LAPT-Laser Assisted Partial turbinectomy done under Local Anesthesia

CT Scan of the Sinuses showing chronic sinusitis

Eosinophils are white blood cells. Eosinophils are produced in the bone marrow and are normally found in the bloodstream and the gut lining. They contain proteins that help the body to fight infection from parasitic organisms, such as worms.

What is eosinophilia?

The term eosinophilia refers to conditions in which abnormally high amounts of eosinophils are found in either the blood or in body tissues. More than 500 eosinophils per cubic millimetre of blood are abnormal, and are called eosinophilia; this number usually amounts to more than 8% of all white cells.
In general eosinophilia arises as a response to parasites (such as filaria or helminths), or from allergy as occurs with asthma and allergic rhinitis, or in some gastrointestinal disorders that may be associated with food allergy.
A few drugs or inhaled allergens can cause inflammatory tissue changes accompanied by eosinophilia in susceptible people.

How does eosinophilia occur?

Increased numbers of eosinophils are produced to fight off allergic disease or parasitic infections. This is helpful in combating parasitic infections but not in cases of allergic diseases as they accumulate in tissues and cause damage. For example, in asthma, eosinophilia causes damage to the airways of the lung.

What are the symptoms of eosinophilia?

The symptoms of eosinophilia are those of the underlying condition. For example, eosinophilia due to asthma is marked by symptoms such as wheezing and breathlessness, whereas parasitic infections may lead to abdominal pain, diarrhea, fever, or cough and rashes.
Sneezing and nasal symptoms are common.

Medicine reactions often give rise to skin rashes, and they often occur after taking a new drug.

Rarer symptoms of eosinophilia can include weight loss, night sweats, lymph node enlargement, other skin rashes, and numbness and tingling due to nerve damage.

In India

In tropical countries like India, parasites are a common cause of eosinophilia, and there is often an association with asthma and allergic rhinitis.
Hypereosinophilic syndrome

Hypereosinophilic syndrome is a condition where there is no apparent cause for eosinophilia. In idiopathic hypereosinophilic syndrome occurs, with an eosinophil count in excess of 1500 cells per cubic millimeter of blood, and the heart or nervous system may be affected.

How is eosinophilia diagnosed?

Eosinophilia in the bloodstream is diagnosed from a simple blood test. Tissue eosinophilia is diagnosed by the examination of the relevant tissue.. Further tests may include blood tests to measure levels of antibodies, chest X-ray, CT scans of the chest and abdomen, skin or lung biopsies, examination of the bone marrow, and bronchoscopy.

Specific treatment for a parasite would necessitate first identifying the cause from a stool specimen, or from a blood specimen taken if there is fever.
If no abnormalities are found on a thorough physical exam, then no other tests may be indicated, although sometimes a biopsy of an involved organ may be appropriate. When there is evidence of skin allergy or asthma, it is usually necessary to use drug therapy.

Treatment

The first line of treatment would be antihistamines. The next to be considered would be oral corticosteroids. For predominant asthma, a trial for several weeks of an inhaled steroid would be appropriate along with an inhaled bronchodilator like ventolin.

Diethylcarbamazine
100 mg three times a day for 2-3 weeks. It is better to start the treatment after giving Albendazole/Zentel to get rid of any intestinal parasites.

Tropical eosinophilia

TPE is an immune hyperresponse to filarial infection. The syndrome includes a high eosinophil count, pulmonary symptoms and radiological changes, fever, dyspnea, and loss of weight.
Tropical pulmonary eosinophilia is reported from southern India, Sri Lanka, Malaysia, and Southeast Asia , caused by filarial parasites.

Diagnosing Tonsils and Adenoid

Examination of the tonsils by looking in the back of your child’s mouth using a light and mirror or a flexible telescope.
Your doctor may recommend a tonsillectomy if your child suffers from frequent bouts of tonsillitis or ear infections, or has breathing problems caused by swollen tonsils.
Xray of the Postnasal space shows enlarged adenoid.

Preop preparation

A tonsillectomy usually requires an overnight stay in hospital. If your child has a cold or infection in the week before the operation, please let your doctor know about it. The operation may need to be postponed until your child has fully recovered.
The operation is done under general anaesthesia. This means your child will be asleep during the procedure. Typically, your child must not eat or drink for about six hours before a general anaesthetic. Often the operation will be planned for the morning, so that your child will only have to miss breakfast.
The surgeon and anaesthetist will usually visit your child before the operation. Please tell them if your child has any allergies, loose teeth or any history of bleeding problems in the family.
You may be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

Operation

Most tonsillectomy operations are done in children under 15. The only effective treatment for recurrent and persistent tonsillitis is to have the tonsils removed. The tonsils will shrink in size as your child grows older, so an operation may not be necessary. Painkillers and antibiotics only provide temporary relief and are not used for long-term treatment. A viral infection won’t respond to antibiotics.
The operation usually takes about 30 minutes. There are several methods available for removing tonsils.

