586 Punches (Figs 14 A, B and L): There are many types of
punches. Kerrison bone punches may be straight upwards
Section 8 w operative procedures and Instruments A cutting (Fig. 14A) or curved upwards cutting (Fig. 14B).
Hajek’s punch forceps are also similar. Sphenoid punch
B (Citelli) is upward biting or downward biting punches.
figs 12A and B: (A) Walsham forceps; (B) Asche’s forceps This is a strong and heavy instrument.
– Uses:
figs 13A to G: Instruments of endoscopic sinus surgery. (A) - Caldwell-Luc operation: It is used for enlarging
Hopkins telescopes 4 mm with fiber optic light transmission (0°, the opening of canine fossa antrostomy in
30°, 70° and 120° Sinuscopes); (B) Trocar and cannula for si- Caldwell-Luc operation.
nuscopy; (C) Suction irrigation tube with channel for inflow and - Sphenoid sinus and pituitary fossa surgery: It
outflow; (D) Blakesley ethmoid forceps; (E) Takahashi ethmoid is also used in the surgeries of sphenoid sinus
forceps; (F) Hartmann nasal cutting forceps; (G) Struycken nar- and pituitary fossa.
row blade nasal cutting forceps for removal of turbinates - Endoscopic dacryocystorhinostomy: It is used
Source: Karl Storz, Germany to remove the medial wall of lacrimal groove.
- Transpalatal approach: It can also be used in
transpalatal operations.
Bone forceps (Figs 15A and B): Double action bone nibbling
forceps are bent at an obtuse angle and have four joints
with double lever systems that allow the blades to close
and open to a limited extent in a narrow deep cavity. They
have strong grasp.
Use: They are used for removing the bony part such as
deviated nasal septum.
Chisels (Figs 15D, E and J): In comparison to an elevator
they have head.
Uses: They are used in various nasal and paranasal sinus
surgeries.
Heymann turbinectomy scissors (Fig 15F): It has a bend in
the center that offers better field of vision. Its narrow stout
blades have blunt tips.
Use: Removal of inferior turbinate.
Elevators (Figs 15G, I and 16E): Freer, Cottle and Killian have
two dissecting faces (ends).
Septal surgery: They are used for the elevation of
mucoperichondrium/mucoperiosteum in nasal septum
Endoscopic sinus surgery instruments: figs 14A to p: Instruments of endoscopic sinus surgery. (A) Ker-
Hopkins telescope/Sinuscope (Figs 13A and 14 C and E): rison bone punches satraight upwards cutting; (B) Kerrison bone
Hopkins Telescopes with fiber optic light transmission punches curved upwards cutting; (C) Sinuscope 4 mm 0°; (D)
are available in various sizes and angles (0°, 30°, 70°, and Sheath for the sinuscopes; (E) Sinuscope 4 mm 30°; (F and G)
120° Sinuscopes). Sinuscopy trocar and cannula; (H) Antrum curved curette; (I) An-
– Uses: They are used for examination of nasal cavity trum cannula with blunt end; (J) Blakesley forceps, straight, oval
and nasopharynx and for endoscopic sinus surgery. cup-shaped jaws; (K) Blakesley forceps, upward curved, oval
Blakesley (Figs 13D and 14J and K) and Takahashi cup-shaped jaws; (L) Antrum punch through cutting; (m) Sickle
(Fig. 13E) ethmoid forceps: Working length of straight knife; (N) reverse through cutting forceps; (O) Suction tube with
Takahashi forceps is 10 cm. Blakesley forceps are cutting finger cut-off; (P) Straight scissor upper part of jaw movable
and are of different sizes and various angles, such as
straight and upward curved (30°, 45°, 70° and 90°).
Blakesley forceps have oval cup-shaped jaws.
– Uses: They are used for removal of polyps and
uncinate process and widening the middle meatus
antrostomy. They can be used during septoplasty
and endoscopic adenoidectomy.
operation. The sharper spade like end begins the dissec- – Caldwell-Luc operation: For canine fossa antrostomy 587
tion in submucoperichondrial plane. Its flat and dull and opening the maxillary antrum.
end elevates the flap in an atraumatic way especially chapter 59 w Instruments
in nasal septal surgery. Periosteum elevator (Fig. 16E): There are various shapes and
Endoscopic sinus surgery: For manipulating uncinate sizes of periosteum elevators. In comparison to a chisel, it
process, middle meatus and bulla ethmoidalis. does not have a head. A rest is provided for a finger and
Tympanoplasty: For separating temporalis fascia from the edge is blunt.
temporalis muscle. Uses: It is used for elevating the periosteum and soft
Nasal speculum (Figs 15M, N and 16I and J): There are many tissues in Caldwell-Luc operation and mastoidectomy
types of nasal speculum including St. Clair Thomson’s and operation.
Killian’s. Its long blades are concave from inside. They keep
mucoperiosteal flaps away. Luc’s forceps (Fig. 16F): These have a screw joint. The blades
Uses: It is used in septal surgery such as submucosal are fenestrated and cup-shaped with sharp edges. The
resection (SMR) and septoplasty. tissue caught by the blades may bulge out through the
7. Mallet or Hammer (Figs 15C and 16C): It consists of handle, fenestra for a better grip.
shaft and a head. Uses:
Uses: To give gentle blows on the gouge for removing – Nasal surgery: They are used in nasal surgery to
spur and doing osteotomy in rhinoplasty. remove polyps, growth and bone/cartilage during
Nasal gouges (Fig. 16D): There are many types of nasal Caldwell-Luc operation, septal surgery, and polyp-
gouges. Killian’s bayonet-shaped gouge has rounded and ectomy (to grasp and avulse polyp).
concave, or “V” shaped edge for a better grip on the septal – Biopsy: Punch biopsy from the nose, oral cavity and
bone. pharynx.
Uses: – Tonsillectomy: They may be used in tonsillectomy for
– Nasal septum surgery: It is used for removal of septal holding the tonsils.
– Adenoidectomy: They may be used in adenoidec-
spurs or bony crests and ridges in nasal septum tomy for removing the tags of adenoids after the
operation. It is used for removing the maxillary crest use of adenoid curette.
of the deviated nasal bony septum.
Ballenger’s swivel knife: The blade of this knife (available in
different sizes) revolves automatically and changes direc-
tion while cutting the cartilage anteroposteriorly, down-
wards and posteroanteriorly. The blade is fitted by swivel
joints to the handle so that the blade can rotate through
360° in the joints.
Method: It is introduced in a cut of the nasal septal
cartilage and is pushed backwards, then downwards
and finally forwards to remove a quadrangular piece
of the septal cartilage.
Use: It is used in removal of septal cartilage in SMR
operation.
figs 15A to o: Instruments for nasal surgery. (A) Jansen middle- figs 16A to J: Instruments for septal surgery. (A) Nasal dressing
ton septum bone forceps with through cutting blades; (B) Jansen forceps bayonet-shaped; (B) Suction cannula; (c) mallet with both
septum bone forceps; (c) cottle mallet; (D) cottle chisel with sides plain faces; (D) Septum gouge, straight, round cutting edge,
depth markings; (E) masing chisel double guarded; (F) Heymann without notch; (E) periosteum elevator; (F) Luc’s forceps with fe-
nasal scissors medium size; (G) Freer elevator double ended; nestrated jaws; (G) Takahashi ethmoidal forceps upward curved
(H) Freer septum chisel straight end; (I) Killian elevator double with oval cup-shaped; (H) Takahashi ethmoidal forceps straight
ended; (J) Killian claus septum chisel with V-shaped cutting oval cup-shaped; (I) Three sizes of nasal speculum; (J) Septum
edge; (K) Luc septum bone forceps; (L) Ferguson suction tube speculum with joint and set screw
with finger cut-off and stylet; (M) Killian-Struycken nasal specu-
lum; (N) cottle nasal speculum with set screw; (O) Krause nasal
snare
Source: Karl Storz, Germany)
588 MoutH GAGS AnD retrActorS (fIGS 17A Disadvantages:
to D AnD 18A to c) – Chances of teeth damage.
Section 8 w operative procedures and Instruments Jennings mouth gag (Figs 17A and 18A): The use is similar – Not used in edentulous patients.
to the Doyen’s mouth gag. Cheek retractor (Fig. 17D): It has a handle and a blade which
Method: It is applied in the centre of the mouth. The is molded to fit snugly into the angle of the mouth. It
retracts the cheek and exposes the teeth, gums and jaws.
blades of this mouth gag fit over the alveolar margins Uses: It is used for making an incision for Caldwell-Luc
and not over the teeth. operation and for interdental wiring for fractures of the
Advantages: Unlike Doyen’s gag, it can be fitted to maxilla and mandible.
edentulous patients and does not damage the teeth.
Doyen’s mouth gag (Figs 17B and 18C): It keeps the mouth Hajek’ lip (cheek) retractor (Fig. 18B): It is S-shaped instru-
open for intraoral tongue surgery. ment has two different types of ends. One end is bent at
Method: It is applied on one side of the mouth on molar right angle and is used for retracting the upper lip. The other
teeth. Its curved blades fit over the teeth. The lower end is bent in a curved manner and is used by the assistant
jaw is depressed by the surgeon and the closed mouth or the surgeon for supporting his thumb against the head
gag is introduced in between the jaws and is gradually of the patient. This end can be used for cheek retraction.
opened. It remains open by a ratchet. Uses: It retracts the upper lip during Caldwell-Luc opera-
Uses: tion and maxillectomy operations.
– Operations of the oral cavity, oropharynx and naso-
ADenotonSIllectoMY (fIGS 19A to p AnD
pharynx, such as tongue-tie release and removal of 21A to K )
large uvula. For the related details of these instruments, see chapter
– Oral toilet in an unconscious patient for keeping “Adenotonsillectomy”.
the airway free. Boyle-Davis mouth gag (Figs 19 A to D and 20B): The mouth
– Improving the movements of the temporoman-
dibular joint ankylosis with trismus. gag remains open because of the ratchet. Tongue blades
– Prevent tongue bite in epileptics. of various sizes are available. It opens the mouth and
retracts the tongue anteriorly and inferiorly. Other types
figs 17A to D: mouth gags. (A) Whitehead mouth gag with of mouth gags are also described in the previous section
tongue depressor; (B) Doyen-Jansen mouth gag with tongue de- of this chapter.
pressor; (c) Heister mouth gag; (D) roux cheek retractor Uses: It is used for the surgeries of the oral cavity,
Source: Aesculap®, Germany
oropharynx and nasopharynx such as
A Bc – Tonsillectomy
figs 18A to c: Different types of mouth retractors. (A) White- – Adenoidectomy
head mouth gag with tongue depressor; (B) Hajek’s retractors; – Snoring surgeries like uvulopalatopharyngoplasty
(c) Doyen’s pattern mouth gag – Palatal surgeries
– Repair of cleft palate
– Excision of angiofibroma
– Removal of antrochoanal polyp
– Craniovertebral anomalies
Method: The built in tongue depressor along with
the closed mouth gag is inserted in the mouth after
depressing the lower jaw. The mouth gag is opened
gradually. It is suspended from Draffin’s bipods (Fig.
20A).
Tonsil holding forceps (Denis Browne’s): They resemble Luc
forceps, but their fenestrated jaws are not sharp. The upper
jaw sits within the larger lower jaw. There are many other
types of tonsil holding forceps (Figs 19F and 20E and F).
Use: These are meant for holding the tonsil during
tonsillar dissection. Luc forceps may also be used for
this purpose.
Tonsil knife (Fig. 19G): This sickle-shaped knife is made of
stainless steel.
Use: It is used for making the first mucosal incision of
tonsillectomy at the upper pole of tonsil.
Tonsil dissector and anterior pillar retractor (Fig. 19I):
Uses:
– Tonsillectomy: Its blunt end is used to dissect the
tonsil. Its C-shaped bent end is used to retract the
anterior tonsillar pillar and helps in inspecting the
589
figs 20A to K: Instruments of adenotonsillectomy. (A) Draffin chapter 59 w Instruments
suspension apparatus (two bipods); (B) Boyle Davis mouth gag
with tongue depressor; (c) Yankauer’s tonsil suction tube; (D)
St. clair Thomson’s adenoid curette with guard; (E) peacock
Vulsellum tonsil holding forceps; (F) Tonsil holding forceps; (G)
Waugh’s tenaculum tonsil dissection forceps with teeth; (H) Ton-
sil dissector and retractor; (I) Eves tonsil snare; (J) Straight tonsil
artery forceps; (K) curved tonsil artery forceps
figs 19A to p: Instruments of adenotonsillectomy. (A) Frame of Negus artery forceps (Fig. 19K): Its tip is sharply curved.
Boyle Davis gag with interchangeable inserts suitable for many Use: It is used as replacement forceps to ligate the
tongue depressors; (B) russel Davis tongue blade with a groove bleeding point.
for holding endotracheal tube, and protecting it from moving,
kinking, or closure by teeth; (c) mcIvor tongue blade; (D) Gast Tonsil needle (Fig. 19L): It consists of needle and handle. The
tongue blade with groove for endotracheal tube and lateral slot; sharp curved needle is at a right angle to the long handle.
(E) Sluder-Ballenger tonsillotome with blade and handle; (F) Use: It is used for sewing the tonsillar pillars together
White tonsil holding forceps; (G) Abraham tonsil knife; (H) Henke for controlling the bleeding, which is not controlled by
Tonsil dissector; (I) Hurd tonsil dissector and pillar retractor; (J) ligation and cauterization of bleeding points.
Tonsil scissor; (K) Negus tonsil artery forceps; (L) Hurd ligature
needle; (m) Yankauer suction tube; (N) Eves tonsil snare; (O) Yankauer’s suction tube (Figs 19M and 20 C): This long
corwin tonsil hemostats with spring clamp and sliding collar for suction cannula consists of large handle and covered tip
holding gauze pad in position; (p) Hartmann tonsil punch forceps that prevents damage to mucosa.
Source: Aesculap, Germany Uses: It is used for suction in tonsillectomy and other
oral, oropharyngeal and nasopharyngeal operations.
fossa for any bleeding. The retraction of anterior
pillar also provides better visualization of tonsil Eve’s tonsil snare (Figs 19N and 20I):
especially fibrosed tonsil before surgery so that Use: When the tonsil has been dissected till the lower
tonsil holding forceps can be applied properly. pole, snare is passed round the tonsil to engage the
– Nasopharynx: It can be used in retracting the soft pedicle. When firmly closed, it crushes and cuts the
palate and uvula during adenoidectomy and for pedicle and minimizes the bleeding.
examining the nasopharynx. Method of application: The index and the middle fingers
Tonsil scissors (Fig. 19J): These are long scissors with slightly are passed into the two rings on the outer tube of the
bent blunt tips. snare, and the thumb is introduced in the ring of the central
Use: They are used for sharp dissection of the tonsils and movable slide. The loop of the fully opened snare wire is
cutting the ligatures. They can also be used for tongue threaded on the tonsil holding forceps. The snare wire
tie release and uvulectomy for long uvula. loop is pushed down up to the lower pole of the tonsil. On
closing by pushing the slide into the tube with the thumb,
the snare wire loop is withdrawn into the tube of the snare
and the tonsil is excised.
Conchotome (Fig. 19P): This punch biopsy forceps open like
the jaws of a crocodile and is bent at an obtuse angle. The
upper smaller ring sits inside the larger lower ring.
Uses: It is used for punching out pieces of the turbinates.
It is also used for removing the tags of adenoids and
taking punch biopsy.
Draffin’s bipod (Fig. 20A): There are two pods and each has
four rings in a row. The two pods are assembled together as
590 A enDoScopeS
There are two types of illumination in the rigid hollow tube
scopes, Jackson and Negus. The illumination is distal in Jackson
type and proximal in Negus type (Table 1).
Section 8 w operative procedures and Instruments B laryngoscopes
Laryngoscope used for direct laryngoscopy has light carrier
c which is connected to a cold light source through a flexible
cable. There are several models of laryngoscopes (Figs 23A to
figs 21A to c: Instruments of adenoidectomy. (A) LaForce ad- K). The size of laryngoscope is selected as per the age of the
enotome; (B) St. clair-Thompson adenoid curette with catcher; patient. The larynx and hypopharynx are visualized directly
(c) Beckmann adenoid curette with the help of laryngoscope. For further related details, see
Source: Aesculap®, Germany chapter Endoscopy.
Direct laryngoscope (Jackson) (Fig. 23A): This U-shaped
per the height at which the tongue blade of the Boyle-Davis
mouth gag is suspended. The lower ends of the pods are laryngoscope consists of a metal tube with illumination at
placed in one of the several depressions of the Magauran’s the distal end (through which laryngoscopy is performed)
plate. and a right-angled handle.
Use: They are used along with Boyle-Davis mouth gag. Uses: They are used for direct laryngoscopy. Some
St. Clair Thomson’s adenoid curette (Figs 20D and 21): There
are two varieties: (1) with cage (guard); and (2) plane laryngoscopes have a detachable posterior blade for
without cage (guard). The curette shaves off the adenoid inserting a bronchoscope or an esophagoscope.
mass while the guard holds the adenoid tissue and prevents Laryngoscopes for microlaryngoscopy and surgery: These
from slipping. The sharp transverse blade cuts adenoids and self-retaining laryngoscopes (Figs 23B to D) are fixed on the
holds them in a cage with the help of the fangs in the cage. chest by a chest piece (Fig. 23E) so that hands of the surgeon
Remaining tags of adenoids may be removed by a smaller remain free for the surgery, which is performed under the
plain adenoid curette, Luc forceps or conchotome. magnification of an operating microscope. Microlaryngeal
Use: For adenoidectomy it is held in dagger holding surgery needs special laryngoscopes, forceps, scissors,
dissectors and knives (Figs 23F to H). The shape and size
fashion. The plane curette is used to remove adenoid of viewing and distal ends and body vary with the types of
tissue around the Eustachian tube. laryngoscopes, such as Holinger hourglass, Jako-Cherry,
Caution: The neck flexion avoids subluxation of atlanto- Bouchayer and Dedo.
occipital joint. Bring the adenoid tissue from lateral wall Advantages: Magnification provides precision and ideal
to midline by right index finger. Keep the curette with for Laser surgery. Both the hands of surgeon remain free
cage in midline. for surgical manipulations.
Tonsil dissection forceps with teeth (Waugh’s) (Fig. 20G)
Use: It is used for putting incision in the mucous comparison between two types of illumi-
membrane and dissection of tonsil. tABle 1 nation (Jackson and Negus) in traditional
Tonsil artery forceps (straight and curved) (Figs 20J and K):
Use: The straight forceps is used to catch the bleeding hollow tube rigid scopes
point and is replaced by curved forceps before tying a
ligature. Jackson pattern Negus pattern
Negus Knot tyer: It has a blunt forked end and slips the
ligature knot beyond the curved tip of the artery forceps. Location of illumination Distal proximal
Use: It helps in tying the ligature knot up to the tip of
curved artery forceps that holds the vessel. Brightness Less bright more bright
Number of illuminants One Two
Visibility of forceps tip Good poor
chances of secretions Frequent Occasional
covering illuminant
Width of scope Narrow Broader
Vision relatively poor Better
Introduction Easy Relatively difficult
IncISIon AnD DrAInAGe of QuInSY fig. 22: peritonsillar abscess forceps
Peritonsillar (Quinsy) abscess forceps (Fig. 22): These bayonet- Source: Aesculap®
shaped quinsy forceps have a sharp trocar point with a
shoulder that prevents deep entry. See chapter“Deep Neck
Infections” for other related details.
Use: It is used for drainage of peritonsillar abscess.
Method: The sharp trocar tip of closed forceps is inserted
into the abscess and then forceps are opened like a sinus
forceps to drain the pus.
The thick and smooth distal tip of esophagoscope allows 591
easy insertion and decreases chances of injuring mucosa.
figs 23A to K: Laryngoscopic instruments. (A) Jackson laryn- chapter 59 w Instruments
goscope; (B) Holinger anterior commissure laryngoscope; (c) One or two smaller side channels are for suction catheters
Kleinsasser operating laryngoscope; (D) Stange hour glass or light carriers.
operating laryngoscope; (E) ricker Kleinsasser laryngoscope
holder and chest support for adult and children; (F) Suction tube; The large central channel allows passage for variety of
(G) Kleinsasser laryngeal forceps: angled scissor (a), straight al- instruments.
ligator (b), angled (c) straight (d) cupped jaws; (H) Handle for use Hopkins road for better illumination and visualization
with Kleinsasser laryngeal instruments: straight (1) curved (2) la- (Figs 24C and D)
ryngeal knife (3) blunt laryngeal hook (3); (I) Hopkins lateral Tele- Foreign body removal forceps [Figs 24E (a, b, e and f )]
laryngo-pharyngoscope 900; (J) magill folding laryngoscope; (K) Biopsy forceps [Figs 24E (b and c)]
mcIntosh folding laryngoscope Foreign body basket [Fig. 24E (d)]
Source: Karl Storz, Germany Suction catheters (Fig. 24F)
Scissors
Bronchoscope Staplers
Dilators
Figures 24A to L show the instruments used for bronchoscopy Electrocautery
and esophagoscopy. Bronchoscope (Fig. 24A) consists of a Laser cables
hollow metal tube. Jackson type has distal illumination. There Syringes
are openings (vents) at the distal part of the tube for the aera-
tion of the side bronchi. The size of bronchoscope should be Oval open esophagoscope: For examination and removal
selected as per the age of the patient (Table 2). A bronchoscope of foreign bodies.
may be used for performing esophagoscopy but the esopha-
goscope cannot be used for bronchoscopy. For further related Round open esophagoscope: For tumors and strictures.
details of bronchoscopy, see chapter “Endoscopy”.
trAcHeoStoMY
esophagoscope Tracheal dilator (Fig. 25, TD): The blades spread out on
Figures 24A to L show the instruments used for bronchoscopy
and esophagoscopy. Esophagoscope (Fig. 24K) appears similar approximating its rings. Its tip is blunt. A curved artery
to the bronchoscope but does not have vents. It is used for forceps can also serve its purpose.
diagnostic and therapeutic esophagoscopy. The size of the Use: It keeps the cut tracheal edges open so that trache-
esophagoscope is selected as per the age of the patient. Handle
at the proximal end of esophagoscope indicates the direction ostomy tube can be easily introduced.
of the bevel at the distal end. A bronchoscope may be used for Tracheal hook (blunt and sharp)
performing esophagoscopy but the esophagoscope cannot be
used for bronchoscopy. For further related details of esopha- Blunt: It retracts the thyroid isthmus and exposes the
goscopy, see chapter “Endoscopy”. trachea. It may also be used for retracting the strap
muscles.
endoscope and Instruments (figs 24A to l)
There are variety of shapes, diameter and lengths of endo- Sharp: It retracts the lower border of cricoid cartilage
and thus stabilizes the trachea when making incision
scopes. Smallest being 3.0 mm inner diameter and 20 mm in the anterior wall of trachea.
length.
types of tracheostomy tubes (figs 25 and 26)
There are various types of tubes. See Box 1 for the classification
of tracheostomy tubes.
