Laryngology Cases

Station 1:

mouth_gag.jpg

What is this surgical position called ?

Name the advantages of this position.

This is known as Rose position. This position is used in tonsillectomy.

In this position there is hyperextension of neck. This is achieved by

placing a sand bag under the shoulder of the patient. There is flexion

of the atlanto occipital joint.

Major advantage of this position is that since the larynx lies at a higher

level in comparison with the oral cavity, there is virtually no risk of aspiration.

There is excellent exposure of oral cavity and its contents. Both the hands of the surgeon are free.

Station 2:

Name the clinical importance of pyriform fossa:

1. Anatomically this is a hidden area. Any malignancy in this area would remain silent till it reaches an advanced stage.

2. This area is richly supplied with lymphatics, any malignancy in this area can easily spread to lymph nodes.

3. Foreign bodies easily get lodged here

4. Superior laryngeal nerve lies in a submucosal plane. To anesthetize this nerve a gauze piece dipped in 4% xylocaine can be placed here.

(Pyriform fossa block)

Station 3:

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Describe this lesion

Proliferative mass seen arising from medial wall of right pyriform fossa

Pooling of saliva could be seen in the right pyriform fossa (Jackson's sign)

Station 4:

Name the causes of Positive Jackson's sign

1. Malignant growth involving the deep portion of the pyriform fossa

2. Foreign body being lodged in the pyriform fossa.

3. Growth involving the crico pharynx or upper oesophagus can also cause pooling of saliva.

Station 5:

mem_tons.jpg

13 years old boy came with c/o pain in the throat (intense) 4 days

Fever ++

Describe this lesion.

Differential diagnosis

Acute membranous tonsillitis.

D/D:

1. Agranulocytosis

2. Infectious mononucleosis

3. Diphtheria

4. Oral thrush

5. Acute streptococcal tonsillitis

6. Vincent's angina

Station 6:

tonsillitis.jpg

1. Comment on the grade of tonsillar enlargement.

2. Comment on the anterior pillar

Grade III tonsillar enlargement.

Anterior pillars are congested, a feature of chronic tonsillitis

Station 7:

tongue_tie.jpg

1. What is the diagnosis ?

2. How do you treat this condition ?

Tongue tie. Normally one should be able to protrude the tongue up to half way point between the lowerlip and chin.

In patients with tongue tie this is not possible as the tongue is fixed to the floor of the mouth.

Tongue tie release operation and speech therapy following surgery to improve patient's ability to speak normally.

Station 8:

subman.jpg

Palpate the lesion.
What could be the probable diagnosis ?
what is the treatment ?

Stony hard mass in the submandibular duct area.
Submandibular duct calculus
Excision of submandibular salivary gland.

Station 9:

thyro_glocyst.jpg

What could be the possible differential diagnosis ?

Name the clinical tests you wound do in this patient ?

Thyro glossal cyst

Thyroid swelling

Dermoid cyst

Infected lymph node

Lipoma

Sebaceous cyst

Hypertrophic pyramidal lobe of thyroid gland

On asking the patient to swallow both these swellings move upwards.

On protrusion of tongue, thyroglossal cyst moves upwards as its tract is commonly attached to the base of tongue

Station 10:

Why is calculi common in submandibular gland?

Submandibular gland is mucinous in nature.
Its duct "Wharton's duct" is placed in a non dependent position (antigravity)
Parotid duct is sqeezed intermittently by the buccinator muscle, where as wharton's duct is not squeezed by any muscle

Station 11:

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Comment on this laryngoscopic finding
What is the causative organism ?

Epiglottis is edematous and inflammed.
Haemophilus influenza

Station 12:

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50 year old individual with c/o swelling in the floor of mouth and pain over the neck - 3 days
Drooling of saliva ++
Known diabetic under poor glycemic control - 15 years

What is the probable diagnosis ?

What are the criteria for this diagnosis ?

Ludwig's angina

To diagnose Ludwig's angina the following features should be present:

1. Rapidly spreading cellulitis with no specific tendency to form abscess.

2. Involvement of both submaxillary and sublingual spaces, usually bilaterally

3. Spread by direct extension along facial planes and not through lymphatics

4. Involvement of muscle and fascia but not submandibular gland or lymph nodes

5. Originates in the submaxillary space with progression to involve the sublingual space and floor of the mouth.

Station 13:

kp_1.jpg

What is the white spot seen over the superior pole of tonsil ?