• Traditional Disection method - a special surgical blade is used to cut out the tonsils. Pressure is applied to stop the bleeding, and dissolvable stitches or heat is used to seal the wound.
• Laser Tonsillectomy

Post op period

Your child will be monitored and will need to rest on their side until the effects of the anaesthetic have passed. Your child will be groggy, and may feel or be sick.
Your child may complain of a sore throat, earache and a stiff jaw. Pain relief and antibiotics are usually prescribed for a week .
You should encourage your child to drink and eat as soon as they feel ready, starting with clear fluids such as water or apple juice.
After about 12 hours, a white or yellowish membrane -slough - will appear where the tonsils were. This is nothing to worry about and is not a sign of infection.
Your child will usually be ready to go home the morning after the operation. Before you go home a nurse will give you a date for a follow-up appointment.

Recovering from tonsillectomy

Once home, follow the surgeon’s advice about pain relief. You can give your child painkillers such as paracetamol or ibuprofen syrup .Follow the instructions in the patient information leaflet that comes with the medicine and ask your pharmacist for advice. Do not give aspirin to children under 16.
If your child is prescribed antibiotics it’s important to finish the course.
Get your child to drink plenty of fluids and eat. It’s best to start with soft or liquid foods which are easier to swallow. Giving your child a dose of pain relief half an hour before meals may help make eating more comfortable. Encourage your child to brush their teeth thoroughly, at least twice a day.
Your child should rest for a few days and stay at home to avoid contact with possible infections at school. Also keep your child away from crowded and smoky places, and from people with coughs and colds.
If your child develops any of the following symptoms, please contact your doctor or the hospital immediately if any bleeding from the nose or throat or a high temperature
You can expect your child to make a full and quick recovery once the initial pain has resolved. Complete recovery can take two weeks.

Side effects?

Tonsillectomy is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.
These are the unwanted, but mostly temporary effects of a successful procedure, for example feeling sick as a result of the general anaesthetic. Common side-effects include:
• sore throat, earache and a stiff jaw - these side-effects may last for up to two weeks
• bad breath - this usually improves after two to three weeks
This is when problems occur during or after the operation. Most children are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or infection. Antibiotics are usually prescribed to help prevent infection.
Specific complications of tonsillectomy are rare but include:
• bleeding within 24 hours - your child may need to go back into theatre to have it stopped
• bleeding four to seven days after the operation (secondary haemorrhage) - this can be the result of an infection
• damage to the teeth or jaw - this can be caused by the instruments used to keep the mouth open during surgery
• chest infection and breathing problems - there’s a risk blood and tissue from the operation may get into the throat and down into the lungs

Causes

They commonly occur in more general diseases such as asthma and cystic fibrosis.
Late onset asthma rather than childhood asthma is associated with nasal polyps. Of the patients with polyps 20% to 40% will have coexisting asthma. Although nasal allergy is present in some cases, more than two thirds of the patients show no evidence of systemic allergic disease. However, 90% of nasal polyps have eosinophilia- Absolute Eosinphil count will be high. These polyps tend to recur more than in other conditions. Nasal polyps are rare in children between the ages of two and 10 years. If found in children cystic fibrosis should be excluded.

Symptoms

Nasal polyps are common in both sexes.One-sided nasal polyps are rare and associated with a range of conditions and need further investigations both in adults and children eg.Antrochoanal polyp, Ringerts pappilloma
Polyps look like small grapes and can appear singly or in clusters in the nasal cavity. The can cause:
• Blocked nose
• Runny nose and/or sneezing are seen in about half of patients
• A poor sense of smell (Anosmia or Hyposmia) and taste which may not always return after treating the polyps
• Chronic Catarrh

Treatment

D N Endoscopy, where a small illuminated endoscope is used to see up the nose will exclude any infection or any unusual feature.

