How to excise an epithelial inclusion cyst over cheek in a young modelling girl?

Epithelial Inclusion cyst of the cheek -two in number

Dr. Arjun Das

Make direct incision on the lesion skin deep. Remove the lesion in toto. Fine suturing. Facial nerve is deep.

Dr. Ajay Jain

Sir, thank you for answering.  she do modelling and do not want any scar on her face.   I was thinking of Bailey incision

Dr. Athira Ramakrishnan

I was having a parallel discussion with a plastic surgeon, small direct incision with immediate post op silastic sheet application was suggested

Dr. Ajay Jain

Hi how does silastic Sheet help here

Dr. Athira Ramakrishnan

It is supposed to hydrate the scar and reduces marks, apparently that is quite the thing to avoid scarring or keloid, it comes in trade name Lysil, think should consider it especially for patient of her profile. It should be applied after suture removal, everyday for a month or so.

Dr. Madhusudan G

*Vertical incision... Just over the lesions, just enough to remove..
*Please make sure you infiltrate xylo+ adr so that the field is bloodless... So that avoid cautery which might touch the skin edges
*Liberal undermining if you plan to excise an ellipse of skin to avoid tension along suture line
*closure- PDS/vicryl rapid/monofilament absorbable interrupted with knot inside followed by 8/0 ethylon for skin with half mattress closure
*scar support with STERISTRIPS for first 5-7 days till the wound heals
*suture removal in 3-4 days followed by continuation of STERISTRIPS.
*scar treatment from 2nd week either by silicone gel sheet/ chin strap at nights/ silicone creams whichever is suitable for the patient for long term usage for at least 3 months with sun exposure avoidance and sunscreens....
Each and every step is crucial for the best final scarring..
Though it looks very lengthy... It is the successful formula for best scar...
At last, the patient commitment for the scar treatment holds the key..
* for subcutaneous closure use PDS/ vicryl rapid 5/0 or less.
*Post op care - regular massage with scar repair creams available in the market- CONTRACTUBEX / HEXILAK / scar repairex anything is fine, but massaging with good pressure is must.

Dr. Satyawati Mohindra

Any body having experience ?Is there no way to go trans buccaly so that you do not touch the skin at all ?Very informative indeed. Thanks adhira and madhu.

Dr. Hitesh

Mam I removed lipoma transoral in same region. Incision on buccal mucosa and blunt dissection will protect facial nerve.

Dr. Ajay Jain

Lipoma is more deeper.  So may be suitable for intraoral approach.  Epithelial inclusion cyst is just underneath the skin and that too two in number and on cheek.   You need head on to separate it well from skin.  Bailey incision could be a suitable alternative.   Any comment on that.

Dr. Satyawati Mohindra

Basically we are tempted to think about trans buccal route for the same reason.You are right ajay but whatever you do there is going to be a scar. The skin is thinned out already. The lesion looks bluish . Are you sure it is epidermal inclusion. Not some hemangioma or something else.[9:10 AM, 9/18/2016] Satyawati Mohindra: Another thing ajay.[9:09 AM, 9/18/2016] Satyawati Mohindra: Bailey incision is also unlikely to help because the cyst is very close to skin. It looks you are likey to have a button hole once to try to separate from skin.        

Dr. Athira Ramakrishnan

Excision entirely knife dissection will help reduce soft tissue manipulation and scarring 

Dr. Mohnish Grover

Wow. Nice discussion on this topic.. lipomas and epidermal inclusion cyst are very dffrnt esp in this area.. as dr ajay said lipoma is much deeper so amenable to intraoral excision. Epidermal inclusion cyst is very superficial, bound to hv a button hole if we do intraoral. A controlled scar here is better than that. Also epidermoids can have that bluish tinge. Its not uncommon. It actually indicates that cyst is superifical.           

Dr. Anandabrata Bose

Excellent discussion. I would go by direct approach and use the facial lines to minimise scars. Even with baileys lot of mobilisation is reqd with a possible button hole close to the cyst. Thay would be bad scarring. Secondly with baileys going to neck produces a scar and with limited exppsure traction and working under a tunnel is uncomfortable unless using robotics!!  I have no experience with silastic gel. How do you use it please?

Dr. Athira Ramakrishnan

Sir, a small portion of that sheet has to be cut and the adhesive surface has to be kept on the scar, entirely covering it, it flattens and hydrates the scar

Dr. Anandabrata Bose

Thanks i will try it.

Dr. Prahalad NB

It up folks. Quite an education for us.  great discussion. Keep it up

Best position to examine a Child's ear.

Ideal position to examine a kid's ear.

Superficial Parotidectomy for Pleomorphic Adenoma.

Submandibular and Submental cellulitis and abscess drainage.

Multiple lateral tongue cysts.

Parotid calculi

Note a small calculi in right parotid gland.

A 45 year gentleman presented with history of two episodes of Rt cheek swelling which responded to conservative treatment. CT showed a small 3.1 mm calculus in rt parotid duct near the parenchyma of parotid gland.

Quote

No surgery is minor and no surgery is major. Appropriate case selection and the trust of the patient is vital to successful outcome.