They can be grouped on the bases of cuff, fenestra, length,
number of lumen and the material. Some of the commonly
used tubes will be described in this section.
Fenestra at the upper curvature of the tube: It helps in speech
production or in weaning from tracheostomy.
Extra length tracheostomy tubes: They are used in cases of
thick or swollen pretracheal tissue, a growth and stenosis
in trachea, postcricoid growth pressing trachea.
tABle 2 Size of bronchoscope and the age of
patient
Age group Size of bronchoscope
lumen (mm)
preterm neonates 2.5–3.0
1–2 years 3.5–4
3–9 years 4.5–5
9–14 years 6
592 Box 1: Classification of tracheostomy tubes
• On the basis of cuff
Section 8 w operative procedures and Instruments figs 24A to l: Bronchoesophagoscopy instruments. (A) Bron-
choscope tube; (B) Adjustable magnifier; (C) Hopkins telescope: – Uncuffed
0°, 30°, and 70°; (D) Rubber telescope guide; (E) Forceps: pea-
nut grasping (a), universal biopsy and grasping (b), circular cup – cuffed tubes
biopsy (c), foreign body basket (d), alligator grasping (e), and
rotating sharp pointed (f); (F) rigid suction tube; (G) Specimen ◊ Single cuff tube
collector may be attached directly to suction tubes; (H) Sponge ◊ Double cuff tube
holder for sterile smear cytology; (I) cotton carrier; (J) Bougie; ◊ Low pressure cuff tube
(K) Oval esophagoscope tube; (L) Broncho fiberscope with in- • On the basis of fenestra at the upper curvature of the tube
strument channel
Source: Karl Storz, Germany – Tubes without fenestra
Adjustable flange long tube: The flange can be adjusted. – Single fenestrated tube
Single lumen (cannula) tube: It has only one cannula.
Double lumen (cannula) tube: It has inner cannula and outer – multiple fenestrated tube
• On the basis of length of the tube
cannula.
Metallic tubes: They are formed from the alloy of silver, – Standard length
copper and phosphorus. – Extra length tracheostomy tube
Polyvinyl chloride (PVC) tubes: They are disposable (single
◊ Adjustable flange long tube
use) and thermolabile. They adjust to tracheal lumen. • On the basis of number of lumens (cannula)
Silicone tubes: The advantages include less crusting and no
– Single lumen (cannula) tube – Nonmetallic
adherence of bacteria and secretions.
Siliconized PVC tubes: They offer advantages of both PVC – Double lumen (cannula) tube – Jackson and Fuller
• Suction-aided tracheostomy tubes – metallic
and silicon tubes. • On the basis of the material
Silastic tubes: They are soft and non-irritating and minimize
– metallic
the crusting.
Rubber tubes: They are most economical. ◊ Jackson
Armored tubes: The plastic tubes are reinforced by a spiral ◊ Fuller
– Nonmetallic
or rings of stainless steel. They do not get kinked.
◊ polyvinyl chloride (pVc)
Fuller’s Bivalved Tracheostomy Tube ◊ Silicone
It has two tubes outer and inner (Figs 25, F1 and F2). The inner ◊ Siliconized pVc
tube is slightly longer than outer tube. The two blades (bivalve) ◊ Silastic
of the outer tube when pressed together can be easily inserted ◊ rubber tube
into the tracheostomy opening. There is no need of a pilot and – mixed
◊ Armored tubes
a tracheal dilator. The central hole in the inner tube provides
a chance to breathe when tube is blocked by a finger, cork or
secretions. The tip of the compressed outer tube is not so blunt
and may cause injury.
Chevalier Jackson’s Tracheostomy Tube
Traditionally, it is made of silver or German silver which is
nonirritating. It has three parts: outer tube, inner tube and an
obturator (Figs 25, J1 to J3).
1. Outer tube: Outer tube fits into the tracheostomy opening.
When the inner tube is removed, the outer tube continues
to serve the purpose. Shield is attached to the proximal end
of outer tube and is fixed to the neck by a tape threaded
through the holes of the shield. Lock fitted on the shield
fixes the inner tube inside the outer tube.
2. Inner tube: The inner tube is slightly longer than outer tube.
It can be fixed to the shield of the outer tube by a lock. The
longer inner tube does not allow the blocking of outer tube
and can be cleaned and replaced regularly.
3. Obturator (pilot): The obturator is passed in the outer tube
and helps in the introduction of tube into the trachea. Its
blunt rounded end is inserted into the outer tube after
removing the inner tube. It is used for inserting the trache-
ostomy tube into the trachea. When tube is inserted in its
position, pilot is withdrawn and inner tube is inserted back
into the outer tube.
Metallic tubes cannot be used during radiotherapy and mrI. In the current two cuffs tube, inflation of the cuff can 593
metal tubes become radioactive by irradiation. patient cannot be alternated. The current low pressure cuff tubes may
speak with patent tube in position. The speaking valve can be not damage the trachea and avoids tracheal stenosis. chapter 59 w Instruments
used with metallic tubes. Cuffed suction aid tracheostomy tube: The inbuilt suction
channel reaches above the cuff and helps in sucking out
Nonmetallic Tracheostomy Tubes (Fig. 26) pharyngeal secretion collected above the cuff.
These tubes are usually larger than the metallic tubes and are
available with or without pressure cuff. These tubes are useful Suction is done before deflating the cuff. It avoids the aspiration
for patients undergoing radiation therapy (metal tubes become of accumulated pharyngeal secretions into the trachea.
radioactive by irradiation) and MRI.
Cuffed tracheostomy tube: The external bulb in cuffed tubes Nonmetallic tracheostomy tubes are useful for patients
undergoing radiation therapy and mrI. They are less traumatic
tells the status of inside cuff. to trachea.
Indications: Cuff tracheostomy tubes are required
Size of tracheostomy tube
when patients need anesthesia or Intermittent Positive Tracheostomy tubes are of different sizes or numbers. Larger
Pressure Respiration. It is used in unconscious patient the number, greater is the inner diameter. In adults, tubes of
or when patient is on a respirator. inner diameter varying between 6 mm and 9 mm or 10 mm are
Advantages: The inflated cuff prevents not only aspira- used. Sometimes, size of tube (Jackson’s or Negus) is expressed
tion of secretions into the trachea but also prevents in French gauge (FG), which is about three times the size of
air-leak and keeps the position in tube. internal diameter. It means 8 mm internal diameter will have
Precautions: Cuff should be deflated every 2 hours for approximately 24 FG.
5 minutes to prevent pressure damage to the trachea. FG = outer diameter x π (π = 3.14 or approx 3)
Children: An appropriate size of tracheostomy tube should
be selected as per the age of the patient (Table 3).
AIrwAY DevIceS (fIGS 27A to H)
nasopharyngeal Airway (trumpet) (fig. 27A)
It is inserted into the hypopharynx through the nose and
provides better patent airway from nose to laryngopharynx.
In conscious patients it is better tolerated than oropharyngeal
airway.
fig. 25: metallic tracheostomy tubes and tracheal dilator (TD). oropharyngeal Airway (figs 27B to D)
This may be plastic or metallic. It brings the base tongue
Fuller’s bivalved tracheostomy tube has two tubes outer two forward and widens the oropharynx. The ventilation can be
provided with face mask or Ambu bag.
blades (bivalve) tube (F1) and inner fenestrated tube (F2). Jack-
son’s tracheostomy tube has three parts: outer tube (J1), inner laryngeal Mask Airway (fig. 27e)
tube (J2) and an obturator (J3) Laryngeal mask airway consists of a tube and a distal end trian-
gular laryngeal mask which fits over the laryngeal inlet in supra-
glottic region. The weight of patient decides the size of mask.
Uses: It is very useful in cases of unsuccessful intubation
when standard mask ventilation is inadequate.
Method: The deflated cuff of mask is positioned over the
larynx and then inflated. It is useful when face mask is inef-
fective and intubation is difficult.
Disadvantages: Laryngeal mask airway does not prevent
aspiration of gastric secretions. It cannot be used in patients
with trismus.
Contraindication: It is contraindicated in cases of laryngeal
obstruction.
fig. 26: Nonmetallic tracheostomy tubes. cuffed (c) and Un- endotracheal tubes (figs 27G and H)
cuffed (U) tubes with their obturator (O) The endotracheal intubation is a quick method of establishing
airway. For the detail procedure, see chapter “Anesthesia”.
Size of endotracheal tube in children: Roughly the size of
endotracheal tube is equal to the size of the child’s little
594 tABle 3 Size of tracheostomy tube and the age of
patient
Age group Tracheostomy tube size
lumen (mm)
preterm neonates 2.5–3.0
1–2 years 3.5–4
3–6 years 4.5–5
6–12 years 5.5–6
12–14 years 7
Adults 8–9
Section 8 w operative procedures and Instruments finger but it can be calculated with the following formula: figs 27A to H: Airway devices. (A) Nasopharyngeal airway; (B)
Size (number) of tube = (Age/4) + 4. It indicates internal Guedel oropharyngeal airway; (c) cuffed oropharyngeal airway;
(D) Sanjivani airway management oropharyngeal airway; (E) La-
diameter in mm. ryngeal mask airway; (F) I-Gel Laryngeal airway; (G) Endotra-
Length of the tube in mm = Size (number) of tube x 3. cheal uncuffed tube; (H) Endotracheal cuffed tube
Example: If the patient is 2-year-old, then the size Source: Dr AS Solanki, consultant Anesthesiologist, Anand, Gu-
jarat
(number) of the tube = (2/4) +4 = 4.5, internal diameter
4.5 mm, and length of tube = 4.5 x 3 = 13.5 mm.
Specialized endotracheal tubes (rAE tubes) have a sharp
bend to angle the tube so that surgeon’s field of vision is not
obstructed during oral cavity and oropharyngeal surgeries.
Section 9 : Related Disciplines
60 Diagnostic Imaging
Adjustment or adaptation is the outcome of the self pitted against external forces tending to suppress it. He who adjusts himself
best lives the longest. Even if I do not preach this, society is changing, it must change.
—Swami Vivekananda
points of focus ¯ CompUteRized tomogRaphy
¯ magnetiC ReSonanCe imaging
¯ ConVentional Radiology
Temporal Bone: Law’s view, Schullar’s view, principle and machines
Stenver’s view, Towne’s view, Transorbital view, Imaging protocols
Submentovertical view ¯ RadionUClide imaging
Nose and paranasal Sinuses: Water’s view, Caldwell ¯ inteRVentional Radiology
view, Lateral view, Right and Left oblique views, ¯ appliCationS of Ct, mRi and US
Lateral and occlusal views of Nasal Bones Comparison of CT and mRI
Neck, Larynx and pharynx: Lateral view and antero- ¯ Ct anatomy of eaR, noSe, thRoat, head and
posterior views of Neck, Soft Tissue Lateral view neCk
Nasopharynx, Submandibular Salivary gland ¯ CliniCal highlightS
¯ oRthopantomogRam
¯ UltRaSoUnd
The increased availability of new imaging modalities are assessment to exclude tuberculosis, pulmonary metastases
replacing the conventional radiology and making the accurate and bronchogenic carcinoma.
diagnostic process easier. It is the key to good otolaryngology
practice. ENT surgeon must be able to recognize the most temporal Bone (figs 1 and 2)
appropriate test to fit the clinical context. Though the simple Areas of translucency (semitransparent): The causes include
and least expensive imaging [conventional X-rays and ultra-
sound (US)] should be preferred but in complex problems, cholesteatoma, mastoidectomy, malignancy, eosinophil
more expensive scans [Computerized tomography/Magnetic granuloma, tuberculosis of mastoid, multiple myeloma,
resonance imaging (CT/MRI)] are more cost-effective as they glomus and large antral and periantral mastoid air cells.
lead to early and confident diagnosis and management. If Law’s view (lateral view of mastoid): Sagittal plane of the
frequent imaging studies are expected, then nonradiation- skull is parallel to the film; X-ray beam is projected 15°
dependent modalities (MRI and US) must be preferred as they cephalocaudal. Key areas of the mastoid (attic, aditus and
avoid the adverse effects of the radiation (especially in children antrum) are not seen well.
and young) such as cancer and genetic defects. Structures seen: External auditory canal (EAC) (superim-
ConVentional Radiology posed on internal auditory canal (IAC)), mastoid air cells,
X-rays are absorbed differently by soft tissue, bone, gas and tegmen, lateral sinus plate and temporomandibular joint.
fat. X-ray of chest is requested commonly for preanesthetic Schullar’s view: This frequently used view is similar to Law’s
view but X-ray beam is projected 30° cephalocaudal and
prevents superimposition of two sides of mastoid bones.
596 Structures seen: Both side temporal bones, arcuate
eminence and superior semicircular canal, mastoid
Section 9 w Related disciplines fig. 1: X-ray mastoid left–Normal antrum, IAC, tympanic cavity, cochlea and EAC.
Source: Dr Jayesh patel, Consultant Radiologist, anand, gujarat
Clinical applications: Acoustic neuroma and apical
petrositis.
Transorbital view: This is an anteroposterior view of skull.
Orbitomeatal line is at right angles to the film. X-ray beam
passes through the orbit.
Structures seen: IAC, cochlea, labyrinth and both
petrous pyramids projected through the orbits.
Clinical applications: Acoustic neuroma and petrous
pyramid.
Submentovertical view: Vertex remains near the film and
X-ray beam is projected from the submental area.
Structures seen: EAC, mastoid cells, middle ear, eusta-
chian tube, IAC, foramen ovale and spinosum and
carotid canal, and sphenoid, posterior ethmoid and
maxillary sinuses (seen best in that order), zygoma,
zygomatic arches, mandible along with coronoid and
condyle processes.
fig. 2: X-ray mastoid right–mastoiditis nose and paranasal Sinuses
Source: Dr Jayesh patel, Consultant Radiologist, anand, gujarat The most common view taken for paranasal sinus is Water’s
view and second one is Caldwell view.
Structures seen: EAC superimposed on IAC, mastoid air Common clinical findings: They include
cells, tegmen, lateral sinus plate, condyle of mandible,
sinodural angle and atticoantral region (key areas for Slight haziness in sinuses due to mucosal thickening
cholesteatoma and its erosion). Presence of cyst (missing tooth in dentigerous cyst)
An opacity with horizontal level due to fluid in chronic
Clinical applications: Extent of pneumatization, sclerotic
mastoid, destruction of intercellular septa (mastoiditis), sinusitis
location of sinus plate (position of sigmoid sinus) and Opacity due to sinusitis, antrochoanal polyp (maxillary
tegmen (roof of middle ear and floor of middle cranial
fossa), cholesteatoma and longitudinal fracture of sinus) and malignancy (opacity beyond the sinus limit
petrous pyramid. due to erosion).
Dense opacity with regular outline (osteoma).
Stenver’s view: Long axis of the petrous bone lies parallel Multilocular swelling expanding the bone (osteoclas-
to the film. toma).
Structures seen: Entire petrous pyramid, arcuate Water’s view (occipitomental view): Nose and chin touch
eminence, internal auditory meatus, labyrinth with its the film and X-ray beam is projected from occipital side.
vestibule, cochlea and mastoid antrum. Open mouth view shows sphenoid sinus. Petrous bones are
projected below the maxillary sinuses. Fractures of right and
Towne’s view: This is an anteroposterior view of skull with 30° left nasal bones and their lateral displacement can be seen.
tilt from above and in front. It shows both petrous pyramids, Structures seen (Fig. 3): Maxillary (seen best), frontal
which can be compared. and sphenoid sinuses, zygoma, zygomatic arch, nasal
bones, frontal process of maxilla, superior orbital fissure
and infratemporal fossa.
Caldwell view (occipitofrontal view): Nose and forehead
touch the film and X-ray beam is projected 15–20° caudally.
Frontal and ethmoidal sinuses are seen well in this view.
Structures seen: Frontal, ethmoid and maxillary sinuses,
frontal process of zygoma, zygomatic process of frontal
bone, superior margins of orbits, lamina papyracea,
superior orbital fissures and foramen rotundum.
Lateral view
Structures seen (Fig. 4): Anterior and posterior extents
of sphenoid, frontal and maxillary sinuses, sella turcica,
ethmoid sinuses, alveolar process, condyle and neck of
mandible.
Right and left oblique views: For seeing the posterior
ethmoid sinuses and the optic foramen.
Lateral views of nasal bones: To see fracture line,
597
fig. 3: X-ray pNS Water’s view–Normal fig. 5: X-ray soft tissue neck and nasopharynx lateral view Chapter 60 w diagnostic imaging
Source: Dr Jayesh patel, Consultant Radiologist, anand, gujarat Source: Dr Jayesh patel, Consultant Radiologist, anand, gujarat
fig. 4: X-ray nasal bones lateral view left and right showing frac- Clinical applications:
ture of septal cartilage – Radio-opaque foreign bodies of larynx, pharynx and
Source: Dr Jayesh patel, Consultant Radiologist, anand, gujarat upper esophagus
– Acute epiglottitis
depression or elevation of the fractures segment. – Retropharyngeal abscess: Retropharyngeal
Lower part of nasal bones, which is thin, fracture more widening with fluid level and straightening of
frequently. Groove for ethmoidal nerve and vessels may cervical spines with or without foreign body and/
look like fracture line (Fig. 4). or tuberculosis of cervical vertebrae
Occlusal view of nasal bone: Film is held between the – Position of tracheostomy tube, T-tube and laryngeal
teeth and X-ray beam is projected perpendicular to the stent
film. It shows fracture line and lateral displacement of – Laryngeal stenosis
the nasal pyramid clearly. – Fractures of larynx and hyoid bone and their
displacement
neck, larynx and pharynx – Compression of trachea by thyroid or retropharyn-
Lateral view of neck (Fig. 5) geal masses
– Caries of cervical spine associated with retropha-
Structure seen: Outline of base of tongue, vallecula, ryngeal abscess
hyoid bone, epiglottis and aryepiglottic folds, aryte- – Osteophytes in cervical vertebrae and injuries of
noids, false and true cords with ventricle in between spine.
them, thyroid and cricoid cartilages, subglottic space
and trachea, prevertebral soft tissues, cervical spines Anteroposteriorviewofneck: It helps in differentiating between
and pretracheal soft tissues and thyroid. a foreign body of larynx and esophagus (lateral view is also
needed). It shows compression or displacement of trachea by
lateral neck masses such as thyroid swellings.
Soft tissue lateral view nasopharynx: For soft tissue masses
in the nasopharynx, soft palate, roof and posterior wall of
nasopharynx.
Clinical applications:
– Adenoids
– Angiofibroma: Soft tissue density arising from
posterosuperior wall of nasopharynx and inter-
rupting the airway.
– Antrochoanal polyp: Soft tissue density with a
column of air between the mass and posterior wall
of nasopharynx.
– Foreign body nose and tumor.
– Choanal atresia: Interruption of air column from
nose to nasopharynx.
Submandibular salivary gland: Radio-opaque calculus can
be seen.
598 Barium Swallow Box 1: Echogenicity of various tissues
For further detail, See “Barium Esophagography” in Chapter:
“Pharyngeal Symptoms and Examination”. • Fat: moderate degree of internal echoes
• Skeletal muscle: Less echogenic than fat
oRthopantomogRam
A pantomograph is a panoramic radiograph machine. It permits • Solid mass: Well-defined margins with variable
visualization of entire maxillary and mandibular dentition, echogenicity but less echogenic than fat
alveolar arches and contiguous structures on a single extraoral
film (Fig. 6). • Cyst: Few internal echoes but strong echogenic back wall
• Calcium and bone: Strongly echogenic
Section 9 w Related disciplines UltRaSoUnd fig. 7: USg neck showing echogenicity of parotid gland (p) and
Ultrasound (US) requires an experienced operator. It is inex- muscle (m)
pensive, quick, reliable, noninvasive and effective investigation. Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat
A transducer placed on skin produces high-frequency
sound waves (3 MHz and 7 MHz), which are reflected back by
body tissues. The echoes (echogenicity) generated are picked
up back by the same transducer, which converts them into an
image that is displayed in real-time on a monitor. Superficial
lesions need high-frequency probe, whereas deeper lesions
require lower-frequency probes. US allows differentiation
between solid and cystic masses and assessment of margins
and texture of neck swellings (Box 1 and Figs 7 and 8).