Medical treatment

Nasal polyps are known to shrink when nasal sprays or drops containing nasal steroids are used. Stronger steroids in drop form can be used but should only be used with care and limited to short courses because some is absorbed into the body.
Polyps respond and shrink using drops or sprays in up to 80% of people. New nasal steroid sprays can be taken to control symptoms for many years as very little is absorbed into the body and they can work well, but many take up to six weeks of treatment before their full effect can be felt.
Steroids in tablet form(Methyl Prednisolone, Defla cort) can provide good relief of symptoms but the effects are short-lived and they are used sparingly because of concerns about side effects. If medicines don’t work then surgery is needed.
Injection of Methyl Prednisolone 80 mg IM once in a month for 3 months can be tried.

Surgical treatment

Nasal Polypectomy. Nasal polyps blocking the nose can be removed surgically and this often helps the patient to breathe better. In three out of four patients the polyps come back after an average period of four years.
FESS.Functional endoscopic sinus surgery is the standard procedure to get the ethmoids opened and better removal of polyps.

Nasal blockage is the sensation of reduced air flow either through one nostril (unilateral) or both nostrils (bilateral). IT can be due to the following
• Mucosal swelling
• Septal deviation
• Collapse of the nasal valves
• Nasopharyngeal obstruction
• Nasal polyps

Allergic rhinitis
The mucosa is the thin moist lining that covers the bone and cartilage inside the nose.This occur in all types of rhinitis and sinusistis.
Vasomotor rhinitis
Clear mucus production is the primary problem with less nasal obstruction. This is due to overactivity of the glands in the nose.
Rhinitis medicamentosa
Overuse of some decongestant nasal sprays (Otrivine, Nasivion). These can help decongest the nose for a few hours if you have a cold but should not be taken for more than a few days as they damage the lining of the nose.
Chronic rhinitis and sinusitis
It is associated with a greenish mucus throughout the day.
Atrophic rhinitis -Ozena
Where neither allergy nor infection can be found yet the lining of the nose is swollen.
A range of rare conditions can affect the lining of the nose. These often cause a lot of crusting, spotting of blood and nasal obstruction. If there is a lot of crusting or whistling then your doctor may refer you to an ear nose and throat surgeon for further tests.

Septal deviation
The septum is a thin piece of bone and cartilage seperating the left and the right side of the nasal cavity. In some people the septum is bent or deviated over to one side and this blocks the air passage of the nose.
Septal deviation may be associated with a visibly deformed nose and a history of nasal trauma although it is not necessary as the cartilage may bend and deform as your nose grows.
Nasal obstruction is the predominant symptom, usually on one side. However, if other symptoms are present other disease processes must be excluded.
Management depends on the severity of nasal obstruction. Surgery to correct the deformity can be undertaken if the nose is blocked or unsightly.

Collapse of the nasal valves
Normally on breathing in through the nostrils there is a small amount of collapse of the nostrils.
Occasionally the problem is primarily due to a ‘floppy’ valve or side wall of the nose collapsing. Treatment using external nasal splints can sometimes be help at night. Surgery in this area is not straightforward.
Adenoids
The back of the nose just before it enters the back of the throat is called the nasopharynx. The adenoids are the most common cause of nasal obstruction in children reaching maximum size between the age of three and five and then reduce in size often by the age of seven or eight and can hardly be seen by the late teens.
Snoring alone is not an indication for adenoid removal but if the child also stops breathing while asleep (apnoea - stops breathing for more than 10 seconds regularly without a cold) then adenoidectomy and tonsillectomy may be helpful.
In children with a blocked nose on one side and a one sided nasal discharge, a foreign body may be in the nose

Treatment

Aim at the cause. Dont try to misuse OTC nasal drops without medical supervision. Please see an ENT surgeon and get examined to see the cause of nasal blockage and get the correct treatment.

Teething Trouble-Ear ache and Runny Nose
Teething can be a painful experience for your baby and an important milestone in child’s development