Anomalous vascular loops in close relations to vestibular cochlear nerve complex as possible cause of tinnitus

Anomalous vascular loops are seen in close relation to vestibulo-cochlear nerve complex on either side at the exit zone (CISS seq uence). Vestibulo-cochlear nerves on either side are normal in course and caliber.

Inner ear anatomy is well defined with normal apical, middle and basal turns on both sides.

All three semicircular canals are normally visualized.

The saccule and vestibule are normally visualized.

Bilateral trigeminal nerves are normal in course and calibre with a normal course at the origin and in the region of the Meckel's ca ve on either side.

Bilateral mastoid air sinuses are normal.

IMPRESSION MR FINDINGS ARE SUGGESTIVE OF ANOMALOUS VASCULAR

LOOP AT THE EXIT ZONE OF VESTIBULO-COCHLEAR NERVE COMPLEX ON EITHER SIDE.

Endoscopic powered Adenoidectomy

This is one surgery in ENT where a blind person can do this surgery. Are you surprised?. I am not kidding. In fact, this surgery is still done blindly by many ENT Surgeons. Adenoid tissues, which are like tonsils but placed behind the nose, is not easily visible. In a child of 3-4 yrs of age, sometimes it is not possible to put typical 4 mm nasal telescopes through nose which is commonly available with ENT surgeons. So, surgeon feels the adenoid tissues through putting a finger through the mouth and with help of specially designed shavers, shaves them off without actually seeing them.

This is no more scene now specially with availability of angled microdebriders. This is wonderful to work like as you are working on a video game but here the real stake is a youngster kid and a little overconfidence may prove detrimental. you have to be very careful not to go too deep with Microdebrider unless it will chop off normal mucosa also.

A typical Microdebrider blade costs roughly around Rs. 6000 INR and most of the insurance company have not recognized this cost and the efforts involved in this endoscopic surgery precluding this as a viable option for many of ENT colleagues. Microdebrider itself costs around 400000/- INR. No wonder, this is not widely available.

Study of Middle ear through perforated ear drum

Almost subtotal perforation of ear drum showing Incus, Incudostapedial joint, Stapes, facial nerve, stapedius tendon, round and oval windows. Identinfy and correlate with next photograph.

Korner's septum

Congenital Cholesteatoma

Better do MRI in case of congenital cholesteatoma as CT will not tell about extension from intracranial part or ruling out CPA cholesteatoma.  Also do MRI after surgery to rule out cerebritis or abscess after surgery.   

X-Ray Adenoid-which view is better-Open Mouth or close mouth

Soft tissue x-ray of Adenoid in lateral position. Compare the view obtained with open mouth and close mouth.

I often see x ray of lateral view of adenoids taken with mouth open. Perhaps that is common belief with radiology technician that all x rays ordered by ENT Surgeon have to be taken with mouth open.

You yourself note that how misleading is the x ray with mouth open. What we are seeking from this x ray is that air passage between adenoid tissues and soft palate. If we keep mouth open, then that air column never forms. So such cases many undergo mistakenly for adenoidectomy.

I hope that my radiologist and ENT friends will spread this message to x ray technicians and correct the positioning of the child for such x rays.

Aphthous ulcer over left tonsil was beign treated as Acute tonsillitis.

Hi This gentleman was being treated with antibiotics for left side throat pain. When I examined him, I found an aphthous ulcer over left tonsil which requires probiotics and NOT antibiotics.

The treatment of these two conditions are different. In fact, Antibiotics may enhance the formation of Aphthous ulcers by killing friendly bacteria of the mouth. These friendly bacteria are essential part of defense mechanism  of oral mucosa.  Such patients do respond to probiotics (present naturally in curd), multivitamins (especially B Complex groups) and local protective gel (glycerin). Passing motions regularly, Exercise, good sleep, maintaining good dental hygiene, High fiber diet and avoiding excess use of tea/alcohol/ caffeine/tobacco and junk foods helps in early healing of ulcers.

Noise induced hearing loss audio gram

Note dip in hearing especially at 4 KHz characteristics of noise induced hearing loss.   

Oral lichen planus

Benign lesion of Larynx appearing like malignancy

An arrow shows the vocal cord lesion. please note the appearance of white slough over the lesion looking more sinister in favour of malignancy

This 50 year gentleman presented with hoarseness of voice for last 18 months. He is non smoker and runs a shop where he has to speak a lot.

He underwent Microlaryngal surgery GA. It was a difficult case as the growth appeared to be pedunculated and appeared to have originated from just below anterior commissure (or just adjacent to anterior commissure from undersurface of left vocal cord).

Histopathological examination of excised specimen showed fibrinoid areas with fibrovascular core with underlining stratified squamous epithelium.

Now he is advised Voice therapy along with anti inflammatory therapy in form of enzymes and low dose steroids for few days.

He is advised to have regular follow up.

CT Scan photographs of Atrophic Rhinosinusitis.

Giant keloid behind the ear

Keloid is a hypermature scar with

Vascular (having good amount of blood in it)

Itching

Spreading

Tender

The treatment of keloid is extremely difficult sometimes. Such big lesions have to be excised meticulously under microscope sometimes and to prevent recurrence, weekly subcutaneous injection of Kenacort (steroid) and Hyluronidase ( enzymes) are given. Oral steroids may be given rarely if benefit outweigh the risks of steroids.

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