Ultrasound beam does not readily penetrate bone, cartilage
and gas. It is attenuated as it passes through the tissues. These
limitations make examination of fatty necks and deep struc-
tures (such as deep parotid lobe and parapharyngeal space)
and staging of many head and neck cancers more difficult.
The probes, which can be combined with fiberoptic endo-
scopes, are available to visualize the esophagus wall.
Doppler ultrasound: It measures blood flow of vessels.
Color Doppler: Flowing blood appears either red or blue,
which depends upon the blood direction, towards or away
from the transducer.
Power Doppler: It can demonstrate tissue perfusion.
CompUteRized tomogRaphy fig. 8: USg neck showing echogenicity of thyroid gland
Computerized tomography (CT) is now becoming readily avail- Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat
able and fast replacing the need of plain X-rays (Figs 9 and 10).
CT is quite commonly used to diagnose refractory cases of
rhinosinusitis and stage head and neck malignancies.
Attenuation values (Table 1):The attenuation values of tissues
(gray-scale image) are related to water (0 HU). Tissue densities
varies from + 1000 (bone) to - 1000 (air). Fat is about - 80 to -
100 HU, while calcium and bone are in the range of 100–400
fig. 9: CT scan plain coronal section nose and paranasal si-
fig. 6: orthopantomogram: Impacted molars nuses showing antrochoanal polyp
Source: Dr Jaydeep Doshi, Consultant Radiologist, anand, gujarat Source: Dr amit goyal, Shillong
Box 2: CT image display 599
fig. 10: HRCT temporal bones coronal sections. Contracted adi- • Window width: Range of attenuation values (HU), which
tus of right side make up the gray scale for a given image
Source: Dr amit goyal, Shillong
• Window level: Center HU value (midpoint of densities) for
taBle 1 Density levels of different types of the given window width (chosen for display) Chapter 60 w diagnostic imaging
structures
• Soft tissue windows: Width: 250–400 HU; Level: 40–70
Average density in HU Structure HU (equal to density of muscles). Display wider range of
densities of calcification, intravenous contrast, muscle and
250–1,000 Compact bone fat
130 Spongy bone • Bone windows: Width: 2,000–4,000 HU; Level: 0– + 400
HU; Wide range of densities from cortical bone
80 Clotted blood
(+ 1,000 HU) to gas (- 1,000 HU). For paranasal sinuses
70 Thyroid gland and temporal bone
65 Liver • Brain windows: Width: 80 HU; Level: + 40 HU (density of
brain tissue); Density > 80 HU appear white while < 0 HU
55 Blood black. Intermediate densities are spread out evenly along
the gray scale
45 Spleen/muscle/Lymphoma
Contrast CT: Intravenous contrast agents allow identifica-
40 pancreas tion of rim enhancement in pathological lymph nodes and
increase the definition of primary tumors.
30 Kidney
CT angiography: The facilities, which enhance characteristics
25 Exudate/Effusion of tissues in both arterial and venous phases of imaging, are
used in CT angiography.
18 Transudate
Processing of volumetric data: The volumetric data can be
17 Suprarenal gland processed to produce
Multiplanar images: Sagittal and coronal
00 Water Three-dimensional (3D) images
Virtual endoscopy: Such as laryngoscopy, bronchoscopy
-15 Fat/Connective tissue and sinuscopy.
-90 Fat magnetiC ReSonanCe imaging
High contrast resolution and multiplanar imaging capability
-700 Lungs make MRI ideal for intracranial, spinal and musculoskeletal
imaging.
-1,000 air
principle
HU. Most fluids are in the range of 0–30 HU.The density levels The protons in the nuclei of hydrogen behave like small spin-
of all soft tissue organs except lungs lie within a narrow range ning bar magnets and align with a strong external magnetic
between 10 HU and 90 HU. field. A radio frequency pulse knocks protons out of alignment,
which release small amount of energy while gradually returning
Due to the high degree of over-lap between the densities to their original position. This energy is detected by sensitive
coils, which are placed around patient. Hydrogen atoms are
(gray tones), it is difficult to differentiate between lymph nodes, abundantly present in body water and MRI can differentiate
muscles and vessels. the water content of various tissues.
Window width/level: By varying the range and centering machines
of densities (window width/level) at a viewing console, an Clinical MRI machines operate at magnetic field strengths of
image appropriate to area of interest can be selected. So, between 0.5 and 2.0 tesla (T). One tesla (T) is equal to 10,000
CT scans can be displayed on soft tissue and bone settings Gauss (G). Higher the field strength of the magnet, higher the
(Box 2). Bone diseases and traumas are best visualized with signal-to-noise ratio and higher is the quality of MRI. The open
bone detail algorithm. access magnets allow interventional procedures.
Spiral CT: Helical or spiral CT scans a volume of tissue and imaging protocols
provides better quality images than the conventional CT. It The strength of signal depends on proton density and relax-
covers more than 300 cm tissue during a single breathhold ation time. T1 is the time taken by proton to return to its original
of 30 seconds. field and T2 is the time proton takes to de-phase.
600 Numerous imaging protocols are available but the provides two-dimensional display of physiological and func-
commonly used pulse sequences are T1-weighted (T1W), tional changes in tissue (thyroid, parathyroid, salivary glands,
Section 9 w Related disciplines T2-weighted (T2W), gadolinium-enhanced T1W, spin (proton) brain and bone metastases). Single photon emission computed
density, fat-suppressed and gradient echo imaging (Table 2). tomography (SPECT) and positron emission tomography (PET),
Fat suppression methods are T2W, short-tau inversion recovery which require special and dedicated set up, are not widely
(STIR), spectral presaturation inversion recovery (SPIR), and available.
chemical shift selective presaturation (fat saturation). Technetium-99m (99mTc)-pertechnetate scan: In salivary
T1W: Because of high soft tissue discrimination, T1W images
glands, this scan is pathognomonic of Warthin’s tumor and
show exquisite anatomical details (Fig. 11). oncocytoma (Fig. 13).
T2W: The pathological lesions increase T2 de-phase times, I-123 scan: It is used for thyroid uptake study to know
whether nodule is hot or cold.
which produce higher signal than surrounding normal Positron emission tomography: It is more sensitive and
tissue in T2W images (Fig. 12). provides physiologic (blood flow and ischemia) and
biochemical data (metabolism of DNA, glucose, amino acid).
The combination ofT1W andT2W images is good for char- In the F-18 fluorodeoxyglucose (FDG) PET scan, a safe low
acterizing fluid containing structures, solid components and dose of short-lived positron-emitting isotope of a glucose
hemorrhage. compound FDG is injected intravenously. Patient is asked
Gadolinium-enhanced T1W: Intravenous gadolinium (used not to take sugars or carbohydrates for the entire day prior
in T1W) reduces T1 relaxation time and enhances lesions, to the scan. Patient observes complete fast (except water)
which appear as high signal intensity areas (improved after midnight for the morning PET scan.
delineation of tumor margins relative to the lower signal of Single photon emission computed tomography: It provides
muscle, bone, vessel and globe). Gadolinium enhancement 3D images.
is optimally used with specific fat suppression techniques.
Short-tau inversion recovery: The STIR sequence suppresses inteRVentional Radiology
high signal intensity from fat (that turn fat black) and fluid
containing structures remain high signal intensity. In STIR, Ultrasound and CT guidance can be employed to choose
decreased signal-to-noise ratio degrades the image. shortest route from skin to the lesion. US, which is quick and
Magnetic resonance angiography: It uses specific sequences flexible, allows needle path in real time without radiation
and demonstrates flowing blood. hazard. Some of the many indications and techniques include:
RadionUClide imaging 1. Percutaneous biopsy
2. Drainage of abscess and fluid collection
Intravenously administered radiopharmaceuticals (radio- 3. Percutaneous gastrostomy
nuclides tagged to substances) such as technetium-99m 4. High local dose of chemotherapy to feeding vessels of tumor
(99mTc)-pertechnetate concentrate selectively in certain tissues
and emit gamma radiation detected by a gamma camera. It
taBle 2 Differences between the images of various pulse sequences of mRI
T1W T2W Contrast T1W STIR
Complete black
Fat Bright or white Low to int. signal White White
White
CSF and vitreous Black Bright white Black Black
Nasal mucosa Low signal White White Low to int. signal
Black
Air, rapid blood flow Dark or black Black Black High signal
and bone Low signal
Higher signal
muscles Low to int. signal Low to int. signal Low to int. signal
6–8
Bone marrow Bright Low to int. signal Bright
Low
Fluid secretions Low signal High signal High signal Long
more
viscus desiccated Int. to high signal Low signal Low signal
mass Low to int. signal Higher signal Higher signal
Best Normal anatomy pathology lesions
Slices Few
Repetition time (TR) Short (500–700 ms) Long (2,000–4,000
ms)
Echo time (TE) Short (15–40 ms) Long (50–90 ms)
Signal-to-noise ratio High
Imaging time Short
motion artifacts Less
Int.: Intermediate; STIR: Short-tau inversion recovery
601
fig. 11: mRI head sagittal section T1-weighted Chapter 60 w diagnostic imaging
Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat
fig. 13: Thyroid scan showing salivary glands
Cervical lymphadenopathy
Trauma, inflammation and cancer of larynx and laryngo-
pharynx with metastatic neck nodes
Large or fixed thyroid tumors invading and compressing
larynx, laryngopharynx, trachea and mediastinum
Paranasal sinuses prior to endoscopic sinus surgery, severe
nasal polyposis, tumors
Facial trauma (Fig. 15).
Temporal bone and skull base tumors, semicircular canal
fistulas, cochlear implants.
fig. 12: mRI head axial section T2-weighted mRi
Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat Tumors of nasopharynx, oropharynx, oral cavity and tongue
5. Angioplasty and vascular stenting (Fig. 16)
6. Therapeutic embolization. Extracapsular spread of tumor from nodes
Perineural spread and extension beyond gland of salivary
appliCationS of Ct, mRi and US
Though CT and MRI have their own advantages, disadvantages, gland tumors
characteristics (Table 3) and definite indications, yet in certain Tumors of nose and paranasal sinuses: Distinguish between
situations they prove to be not competing, but rather comple-
menting to each other. Usually CT and MRI are performed tumor and obstructed sinus secretions (hydrated fluid,
before biopsy or resection of lesion. viscous, desiccated); perineural spread to anterior cranial
fossa, orbit, parapharyngeal space and pterygopalatine
fossa and cribriform plate extension
Lesions of IAC, facial nerve canal, and jugular foramen;
acoustic schwannoma
Skull base tumors.
CT and mRI temporal bone: Thin sectioned HRCT is ideal for
looking temporal bone abnormalities or fractures, but mRI is
gold standard for acoustic neuroma.
Ct US
Extension of mucosal tumors of suprahyoid neck (Fig. 14) Differentiating cystic from solid masses
Metastatic lymph nodes of lower two-third of internal
and metastatic neck lymph nodes (ring enhancement)
Postoperative neck jugular vein, spinal accessory nerve, submental and
Salivary gland tumors and metastatic neck lymph nodes submandibular triangles (more sensitive than CT)
Computed tomography sialography Tumor invasion of carotid vessels and internal jugular vein
602 taBle 3 Comparison of advantages, disadvantages and characteristics of CT and mRI
Section 9 w Related disciplines Hazards ionizing radiations CT MRI
Spatial resolution present absent
Speed of acquisition good poor
Dental amalgam artifacts Fast with spiral CT Slow
Beam hardening artifacts from bony more Less
surfaces present absent
motion artifacts: swallowing and
respiration Less chances more chances
Eyelid mascara artifact
multiple pulse sequences absent present
Soft tissue/bone settings absent present
plane of direct scanning present absent
Ideal for axial, + coronal in skull multiplanar (axial, coronal, sagittal)
Blood vessels Bone lesions Soft tissue lesions
availability Seen with contrast Seen without contrast
Cost more Less
Claustrophobia Less more
Direct imaging bone marrow Less more (less in open systems)
Cortical and trabecular bone poor good
In metallic implants/foreign body good delineation poor delineation
Contrast agent Can be done Contraindicated
appearance of bone Ionizing/nonionizing gadolinium
appearance of fat White Black
Black White
fig. 14: CT scan neck axial section showing pharyngeal mass fig. 15: CT scan head coronal section showing condylar fracture
Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat of mandible
Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat
(loss of echogenic fascial plane between vessel wall and
tumor) better than CT/MRI Ct anatomy of eaR, noSe, thRoat, head
Tumors of parotid and submandibular salivary glands and neCk
Salivary duct stones even less than 2 mm Ear and temporal bone (Figs 17 to 20)
Detection and drainage of salivary gland abscess under Nose and paranasal sinuses (Figs 21 to 32)
US guidance Oral cavity and oropharynx (Figs 33 and 34)
Masses of thyroid and parathyroid glands and US guided Laryngopharynx and neck (Figs 35 to 37)
fine needle biopsy Larynx and neck (Figs 38 and 39)
Neck lymphoma.
603
fig. 16: mRI neck showing tongue lesion fig. 17: CT scan axial section. pneumatization of temporal Chapter 60 w diagnostic imaging
Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat bone
fig. 18: HRCT temporal bone axial section showing vestibular anatomy
604
fig. 19: HRCT temporal bone axial section showing internal fig. 20: mRI temporal bone showing membranous labyrinths of
auditory canal both the sides
Source: Dr amit goyal, Shillong
Section 9 w Related disciplines
fig. 21: CT pNS coronal section showing frontal sinuses fig. 22: CT pNS coronal section showing agger nasi cells
fig. 23: CT pNS coronal section showing ethmoidal and maxil- fig. 24: CT scan nose and paranasal sinuses coronal section
lary sinuses
605Chapter 60 w diagnostic imaging
fig. 25: CT scan nose and paranasal sinuses coronal section fig. 26: CT pNS coronal section showing sphenoidal sinuses
fig. 27: CT scan head axial sections showing nose and parana- fig. 28: CT scan head axial sections showing nose and
sal sinuses paranasal sinuses
fig. 29: CT scan head axial sections showing nose and parana- fig. 30: CT scan head axial sections showing nose and
sal sinuses paranasal sinuses
606
Section 9 w Related disciplines fig. 31: CT scan nose and paranasal sinuses axial section fig. 32: CT scan nose and paranasal sinuses axial section
fig. 33: CT scan oral cavity and oropharynx fig. 34: CT scan oropharynx
Source: Dr Ritesh prajapati, Consultant Radiologist, anand, gujarat
fig. 35: CT scan laryngopharynx fig. 36: CT scan laryngopharynx
607
fig. 37: axial CT scan at hyoid bone level show necrotic nodes fig. 38: CT neck with contrast showing larynx and other Chapter 60 w diagnostic imaging
at level Ia on left side cervical structures
fig. 39: CT neck with contrast showing larynx and other cervical structures
Clinical highlights
1. high resolution Ct scan: This is best to assess temporal bone fractures.
2. Ultrasound: It is better than CT in differentiating solid from cystic lesions.
3. mRi, doppler and ultrasound: These imaging technologies do not use ionizing radiation.
4. mRi contraindication: It should not be used in the third trimester of pregnancy.
5. acoustic neuroma: mRI is superior to CT in diagnosis of acoustic neuroma.
fURtheR Reading
1. Bansal M. Virtual endoscopy. Medical Informatics: A Primer. New Delhi: Tata McGraw Hill; 2003.
2. Barghouth G, Prior JO, Lepori D, et al. Paranasal sinuses children: size evaluation of maxillary, sphenoid, and frontal sinuses by magnetic
resonance imaging and proposal of volume index percentile curves. Eur Radiol. 2002;12:1451-8.
3. Bradoo RA, Nerurkar NK, Joshi AR, et al. Virtual bronchoscopy: Our early experience. Indian J Otolaryngol Head Neck Surg. 2005;57;142-4.
4. Gupta SC, Singh M, Jain A, et al. A comparative study of radiological and antroscopic findings in the lesions of maxillary sinus. Indian J
Otolaryngol Head Neck Surg. 2004;56;09-13.
5. Joshi AA, Shah KD, Bradoo R. Radiological correlation between the anterior ethmoidal artery and the supraorbital ethmoid cell. Indian J
Otolaryngol Head Neck Surg. 2010;62:299-303.
61 Radiotherapy and
Chemotherapy
Education is not the amount of information that is put into your brain and runs riot there, undigested all your life. We must have
life-building, man-making, character-making, assimilation of ideas. If you have assimilated five ideas and made them your life and
character, you have more education than any man who has got by heart a whole library.
—Swami Vivekananda
Points of Focus ¯¯Complications of Radiotherapy
Early Complications
Radiotherapy Late Complications
¯¯Basic Physics Patient Care during Radiotherapy
Electromagnetic Radiations Chemotherapy
Ionizing Radiations Principles
Effects of High-Energy Photons in Tissues Single Agent Doses and Toxicity
Radiation Units Criteria for Response
Sources of Radiation Prognostic Factors
Depth-Dose Performance Status
Work-up Before Chemotherapy
¯¯Radiobiology Toxicity of Anticancer Drugs
Oxygen Enhancement Ratio (OER)
¯¯Palliative Chemotherapy
¯¯Therapeutic Window ¯¯Combined Modality Therapy
¯¯Modes of Radiotherapy
Induction Chemotherapy
External Beam Therapy (Teletherapy) Chemoradiation
Brachytherapy Adjuvant or Posterior Chemotherapy
Unsealed Radionuclide Therapy
¯¯Organ Preservation
¯¯Combined Modality Treatment ¯¯Intra-Arterial Chemotherapy
Preoperative Radiation ¯¯Prevention of Cancer
Postoperative Radiation
Intraoperative Radiotherapy (IORT) Lifestyle Modifications
Radiotherapy and Chemotherapy Chemoprevention
¯¯Planning of Radiotherapy ¯¯Clinical Highlights
Factors Affecting Response to Radiotherapy
Fractionation of Radiotherapy
Radiotherapy Fractionation (fx) scheme
Intensity Modulated Radiation Therapy (IMRT)
Radiotherapy Table 1 Range of wavelength (in meters) in elec- 609
tromagnetic spectrum
Radiation oncology has emerged as a separate medical
specialty. Radiotherapy forms an integral part in the manage- Radio waves 105–10–3 m
ment of head and neck malignancies. It may be used either
alone or in combination with surgery and/or chemotherapy. Infrared waves 10–3–10–6 m
It is used alone (curative radiotherapy) in early cancers (such
as glottic cancer) to preserve the function of the organ. As Visible light 4–7 x 10–7 m
an adjuvant to surgery or chemotherapy, it can increase the
survival rate in more advanced lesions. Palliative radiotherapy Ultraviolet 10–7–10–9 m
in advanced lesions, when total control of disease is not
expected, helps in controlling local symptoms of pain, bleeding X-rays 10–9–10–11 m
or obstruction to air and food channels. It has also been found
useful in the treatment of benign vascular lesions (angiofibroma Gamma rays 10–11–10–14 m
and glomus tumor) and to control excessive scar formation in
cases of keloids. Cosmic rays Less than 10–14 m
volts (MeV). Energies of 3–5 electron volts (eV) (correspond to Chapter 61 w Radiotherapy and Chemotherapy
less than 10–6 m) are required to break chemical bonds.
BASIC PHYSICS Ionizing Radiations
A wave can be of various types. It is a periodic disturbance in The sufficiently high energy of ionizing radiations results in
a medium or space. The chief characteristics of a wave are its ionization in the medium through which it passes. In biological
speed of propagation, its frequency, its wavelength and its tissue, its effect can be very serious, as a consequence of the
amplitude (Box 1). ejection of an electron from a water molecule and the oxidizing
or reducing effects of the resulting highly reactive species. The
Electromagnetic Radiations ionizing radiations are enumerated in Box 2.
The energy of electromagnetic radiations (a stream of photons)
can be regarded as waves propagated through space (need no The principal processes by which high-energy electrons
supporting medium). They travel in a vacuum with the speed are produced in the body tissue by the high-energy photons
of light. Photon travels at speed of light. It is a particle with (X-rays and gamma rays for radiotherapy) are shown in Table 2.
zero rest mass consisting of a quantum (minimum amount by
which certain properties, such as energy or angular momentum Photon beams include both X-rays and gamma rays. They
of a system can change) of electromagnetic radiation. are the most common forms of radiation. X-rays are produced
Electromagnetic spectrum is the range of wavelengths over when high-energy electrons bombard a metallic target. Gamma
which electromagnetic radiation extends. The longest waves rays are emitted by radioactive sources, e.g. cobalt-60.
are radio waves (Table 1) while the shortest are cosmic rays.
