Removal of Adenoids and Tonsils:Which technique?How to take decision?

Removal of Adenoids and Tonsils/Adenotonsillectomy is commonly indicated in the following conditions:

1. Recurrent infections:more than 3-4/years for 2 consecutive years 
2. Upper airway obstruction due to enlarged tonsils and adenoids
3. Peritonsillar Abscess
4. Asymmetrical Size of Tonsils
5. Adenoidectomy especially if recurrent middle ear infections or sinusitis in children

Surgical Removal of adenoids and Tonsils can be done through following techniques:

in the order of older to newer techniques as they evolved.We shall discuss how we decide which technique to be used at the end of the article.

• Cold knife (steel) dissection:Gold old method using surgical dissection of tissues with bleeding controlled with taking ties.
• ElectrocauteryThermal Dissection
• Harmonic scalpelThis medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second.
• Radiofrequency ablationMonopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis. However, tonsils may re-grow after this procedure.
• Carbon dioxide laserHand-held CO2 or KTP laser to vaporize and remove tonsil tissue.  
• MicrodebriderThe microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery.  
• Bipolar Radiofrequency Ablation (Coblation):This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs.

I have personally been trained and used all above techniques.Harmonic Scalpel and Coblation while training in the U.K.I also learned Bipolar Tonsillectomy which if used carefully gives good outcomes.

As a Surgeon,my decision to use any particular technique depends on following factors :

• I have to first be familiar and learn each technique.
• Then go through medical literature about randomised controlled trails and their results about each technique.
• Availability of equipment in my setting
• One technique or combination of technique
• What has worked for my patients so far in terms of less bleeding and less pain
• Lastly..Do No Harm.

Tonsils can be examined in the opd on oral examination.

I must make a special mention about Adenoids here.Anatomically the adenoids sit at the back of the nose,behind and above soft palate.Here is a picture of nasoendoscopy done in the opd (picture 1) to look for the size of adenoid(picture 2)

The approach to adenoid has improved with endoscopes through the nose.There is a risk of incomplete removal of adenoids with traditional method.Newer techniques like Microdebrider and Coblater will ensure complete removal and avoid regrowth.

I am very comfortable to use dissection Technique for tonsillectomy with minimal bipolar for hemostasis with excellent outcomes in the last 9 years.For Adenoidectomy,I use Microdebridor or Coblator.

What medical literature says..these are articles from Medline Database

Laryngoscope. 2009 Jan;119(1):162-70. doi: 10.1002/lary.20024.
Comparison of three common tonsillectomy techniques: a prospective randomized, double-blinded clinical study.
Wilson YL1, Merer DM, Moscatello AL

Otolaryngol Head Neck Surg. 2003 Oct;129(4):360-4.
Hot versus cold tonsillectomy: a systematic review of the literature.
Leinbach RF1, Markwell SJ, Colliver JA, Lin SY

Cochrane Database Syst Rev. 2007 Jul 18;(3):CD004619.
Coblation versus other surgical techniques for tonsillectomy.
Burton MJ1, Doree C

Dear Patient "Lets talk simple..not Google"...

 Particularly in 2014 ,I felt more & more patients have been expressing themselves in medical terms.
"Doc,I have sinus..I have bent nasal bone"..
"I have chest congestion"
This could have been expressed as headache,facial pain or nose block or a difficulty in breathing.

In medical school,we were taught to take a history which is asking symptoms like pain in ear/throat,block,discharge and so on..
Then we need to examine & look for signs of the disease.

A combination of signs, symptoms & clinical examination leads to a diagnosis.
This diagnosis can be final or provisional.
In provisional diagnosis ,we need further tests or another visit for a final diagnosis.

Patients should lead us to diagnosis rather than expressing the diagnosis themselves.

Another new in the passing year is the stress on time spent.This is not dependent on the successful diagnosis reached.
The same symptoms will be told by patients in various ways & it eventually means the same to me.Hence sometimes,I may have to stop them & come to the diagnosis & treatment.

Even a viral cold needs attention & empathy.However due to the pressure of seeing various patients,some having tumor or cancer or disability, I am hard pressed to spend less time with above patients. 

In the treatment- things like after food or before food tablet is necessary.If I miss it patients do ask repeatedly & its fine.

