple was prominent. Laryngeal contour normal. Gutzmann pressure test (external downward pressure on the thyroid cartilage will often evoke normal sounding voice) was positive. Secondary sexual characters developed normally. Psychological evaluation shows the patient was psychologically disturbed. Initially he was referred to speech therapist and completed a course of voice therapy but he did not show any improvement . He was emotionally disturbed and anxious to get normal adult voice. So isshiki type 3 relaxation thyroplaty was planned under local anesthesia

Procedure:

Procedure was done under local anesthesia. Previously patient was put on nil per oral for 6 hours. A 1 and half inch incision given over proximal neck crease.

With gentle dissection thyroid cartilage was exposed.

Two incisions were given just 3 mm parallel to midline and anterior thyroid cartilage was pushed posterior so that lateral thyroid cartilages override the midline thyroid cartilage.

CONCLUSION

Even though speech therapy is the most accepted management modality in managing these patients, in extreme cases if the situation warrants a surgeon should extend his longest arm to rescue the patient

Bilateral Sloughed vocal cords in a case of non hodgekin lymphoma patient on chemotherapy and diabetic.

Bilateral sloughed vocal cords in a case of NHL and diabetic person.

On biopsy, not a single drop of blood came out and the picture was like of Mucormycosis of paranasal sinuses. Such thing is rare in vocal cords.

Association of Otolaryngolgist of India life membership certificate

Right peritonsillar abscess

Drainage of peritonsillar abscess works like magic.  Within 24 hours of drainage, smile of the very sick patient comes back.  Pain is gone almost immediately.   

This particular patient presented with short history of severe pain and difficulty in swallowing. She was not responding to treatment by family doctor.  She was diagnosed with peritonsillar abscess in my Clinic and advised the incision drainage.  

She was taken to minor OT.  1 ml of 2 plain xylocaine was injected in right peritonsillar fossa.  She felt immediate relief in pain.  With hydrostatic pressure, her abscess ruptures through one of tonsil crypts and foul smelling thick pus came out which was collected for culture and antibiotic sensitivity.   

Usually a small incision is given over anterior tonsil pillar to release the abscess.  If incision is not given, the pus may track into deep neck spaces and even into chest causing severe life threatening complications.  

Fordyce spots in oral cavity