Telltale signs

1. Irritability and bad temper: As the new tooth rises closer to the surface your baby’s gums may become increasingly more sore and painful, leading to fussiness and crying.
2. Drooling and chin rash From three to four months of age you may see your baby start drooling more often than normal. Teething stimulates drooling, which may be worse with some babies than others. If your baby is a heavy drooler, the constant contact with saliva may cause the skin around the chin and mouth to become irritated.
3. Biting & gnawing: A teething baby will gnaw and gum down on anything. The counter pressure from biting helps relieve the pressure from under the gums and temporarily numbs the pain. Teething aids designed specifically for babies are safe and effective.
4. Ear ache and pulling: Pain in the gums may spread to the ears and cheeks particularly when the back molars begin coming in. This is why you may see your baby rubbing their cheeks or pulling at their ears. However, keep in mind that pulling at an ear can also be a sign of an ear infection, especially when accompanied by a fever.
5. Diarrhea: Most parents usually notice slightly looser bowel movements when a baby is teething. A recent study done by the Children’s Hospital in Australia found this to be the most common symptom of teething, yet many doctors still disagree and discount diarrhea as a symptom of teething. The most likely cause of diarrhea during teething is the extra saliva swallowed, which then loosens the stool. Report any diarrhea that lasts for more than three bowel movements to your doctor.
7. Crankiness and Trouble sleeping .You may find your child wakes more often at night. Most parents agree that night waking occurs more frequently when the molars are coming in.
6. Low-grade fever: A fever is another symptom that doctors are sometimes hesitant to directly link with teething. Many parents however find their baby gets a low-grade fever while teething. Notify your doctor if the temperature rises above 39C (102F) or if the temperature remains elevated for more than 2 days.
8. Cold like symptoms -runny nose and nasal congestion: Some parents find that their baby displays cold-like symptoms when teething. Runny noses, coughing and general cold symptoms are believed to be a result of frequent hand-to-mouth movements in an attempt to alleviate the pain. Notify your doctor if cold-like symptoms occur for more than 3 days and do not improve on their own.

What can be done?

Let your child chew on a cold, hard object, such as a teething ring. The coldness helps ease the discomfort and the hardness will speed up the eruption of the tooth.
Massaging your child’s gums with a clean finger can help reduce pain and discomfort during teething.
Teething gels or ointments are used to numb the gums and reduce the discomfort.
Medicine - If your baby is having trouble sleeping or is especially cranky, acetaminophen or ibuprofen may help. Paracetamol might help if your baby has a fever. Check to ensure the medicine is suitable for a baby of your child’s age. Decongestants (Phenergan, Dimotap) also help to reduce nasal congestion.

Ear Drops. Most children have to be examined to rule out any fungal or bacterial infection of the ear. An analgesic ear drops will help to ease the pain.

Atrophic rhinitis (Ozena) is a rare chronic inflammatory disease that affects the lining of the nasal cavity. This condition is characterized by a wasting away or an atrophy of the bony ridges and the mucus membranes inside of the nasal cavity. It is characterized by progressive nasal mucosal atrophy, nasal crusting, fetor, and enlargement of the nasal space with paradoxical nasal congestion.
The nasal cavities are roomy with lot of crusts which is foul smelling.
Exact cause unknown, but Endocrine, nutritional deficieancy, autoimmune causes, infective etiology are blamed.

Pathology

The ciliary epithelium is replaced by stratified squamous epithelium, atrophy of mucous glands.The turbinates also atrophy.

Symptoms

The symptoms include nasal crusting, discharge, and a bad odor

Examination of the nasal passage shows greenish discharge. Septal perforation may co exist.

Treatment

Nasal irrigation with alkaline solution(1 litre boiled and cold water add 1 tsp salt, sugar and soda bicarb) or normal saline.
25%glucose in glycerin nasal drops
Local antibiotic ointment, drops
Systemic antibiotics with anerobic cover.

Surgery

The aim of surgery is either to narrow the nasal cavity or in special cases to close the nostril. Closure of the nostril (Young’s operation), is achieved by raising a circular skin flaps. Raising the skin flap is difficult, the suture line may break down and an excessive scar tissue may form resulting in vestibular stenosis.

Modified Young’s operation aim at partial closure of nostrils one at a time.

Prognosis

There is a tendency to recover spontaneosly.

Having a cold or Flu?

The cold and flu are both respiratory illnesses, but they are caused by different types of viruses.

Flu symptoms usually come on quickly (within 3-6 hours) and consist of a fever, body aches, dry cough, and extreme tiredness. Cold symptoms are less severe and people experience a stuffy nose, productive cough, slight tiredness, and limited body aches.

Flu Virus
Influenza A and B viruses are responsible for seasonal flu epidemics each year …

Symptoms

Avoid Getting a Cold and Flu

Wash your hands often. You can pick up cold germs easily, even when shaking   someone’s hand or touching doorknobs or handrails.

Avoid people with colds when possible.

Sneeze or cough into a tissue and then throw the tissue away.

Clean surfaces you touch with a germ-killing disinfectant.

Don’t touch your nose, eyes, or mouth. Germs can enter your body easily by these paths.

A flu shot can greatly lower your chance of getting the flu.

What to do then?

Drink plenty of fluids.

Get plenty of rest.

Use a humidifier — an electric device that puts water into the air.

Avoid alcohol and tobacco

Antibiotics rarely help

Medicines