Other waves in the descending order of their wavelengths are: Electron beam is a type of particle radiation. It is the second
infrared waves, narrow band of visible light, ultraviolet waves, most common forms of radiotherapy, which have rapid dose
X-rays and gamma rays. Gamma rays produced from a 60Co build up and sharp dose fall off with very little scatter. Electron
correspond to a wavelength of 10–12 m and 1.3 million electron beams are produced by linear accelerator, betatron and
Box 1: Different types and characteristics of waves Box 2: Ionizing radiations
•• T raveling wave (Progressive wave): Energy is transferred • Stream of high energy particles
from one place to another by the vibrations. The profile –– Electrons
moves through the medium at the speed of wave. –– Protons
–– α-particles
•• Electromagnetic waves: A type of transverse wave (such • Short wavelength electromagnetic radiations (photon beams)
as water), where electric and magnetic fields vary in a –– Ultraviolet rays
periodic way at right angles to each other and to the –– X-rays
direction of propagation. –– Gamma rays
•• Sound waves: A type of longitudinal waves, where the air Table 2 Effects of high-energy photons in tissues
is alternately compressed and rarefied by displacements
in the direction of propagation. Photoelectric Photon, 10–50 kilo electron volts (keV) used
effect in diagnostic radiology, excites a tightly
•• Speed of propagation: Distance covered by the wave in bound inner shell electron and is completely
unit time. annihilated
•• Frequency: Number of complete disturbances (cycles) in Compton effect Photon, 500 keV–10 MeV used in radio-
unit time expressed in hertz. therapy, excites loosely bound outer elec-
tron and emerges at a lower energy (long
•• W avelength: Distance in meters between successive wavelength)
points of equal phase in a wave.
Pair production High-energy photon is annihilated in strong
•• Amplitude: Maximum differences of the disturbed quantity
from its mean value. electromagnetic field of an atomic nucleus
and produces an electron-positron pair
610 microtron. They boost up the radiation dose to the target area 1.2 cm for 4 MV (80 cm SAD)
and avoid radiation to adjoining vital structures such as spinal 1.3 cm for 6 MV (100 cm SAD)
Section 9 w Related Disciplines cord. Other particle radiations, which are still under investiga- 3.0 cm for 15 MV (100 cm SAD)
tion, include fast neutrons, a-particles, protons or pions.
RADIOBIOLOGY
Radiation Units Radiotherapy kills the cancer cells (in mitosis), which divide
They are expressed in terms of energy that is deposited in a more frequently but repair less efficiently. There are primarily
unit of material. two mechanisms (direct and indirect) by which radiations act
Rad: The conventional dose unit rad (radiation absorbed on biological cells.
1. Direct mechanism: In the direct mechanism of action, key
dose) is equivalent to 100 ergs deposited per gram of
material. targets of radiations are DNA, nuclear membrane and mito-
Gray: The recent dose unit gray (Gy) agreed by international chondria, which result in cell killing.
commission is equivalent to 1 joule deposited per kilogram 2. Indirect mechanism: Indirect mechanism of action affects
of material. molecules in cell cytoplasm, which then result in sequence
Rad and gray: One hundred rads is equal to 1 Gy, which of complex chemical reactions.
has 100 centigrays (cGy). Therefore, 1 rad is equal to 1 cGy. Though radiations usually employ both the mechanisms,
low-LET radiations primarily affect cell through indirect mecha-
Sources of Radiation nism while high-LET kills cells through direct mechanism.
Higher the energy of radiations, deeper do they penetrate.
Earlier X-ray machines, which could be used for superficial Oxygen Enhancement Ratio
tumors of the skin or lip, produced energy only in kilovolts (kV). A synergy has been reported between ionizing radiations
Newer machines produce radiations of high energy in million and oxygenation, and hyperthermia. Indirect mechanism of
volts (MV), which have greater penetrating power. They can be radiation action on molecules of cytoplasm results in free
used for deep seated tumors and spare untoward effects on radicals, which contain unpaired electrons and are highly
the skin and bone. The common sources, which are used for reactive. Oxygen facilitates diffusion of these free radicals to
radiotherapy, include following: DNA and other target regions where they produce damage.
Kilovoltage machines: They are becoming obsolete and Regions of necrosis surrounded by hypoxic cells are present
in large tumors, which make them relatively radioresistant.
consist of superficial (50–150 kV) and ortho (200–400 kV) High-LET, which primarily kills cells directly, avoids this problem.
voltage X-ray machines that produce X-rays of 50–400 kV. Generally, oxygen enhancement rate decreases with increasing
Cobalt-60 machine: This is the most commonly used source LET.
for radiotherapy. It uses radioactive cobalt-60 that produces
gamma rays of 1.17 and 1.33 MeV. The radioactive cobalt-60 THERAPEUTIC WINDOW
has its natural decay time. It needs replacement after every There are some intrinsic differences in the properties of tumor
5 years. and normal cells. A therapeutic dose of radiation in a radiosen-
Linear accelerator: These megavoltage machines can sitive tumor has wide “therapeutic window,” which results in
produce photon and electron beams of 4–25 MV depending 95% chances of tumor control and 5% chances of normal tissue
on whether an intervening metallic target is used in complications. In contrast radioresistant tumors have narrow
machine or not. They work on electricity. Other examples of “therapeutic window,”which means a therapeutic dose of radia-
this category of machines include betatron and microtron. tion has 95% chances of tumor control with very high chances
Radioactive material: Radium-226 used in the form of of normal tissue damage. The following techniques exploit this
needles has been replaced by safer radionuclides, which therapeutic window concept:
include Cesium-137 pellets, Iridium-192 wire, Gold-198 Three-dimensional treatment planning and delivery
seeds and Iodine-125. Brachytherapy
Intraoperative radiotherapy
Depth-Dose Use of high-LET and charged particle radiations
The energy deposited by a radiation beam is characterized Altered fractionation schedule
by its linear energy transfer (LET) spectrum. The deposited Use of radiosensitization and radioprotective schedule.
dose of photon beams (X-rays and gamma rays) is low at the
surface and more in depth. After reaching to a maximum, then MODES OF RADIOTHERAPY
it decreases with depth because of attenuation. The skin and External beam therapy (teletherapy): This mode of radio-
subcutaneous tissues are spared and delivery of radiation is
more to deeper tumor. therapy uses photon and electron beams. They project to
the target area through the skin from a distance. The main
Electron beam penetrates a given distance and then fall off advantages of megavoltage radiotherapy are its better
rapidly. There occur slight amount of skin sparing with 6 MeV precision, skin sparing, diminished bone absorption and
beam. These beams are used for cancers of skin and mucosa increased dose to deep tumor.
of oral cavity. Brachytherapy: Brachytherapy uses radioactive material,
Dmax: It refers to the distance of the dose maximum from the which is applied in the form of mould, interstitial implant
surface, which varies with energy and source axis distance
(SAD):
and intracavitary implant. They are placed in close contact palpable tumor mass or occult metastasis to lymph 611
with the tumor. nodes.
Interstitial implants: The interstitial implants are in the Disadvantages Chapter 61 w Radiotherapy and Chemotherapy
The central part of large tumor responds poorly to radia-
form of needles (226Ra and 137Cs), wires, ribbons or seeds. tion because of poor oxygenation.
They are inserted into the tumor. Radiation induced reduction in the vitality of tissues
Shorter half-life: Some of the radioactive materials (198Au increases the chances of postoperative complications,
and 125I) have shorter half-life and are permanently left which include delayed healing, flap necrosis, fistulae
in the tissues. formation and carotid blowouts.
Intracavitary implants: The radioactive material is placed
in a hollow cavity next to the tumor for either minutes, Postoperative Radiation
hours or days. Examples include nasopharynx and Advantages
maxillary antrum.
Recent developments: The following recent deve It is more effective as the remaining tumor mass after
lopments is again making brachytherapy popular, which the radical surgery is limited.
was abandoned due to the hazards of radiation to the
physician, nurses and other personnel: As the extent of disease is well defined after the surgery,
–– After-loading techniques (192Ir) radiotherapy can be better planned for the suspected
–– Safer radionuclides areas of residual disease.
–– Computerized dosimetry
Currently, high-dose rate remote after-loading devices Surgical resection is easier and postoperative complica-
are available, which push 192Ir via a set of interstitial tions are lesser in comparison to the cases of preopera-
catheters. Computers control dwelling time throughout tive radiotherapy.
the implant.
Unsealed radionuclide therapy: Radioactive isotopes are Disadvantages: Blood supply of the tissues is affected,
given either orally or intravenously. They are concentrated which results in relative hypoxic cells that respond poorly
by metabolic pathways in malignant tissue, which receive to radiation.
large radiation doses. The normal tissues are relatively
spared.The best example is the radioactive iodine treatment Indications: Postoperative radiotherapy is usually indicated
of differentiated thyroid carcinoma of follicular cell origin. in following conditions:
COMBINED MODALITY TREATMENT When the margins of growth are reported positive or
very close.
In the presence of invasion of bone or cartilage.
Extracapsular invasion of lymph nodes.
Neck nodes are multiple or the size of a node is greater
than 3 cm.
Curative radiotherapy for small cancerous lesions not only Intraoperative Radiotherapy
cures the cancer but also has the advantage of preserving A single large fraction of radiation is given to the exposed
the function of the organ. Surgery does give good results tumor bed at the time of operation. This technique employs
in these early cases but functions are significantly affected. either orthovoltage X-rays or megavoltage electrons. During
The curative dose of radiotherapy in head and neck cancer the surgery at the time of radiotherapy, critical structures are
ranges from 65–75 Gy (6,500–7,500 rads/cGy). moved outside the field of radiation.
Palliative radiotherapy is given in advanced inoperable Radiotherapy and Chemotherapy
tumors, or patients with distant metastases, or poor general Chemotherapy is used either before, during or after radio-
condition (poor nutrition and diseases of heart, lung, liver therapy.
and kidney). Induction chemotherapy (before radiotherapy) reduces the
Combination therapy combines radiotherapy with surgery bulk of tumor and may help in organ preservation. The
and chemotherapy. Radiotherapy can be given before, after vascularity of the lesion is maintained and enhanced.
and even during the surgery to achieve better control of Concomitant chemotherapy acts as a radiosensitizer
disease. Each modality has its own advantages and disad- and improves the effect of radiation on the tumor cells.
vantages; however postoperative radiotherapy is the most Methotrexate and bleomycin are good radiosensitizers.
common and well established. Adjuvant chemotherapy is used after radiation. It helps in
controlling distant metastases (see section“Chemotherapy”).
Preoperative Radiation
Advantages PLANNING OF RADIOTHERAPY
Shells are prepared for accurate treatment of tumor and sparing
It reduces the tumor bulk and can convert inoperable adjacent normal and critical structures. The treatment simulator
tumor into operable one. consists of diagnostic X-ray machine with image intensification
facilities. It allows distance adjustment to make rectangles of
Response to radiation better because of the better any size. The introduction of blocks shapes the radiation beam
oxygenation of tissues, which is affected in operated to shield normal critical structures.
cases.
Radiation blocks the lymphatics and the chances of
dissemination of tumor cells during surgery are less.
It decreases the chances of microscopic spread beyond
612 The histology nature, site, size and extent of tumor (T) and shape the beam, which allowed the field to be shaped to cover
its draining lymph nodes (N) must be known.The primary tumor area of interest. In three-dimensional conformal radiotherapy,
and its draining lymph nodes are included in the radiation field. isodose curves conform closely to tumor shape but close
Extent of tumor can be found by clinical examination (palpation normal tissues are not spared.
under anesthesia) and radiological studies.
Intensity modulated radiation therapy delivers the dose as a
Factors Affecting Response to Radiotherapy gradient across the area of interest. The main advantage of IMRT
Smaller the tumor, better is the response. is sharper gradient between tumor tissue and normal tissue.
Tumors of lymphoid tissues are very radiosensitive. Techniques: There are three techniques of IMRT:
Anaplastic tumors and embryonal tumors are also radio-
1. Dynamic IMRT: It is similar to tomotherapy unit, which
sensitive. circle around patient.
The differentiated squamous cell carcinomas do not
2. Stepwise delivery: It is similar to three-dimensional
respond well. conformal radiotherapy.
Adenocarcinomas, sarcomas and bone tumors have low
3. Step and soot IMRT: It is the hybrid of former two where
sensitivity. multiple beam arrangements are used but leaves are
changed in real time.
Section 9 w Related Disciplines Fractionation of Radiotherapy COMPLICATIONS OF RADIOTHERAPY
Curative: The curative dose of 65–70 Gy (6,500–7,500 rad/ Complications of radiotherapy depend on the site of radia-
tion, dose delivered and its daily fractions. They can be early
cGy) is usually delivered in fractions of 2 Gy (200 rads/cGy) and late. Higher the total dose and larger the daily fraction,
daily for 5 days in a week (monday to friday) till the comple- more are the complications. Acute radiation side effects are
tion of desired curative dose. caused by changes in tissues, which are composed of rapidly
Preoperative: Preoperative radiation, which is not used proliferating cells. The delayed effects are caused by changes
frequently, consists of 50 Gy (5,000 rads/cGy) delivered in in tissues, which have slowly proliferating cells.
fractions of 2 Gy (200 rads/cGy) daily for 5 days in a week for
5 weeks to the primary tumor and neck nodes. It is followed Early Complications
by surgery in 4–5 weeks. Surgery is not delayed beyond 6 Radiation sickness (anorexia and nausea).
weeks as it causes regrowth of the tumor cells. Mucositis (ulcers in mouth and pharynx).
Postoperative: Postoperative radiation dose is 50–60 Gy Dryness of mucous membranes (xerostomia).
(5,000–6,000 rads/cGy) and is started 4–6 weeks after Skin reactions are erythema, dry and wet desquamation
surgery. Postoperative radiation should not be delayed. It
can result in a regrowth of tumor cells. of skin (Fig. 1).
Fractionation schedules: They vary from center to center. Pharyngeal edema.
Some of them are given in Table 3. Conventional fraction- Laryngeal edema (stridor).
ations use 2 Gy per day for 5 days a week. To avoid the Fungal infections: Candida.
prolong treatment time, multiple daily fractions with a Hematopoietic suppression.
minimum 6 hours interval are given in hyperfractionation
and accelerated fractionation schemes. Late Complications
Hypofractionation consists of smaller number of frac- Permanent xerostomia (Dryness of mouth)
Atrophy of skin and subcutaneous fibrosis
tions, which are larger than 2 Gy. Teeth decay
In hyperfractionation, larger numbers of fractions, which
are smaller than 2 Gy, are employed.
Accelerated fractions shorten the overall time.
Split courses provide gap, which allows acute reactions
to settle.
Intensity Modulated Radiation Therapy
The aim of any radiotherapy is to deliver entire dose to the
tumor and none to normal tissue. The intensity modulated
radiation therapy (IMRT) is current step in that direction. In the
past, customized cerrobend and multileaf collimators used to
Table 3 Radiotherapy fractionation (fx) scheme
Hyperfractionation 81.6 Gy, 1.2 Gy/fx, 2 times a day, 68 fx, 5
days a week
Accelerated 54 Gy, 1.5 Gy/fx, 3 times a day, 36 fx, 7
intense days a week
Accelerated split 67.2 Gy, 1.6 Gy/fx, 2 times a day, 42 fx, 5
course days a week Fig. 1 Skin reactions after postoperative radiotherapy
Osteoradionecrosis Principles 613
Trismus due to fibrosis of temporomandibular joint and Though the single drug as well as combinations of various drugs
have been employed to treat head and neck malignancies, it has Chapter 61 w Radiotherapy and Chemotherapy
muscles been observed that combination of two or more drugs provide
Transverse myelitis relatively better overall response. The drugs, which are found
Eye: Retinopathy and cataract effective in head and neck malignancies, and their side effects
Endocrinal deficit: Thyroid and pituitary and doses, are listed in Table 4.
Malignancy: Thyroid cancer and orbital osteosarcoma. Phases of drug evaluation: The evaluation of drugs occurs in
Patient Care during Radiotherapy the following three phases:
Nutrition: Diet should be rich in protein, vitamins and iron. 1. Phase I: Determination of toxic effects and establish-
Nasogastric tube feeding is started if needed. Blood transfu- ment of highest safe dose.
sion is given if patient has severe anemia. 2. Phase II: Determination of activity (response rate) in
Teeth care: Dental evaluation and extraction if needed are of
paramount importance and prevent osteoradionecrosis of patients with same tumor type.
mandible. Wound of extraction must heal before the begin- 3. Phase III: Randomized comparisons (response duration
ning of radiotherapy. Xerostomia facilitates caries of teeth.
Skin care: Skin reactions were common with old superficial and progression-free survival) of two or more treatment
and orthovoltage X-ray machines.The modern megavoltage options.
therapy machine has a skin sparing effect. Electron beam
therapy to skin can also result in skin reactions. Advises, Criteria for Response
which are given to patients during radiotherapy, include: The efficacy of chemotherapy is investigated through clinical
Keep the skin dry and avoid soap, water and wet shaving. trials, which use standard definitions that allow objective
Avoid sunlight. reporting of results (Table 5).
Avoid abrasive dressing and clothing and adhesive
Prognostic Factors
plaster for dressings, which peels off the desquamated The survival time may be prolonged in patients who achieve
skin. a complete response. Lower response rates are observed in T4
Skin should be covered with soft cloth, which should and N3 stage cancer. The overall survival time correlates with
provide free aeration to the skin. performance status, T and N stage, primary site and nodal
For moist desquamated skin, use antibiotic ointment. extracapsular extension of tumor. After analyzing many chemo-
Topical steroid creams relieve itching and pain. therapy trials for patients with recurrent disease, following poor
Mouth care: Dryness of mouth (xerostomia) and ulcerations prognostic factors have been identified:
(mucositis) are common and interfere with feeding. Acute Low performance status (Box 3).
radiation mucositis generally persists for 8–12 weeks Poor nutrition.
after radiation. Irradiated patients are prone to develop Large tumor burden.
candida infection, which can affect mucosa of oral cavity Extensive previous radiotherapy and surgery.
and pharynx. Tumor progression during or shortly after surgery or radio-
Patient is asked to avoid alcohol, tobacco and spicy food.
Irritating mouthwashes contain alcohol and should be therapy.
avoided.
Milk of magnesia neutralizes the acid pH and prevents Biologic factors
caries of teeth and soothes and protects inflamed The following biologic factors, which may be used to predict
mucosa. response and survival outcome, are under investigations:
Xylocaine viscous relieves pain and discomfort of muco- DNA content
sitis and facilitates food taking. Immunologic status
Oral candida is usually treated by topical application of Circulating immune complexes.
nystatin and clotrimazole. Systemic antifungal therapy
is needed for the mycelia, which may lie protected Work-up Before Chemotherapy
beneath organic debris. Patients who are candidates for cancer chemotherapy should
be subjected to following investigations:
Chemotherapy History and clinical examination: Exclude kidney, heart and
Chemotherapy can be used either alone or in combination with lung disease.
surgery and radiotherapy. The drugs, which are found effective CBC: Hemoglobin, total and differential WBC count and
in head and neck squamous cell cancers are, methotrexate,
cisplatin, bleomycin and 5-fluorouracil. Adriamycin has been platelet count. Many drugs are myelosuppressive.
used for adenoid cystic carcinoma and dacabazine for mela- Urine examination.
nomas. Lymphomas, both Hodgkin and non-Hodgkin types, Biochemistry: Blood urea nitrogen and creatinine and liver
which have multifocal origin and widespread involvement, are
also treated by chemotherapy. function tests. Methotrexate and cisplatin are nephrotoxic.
Radiology: X-ray chest, CT scan/MRI (to know extent of
disease) and ultrasound abdomen for liver/spleen.
614 Table 4 Single agent doses and toxicity
Drug and doses Acute toxicity Delayed toxicity
•• Alkylating Agents Nausea and vomiting with higher doses N eutropenia, alopecia, hemorrhagic cystitis
Cyclophosphamide
100–400 mg/m2/d; 1–1.5 g/m2 IV every
3–4 weeks
Ifosfamide Myelosuppression, alopecia, confusion;
1.5–2.5 g/m2 twice weekly mesna prevents cystitis
Cisplatin Severe nausea and vomiting Nephrotoxicity, ototoxicity, neuropathy
50–100 mg/m2 IV 3 weekly
Section 9 w Related Disciplines Carboplatin Severe nausea and vomiting Myelosuppression, prolonged anemia
360 mg/m2 IV, 4 weekly
None Mucositis (oral and GIT ulcers), myelosup-
•• Antimetabolites C itrovorum factor (leucovorin) rescue for pression, acute renal failure, rash, hepatotoxic
Methotrexate doses over 100 mg/m2
2.5–5 mg/d orally; 20–25 mg IM twice None N ausea, mucositis, diarrhea, myelosuppres-
weekly; 500–1,000 mg/m2 IV every 2–3 sion and dacryocystitis
weeks A llergic reactions, fever and hypotension
Fever, pulmonary fibrosis, dermatitis (skin
5-Fluorouracil rash), mucositis
1 5 mg/kg/d IV for 3–5 days every 3 weeks
•• Antibiotics
Bleomycin
U p to 15 units/m2 IM/IV/SC twice weekly
Adriamycin Vesicant, nausea, vomiting, diarrhea C ardiotoxicity, mucositis, myelosuppression,
60–90 mg/m2 IV monthly alopecia
Mitomycin Severe vesicant; nausea Bone marrow depression, hemolytic-uremic
10–20 mg/m2, 6–8 weekly syndrome
Severe vesicant
•• Vinca Alkaloids M ild nausea and vomiting; severe vesi- Areflexia, neurotoxicity, alopecia, myelo-
Vincristine cant suppression, paralytic ileus, syndrome of
1.5 mg/m2/week (Max 2 mg) M ild nausea vomiting; hypersensitivity inappropriate antidiuretic hormone secretion
reaction (premedicate with diphenhydr- constipation
Vinblastin amine and dexamethasone)
0.1–0.2 mg/kg (6 mg/m2)IV Myelosuppression, neuropathy
None E dema (fluid retention), neutropenia, neurop-
•• Taxanes athy
Paclitaxel (Taxol)
135 mg/m2 IV infusion 24 hours every Enhances toxic effects of fluorouracil
3 weeks
Docetaxel (Taxotere)
60–100 mg/m2 IV 3 weekly
•• Supporting Agents
Leucovorin
10 mg/m2, 6 hourly IV/oral
Mesna Nausea, vomiting, diarrhea None
20% of ifosfamide dosage
New agents under investigation: Topoisomerase-I inhibitors, gemcitabine (pyrimidine antimetabolite), vinorelbine (semisynthetic
vinca alkaloid), trimetrexate, edatrexate, and piritrexim.