Will tonsillectomy help this patient ?

Keratosis tonsil.
It is known to recur even after removal of tonsil.
Mouth gargling using hypertonic urea solution helps.

Station 14:

pleo.jpg

This patient came with H/O swelling hard palate - 6 years
What could be the possible diagnosis ?

Ectopic salivary gland tumor of palate
Exostosis of palate

Station 15:

Watch this video.

What could be the possible cause for this problem?

This video shows bilateral lingual tonsil hypertrophy.
Possible causes include:
Foreign body
Chronic post nasal drip
compensatory hypertrophy following adenotonsillectomy
GERD

Station 16:

20 years old male patient came with C/O:

Change in voice - 2 weeks
H/O GERD ++

Laryngoscopy:

rinke.jpg

What could be the possible diagnosis?

Reinke's oedema.
Possible treatment modalities include:
Antireflux therapy
Voice rest
Surgical stripping of redundant mucosa over vocal folds

** Station 17 **

Shown below is a video laryngoscopic examination done on a patient.

Comment on this finding.
What could be the primary complaint of this patient?
What precaution should be taken prior to surgery in this patient?

A large cystic lesion could be seen arising from left aryepiglottic fold. The cyst could be seen completely occluding the laryngeal inlet.
This patient would have presented with stridor.
Elective tracheostomy should be performed to facilitate easy intubation during anesthesia.

Station 18

Given below is a videolaryngoscopy video.

Describe the findings.

Enumerate two causes that could cause this problem.

Left vocal cord is paralysed.
It lies in the cadaveric position.
Right cord mobile.
Right arytenoid crosses over over-riding the left arytenoid.
Glottic chink++ Phonatory waste ++

Causes of left vocal cord palsy include:

1. Idiopathic
2. Thyroid malignancies
3. Following thyroid surger4. Left vocal cord is commonly paralyzed because of the long tortuous course taken by the left
recurrent laryngeal nerve

Station 19:
This 58 years old female patient came with complaints of:

1. Foul breath - 6 months

2. Pain in the right side of throat - 2 months

3. Patient also gave history of recurrent episodes of tonsillitis

On examination:

tonsil_lith.jpg

What could be the probable diagnosis?
How will you manage this condition?

It is a tonsillolith.
Unilateral tonsillectomy should be performed after treating the acute inflammation with antibiotics and antiinflammatory drugs.

Station 20:

30 years old female patient complains of swelling in the inner side of right upper jaw - 14 years.

Progressively enlarging in size. No h/o pain or bleeding.

On examination the mass was circumscribed and hard, attached to the inner alveolar border of left maxilla.

What could be the probable diagnosis?

List out the indications for surgery in this patient

torus.JPG

Probable diagnosis is torus mandibularis.

Indications of surgery include:

1. Before fitting a denture
2. Rapid enlargement of the mass
3. As a source of autologous bone graft

Station 21

glott_web.png

Shown above is the image captured during videolaryngoscopic examination.

This 10 years old boy presented with tracheostomy done 4 years back for stridor.
He wanted to be extubated. He also gave h/o prolonged intubation and ventilatory
support following a suicide attempt.
What is the ideal treatment for this patient?

The image shows posterior glottic web.

Arytenoidectomy with resection of posterior glottic web

Station 22

vc_cyst.png

This 30 years old female patient came with c/o hoarseness of voice - 6 months duration.
She gave no h/o voice strain / abuse.
She gave no h/o repeated URI.
Videolaryngoscopic image is given above.

What is yr impression?
What could be the optimal treatment modality?

This patient appears to be having a cyst in the right vocal cord.
Probably it is a cordal cyst.
Treatment is by microlaryngeal marsupialization of the cyst.

** Station 23**

ling_thy.JPG

This 6 years old girl came with c/o swelling behind the tongue - 2 years duration
What could be the probable differential diagnosis?
1. Lingual thyroid
2. Vallecular cyst
3. Cystic lingual tonsil

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