Look at following questions I have been repeatedly asked:

Salt warm water gargles is with common salt/iodised/rock salt?
How to take steam inhalation?
To apply ointment over skin before food or after food ?

Sometimes in practice these questions can be annoying.
Probably I am from old school of thought.
I do understand that except boiling water,there are various options for steaming available now like an electric steamer or sauna!

Lets stand together & hope even better relationship with patients in the coming year.... 

Google and internet searches are also required.Search Engine optimization is also there....Be careful on fully trusting all information on the net.

Alexander Graham Bell Association’s Recommended Protocol for Audiological Assessment, Hearing Aid and Cochlear Implant Evaluation, and Follow-up | Listening and Spoken Language Knowledge Center | AGBell

Alexander Graham Bell Association’s Recommended Protocol for Audiological Assessment, Hearing Aid and Cochlear Implant Evaluation, and Follow-up | Listening and Spoken Language Knowledge Center | AGBell

Status of DRDO's Indigenous Cochlear Implant & my interview with MINT

I was interviewed recently by MINT (Mint is India's second largest business newspaper published by HT Media Ltd, the Delhi-based media group which also publishes the Hindustan Times) 
Kindly read the third article in the link attached..DRDO is hopefully ready with indigenous cochlear implant for trails.Thanks to the efforts of Prof.Abdul Kalam & recent push by Prime Minister Narendra Modi.
Once it is commercially available ,so many kids will benefit..eagerly waiting. 

just a little correction as you read the article.. you will read..hearing aids are only useful in mild hearing loss..this is not correct.During interview I have mentioned every child with hearing loss mild,moderate,severe & profound is first given hearing aids & speech therapy.
Its the severe to profound one who do not develop language & communication with hearing aids need cochlear implant.

here is the article copied..

DRDO TO SEEK APPROVAL FOR CLINICAL TRIALS FOR BIONIC EAR

New Delhi: Bionic ears, or artificial hearing devices that are partly implanted under the scalp, could be made in India in the near future, bringing down their prices by nearly a sixth and benefiting thousands of people suffering from significant hearing loss.

India’s Defence Research and Development Organisation (DRDO), which developed these devices, has completed two-year-long tests to ensure the human body does not reject these implants. It will seek approval from the Drug Controller General of India (DCGI) this month to carry out clinical trials, before starting commercial production.

The bionic ear, or cochlear implant, picks up sound, converts it into electrical energy and feeds it to the auditory nerve which goes to the brain, which perceives it as sound. The cochlea is the auditory part of the internal ear.Though the first cochlear implant was approved by the US Food and Drug Administration in 1985, the prosthesis is still not affordable for most, especially in developing countries.

“DRDO will produce a bionic ear which will not cost more than `1-1.5 lakh, and will be the world’s cheapest cochlear implant,” said Bhujanga Rao, director general (naval systems and materials), DRDO. “With the help of philanthropists and governments, the prices can come down further,” he added. More than 3,00,000 people across the world are already using such implants, as against 5,000 in India, according to Rao.

“The final results will be out after eight months to one year, after which production can begin. The observation will take time as a person needs to be given time to heal after the surgery for implantation of the device,” Rao said.

He added that it has been decided that 50 people will be part of the clinical trials, five in 10 centres, overseen by ethical committees. The final details are still being worked out.

“A doctor once told me, for every implant that he is doing, he is turning away 100 patients. That is the gap in demand in India,” said Rao. More than 90% of the market for cochlear implants is cornered by three companies from Australia, Austria and the US, and the implants sold by them cost `6 lakh and above, said Rao.

Cochlear implant surgeries are state funded for children in European Union countries and the US because of the high cost. In India, there have been a few attempts by some state governments to make these expensive surgeries free for the poor or be financed through insurance schemes in designated government hospitals. In 2009, the health ministry had issued a notice saying that it would reimburse as much as `5,35,000 for cochlear implant surgeries of children, but only after it is approved by a standing committee of experts.

Lack of awareness, even among people who can afford the expensive procedure, is also a hindrance, experts say.

“The problem, however, is not restricted to affordability, but lack of awareness, lack of early diagnosis and groundwork. Even parents who can afford these implants for these children often do not know about the available options, or they are too late in getting the implant,” says Sheelu Srinivas, a surgeon with Fortis Hospital in Bangalore. “Statistically most of the children in India get cochlear implants after they turn five years old by which time most of the cerebral growth is over, but cochlear implants can only be effective if they are implanted in a child till she turns two.”