Table 5 Criteria for response Box 3: Performance status Eastern Cooperative Oncology
Group, Southwestern Oncology Group Zubrid scales
Complete response No evidence of tumor for at least 4
weeks 0. Fully active; carry on all the housework and office work
without restriction
Partial response 50% tumor regression for at least 4
weeks 1. Restricted activity; carry on light house work and office
work
Minor response Less than 50% tumor regression
2. No work activities but capable of all self-care; ambulatory
Stable disease No appreciable tumor regression for more than 50% of waking hours
Progressive disease 25% increase in tumor size or 3. Capable of only limited self-care; ambulatory for less than
appearance of new lesions 50% of waking hours
4. Completely bed ridden; unable to do any self-care
5. Dead
Pulmonary function tests: Bleomycin causes interstitial It eliminates problems of poor vascularity (after surgery and 615
pulmonary fibrosis. radiotherapy) and helps in preservation of organ function.
Chapter 61 w Radiotherapy and Chemotherapy
ECG: Adriamycin has cardiotoxicity. Response to anterior chemotherapy correlates with
Audiogram: Cisplatin causes high frequency hearing loss. response to subsequent radiotherapy. It does not correlates
Nutritional status. with surgical and radiotherapy complication rates. Some of
the most important randomized trials of neoadjuvant chemo-
Toxicity of Anticancer Drugs therapy before surgery or radiotherapy are listed in Table 6.
Anticancer drugs act on not only rapidly dividing cancer cells
but also normally dividing cells of hair follicles, gastrointestinal Encouraging data emerge from neoadjuvant chemotherapy
mucosa and bone marrow. They can cause alopecia, stomatitis, trials. The overall response rates range from 60–90% (after 3
nausea, vomiting, diarrhea, anemia, leukopenia and thrombo- cycles). Survival time is improved in cases with a complete
cytopenia (Table 4). Some drugs have selective action on certain response (Table 5), which ranges from 20–50%. The critical
systems, such as kidney (methotrexate and cisplatin), nerves prognostic factors are: TN stage and type of chemotherapy. A
(vincristine and cisplatin), heart (adriamycin) and bladder significant decrease in distant metastases has been reported.
(cyclophosphamide). It has the potential to improve quality of life with organ pres-
ervation.
Indications for chemotherapy include: Chemoradiation
• To make radiotherapy more effective for local primary In cases of unresectable tumors, concurrent radiotherapy
treatment. and chemotherapy, which may result in additive or syner-
• Combined with radiotherapy for organ-preservation therapy gistic enhancement, is used to improve local and regional
control.
especially of laryngeal cancers. It usually enhances acute radiation-induced toxicity (mainly
• Induction or neoadjuvant therapy facilitates less extensive mucosal), which can result in dose reduction and interrup-
tion in radiation.
local surgery. The survival benefits are not well established.
• To control symptoms in metastatic disease. The single agents, which have been combined with radiation
to improve cellular cytotoxicity are: methotrexate, hydroxy-
Palliative chemotherapy urea, bleomycin, 5-fluorouracil, mitomycin and cisplatin.
Palliative chemotherapy includes use of cytotoxic drugs either Multiple agents’trials of concomitant or alternating combi-
singly or in combination in advanced, recurrent or metastatic nation chemotherapy and radiation are listed in Table 7.
disease just to relieve the symptoms. It is not well proved that
they prolong life. The response duration to commonly used Adjuvant or Posterior Chemotherapy
single agents tends to be 2–4 months. The complete response Chemotherapy used after surgery or radiation is aimed to cure
was observed in less than 5%. Some of the combination micrometastases and decrease distant metastases. It is also
chemotherapy regimens, which have been used and improve called posterior chemotherapy. There appears to be no role of
the response rates, are the following: maintenance chemotherapy in low-risk cases, although high-
Cisplatin and 5-fluorouracil risk cases (extracapsular extension in cervical lymph nodes,
Cisplatin and methotrexate carcinoma in situ, close surgical margins) may benefit.
Carboplatin and 5-fluorouracil Advantages: The potential advantages are:
Cisplatin and bleomycin
Cisplatin, methotrexate and bleomycin Surgery is not delayed.
Cisplatin, vinblastine and bleomycin
Cisplatin, methotrexate, vinblastine and bleomycin.
COMBINED MODALITY THERAPY Table 6 Trials of induction chemotherapy
The chemotherapy may be used either before, during or after
other modalities of treatment, such as surgery and radiotherapy. Regimen Sites
The three general approaches, which have been undertaken for
the sake of improving primary treatment program by using PF (most common) OC, OP, HP, NP, L
combined modality therapy, are: induction, chemoradiation
and adjuvant therapy. PB with/without M OC, L, HP, OP
Induction or Anterior Chemotherapy CF OC, OP, HP, L
(Neoadjuvant Chemotherapy)
When chemotherapy is used before surgery or radiation, it is BEP NP
called induction or anterior chemotherapy. It helps in reducing
tumor burden and micrometastases, which can occur during PBVM OC, OP, HP, L
surgery or before radiation. This neoadjuvant chemotherapy
has better compliance and tolerance in downstaging patients. BVcBP OC, OP
PFBM OC, OP, HP, L
K ey: B, Bleomycin; Key: HP, Hypopharynx; L,
C, Carboplatin; E, Epirubicin; Larynx; NP, Nasopharynx;
F, 5-fluorouracil; M, OC, Oral cavity; OP,
Methotrexate; P, Cisplatinum; Oropharynx
V, Vinblastine; Vc, Vincristine;
616 Table 7 Multiple agents and radiotherapy Occupational risks.
Obesity, parity and length of lactation (breast cancer).
Concurrent MMC + F/RT Sequential VBM → RT High intake of fat and specific fatty acids (breast, colon,
Alternating PF/RT Concurrent VBM with/without prostate and lung cancer).
F/RT Exposure to ultraviolet light (use of sunscreens protects
Concurrent PF/RT Sequential VBM with/without skin from sunlight).
F → RT Protective role of exercise, folate and calcium supplementa-
Sequential PF → RT Concurrent PFL/RT tion, fruit and vegetable intake and dietary fiber (colorectal
cancer and adenomas).
Alternating VBM/RT
Chemoprevention
Key: B, Bleomycin; F, 5-fluorouracil; L, Leucovorin; M, Methotrexate; Chemoprevention is an important area of research. It consists of
MMC, Mitomycin-C; P, Cisplatin; Pc, Carboplatin; RT, Radiotherapy; administration of drugs, which inhibit carcinogenesis or reverse
a premalignant condition.
V, Vinblastine Indications: Following high-risk patients have been identi-
No blurring of tumor margins as it occurs in neoadjuvant fied for chemoprevention:
chemotherapy. Past history of cancer (for preventing second cancer).
Premalignant lesions, such as leukoplakia.
Section 9 w Related Disciplines ORGAN PRESERVATION Risks due to family history, lifestyle and occupation.
The radical surgery of stage III and IV tumors results in loss Pharmacological agents: The following agents have been
of speech, loss of swallowing function, or disfigurement. The tried in different designs (induction, maintenance and
neoadjuvant chemotherapy followed by radiotherapy has been adjuvant) in head and necks malignancies:
used to preserve functions for tumors of hypopharynx, larynx Retinoids (synthetic and natural analogs of vitamin
and oropharynx. The patients who achieve either partial or
complete response with neoadjuvant chemotherapy go for A): Retinoids have both acute toxicities (dryness of
radiotherapy, while nonresponders go for radical surgery. No conjunctiva and oral mucous membrane, cheilitis, skin
significant survival difference is reported in either group. desquamation, hypertriglyceridemia, bone tenderness,
arthralgia and myalgia) as well as chronic toxicities (tera-
Organ preservation therapy: Chemotherapy may play an togenic, hepatotoxic and bone remodeling).
important role in organ preservation. It avoids extensive surgery –– Vitamin A (retinol)
and is the main treatment for metastatic head and neck cancers. –– β-all-transretinoic acid (retinoid)
Radiotherapy becomes more effective as well as more toxic –– 13-cis retinoic acid (isotretinoin)
when combined with chemotherapy. –– Etretinate (aromatic ethyl ester derivative).
Carotenoids: β-carotene is a major source of vitamin A
INTRA-ARTERIAL CHEMOTHERAPY in diet. Carotenoids results in yellowing of skin.
Intra-arterial chemotherapy, a type of regional drug delivery, a-tocopherol (vitamin E).
which is not yet viewed as a standard of care, can increase tumor Calcium and selenium.
drug exposure (maximum cancer cell killing) and decrease N-acetyl cysteine: N-acetyl cysteine is relatively nontoxic.
systemic drug toxicity. Epidermal growth factor receptor.
Farnesyl transferase.
PREVENTION OF CANCER Aspirin and cyclooxygenase-2 inhibitors.
Other: Other diet and pharmacological agents, which
Lifestyle Modifications are under investigations include: soy isoflavones, folic
The lifestyle factors, which accounts for a majority of avoidable acid, dietary fat and fish oils, raloxifene, sulindac and
cancer, include: polyphenols in green tea.
Chewing of paan, sopari and tobacco. Further information about ongoing trials: It can be obtained
Smoking and alcohol. from USA’s Chemoprevention Branch of National Cancer
Institute (301-496-8563).
Clinical Highlights
1. Radiotherapy: Sensitivity to radiation is more on the well oxygenated peripheral cells of carcinoma than the hypoxic
central cells of carcinoma.
2. Lhermitte’s sign: This rare sign is seen after radiation of cervical spine. On flexing the neck, patient develops electric
current like sensation in arms, dorsal spine and both legs.
3. Radioactive iodine: It cannot be used in the ablation of medullary carcinoma of the thyroid.
4. Adjuvant chemotherapy: The chemotherapy used after surgery or radiotherapy for cancer is called as adjuvant
chemotherapy.
5. Bleomycin: This antineoplastic drug causes pulmonary toxicity.
FURTHER READING 617
1. Agarwal AK, Sethi A, Sareen D, et al. Treatment delay in oral and oropharyngeal cancer in our population: the role of socio-economic Chapter 61 w Radiotherapy and Chemotherapy
factors and health-seeking behaviour. India J Otolaryngol Head and Neck Surg. 2011;63:145-50.
2. Agrawal N. Combined chemoradiation for advanced unresectable head and neck carcinomas. Indian J Otolaryngol Head Neck Surg.
2005;Special issue-I:49-51.
3. Ahluwalia H, Gupta SC, Singh M, et al. Spectrum of Head Neck Cancers at Allahabad. Indian J Otolaryngol Head Neck Surg. 2001;53:16-21.
4. Ashraf M, Kumar P, Reza MA, et al. Neoplastic diseases of the head and neck in children. Indian J Otolaryngol Head Neck Surg. 2006;58:343-6.
5. Asif R, Chandra K, Chopra V, et al. Concurrent cisplatin and radiotherapy in advanced head and neck cancer. Indian J Otolaryngol Head
Neck Surg. 2003;55:94-6.
6. Aziz Y, Siddique SA, Aslam M. Hyperfractionation and concomitant chemoradiation—A comparative evaluation in advanced head and
neck malignancies. Indian J Otology. 2005;Special issue-I:97-9.
7. Bhagat DR, Chowdhary A, Kumar R, et.al. Taste sensation in patients undergoing radiotherapy for various head and neck cancers. Indian
J Otolaryngol Head Neck Surg. 2005;Special issue-I:52-5.
8. Bhattacharjee A, Chkraborty A, Purkashyatha P. Prevalence head and neck cancers in the north east—An institutional study. Indian J
Otolaryngol Head Neck Surg. 2006;58:15-9.
9. Chakravarti A, Shashidhar TB, Naglot S, et al. Head and neck teratomas in children: a case series. India J Otolaryngol Head and Neck Surg.
2011;63:193-7.
10. Dastidar AG, Saha S, Srivastava A, et al. Management of unresectable head and neck cancer—a retrospective analysis at a rural medical
college of India. Indian J Otolaryngol Head and Neck Surg. 2010;62:49-54.
11. Kamath MP, Hegde MC, Sreedharan S, et al. Radiotherapeutic effect on oropharyngeal flora in head and neck cancer. Indian J Otolaryn-
gol Head Neck Surg. 2002;54:111-4.
12. Manocha S, Suhag V, Sunita BS, et al. Comparison of sequential chemoradiation with radiation alone in the treatment of advanced head
and neck cancers. Indian J Otolaryngol Head Neck Surg. 2006;58:57-60.
13. Mishra A, Pandey A, Nog X. Head and neck squamous cell cancer: biology (1). Indian J Otolaryngol Head Neck Surg. 2007;59:28-32.
14. Mitra D, Basu S, Deb AR, et al. Chemoradiotherapy for advanced head and neck cancer—analysis of a prospective, randomized trial.
Indian J Otolaryngol Head Neck Surg. 2006;58:360-3.
15. Pandey A, Raizada RM, Puttewar MP, et al. Effects of radiation therapy and chemotherapy on otological structures in head, neck and
oesophageal malignancies. Indian J Otolaryngol Head Neck Surg. 2005;Special issue-I:33-9.
16. Patel JA, Shah FG, Kothari JM, et al. Prevalence of head and neck cancers in Ahmedabad. Indian J Otolaryngol Head Neck Surg. 2009;61:4-10.
17. Sharma JK, Agarwal M. Study of effect of radiation therapy on cochleovestibular functions in patients with head and neck cancer. Indian
J Otology. 2005;Special issue-I:68-71.
18. Srivastava A, Ghosh A, Saha S, et al. Sarcomas of head and neck—A 10 years experience. Indian J Otolaryngol Head Neck Surg.
2007;59:322-6.
19. Thakur S, Chaturvedi VN, Kennedy Singh AK, et al. Pattern of ear, nose, pharynx, larynx and oesophagus (ENPLO) cancers in a rural based
hospital. Indian J Otolaryngol Head Neck Surg. 2001;53:93-9.
20. Tuli BS, Gupta KK, Dugg MS. Retrospective and prospective study of head and neck cancer. Indian J Otolaryngol Head Neck Surg.
2003;55:10-3.
21. Upadhya, Jariwala N, Datar J. Ototoxic effects of irradiation. India J Otolaryngol Head and Neck Surg. 2011;63:151-4.
62 Anesthesia
Be not a traitor to your thoughts. Be sincere; act according to your thoughts; and you shall surely succeed.
Pray with a sincere and simple heart, and your prayer will be heard.
—Sri Ramakrishna Dev
Points of Focus Thyroid Surgery
Complications
¯¯Introduction Malignant Hyperthermia (MH)
Preoperative Medications
¯¯Immediate Airway Management
¯¯General Anesthesia Endotracheal Intubation
Inhaled Anesthetics Other Procedures for Immediate Airway Management
Intravenous Anesthetics Assessment for Difficult Intubation
Skeletal Muscle Relaxants Complications
Hemostasis and Blood Pressure Control
Monitoring During Anesthesia ¯¯Local Anesthesia
Recovery Two Groups of Local Anesthetics
Day Care (Ambulatory) Surgery Types
Laser Surgery
Endoscopy ¯¯Clinical Highlights
Head and Neck Oncology
introduction Analgesics: Opioids.
Advances in anesthesia have been driven by the advances in Anticholinergics: They prevent increased salivation and
the surgical practices. The anesthetist prime duty is not only
to maintain patient’s safety but also to optimize operative vagal tone.
conditions. An anesthetist care begins before surgery and Antiemetics: Droperidol and ondansetron control postop-
extends into the postoperative period until the patient is in
surgical ward or intensive care unit. The anesthetist should erative nausea and vomiting.
assess the patient preoperatively and discuss general medical Gastric emptying: If needed it can be done with metoclo-
condition and specific anesthetic risk factors with the patient
and relatives. pramide or intraoperative gastric suction.
Preoperative Medications General Anesthesia
Following medications may be considered before otolaryn- General anesthetics are now safer and more controllable.
gology operations: General anesthesia is usually induced intravenously and
Sedatives and tranquilizers: Benzodiazepines (BZs) and maintained by halothane, enflurane, desflurane or sevoflurane.
Propofol, which is being used as induction as well as main-
barbiturates. tenance anesthetic, has been replacing thiopentone as the
intravenous induction agent. The nonpungent sevoflurane can
also be used as an inhalational induction especially in children
and needle phobic adults.
Analgesic agents at the time of induction reduce cardiovas- Intravenous Anesthetics 619
cular response to endotracheal intubation. Oxygen-enriched air Thiopental: This rapid onset and short-acting barbiturate
mixtures are becoming more popular than nitrous oxide espe- Chapter 62 w Anesthesia
cially for longer surgeries. The newer agents, such as desflurane is used mainly for induction of anesthesia. It depresses
and sevoflurane, have more rapid action and recovery with respiratory and cardiac function. It is metabolized in liver.
fewer side effects. It does not increase cerebral blood flow.
Propofol: It is particularly used in outpatient surgery and
Nitrous oxide is not commonly used during tympanoplasty and has antiemetic effect. Propofol has very rapid onset and
if used should be stopped 15 minutes or more before putting recovery. It is used for both induction and maintenance.
the tympanic membrane graft. Nitrous oxide is 34 times more Ketamine: This fast and short acting anesthetic causes“disso-
soluble than nitrogen and rapidly enters in air filled middle ear ciative anesthesia” that consists of amnesia, catatonia1 and
cavity and results in increased middle ear pressure. analgesia. It causes cardiovascular stimulation. Emergence
reactions (vivid dreams and hallucinations) can be partly
Total intravenous anesthesia: It comprises propofol, alfen- taken care of by BZs.
tanil (short-acting opioid analgesic), neuromuscular Midazolam: This intravenous benzodiazepine (BZ) is used
blockade and pulmonary ventilation with air and oxygen. It for conscious sedation and causes anterograde amnesia. It
is preferred during airway laryngeal surgery and endoscopy. depresses respiratory function that is reversed by flumazenil
(BZ receptor antagonist).
Upper respiratory infection: A child with acute upper respira- Fentanyl: This short-acting strong opioid analgesic is used in
tory infection (URI) with fever and productive cough should anesthesia. Chest wall rigidity can occur with intravenous use.
not undergo general anesthesia as the chances of following Oral and patch formulations are also available.
complications are relatively more: bronchospasm, laryngo-
spasm, desaturation, pulmonary aspiration, negative pressure Neuromuscular Blockade (Skeletal Muscle Re-
pulmonary edema and aggravation in respiratory infection. laxants)
The children with mild URI in the absence of fever and produc-
tive cough have minimal intraoperative and postoperative The neuromuscular blockade provides relaxation of muscle to
difficulties. facilitate surgery and mechanical positive pressure ventilation.
These agents are not hypnotic and are used as an adjunct to
Inhaled Anesthetics general anesthesia. They interact with nicotinic receptors at the
They include nitrous oxide and halogenated hydrocarbons and skeletal muscle end plate.
have varying potency in proportion to their lipid solubility (Table
1). They interact with neuronal membrane lipids and lead to Depolarizing muscle relaxant (suxamethonium or succinyl-
inhibition of ion flux. Nitrous oxide (laughing gas) has euphoric choline): This rapid and short acting agent is excellent for
and behavioral disinhibitory effects. brief duration during endotracheal intubation. Though rare
it may cause prolonged muscular relaxation in patients with
Minimal alveolar concentration value: It is the minimal plasma pseudocholinesterase deficiency.
alveolar anesthetic concentration, (percentage of inspired Side effects: It may cause hyperkalemia and is implicated
air) at which 50% of patients do not respond to surgical in malignant hyperthermia (MH). It frequently causes
stimulus.Minimal alveolar anesthetic concentration value postoperative diffuse muscle pains.
is a measure of anesthetic potency. These values are addi-
tive. They are lower in elderly and in presence of opioid Competitive neuromuscular blocking agents (nondepo-
analgesic, local and intravenous anesthetics, and sedative larizing): These long acting muscle relaxants are less
and hypnotics. dependent on hepatorenal function for metabolism and
excretion. They need careful timing of doses so that their
action is over by the end of surgery. A peripheral nerve
stimulator can check the adequate depth of blockade
Table 1 Characteristic features of inhaled anesthetics
Inhaled anesthetic Heart rate MAC values Blood gas ratio* Characteristic features
Nitrous oxide Minimal effect > 100% 0.5 Rapid onset and recovery, lowest potency, used in
combinations
Halothane Decrease 0.8% 2.3 Hepatitis, malignant hyperthermia, sensitizes heart to
catecholamines, cardiac arrhythmias
Isoflurane Increase 1.3% 1.4 Vasodilation, bronchial secretions, spasms
Enflurane Decrease 1.7% 1.9 Tonic/clonic muscle spasms
Desflurane Increase 7.2% 0.4 Most rapid onset, rapid recovery, airway irritation and
coughing
Sevoflurane Decrease 2.5% 0.7 Rapid onset and recovery
* Higher the solubility ratio slower the onset of action and recovery time
Key: MAC, minimal alveolar anesthetic concentration
1(G. katatonos, stretching down, depressed) A syndrome of psychomotor disturbances characterized by periods of physical rigidity, negativism (stub-
bornly resist or do opposite of what one is requested to do) or stupor.
620 during the surgery and confirm adequate recovery at the Airway obstruction.
time of extubation. Sedation from drugs and anesthetics.
Section 9 w Related Disciplines Mode of action: They bind competitively to one of the Hypoxia.
Hypercarbia may be due to mechanical overventilation.
alpha subunits to prevent depolarization (receptor Effect of muscle relaxants.
antagonists). They can be reversed by acetylcholines-
terase inhibitors (e.g. neostigmine, pyridostigmine). Day Care (Ambulatory) Surgery
Specific drugs: They include curare and its modern Preoperative assessment should assess the medical, surgical,
successor atracurium, cisatracurium, vencuronium, and as well as social needs of the patient. Anesthetics that have
rocuronium. rapid and short action and recovery, such as propofol,
–– d-Tubocurarine: It blocks ganglia of autonomic sevoflurane and desflurane, are preferred. Drugs having
prolonged central depression including preanesthetic agents
nervous system and releases histamine. Its side are avoided. Preferably these patients should be managed
effects include fall in blood pressure, bronchial secre- with laryngeal or face mask. Postoperative analgesics should
tions, bronchospasm and MH. It is not used now. be strong enough to cope with the pain.
–– Pancuronium: More rapid onset and recovery. It is
vagolytic and sympathomimetic and raises blood Laser Surgery
pressure. The following anesthesia measures are taken to prevent laser
–– Atracurium: This rapid onset and recovery agent is related fires when surgery is in close proximity to endotracheal
safer in hepatic and renal dysfunction as it is spon- tube (ET):
taneously inactivated. Nitrous oxide: It is avoided as it supports combustion.
–– Mivacurium: This very short acting agent is metabo- Oxygen concentration: Lowest possible inspired oxygen
lized by plasma pseudocholinesterase and releases
histamine. concentration guided by pulse oxymeter.
Endotracheal tubes: If possible, perform laser surgery
Hemostasis and Blood Pressure Control
A 20–30% reduction of preoperative mean arterial blood pres- without ET or via a ventilating bronchoscope. Or use ET
sure in otherwise healthy patient reduces not only the total that resist laser ignition.
blood loss but also facilitate surgery by providing the relatively Cuff of ET is filled with saline. If laser accidentally strikes
bloodless operative field. The deep levels of anesthesia and
slightly reduced arterial carbon dioxide (CO2) tension also the cuff it will puncture and saline may extinguish a
prevent excessive bleeding. If surgeon needs, induced controlled potential fire and irrigate tracheal tissue.
hypotension can be achieved with hypotensive drugs. Methylene blue dye in the saline alerts the ENT surgeon
to a punctured cuff. The blue dye will be seen leaking
Monitoring During Anesthesia in the surgical field.
The following parameters are monitored during the anesthesia: Management of ET ignition: The smoke of burning tube
Oxygen: contains toxic chemicals.
Remove the ET immediately.
Inspiratory oxygen concentration. Irrigate the burning tracheal tissue with normal saline.
Pulse oxymetry for oxygen saturation. Immediate reintubation: Trachea rapidly becomes
Carbon dioxide: CO2 tension. edematous because of chemical and thermal injuries.
Blood pressure: Careful control of blood pressure and blood
loss. Endoscopy
Electrocardiogram: Cardioscope for continuous electrocar- During endoscopy airway is shared between ENT surgeon
diogram. and anesthesiologist. The oxygenation and ventilation must
Temperature: Vasodilation, cold infusions, loss of body heat be adequately maintained. The following measures facilitate
and fluid evaporation from open wounds can cause hypo- better outcome:
thermia, which can be hazardous especially in children and In patients with intubation ET is positioned to left side so
elderly patients. Hypothermia and shivering increase the
oxygen consumption and vascular resistance and predis- that ENT surgeon has relatively better access to right side.
pose elderly patients to myocardial infarction. Oxygenation can be maintained with ventilating broncho-
Muscle relaxation: It allows proper ventilation and surgical
exposure. scope or laryngoscope.
Unconsciousness and pain control: They minimize patient’s Topical anesthesia aids to the outcome.
distress. Anticholinergics reduce the secretions.
Major surgery: Hourly urine volume and invasive direct
monitoring of circulation. Head and Neck Oncology
The following special considerations are worth remembering:
Recovery Airway difficulty: The muscles of airway lose tone after the
Patient’s respiration must be observed for any inadequacies,
which may result from the following factors: administration of muscle relaxant and tumor may unexpect-
edly increase the airway obstruction. So awake tracheos-
tomy or awake fiberoptic intubation should be considered.
Alcohol abuse: Many cancer patients have alcoholic hepatic
damage. The coagulopathies can cause extensive airway defect in skeletal muscle is exposed to potent inhalation 621
bleeding. anesthetics and succinylcholine, calcium is released
Smoking: Chronic smokers have increased secretions and at an enhanced rate from sarcoplasmic reticulum. The Chapter 62 w Anesthesia
chronic obstructive pulmonary disease. excess calcium causes hypermetabolic state which
Radiation: Preoperative radiotherapy can cause epiglottic decreases the amount of available ATP. The actin-myosin
fibrosis and laryngeal edema. bridge cannot detach and muscle remains contracted
and rigid.
Thyroid Surgery Clinical features: Malignant hyperthermia has highly variable
The following considerations are unique for thyroid surgery: clinical presentation. The hypermetabolic skeletal muscles
Hyperthyroidism: These patients should be rendered euthy- result in tachycardia, trismus, muscle rigidity, hyperventi-
lation, cyanosis, sweating, fluctuating blood pressure and
roid with antithyroid agents, which must be given even in increased temperature.
the morning of surgery. Masseter muscle rigidity (MMR): It may be an early
Tracheomalacia: A large goiter can cause tracheomalacia
and potential airway difficulties. sign of MH in children. Malignant hyperthermia may
Depth of anesthesia: The maintenance of appropriate develop within 10–20 minutes. If MMR lasts for more
depth of anesthesia and careful use of perioperative than 2–3 minutes halothane and succinylcholine must
medications prevent exaggerated sympathetic response. be stopped.
Muscle relaxant: Vecuronium is preferred as it provides Laboratory findings: Hypercarbia, hyperkalemia, increased
cardiovascular stability. creatinine kinase (often >20,000 IU), respiratory and meta-
bolic acidosis, hypoxia and myoglobinuria.
Complications Treatment: Operation is stopped as soon as possible. Stop
Intraoperative: all triggering anesthesia medicines immediately. Team
should be prepared for the management of ventricular
Tachycardia: Hypoxia is the most common cause of tachycardia. The following medical treatment must be
tachycardia. started immediately:
–– Cardiac causes: They include cardiac arrhythmia, Hundred percent oxygen and hyperventilation.
ventricular tachycardia and supraventricular tachy- Hyperthermia: Manage with cooling blankets.
cardia. Dantrolene 2.5 mg/kg: It blocks calcium release from
–– Secondary causes: They include hypercarbia, pain, sarcoplasmic reticulum and thus decrease muscle
fever, sepsis, MH and hyperthyroidism. contractility and extreme rigidity.
–– Drugs: Atropine, glycopyrrolate, catecholamines, Sodium bicarbonate 1m Eq/kg to begin with.
isoflurane, pancuronium and cocaine. Glucose 0.5 gm/kg.
Insulin 0.15 U/kg.
Malignant hyperthermia. IV fluids.
Postoperative: Diuretics like furosemide mannitol as per the need.
Respiratory acidosis: Residual anesthetics and muscle Immediate Airway Management
relaxants blunt the response to rising PaCO2.
About 30% surgical anesthesia deaths are caused by impaired
Metabolic acidosis: It occurs due to inadequate volume airway, which is usually due to inadequate ventilation, unrec-
replacement after bleeding and third-space losses. ognized esophageal intubation and unanticipated difficult
tracheal intubation. The methods to maintain airway during
Respiratory alkalosis: It occurs due to pain or anxiety. general anesthesia include jaw thrust, Guedel or laryngeal
Dilutional thrombocytopenia: Blood transfusion when mask airway or an ET.
approaches the patient’s entire blood volume can cause
this coagulopathy because the original platelets are
either lost or diluted. Stored red blood cells have almost
no active platelets.
Dilutional thrombocytopenia is the most common coagulopathy Endotracheal Intubation
that is seen after massive blood transfusion. Endotracheal intubation is a quick method of establishing
airway. The larynx is visualized with a laryngoscope and an
Malignant Hyperthermia (MH) ET or a bronchoscope is inserted into the trachea. There is no
This autosomal dominant inherited anesthesia complication need of anesthesia in emergency cases. Later on an orderly
has 5–20% mortality. It seems that multiple genes play a role. tracheostomy can be performed if needed. This avoids
The incidence in adults is about 1 in 40,000 anesthetics and 1 complications of an emergency tracheostomy, which are
in 10,000–15,000 in children. It is exceedingly rare in children relatively frequent. Endotracheal tubes and their size selec-
under 3 years of age. tion are described in chapter “Instruments.”
Risk factors: This rare condition occurs in patients with
• In cases of difficult intubation, first pass a stylet and then
Duchenne’s muscular dystrophy, family history of MH, and rail road the ET or take the help of flexible bronchoscope.
past history of anesthetic reaction.
Pathophysiology: When patients with inherited membrane • In cases of dental wiring and jaws shutting, nasal
endotracheal intubation is done.
622 Other Procedures for Immediate Airway Assessment for Difficult Intubation
Management (Figs 3A and B)
Section 9 w Related Disciplines Four distinct classes for difficult intubation are described on
Jaw thrust (Fig. 1): In unconscious patients, extension of neck the bases of oral cavity view:
and lifting of mandible anteriorly displace the tongue base I. Uvula, faucial pillars, soft palate and hard palate visible.
anteriorly away from the posterior pharyngeal wall and II. Faucial pillars, soft palate and hard palate visible.
widens and straightens the airway. Neck extension is not III. Soft palate and hard palate visible.
indicated in cases of cervical spinal injuries. The ventilation IV. Only hard palate visible.
can be provided with face mask or Ambu bag.
In anticipated cases of difficult intubation (class III and IV),
Oropharyngeal, nasopharyngeal and laryngeal mask awake nonsurgical intubation techniques or awake surgical
airways: They are described in chapter “Instruments.” techniques must be employed.
Transtracheal jet ventilation (Fig. 2): In this invasive method, Complications of Endotracheal Intubation
an intravenous catheter (12 or 14-gauge) is inserted into the Tracheostomy must be done at the earliest when need for
subglottic region through the cricothyroid membrane. The prolonged artificial airway is anticipated. The rate of compli-
direction of the catheter is kept towards the trachea and cations of endotracheal intubation, which include following,
intraluminal position is confirmed by the aspiration with significantly increases beyond the 10th day:
a syringe. After withdrawing the needle jet ventilation can Laryngeal injury
be started through the catheter. Glottic and subglottic stenosis
Caution: Expiration of air must be insured to avoid Infectious complications
pulmonary barotrauma with pneumothorax, pneumo- Tracheomalacia
mediastinum and surgical emphysema. Tracheal stenosis
Tracheostomy facilitates suctioning, feeding, mobility, early
return of speech and easy breathing.
Fig. 1: Jaw thrust Local Anesthesia
Fig. 2: Jet ventilation For local anesthesia (LA) it is not necessary to keep the patient
nil by mouth preoperatively. If the LA fails general anesthesia
may be necessary. Compensation for an inadequate LA by
heavy sedation carries risk of airway obstruction and aspira-
tion of vomitus.
Prerequisites: The patient’s willingness and cooperation
are important for LA. Resuscitation measures and oxygen
supply should be available.
Contraindications: They include allergy and local infection.
Side effects: They may be local or systemic:
Local: Infection and hematoma.
Systemic: Recent agents, such as ropivacaine and
levobupivacaine, are said to have better cardiovascular
safety profiles. Accidental intravascular injection or
overdoses can result in:
–– Neurotoxicity: Dizziness, nystagmus, depressed
conscious level, convulsions.
–– Cardiovascular: Depresses cardiovascular param-
eters except cocaine that increase heart rate and
blood pressure. Cardiac arrest (especially with bupi-
vacaine) may be heralded by circumoral paresthesia
and lightheadedness.
–– Methemoglobinemia (prilocaine).
–– Allergy: It is via para-aminobenzoic acid in esters.
Adrenaline: Local anesthetics if given with adrenaline
(1:200,000–1:125,000) has the following benefits:
–– Quick onset of action.
–– Prolong duration of action.
–– Slow absorption in circulation.
Contraindications: Hypertension, monoamine oxidase
inhibitors, tricyclic antidepressants and end-arterial
locations.
623
A
B Chapter 62 w Anesthesia
Figs 3A and B: Difficult airway. (A) Four classes of Mallampati oral view; (B) Four grades of Cormack and
Lehand laryngoscopic view
Epinephrine (adrenaline) 1:200,000 contains 5 mcg/ml. 1% lignocaine with adrenaline can be safely used in a
Halothane may cause ventricular ectopy if patient has received 70 kg person. Its early onset and short duration of action is
adrenaline 2 μg/kg. good for sensory blocks. It is available in 2% xylocaine with
and without adrenaline, 4% xylocaine, xylocaine viscus,
Local Anesthetics xylocaine jelly and xylocaine ointment.
They block sodium channels and the cell cannot achieve 3. Bupivacaine: It has longer duration of action than lignocaine.
threshold potential. The nerve conduction is blocked as a Bupivacaine 0.25% is effective for sensory block. It is more
propagated action potential fails to develop. They are catego- cardiotoxic and is never given intravenously.
rized in two groups: ester and amide (Table 2). 4. Ropivacaine and Levobupivacaine: These recent agents
1. Cocaine: This ester agent, which is used topically on mucosal have better cardiovascular safety profile. They offer better
sensory block than motor block.
surfaces, is almost exclusively used in otorhinolaryngology. 5. Prilocaine: Methemoglobinemia causes blue-brown skin
It has a unique advantage of vasoconstriction. So, it color.
provides topical anesthesia and vasoconstriction, which
offer relatively blood-less operative field. In association with Pain sensation is usually lost before the paralysis of motor
adrenaline or halothane, cocaine can sensitize myocardium activity by local anesthetics. Small, myelinated nerves (A-delta
to arrhythmias. pain fibers) are blocked before small unmyelinated (C fibers)
or large nerves.
Cocaine was the first known local anesthetic agent which is still
very popular especially in nasal surgeries. Types
Topical anesthesia: Topical anesthetic agents (e.g. ligno-
2. Lignocaine (lidocaine): Lignocaine 1% (10 mg/ml) is
effective for most sensory blocks. It is a vasodilator caine) are used on the skin and mucosa (such as nasal, oral,
and often prepared with epinephrine. About 50 ml pharyngeal, laryngeal and tracheobronchial).
Table 2 Two groups of local anesthetics with their maximum doses
Amide* Max dose Ester** Max dose
Lidocaine 3 mg/kg or 7 mg/kg with adrenaline Cocaine 2–4 mg/kg
Bupivacaine 2 mg/kg Tetracaine 1.4 mg/kg
Mepivacaine 4 mg/kg Procaine 6 mg/kg
Etidocaine 4 mg/kg Chloroprocaine 11 mg/kg
Prilocaine 400 mg **Metabolism in plasma by pseudocholinesterase; May cause allergic
Ropivacaine 225 mg reactions because they are metabolized to para-aminobenzoic acid;
Levobupivacaine 150 mg One i in names.
*Metabolism in liver; Allergy reactions rare; two i’s in names.
624 Amethocaine: It is well absorbed by mucosa. contraindicated in patients with clotting disorders as it may
Cocaine: It has vasoconstrictive property. cause hemorrhage.
Lignocaine and prilocaine eutectic mixture on skin: It is Regional anesthesia: It includes blockade of major nerve
trunks, spinal and epidural anesthesia.
used frequently in children before venepuncture. Adjunct to general anesthesia: It provides pain relief during
Local infiltration: Local anesthetic agent may be infiltrated the postoperative period.
into and around the wound and surgical site. It is contrain- Peak anesthetic effect of topical lignocaine and cocaine occurs
dicated near infection site because it can spread the infec- within 2–5 minutes and lasts for 30–45 minutes.
tion and acidity produced by infection blocks the action
of local anesthetic agent and makes it ineffective. It is also
Section 9 w Related Disciplines Clinical Highlights
1. Down syndrome: Children with Down syndrome have macroglossia and atlantoaxial instability. Preoperative airway
assessment is important.
2. Cocaine: It is a catecholamine re-uptake inhibitor that causes vasoconstriction.
3. Order of neuron sensitivity of LA: Type B and C > Type A delta > Type A beta and gamma > Type A alpha.
FURTHER READING
1. Bridenbaugh P, Cruz M, Helton SH. Anesthesia for otolaryngologic procedures. In: Paparella MM, Shumrick D, Gluckman J, Meyerhoff W
(Eds). Otolaryngology, 3rd edition. Philadelphia: WB Saunders; 1991. pp. 2949-70.
2. Brown A. Anesthesia. In: Cummings CW, Harker L, et al (Eds). Otolaryngology-Head and Neck Surgery, 2nd edition. St Louis: Mosby; 1993.
pp. 214-42.
3. Campell JP, Campbell CD, Warren DW, et al. Comparison of vasoconstrictive and anesthetic effects of intranasally applied cocaine versus
xylometazoline/lidocaine solution. Otolaryngol Head Neck Surg. 1992;107:697-700.
4. Kaus SJ, Rockoff MA. Malignant hyperthermia. Pediatr Clin North Am. 1994;41:221-37.
63 Laser Surgery and
Cryosurgery
Each work has to pass through these stages—ridicule, opposition and then acceptance. Each man who thinks
ahead of his time is sure to be misunderstood.
—Swami Vivekananda
Points of Focus Radiofrequency Surgery
Indications
Laser Material and Method
¯¯Related Physics
Cryosurgery
Properties of Radiant Laser Energy Principle
¯¯Control of Laser Tissue Effect
Technique
Transverse Electromagnetic Mode Indications
¯¯Tissue Effect Advantages
¯¯Laser in Otolaryngology Disadvantages
Properties of Commonly Used Lasers Hyperbaric oxygen therapy
Argon Laser Mode of Action
Potassium-Titanyl-Phosphate–532 Laser Material and Method
Neodymium:Yttrium-Aluminium-Garnet Laser Indications
Carbon Dioxide Laser
Complications and Safety ¯¯Clinical Highlights
¯¯Photodynamic Therapy
Principle
Indications
Side Effects
LASER around the nucleus in one of several discrete orbits. The
orbits closure to nucleus, have lower energy levels than
LASER is an acronym for Light Amplification by Stimulated the larger shells, which are away from nucleus. The interac-
Emission of Radiation. Laser light is the brightest monochro- tion of electron with photon (called absorption), which is
matic (one wavelength) light. In addition to diagnostic medi- a quantum of light, makes the atom excited. During exci-
cine and surgery, the laser is used in research laboratories, tation, an electron of low energy level can go into higher
communications, surveying, manufacturing, lecture pointers, energy orbit. But within a very short time (10–8 sec) the
printers, CD players and engraving. Bar code scanners are used electron spontaneously drops back to its lower level and
in supermarkets and shops. gives up energy difference. During this process, atom emits
extra energy as photon of light, which is called as sponta-
Related Physics neous emission of radiation.
Spontaneous emission of radiation: In a stable atom, there are Stimulated emission of radiation: If a photon of correct
energy hits an excited atom, it results in emission of two
equal number of protons and electrons. Electrons revolve identical photons, which have same frequency and energy
626 and travel in same direction. This stimulated emission of on the tissue. Energy that is absorbed results in surgical interac-
radiation, which was described by Einstein, is the basic tion with tissue and varies with laser’s wavelength.
Section 9 w Related Disciplines fundamental principle of laser science.
Radiant laser energy: The stimulated radiation is ampli- Wavelength: Shorter the wavelength, more is the scattering,
fied with the help of two mirrors in an optical resonating which spreads the energy and limits the penetration depth.
chamber, which is filled with an active medium, such as
Ar, Nd:YAG or CO2. An electric current excites this active Levels of heating and tissue changes: The primary form of
medium, which can consist of molecules, atoms, ions semi- interaction of absorbed laser with tissue is heating, the
conductors or even free electrons in an accelerator. Mirrors level of which decides the following changes in the tissue:
reflect the photons back and forth. One of the two mirrors 60–65°C: Protein denaturation and blanching of tissue
is partially transmissive, which emits some of the radiant 100°C: Vaporization of intracellular water, vacuole
energy as laser. formation, craters and tissue shrinkage
Several 100°C: Carbonization, disintegration, smoke,
Properties of Radiant Laser Energy destruction and gas generation.
The radiant laser energy is a type of electromagnetic radiations.