The device is usually implanted before a child turns two, as the brain has a tendency to slowly disable the audio cortex from functioning in the absence of sound stimulus. Conventional hearing aids can only help those suffering from mild hearing loss.

“Cochlear implants also involve a lot of signal processing, irrespective of the language. The brain has to understand all languages. We have to make a common brain language using signal processing,” said Rao, who is also a distinguished scientist. “This implant can enable a person to hear frequencies ranging from 100Hz to 8kHz, which can include telephonic conversation, normal speech to loud music,” he explained.

The cochlear implant developed by DRDO will be manufactured by Pacetronix, an Indore-based firm that makes pacemakers. So far, 50 bionic ears have been made for DRDO’s biocompatibility tests.

“There are some materials the body can accept; we have to use medically graded materials only. There are also some processes, such as welding and joining, through which we introduce foreign materials inside the head. These have to be accepted by the body,” said Rao, explaining these tests.

“This month, we are submitting the documentation for biocompatibility tests, design, advice to doctors and reliability studies to the DCGI. We will seek approval for multi-centric clinical trials, and if we get approval, clinical trials can start in the next three to four months,” Rao said.

The DRDO’s unit which developed the device has done much work in the area of signal processing. Two years ago, former President A.P.J. Abdul Kalam had announced that the cochlear implants would enter clinical trials that year, but was delayed due to biocompatibility tests.

On 20 August, Prime Minister Narendra Modi had criticized DRDO and asked it to complete its projects sooner to put India ahead in the world,  Press Trust of India had reported. India is left behind in defence research because products which are “two steps ahead” come into the market even before India conceptualises a system, PTI quoted Modi as saying.

(Source: Mint August 27, 2014)

 http://beta.thearabianpost.com/govt-nails-finmeccanica-protects-current-contracts/

Robotics in ENT

ENT Surgery had a revolution with introduction of nasal endoscopes in the late 80's.Since then, ENT Surgeons have expanded their horizon from nasal cavity to the base of skull.Presently endoscopes are also used for ear surgeries.

As surgeons we need to update ourselves with the latest techniques available & above all learn to use them.

Before adapting any technique in practice ,we go through rigorous training on cadavers.I remember attending 3-4 dissection courses per year for mastering the nasal endoscopic surgery & the hands on training still continues every year.Training & learning never stops as we expand our horizons.

Robotic in surgery has been there for a while now. The da Vinci Surgical System is a robotic surgical system made by the American company Intuitive Surgical. Approved by the Food and Drug Administration (FDA) in 2000, it is designed to facilitate complex surgery using a minimally invasive approach, and is controlled by a surgeon from a console.  

The main applications for Robotic surgery have been  in Urology,Gynecology & General surgery.The first Robotic set up came to India in January 2011. Vattikuti Technologies are the distributors in India for the da Vinci® surgical systems.  

Above picture depicts the latest Model. da Vinci Si HD. The surgeons at the console,the Robot at the patient table,scrubbed nurse for helping with instruments & the display tower

Recently I had the opportunity to a attend a training on the da Vinci Simulator organised by Vattikutti Technologies.It was a humble experience.The Vattikutti technologies are based in Bangalore & they offer these training sessions for surgeons.It starts with introductory videos & interactive session with their engineers.Then hands on with the robot stationed there.

There is a learning curve for this technology as with any new gadget.The most impressive things for me was the amazing "Endowrist" intrumentation (180 degree articulation & 540 degree rotation) The latest model in the first picture has two consoles ,useful for training as well TilePro is another plus as the surgeon can see  multisource videos in the same screen.

The application in ENT Surgeries has been mainly in oral cavity & neck.Procedures like  lingual tonsil excisions, tongue base resections & supraglottic resections have been performed so far. Case selection is very important.

Though it comes with set of instruments & forceps as ENT surgeons use it more ,we can modify instruments suitable for ENT use.For Pediatric ENT ,surgeons are working on smaller & flexible scopes.

The use of Robotics in ENT Surgery is new & indications are expanding.Cost effectiveness is a challenge at the moment.

I must finally thank Vattikutti Technologies & their team for the excellent insight in to robot handling and their hospitality.

New techniques or gadgets for disease management : How do patients decide ?