It has following qualities that distinguish it from disorganized CO2 laser: In the center of the wound is an area of tissue
light of a bulb: vaporization. It which is surrounded by an area of thermal
Monochromatic, i.e. same wavelength (single color) necrosis (small vessels, nerves and lymphatics are sealed)
Collimated (unidirectional) which is further surrounded by an area of thermal conduc-
Coherent: Both temporally (waves of light oscillating in a tivity and repair. The short laser pulse minimizes the lateral
thermal damage.
phase) and spatially (photons are equal and parallel)
Extremely intense. LASER IN Otolaryngology
CONTROL OF LASER The lasers beams are used to vaporize, cut and coagulate the
The variables of lasers, which can be controlled, are power tissue. The clinical applications depend on their wavelength
(watts), spot size (millimeters) and exposure time (seconds). and special absorptive powers of the target tissues. The laser
Irradiance (W/cm2): It considers surface area of focal spot. can be ultraviolet, which result in heating and photodissocia-
tion of chemical bonds, but most commonly used lasers emit
It is more useful measure than power, which may be kept either visible [Argon (Ar) and Potassium-titanyl-phosphate-532
constant. Irradiance varies directly with power and inversely (KTP-532) lasers] or infrared light [carbon dioxide (CO2) laser].
with spot size. The laser lens setting (focal length) and Properties of commonly used lasers and ENT applications:
working distance combinations decide the size of focal spot.
Larger the focal spot (unfocussed, away from focal plane), They are given in Table 1.
lower the irradiance. Smallest the focal spot (focused in Most commonly used: They are CO2, neodymium:yttrium-
focal plane), highest the irradiance, which results in precise
cutting and vaporization. aluminium-garnet (Nd:YAG), KTP-532 and Ar.
Depth of focus: The beam waist presents over a range of Other: Other lasers used in otolaryngology are Ar tunable
distances called depth of focus.
Fluence (J/cm2): It is a measure of the total amount of laser dye laser and flash lamp pumped dye laser.
energy per unit area. It varies directly with exposure time Under investigations: The lasers under investigations include
(seconds) of laser beam to a unit area. Working in pulsed
mode or in continuous mode can change fluence. erbium:YAG (Er:YAG) and holmium:YAG (Ho:YAG) lasers.
Transverse Electromagnetic Mode Argon Laser
Transverse electromagnetic mode (TEM) determines the shape
of laser spot. It refers to the distribution of radiant energy of Argon laser passes through clear fluid and is absorbed by
laser beam across the focal spot. The different modes of TEM are: hemoglobin and pigmented tissues.
TEM00: Laser spot is circular on cross-section. The power
Indications:
density is greatest at the center and progressively dimin- Vascular lesions: Photocoagulation of portwine stain,
ishes peripherally (Gaussian distribution). hemangioma and telangiectasia.
TEM01 and TEM11: Beams cannot be focused to a small Retinal lesions: It passes through the clear aqueous
spot and have complex distribution of energy. It results in tissues (cornea, lens and vitreous).
predictable tissue vaporization. Ear microsurgery: Its uses in ear microsurgery are lysis of
middle ear adhesions, spot welding or tympanoplasty
TISSUE EFFECT grafts.
The tissue deals with incident laser energy in four ways: reflects, –– Stapedotomy: A drop of blood is kept on stapes
absorbs, transmits and scatters. The energy, which is reflected footplate before its use in stapedotomy.
from or transmitted through the tissue, will not have any effect
Potassium-Titanyl-Phosphate-532 Laser
(KTR-532)
Potassium-titanyl-phosphate laser has wavelength of 532 nm
(blue-green) and comparable with Ar laser. It falls in visible
spectrum and is selectively absorbed by pigment and more
Table 1 Properties of commonly used lasers and their ENT applications 627
Ar laser Nd:YAG laser CO2 laser
Invisible infrared
Electromagnetic range Visible Invisible infrared Red light of helium-neon
Color 10.6 μm
Wavelength Blue-green Colorless 0.03 mm
Extinction length*
Transmitted through 0.488 and 0.514 μm 1.064 μm Water, tissue with high water
Absorption by content
80 m 40 m Negligible
Scattering Extremely versatile use in ear,
Clinical applications Clear aqueous tissue Clear liquids nose and throat lesions
Precision Hemoglobin, pigmented Darkly pigmented tissue, Good
tissue charred debris
Less More
Portwine stains, Obstructing lesions Chapter 63 w Laser Surgery and Cryosurgery
hemangiomas, telangiectasis, of trachea, bronchus,
stapedotomy esophagus; vascular,
lymphatic lesions
Good Less
Ar, Argon; Nd:YAG, Neodymium:Yttrium-Aluminium-Garnet; CO2, Carbon Dioxide
*Extinction length: The thickness of water necessary to absorb 90% of the incident laser energy
strongly by hemoglobin. Hand-held probe facilitates its use Carbon Dioxide Laser
in endoscopic sinus surgery and microlaryngeal surgery. The Carbon dioxide laser requires aiming beam of helium neon
optical fiber delivery can be manipulated through rigid bron- laser. It is the most commonly used laser in ENT surgery. It
choscope. is transmitted through an articulating arm and can be used
Indications: It is first choice in the following conditions: free-hand for microscopic surgery, attached to microscope
and adapted to rigid bronchoscope. Its main limitation is that
Ear: Stapedotomy it cannot pass through the flexible endoscopes.
Nose: Polyps, concha bullosa, epistaxis, turbinate hyper-
It is effective not only in vaporizing tissues, but it also
trophy and telangiectasia provides bloodless field. Surgery can be performed in cases
Oral cavity: Verrucous and T1 carcinoma, leukoplakia, of hypertension, bleeding dyscrasias and coagulopathies. The
other advantages are precision surgery and less postoperative
erythroplakia, early tongue cancer T1, lymphangioma edema and pain.
Oropharynx: Recurrent tonsillitis and hypertrophy, Advantages
uvulopalatopharyngoplasty in obstructive sleep apnea, Negligible scattering and reflection
T1 and T2 carcinoma Absorption independent of color
Larynx: Laryngocele, cyst, granulomas, stenosis (glottic, Minimal thermal effect on adjacent tissue
posterior and subglottic), bilateral vocal cord paralysis, Indications
recurrent respiratory papillomas, suprahyoid supraglottic Nose: Papillomas, rhinophyma, telangiectasis, nasal
T1 carcinoma and obstructing carcinoma
Skin: Pigmented dermal lesions. polyps, choanal atresia and turbinate hypertrophy.
Oral cavity: Leukoplakia, erythroplakia, small superficial
Neodymium:Yttrium-Aluminium-Garnet Laser
(Nd:YAG) cancers and debulking of large, recurrent or inoperable
Neodymium:yttrium-aluminium-garnet laser can be trans- tumors
mitted by flexible endoscopes and has effective coagulative Oropharynx: Recurrent tonsillitis and hypertrophy,
properties. It controls the bleeding well. The flexible fiberoptic tonsillar and pharyngeal tumors, tongue T1 and limited
delivery system allows its use with flexible endoscope. T2 cancer
Larynx: Papilloma, web, stenosis (glottic, subglottic,
It is excellent for tissue coagulation, but the precision is and posterior), capillary hemangiomas, vocal nodule,
poor as the tissue damage is widespread and depth of tissue Reinke’s edema, leukoplakia of cord, polypoid degenera-
penetration is less predictable. It can be used in combination tion of cord, arytenoidectomy, T1 midcordal carcinoma
with CO2 laser. without anterior commissure involvement, suprahyoid
Indications: It is advantageously used for following lesions supraglotticT1 cancer, laryngocele, cysts and granulomas
Trachea and bronchi: Recurrent papillomatosis, tracheal
as control of bleeding (dangerous in bronchoscopy) is stenosis, granulation tissue and bronchial adenoma,
more secure. debulking of obstructive malignant lesions of trachea
Obstructing malignant tumor of trachea, bronchus and or bronchi
Plastic surgery: Benign and malignant tumors of skin,
esophagus vaporization of nevi and tattoos
Vascular lesions: Hereditary hemorrhagic telangiectasia Ear: Stapedotomy and acoustic neuroma.
of nose
Lymphatic disorders: Lymphangioma.
628 Complications and Safety Superficial cancers of larynx have been treated with PDT. It
has got US FDA approval for treating obstructing esopha-
Section 9 w Related Disciplines The laser is a potentially dangerous instrument. The utmost geal and endobronchial tumors and minimally invasive
caution is required to prevent accidents, which can injure not only endobronchial non-small cell carcinoma.
patient but also health care personnel present in operation room.
Side Effects
Education of staff: The operating surgeon and anesthesiol- The main side effect of PDT is generalized skin photosensi-
ogist must have proper experience and training. Nursing tization. Patient should use sun-protective clothing to avoid
and operation theater personnel should be conversant exposure to sunlight.
with safety measures while operating laser.
Radiofrequency Surgery
Protection of eye: Protective eyeglasses with side protec-
tors, which are specific for the wavelength of each laser Radiofrequency (RF) surgery reduces the volume of tissues. This
(blue-green glasses with optical density of 6 for Nd:YAG minimally invasive surgery can be done as an OPD procedure.
laser; orange yellow glasses for Ar, KTP or dye lasers), must
be worn by the patient, surgeon, anesthetist, assistants, Indications
nurses and all other personnel present in operating room. Radiofrequency cuts and coagulates tissues with minimal lateral
They prevent accidental burns to cornea, retina and lens tissue damage. It can be used in the following disorders:
(lenticular opacities). Patient’s eyes are protected by a Nasal obstruction:
double layer of saline moistened eye pads.
Reduction of hypertrophied inferior turbinates.
Protection of skin: All exposed parts of the patient not in Sleep apnea and sleep-disordered breathing including
surgical field, which include skin, mucous membranes
and teeth, are protected by saline soaked towels, pads or primary snoring, upper airway resistance and obstructive
sponges that are moistened periodically. sleep apnea (OSA). See Chapter on“Sleep Apnea and Sleep-
Disordered Breathing”.
Evacuation of smoke: Two separate suctions, one for the Reduction of redundant soft palate and uvulopalato-
blood and mucous and the other for smoke and steam
(produced by laser vaporization of tissues) are used. plasty
Reduction of fullness in base of tongue.
Anesthetic gases and equipment: The endotracheal tube fire Lingual thyroid
is the dreaded complication. Only noninflammable gases Tonsillotomy
(such as halothane or enflurane) are used. During the CO2 Microlaryngeal surgery to remove granuloma, papilloma
laser, red rubber or silicone tube is wrapped by reflective and cyst
metallic foil. Cuff of endotracheal tube is inflated with Myringotomy
saline water, which may be colored by methylene blue that Rhinophyma
helps in warning about the leak of cuff. Tubes are further Cosmetic: Removal of skin lesions.
protected with saline soaked cotton. The colorless or white
polyvinyl or silicone tube that does not have any black or Material and Method
dark marking or a lead lined marking along the side, is safest The machine generates electromagnetic waves of very high
with the use of Nd:YAG laser. frequency (350 kHz to 4 MHz). Usually 460 kHz RF is delivered
through the probe, which is inserted into the tissue and causes
PHOTODYNAMIC THERAPY ionic agitation. Heating of the tissue causes protein coagulation
and tissue necrosis. There is no charring. The scar formation
Principle occurs in 3 weeks and reduces the size of tissue. The parameters,
Photodynamic therapy (PDT) is an upcoming modality. It is which can be controlled by the device, include:
based on the principle that photosensitizing agent is taken up Power in watts
preferentially by the malignant cells, which are then exposed to Temperature in degrees of celsius
specific wavelength of laser (such as Ar tunable dye laser with Resistance in ohms
a wavelength of 630 nm). Laser activates the photosensitizing Treatment time in seconds
agent and thus destroys the cancer cells. There is preferential Energy in joules (watts × seconds).
uptake of photosensitizer photofrin (dihematoporphyrin ether
or DHE) (given intravenously) by the malignant cells. CRYOSURGERY
Light activation of photoconcentrated DHE results in mito-
chondrial damage and apoptosis in malignant cells. Erythrocyte
leakage and endothelial damage of vessels cause ischemic
necrosis of tumor tissue.
Indications Principle
Photodynamic therapy is helpful in treating cancer of skin, At –30°C and below, rapid freezing of tissues and slow thawing
results in the destruction of tissue. This principle is used in
larynx, nasopharynx, aerodigestive tract and endobronchial cryosurgery, which has been used to treat benign, premalignant
region. and malignant lesions.
It has also been used in cases of recurrences after radiation
or surgery. The freezing agents are used either by an open method
(liquid nitrogen spray or CO2 snow) or through a closed system necrosis of bone and cartilage, which may underlie the 629
cryoprobe, which is based on Joule-Thomson effect (rapid lesion. Recurrent tumors and ill-defined lesions are not
expansion of compressed gas through a small hole produces good cases for cryotherapy. Chapter 63 w Laser Surgery and Cryosurgery
cooling). The freezing agents employed in closed systems Nose: Reduction of turbinates improves the airway. In
probes are: liquid nitrogen, nitrous oxide or CO2. The probes allergic rhinitis, it controls sneezing and rhinorrhea.
are available in different sizes and designs and produce a tip Tonsils: Cryodestruction of tonsils can be done in poor risk
temperature of –70°C. The thermocouples of probes can be patients.
inserted into the tissue to monitor the temperature.
Advantages
Tissue Effect No need of general anesthesia. Therefore, it is useful in poor
The cell death occurs through following mechanisms:
Dehydration occurs due to crystallization of intracellular risk patients.
The patients with bleeding disorders or coagulopathies
and extracellular water with consequent rise in electrolytes
concentration. The pH changes as the buffering substances can be managed.
crystallites out. Urea and dissolved gases increase to reach Palliation in multiple and recurrent cancers where second
toxic concentrations, which cause cell death.
Denaturation of cell membrane lipoproteins makes cell course of radiotherapy cannot be used.
membrane permeable to cations. Thawing of cells, which Minimal after effects, such as discomfort and pain.
become full of cations, results in lysis of cells. Minimal scarring. Therefore, it can be used at sites well‑
Thermal shock arrests the cellular respiration.
Vascular stasis of both arterial and venous blood results known for keloid development, such as sternal area.
in ischemic infarction. Cryosurgery is useful in the treat- Cryosurgery can be done as an OPD procedure.
ment of vascular lesions (hemangioma, angiofibroma and Lower cost in comparison to laser.
glomus tumors) because thrombosis of capillaries results
in less bleeding. Disadvantages
Autoantibodies specific to the frozen tumor tissues may Excisional biopsy and histopathological assessment of
provide tissue specific immunity to subsequent recurrence.
tumor margins are not possible.
Depth of freezing is unpredictable.
Causes skin depigmentation and loss of hair (destruction
of hair follicles).
Technique Hyperbaric Oxygen Therapy
1. Anesthesia: Cryosurgery can be done under either local
Mode of Action
anesthesia or mild sedation or even without anesthesia Increased partial pressure of oxygen (up to 460% increase
because tissue freezing itself causes numbness.
2. Freezing: The cryoprobe is applied into or upon the tissues in pO2) in perilymph and endolymph supplies oxygen to
(which is insulated and include a margin of normal tissue) the inner hair cells. The pO2 level remains 60% above the
for 3–8 minutes. It results in rapid freezing. normal after 1 hour of termination of hyperbaric oxygen
3. Thawing: Then the frozen tissue is allowed to thaw slowly. (HBO2) therapy.
4. Repetitions: The procedure may be repeated as required Reduction of hematocrit and decrease in blood viscosity
once or twice to achieve the best result. improves diffusion of oxygen to ischemic cells.
5. Thermocouple: If available, a thermocouple will ensure
freezing at an adequate depth. Material and Method
6. Healing: The area is allowed to heal by secondary intention.
The necrotic slough usually falls off in 3–6 weeks. If needed, Patient inhales 100% oxygen for 1 hour at atmospheric pressure
repeat the cycles of cryotherapy. 2.4 in a HBO2 chamber. In addition to 1 hour oxygen inhalation
under pressure, the compression and decompression time of
Indications the chamber is 10–15 minutes respectively. Usually a total of
The increasing availability and popularity of laser is fast 10–20 such sittings (six per week) are given.
declining the indications of cryosurgery. Its lower cost still
makes it an option in developing countries. Indications
Benign vascular tumors: Hemangiomas of skin, oral cavity Hyperbaric oxygen has been used with success in following
disorders:
and oropharynx, angiofibroma and glomus tumor 1. Sudden idiopathic sensorineural hearing loss and tinnitus:
Premalignant lesions: Leukoplakia of cheek, tongue, floor of
The results are better if therapy is started earlier. In various
mouth and solar keratosis (precancerous condition of skin). studies, improvements have been reported in 30–80% of
The scarring is less and quality of regenerated epithelium the patients.
is better in comparison to diathermy. 2. Acoustic trauma
Malignant lesions: Intraepithelial carcinoma (Bowen’s 3. Noise-induced hearing loss
disease) and basal cell carcinoma of skin. Palliation of 4. Malignant otitis externa
advanced cancers, recurrent and residual tumors. Debulking 5. Mucormycosis of paranasal sinuses
of tumor facilitates deglutition and respiration. It reduces 6. Skin flaps with compromised blood supply.
bleeding and relieves pain. Cryotherapy does not cause
630 Clinical Highlights
1. Argon laser: It is useful for middle ear surgery.
2. Cryosurgery: To cause cell death, temperature should at least reach –30°C. In cryosurgery, liquid nitrogen is applied at
–30°C. The cryoprobe is kept for 3–8 minutes so that area is frozen rapidly reaching a temperature of about –70°C.
Section 9 w Related Disciplines FURTHER READING
1. Behranwala KA, Ali Asgar B, Borges A, et al. Laser in treatment of laryngeal amyloidosis. Indian J Otolaryngol Head Neck Surg.
2004;56:46-8.
2. Hazarika P, Parul P, Kailesh P, et al. KTP laser assisted microendoscopic cricopharyngeal myotomy and web excision for dysphagia
management. Indian J Otolaryngol Head Neck Surg. 2005;57:290-3.
3. Hazarika P, Pillai S, Balakrishnan R, et al. Endoscopic KTP-532 laser assisted diverticulotomy for Zenker’s diverticulum. Indian J
Otolaryngol Head Neck Surg. 2005;57:71-4.
4. Kameshwaran M, Anand Kumar RS, Murali S, et al. KTP-532 laser in the management of rhinosporidiosis. Indian J Otolaryngol
Head Neck Surg. 2005;57:298-300.
5. Nayak DR, Hazarika P, Rodrigues RAW, et al. Endoscopic Dacryocystorhinostomy vs KTP-532 laser assisted endoscopic dacryocys-
torhinostomy. Indian J Otolaryngol Head Neck Surg. 2005;57:278-82.
6. Ramdev S, Ghosh P, Mukhopadhyaya S. Endoscopic laser excision in the management of laryngotracheal stenosis. Indian J Oto-
laryngol Head Neck Surg. 2005;57:189-90.
7. Satish R, Parikh Deepak M. Role of carbon dioxide laser in cancer of the buccal mucosa. Indian J Otol. 2005;Special Issue-I:71-4.
8. Verma A, Khaaboori MA, Zutshi R. Endonasal carbon dioxide laser assisted dacryocystorhinostomy verses external dacryocyst-
orhinostomy. Indian J Otolaryngol Head Neck Surg. 2006;58:9-14.
Appendix
Today the human body is, tomorrow it is not; even the shortest span of life is beset with pain and misery. Just surrender yourself to God; you will then feel
His grace. Do not be afraid; the Master is behind you, and I am, too as your Mother. Whenever you are in distress, say to yourself ‘I have a mother’.
—Holy Mother Sarada Devi
Top 101 Clinical Secrets Problem Oriented Cases Miscellaneous Key Points
Top 101 Clinical Secrets
1. Outer hair cells: They serve an amplifying role in cochlea and 8. Surgical treatment of temporomandibular joint
are more sensitive to noise exposure and ototoxicity. They disorder: It is indicated only for internal derangement of
are responsible for generating the cochlear microphonic and
otoacoustic emissions. Otoacoustic emissions are measured the temporomandibular joint (TMJ). It is not suggested for
to test hearing in infants and others difficult to test patients.
musculoskeletal disorders.
2. Danger space: It lies between the alar fascia and the 9. Pneumatic otoscopy: It is the gold standard for the diagnosis
prevertebral space. Infection of this space can lead to
mediastinitis and death if not properly treated. of otitis media.
10. Tinnitus: It is a symptom and not a disease. It can be so
3. Drugs: Physicians are supposed to know the indications,
interactions and side effects of drugs they prescribe. They disabling that the patient can have suicidal tendencies.
must update themselves regarding the newer drugs which can 11. Subjective tinnitus: It is most common type of tinnitus and is
have advantages and disadvantages over existing drugs.
heard only by the patient.
4. Penicillin allergy and cephalosporins: Cephalosporins 12. Objective tinnitus: It can be heard by both patient as well as
can be given safely to patients with a history of rashes with
penicillin but not in patients with a history of anaphylaxis. examiner.
13. Pulsatile tinnitus: In cases of pulsatile tinnitus always
5. HIV/AIDS: Biopsy of new oral lesions must be done early to
rule out malignancy. first rule out the paraganglioma (glomus tympanicum or
6. ENT examination: Keep a specific order with clinical jugulare).
examination (and even within each area) such as ear, nose, 14. Tuning fork tests: They should confirm the results of
mouth, pharynx and larynx, face and scalp, neck, and neurologic
exam. It ensures complete examination and avoids missing audiometry. Never trust the audiogram alone when surgical
anything.
intervention is considered. The inconsistency must be resolved
7. Temporomandibular disorder: Most patients respond to
nonsurgical therapy that includes rest, and medical, physical with the audiologist.
and splint therapies. 15. Conductive hearing loss: The most common causes are ear
wax, otitis media, otomycosis, and otosclerosis.