Thanks to www....& Google,patients have access to so much of information...how do they decide?
Of course you may say "patients depend on their doctors or surgeon to decide what's best for them".Its the doctors responsibility not only to critically study the new technology but also to train themselves to handle it.
It's not unusual to get a patient who demands for a surgery using a particular technique.For example ,I recently had a young boy who wanted tonsillectomy using a particular technique.He aspires to be a singer & his teacher in the U.S.advised this new technique.How much ever I spent time explaining that I was actually involved in a nationwide study in the NHS in the U.K. & shared the outcomes,he was fixed on his idea.He went ahead at another center with this surgery & surprise comes back with all the possible risks explained!!
I have seen patients having similar faith in lasers.I fail to understand from where it's come but they think everything can be operated with laser & it's all bloodless & painless!! Ofcourse lasers are useful for selected conditions & the results are excellent if a particular type of laser is used.
Every new gadget may not be suitable for every patient.It depends on the stage of disease & also patient as well as doctor factors.
I recently came across this article about cancer advertisements in a reputed medical journal.Especially in cancer treatment, there are standard staging systems & treatment is offered according to classification or stage.Few other diseases have such protocol.
Sharing it....

The full report is titled “What Are Cancer Centers Advertising to the Public? A Content Analysis.” It is in the 17 June 2014 issue of Annals of Internal Medicine (volume 160, pages 813-820). The authors are L.B. Vater,
J.M. Donohue, R. Arnold, D.B. White, E. Chu,
and Y. Schenker. 

Summaries for Patients
Understanding Cancer Center Advertisements
What is the problem and what is known about it so far?
A new diagnosis of cancer can be frightening. Many decisions need to be made, the first of which is usually where to receive care. Throughout the United States, cancer centers are increasingly purchasing magazine and television advertisements aimed directly at patients with the intent of informing them about their centers.
Why did the researchers do this particular study?
To examine television and magazine advertisements placed by cancer centers for information provided about clinical services and the use of emotional advertising appeals and patient testimonials.
What was studied?
Advertisements in the top 269 consumer magazines and in 44 television markets that reached more than 1 million viewers in the United States. However, the researchers could not be sure whether television advertisements were local or national in their distribution.
What did the researchers find?
The advertisements tended to focus on the newest or most innovative treatments offered for particular types of cancer. They often included patient testimonials but did not indicate whether the experience of that patient was typical. In general, the advertisements appealed to a person’s emotions but did not provide more concrete information about benefits and risks of therapy, what other therapies a patient may use, or whether the centers accepted all types of insurance.
What were the limitations of the study?
The study analyzed the advertisements but did not study people watching the advertisements to see how they were affected.
What are the implications of the study?
Although it is natural for patients with a new diagnosis of cancer to look for the best news possible, they should try to view cancer center advertisements as critically as they view any other advertisements. They should not believe that the patient experiences portrayed in such advertisements are typical or that their own experience will be the same. They should choose where they receive cancer care on the basis of all issues important to them, including benefits, risks, and costs
 This article was published online first at www.annals.org on

27 May 2014. 

Dizziness Part III :Management

Dizziness...like fever or pain is just the symptom of an underlying pathology.Hence for effective treatment ,we need to diagnose the underlying cause.As I have already mentioned,sometimes appropriate diagnosis needs few visits.

The treatment of vestibular or inner ear related vertigo is divided into immediate symptomatic relief & to promote vestibular compensation.

Medications for vertigo mainly provide symptomatic relief.Drugs like antiemetic (for nausea & vomiting ) & anti vertigo drugs are given for short duration (3-5 days).In Meneire's disease Histamine agonists drugs are used for longer duration.

The mainstay of management is to promote vestibular compensation.Vestibular compensation is a natural process that allows the brain to regain balance, and minimise dizziness when there is damage to the inner ear.These include various exercise manuvers specific to a diagnosis.For example in BPPV, we usually perform Semont's Manuver or Epleys Manuver. There are also certain eye movements,neck & head exercises.I am not describing them here as I do not want any patient to perform them without doctors advice.

Appropriate referrals to neurologists,cardiologists,endocrinologists or other specialities if suspected cause is not the inner ear.

Finally lot of reassurance & regular follow up.Also concentrate on the concomitant psychological & cognitive impairment for a holistic recovery.

Picture of a rainbow over a volcanic eruption in Tanzania.....courtesy National Geographic