16. Otosclerosis: Fifty percent of patients give positive family
history. Patient has conductive hearing loss with normal
tympanic membrane and impaired acoustic reflexes. The
patients with negative Rinne [Bone conduction (BC) > Air
632 conduction (AC)] are candidate for stapedectomy, which 35. Clinical features of temporal bone fracture: Clinical
provides very gratifying results.
Diseases of Ear, Nose and Throat 17. Reversible causes of sensorineural hearing loss: They features include hearing loss, dizziness, facial weakness, ear
must be ruled out even in patients with the most common
causes of hearing loss.Such as presbyacusis and noise-induced bleeding, hemotympanum, raccoon eyes, and/or bruising over
hearing losses
18. Deaf and dumb: Deaf persons are not intellectually dumb. the mastoid cortex (Battle’s sign).
Psychological tests usually overlook the intellectual capacity 36. Radiological investigation for temporal bone fracture:
of deaf people as they consist of culturally biased material.
19. Mild hearing loss in children: Address even mild hearing The best radiologic examination is a fine cut, axial and coronal,
loss early to prevent speech delay in children.
20. MRI and cochlear implants: MRI is contraindicated in temporal bone high-resolution computed tomography (HRCT)
patients with conventional cochlear implants. There is risk of
implant movement. scan.
21. Live insect in external ear: Never remove live insect from 37. Indications for surgical exploration of the facial nerve in
external ear. First either drown or anesthetize the insect. Live
angry insect can further damage the canal. temporal bone fracture: They include:
22. Otitis externa treatment: First line treatment for otitis
externa is topical antibiotics. Systemic antibiotics are given a. Immediate onset of complete facial paralysis
only for severe infections.
23. Eustachian tube dysfunction: It is the key to the pathogenesis b. Delayed onset of complete facial paralysis associated with–
of otitis media.
24. Persistent unilateral otitis media in an adult: i. Radiologic evidence of a fracture through the fallopian
Nasopharyngoscopy must be done to rule out neoplastic
lesion of the nasopharynx. canal of facial nerve.
25. Congenital cholesteatoma: A whitish mass behind a child’s
intact tympanic membrane with hearing loss indicates ii. Poor prognostic testing with electroneuronography
congenital cholesteatoma.
26. Cholesteatoma: It is collection of squamous epithelium and (EnoG) or electromyography (EMG).
keratin debris in the middle ear. It which erodes bone and can 38. Anosmia: The three most common causes are sinonasal
cause life-threatening complications. Patient presents with
purulent and putrid ear discharge and conductive hearing disease, post-upper respiratory tract infection and trauma
loss. Otoscopy may show a “trail sign” of debris along the
posterosuperior canal wall to the marginal perforation. The (injury to olfactory nerves at cribriform plate or brain injury).
usual treatment is modified radical mastoidectomy. 39. Posterior epistaxis: One to two percent of patients die within
27. Gradenigo’s triad: It consists of otorrhea, abducens palsy, and
retrobulbar pain. It is the classic presentation of petrous apicitis. 1 year.
28. Tullio’s phenomenon or Hennebert’s sign: They are present 40. Antibiotic resistance patterns in acute bacterial
in patients with labyrinthine fistula.
29. Dix-Hallpike examination: It is the most important clinical rhinosinusitis: Penicillin resistant Streptococcus pneumoniae
test for dizzy patients because 25% of all dizzy patients have
benign paroxysmal positioning vertigo. (25–40%), beta lactamase producing Haemophilus influenzae
30. Downbeating nystagmus: A pure downbeating nystagmus
during Dix-Hallpike testing suggests Chiari malformation or (30–40%) and beta lactamase producing Moraxella catarrhalis
other posterior fossa lesions. MRI must be done.
31. Peripheral and central vertigo: Patients with central (92%).
dizziness complain few symptoms but have many findings 41. Chronic hyperplastic rhinosinusitis: Eosinophilic infiltration
(sensory/motor deficits). Patients with peripheral vertigo have
many symptoms (severe whirling vertigo with or without is the hallmark in most of the patients and about 50% of
otological symptoms) but few findings.
32. Multisensory imbalance: It is suggested when dizziness patients have asthma.
appears on walking but is relieved by pushing a grocery store 42. Autoeczematization (“id” reaction): This is a cutaneous
cart.
33. Vertigo spells in children: Migraine is not uncommon in response to remote infections.
children. It must be considered when vertigo spells are not 43. Allergic rhinitis: Tree, grass, and weed pollens in their seasons
associated with ear malformations or middle ear infections.
34. Facial nerve: The regeneration and degree of return to normal may cause symptoms of allergic rhinitis in atopic individuals
is dependent on the degree of initial injury (neuropraxia vs.
neurotmesis). The most important factor in history is whether (hereditary predisposed). Immunotherapy attenuates allergic
the palsy develops slowly over days or immediately at the time
of the injury. response by hyposensitization to the allergens.
44. Septal hematoma: Before reducing the nasal bone fractures,
a septal hematoma must be ruled out because failure to drain
it may result in a septal abscess, septal perforation and saddle
nose deformity.
45. Polychondritis: Seventy to eighty percent patients have
involvement of the nasal septum.
46. Life-threatening injuries: Most of them can be identified
during the primary survey.
47. Cervical spine immobilization in trauma patients: It is vital
to maintain cervical spine immobilization while managing the
airway.
48. Blood loss: Young healthy patients can lose up to 30% of
blood volume with minimal symptoms.
49. Intubation: It is required if the patient has Glasgow Coma
Scale score of 8 or less.
50. Facial trauma: Thin cut (1–3 mm) facial CT with coronal
reformatting is the ideal imaging study.
51. Healing: Primary closure of a facial defect is best if possible.
Other options include healing by secondary intention, local
flaps, skin grafts and regional or free flaps.
52. Mandibular fractures: Open reduction and internal fixation
(ORIF) with bone plates and lag screws is the most accepted
treatment. It provides stable rigidity and early patient function.
53. Condylar fractures: Severe fractures are problematic even
with the open reduction and internal fixation.
54. Orbital blowout fractures: The simple forced duction testing
detects extraocular muscle entrapment.
55. Foreign body nose in children: A unilateral foul smelling pharyngeus, throat clearing and difficulty in swallowing. 633
purulent nasal discharge in a child is mostly due to forgotten Gastrointestinal symptoms are absent in more than 50% of
foreign body nose. patients with gastroesophageal reflux diseases (GERD). Appendix
76. Laryngoscopy in laryngopharyngeal reflux: It shows posterior
56. Inverted papilloma: The excision should be aggressive laryngitis, pachydermia, Reinke’s edema, and granulomas.
because this aggressive nasal benign tumor has frequent 77. Complications of laryngopharyngeal reflux: Gastro
coexisting carcinoma. esophageal reflux disease may be a risk factor for subglottic
stenosis and laryngeal cancer.
57. Jaw swellings: The panoramic OPG (Panorex) X-ray is 78. Squamous cell carcinoma of esophagus: Prior head and
indispensable for the diagnosis. neck cancer increases the risk of this cancer eightfold.
79. Dissemination of carcinoma of esophagus: There occurs
58. Oral and pharyngeal examination: It also includes palpation. rapid dissemination of mucosal cancer because esophagus
It is important because certain lesions such as submucosal does not have serosal layer.
mass/nodule of carcinoma tongue can be felt and not seen. 80. Flexible laryngoscopy: If you have difficulty in seeing into
nasopharynx and oropharynx request the patient to breath
59. Taste and flavor: They are usually confused. The taste includes through nose that will clear the soft tissue obstruction.
only the ability to sense sweet, salty, bitter, and sour tastes. 81. Valsalva maneuver during flexible laryngoscopy: It can
Flavor includes both taste and smell (80%). Patients with taste better show the pyriform sinuses because it would stent open
problems may be having flavor and a smell disorder. them.
82. Reflux laryngitis: In cases of chronic hoarseness and cough,
60. Sense of taste: It is highly redundant due to its innervation. It or globus, first rule out neoplasm and then consider reflux
is nearly impossible to lose all sense of taste. laryngitis.
83. Laryngeal cancer: The most common malignancy of the
61. Oral thrush in adults: The common risk factors are larynx is squamous cell carcinoma.
corticosteroid and broad-spectrum antibiotics, pregnancy, 84. Tracheotomy: It is the general opinion that the best time of
diabetes mellitus, nutritional deficiency and human doing tracheostomy is when you first think that patient needs
immunodeficiency virus. tracheotomy. No one would like to end up in doing a “slash”
tracheotomy later!
62. Viral sialadenitis: Mumps is the most common parotid viral 85. Airway: Before aggressive ventilation, always confirm the
infection. Less common viral infections are cytomegalovirus, placement of an endotracheal or tracheotomy tube by observing:
coxsackie and Epstein-Barr viruses. a. Humidification in the tube upon expiration,
b. Affirm CO2 return
63. Bacterial sialadenitis: It is usually caused by coagulase c. Auscultation for bilateral breath sounds to rule out main-
positive Staphylococcus aureus. S. pneumoniae, Escherichia
coli, H. influenzae and oral anaerobe. stem bronchi placement.
86. Respiratory distress: If a child with respiratory distress
64. Sjögren’s syndrome: A positive anti-nuclear antibodies
(ANA), rheumatoid factor (RF), Sjögren’s syndrome (SS)-a, SS-b is becoming quiet, it indicates that s/he is about to have
and an elevated erythrocyte sedimentation rate (ESR) are respiratory collapse.
indicative of Sjögren’s syndrome. Biopsy from lip confirms the 87. Congenital laryngeal lesions: Aspiration is more common
diagnosis and shows atrophy of minor salivary glands with an with tracheoesophageal fistula, whereas hoarseness is more
abundance of lymphocytes and histiocytes. common with vocal cord palsy.
88. Laryngomalacia: It is the most common cause of stridor in
65. Malignancy of salivary glands: Their presentation may be childhood and usually occurs within the first 2 weeks of life.
similar to benign tumors and can lead to delay in diagnosis. 89. Features of laryngomalacia: It has multiple anatomic
abnormalities and includes exaggerated omega-shaped
66. Facial nerve in parotid: The most common landmark epiglottis and short and inward collapse of aryepiglottic folds.
for identifying facial nerve during parotid surgery is the Gastroesophageal reflux is probably secondary to increased
tympanomastoid suture. negative intrathoracic pressure.
90. Congenital vascular lesions: They grow a bit but then usually
67. Group A beta-hemolytic streptococci: It is the most start regressing and do not need any treatment. Complete
common cause of acute tonsillitis and can also result in involution may take many years.
rheumatic fever and post-streptococcal glomerulonephritis. 91. Carotid triangle: The most common causes of swellings in
this region are paragangliomas, schwannomas, meningiomas,
68. Infectious mononucleosis: Amoxicillin or ampicillin can and nodal metastases.
cause a salmon-colored rash. 92. Silent primary sites and metastatic neck nodes: In patients
with metastatic neck nodes when the primary lesion is not
69. Adenoidectomy: It should be modified or avoided in cases of found upon physical examination including flexible/rigid
submucous cleft palate. endoscopy, biopsies from four silent primary sites should be
taken. These four silent sites are nasopharynx, tongue base
70. Juvenile nasopharyngeal angiofibroma: In an adolescent valleculae, pyriform sinus and tonsils (tonsillectomy).
male, profuse recurrent episodes of nosebleed suggests juvenile 93. Thyroid nodules: Six to seven percent of adult females and
nasopharyngeal angiofibroma until proven otherwise. 1–2% of adult males will show a thyroid nodule on thorough
clinical examination.
71. Esophageal foreign body in children: The most common
site is just distal to the upper esophageal sphincter.
72. Caustic ingestion: Oral burns may not correlate with severity
of esophageal lesions. Alkaline agents penetrate deeper tissue
layers.
73. Management of caustic ingestion: Watch for sign of
airway obstruction because airway control must be the prime
concern. Watch also for the features of mediastinitis (such as
tachycardia, chest pain, fever, sepsis) and peritonitis.
74. Esophagoscopy in caustic ingestion: It is controversial. It
may lead to further injury. Early esophagoscopy may help in
diagnosis and placements of feeding tube. It is terminated if a
significant burn is seen. It is contraindicated after 12 hours.
75. Symptoms of laryngopharyngeal reflux: They include in
descending order of frequency hoarseness, cough, globus
634 94. Thyroglossal cyst: This midline neck mass is recognized by its 99. Esophageal perforation: Fever after esophagoscopy heralds
perforation. Swallow study confirms diagnosis. Early surgical
movement with swallowing. An ultrasound neck will evaluate repair is important. Draining the perforation may prevent
complications. Antibiotics can mask the clinical features.
for ectopic thyroid tissue.
95. Skin cancers: Surgical excision is the treatment of choice. 100. CT and MRI temporal bone: Thin sectioned HRCT is ideal for
96. Paragangliomas: These vascular tumors are strongly looking temporal bone abnormalities or fractures, but MRI is
gold standard for acoustic neuroma.
enhancing on CT. They contain small regions of single void on
101. Organ preservation therapy: Chemotherapy may play
most MR pulse sequences. an important role in organ preservation. It avoids extensive
97. Bronchoscopy biopsy of the right upper lobe carina/ surgery and is the main treatment for metastatic head and
neck cancers. Radiotherapy becomes more effective as well as
spur: It is the most dangerous site for biopsy because of the more toxic when combined with chemotherapy.
underlying right pulmonary artery.
98. Esophagoscopy: Application of too much force on upper
esophageal sphincter (UES) is the most common cause of
cervical esophageal perforation.
Diseases of Ear, Nose and Throat Problem-oriented cases
What is your spot diagnosis in the following clinical cases? See the 7. An elderly man, who has been suffering from chronic ear
footnotes (bottom of the page) for the answers. discharge for many years, develops facial palsy and pain in the
1. A 30-year old female has been suffering from bilateral hearing ear which is worse at night. Otoscopy shows a friable ear polyp,
which has a tendency to bleed.7
loss for 5 years. She does not give any past history of ear
discharge. She says that her hearing loss increased during her 8. A 20-year-old female from Uttar Pradesh is having nasal
pregnancy.1 obstruction and crusting of nose. Your examination of patient
2. A patient comes to you with ear bleeding, pain, tinnitus and reveals an infiltrating lesion that involves nasal vestibule and
progressive deafness. On examination, you see a red swelling upper lip with broadening of nasal dorsum.8
behind the intact tympanic membrane which blanches on
pressure with pneumatic speculum.2 9. A biopsy taken from a granulomatous lesion of nose shows
3. A 10-year old child develops torticollis, a tender swelling behind Mikulicz’s cells and eosinophilic structures in the cytoplasm of
the angle of mandible and fever. He has been suffering from the plasma cells.9
chronic foul smelling ear discharge for 5 years. Ear examination
shows purulent putrid discharge with granulations in the ear 10. A 10-year boy presents with chronic sinusitis and multiple
canal.3 nasal polyps, recurrent chest infections and malabsorption
4. A child with an acute suppurative otitis media was being syndrome. Sweat chloride test confirms the diagnosis.10
treated with antibiotic ear drops, oral antibiotics and
analgesics. Two weeks later, the child develops a swelling over 11. A 4-year-child presents with chronic right side serosanguinous
the mastoid, pain in the ear, fever, and pulsatile ear discharge.4 (purulent blood tinged) nasal discharge, which is not getting
5. A pregnant lady in her third trimester starts hearing her cured with medical treatment.11
own sounds. On otoscopy you could see movements of
tympanic membrane that are synchronous with respiration. 12. A 3-year-child presents with a unilateral single nasal polyp,
The tympanic membrane movements are exaggerated when which does not bleed on touch. Which condition would you
patient breaths only through the ipsilateral side of nose.5 like to rule out or confirm?12
6. An adult lady develops hearing loss during pregnancy. Her
mother had similar problem. Hearing loss is bilateral and 13. An elderly diabetic patient develops left sided orbital cellulitis.
slowly progressive. She feels that her hearing improves in CT scan shows evidence of left sided maxillary sinusitis. Gram
noisy background. Pure tone audiometry shows conductive stained smear of orbital exudates reveals irregularly branching
hearing loss. Bone conduction dips at 2,000 Hz.6 septate hyphae.13
14. A 15-year old boy presents with right side nasal obstruction
and episodes of profuse bleeding. On examination you see
marked anemia and fullness of right cheek.14
15. A 45-year old man presents with right side facial pain in
temporoparietal and the lower jaw area. On examination you
1 Otosclerosis
2 Glomus jugulare
3 Bezold’s abscess
4 Coalescent mastoiditis
5 Patulous eustachian tube
6 Otosclerosis
7 Carcinoma of middle ear
8 Rhinoscleroma
9 Rhinoscleroma
10 Cystic fibrosis
11 Foreign body nose
12 Intranasal meningocele
13 Aspergillus maxillary sinusitis
14 Juvenile nasopharyngeal angiofibroma
15 Trotter’s syndrome
find right side conductive hearing loss and immobile soft tube and was discharged. It seems that the patient has 635
palate.15 developed tracheal stenosis. What would be your next line of
16. A 5-year old boy presents with recurrent upper respiratory treatment?26 Appendix
tract infections, mouth breathing, and nasal obstruction. His 27. A 10-year old child after an episode of diphtheria develops
parents observed that the child’s hearing has deteriorated.16 hoarseness of voice. Laryngoscopy reveals right vocal cord
17. A neonate female child presents with a unilateral parotid palsy. In addition to the medical treatment what else would
swelling with bluish overlying skin. The swelling increases you like to do for the paralyzed vocal cord?27
when child is crying. There is no other abnormality.17 28. A patient of carcinoma larynx involving anterior commissure
18. HIV infected patient develops painless nontender parotid and vocal cord has perichondritis of thyroid cartilage. What will
gland swelling. What is the most common cause?18 be your line of treatment?28
19. A 50-year old man had plenty of drinks followed by a heavy 29. An adult male patient of 35 years of age has been diagnosed as
dinner. He developed severe vomiting and chest pain and squamous cell carcinoma of left lateral border of anterior two-
collapsed. Hydropneumothaorx was seen on X-ray chest third tongue. The size of local ulceroinfiltrative lesion is 6 cm.
posteroanterior (PA) view.19 The size of swelling of level 3 left cervical lymphadenopathy
20. A 20-year old boy presents with throat pain and easy is 4 cm. General and systemic examination do not show any
fatigable voice. During indirect laryngoscopy both vocal evidence of distant metastasis. Do TNM classification and
cords approximate well but leave a triangular gap in the staging of his cancer disease.29
interarytenoid region.20 30. What will be the staging of a squamous cell carcinoma if the
21. A 40-year old patient presents with frequent episodes of TNM classification has T1, N1 and M0?30
transient but severe unbearable throat pain that radiates to 31. An adult patient who is a chronic smoker has squamous cell
the ear and posterior part of tongue and is aggravated on carcinoma of larynx. The local laryngeal lesion is involving
swallowing. ENT head and neck examination does not show unilateral vocal and false cords. Vocal cords are mobile. There
any positive findings.21 are no neck nodes. Do the TNM classification and staging
22. A 35-year old patient develops trismus, fever, and swelling according to American Joint Committee on Cancer (AJCC)
that is pushing the tonsils medially and spreading laterally classification.31
posterior to sternocleidomastoid. He had extraction of third 32. A child aged 2 years has severe bilateral sensorineural hearing
molar caries tooth few days back.22 loss. Hearing aids were used but with no benefit. What for will
23. A middle aged chronic smoker male patient has been suffering you further evaluate the child?32
from hoarseness of voice for 2 years. On indirect laryngoscopy, 33. A 50-year-old patient presents with 3 cm indurated infiltrative
reddish areas of mucosal irregularity are seen on both vocal ulcerative lesion of right buccal mucosa. Cervical palpation
cords. What will be your line of management?23 reveals multiple nodes on the right side in the submandibular
24. A 3-year old boy presents with hoarse voice and slight region. None of the nodes is more than 3 cm. Biopsy confirms
respiratory distress. The child is having multiple laryngeal the diagnosis of squamous cell carcinoma. Stage the disease
papillomas, which also involve glottis. Which is the best line of and tell the best line of treatment.33
treatment?24 34. A 50-year-old man who is smoker and alcoholic develops
25. A 4 year old child presents in emergency with mild respiratory gradually progressive lymphadenopathy in the upper cervical
distress. Laryngoscopy reveals multiple juvenile papillomatosis region. On thorough ENT examination, no primary site of
of the larynx. What will be your first line of treatment when cancer was seen. What will be your next diagnostic step?34
the immediate facility for microlaryngoscopy surgery is not 35. A child was scheduled for tonsillectomy. On the day of surgery
available?25 he comes with upper respiratory infection (URI, cough, cold,
26. A 30-year old patient comes back to hospital with gradually and fever). Will you proceed for surgery?35
increasing respiratory distress in 4 days. The patient was on 36. A tracheostomy patient with Portex tracheostomy tube
mechanical ventilation and had orotracheal intubation for 2 in position develops severe respiratory distress due to the
weeks. The patient was fine after removing the endotracheal blockage of the tube. What immediate action will you take?36
16 Adenoid hypertrophy and otitis media with effusion
17 Hemangioma
18 Lymphoepithelial cysts
19 Boerhaave’s syndrome
20 Phonasthenia
21 Glossopharyngeal neuralgia
22 Parapharyngeal abscess
23 Microlaryngoscopy and biopsy
24 Microlaryngoscopy and excision
25 Tracheostomy
26 Intravenous steroids
27 Wait and watch for the spontaneous recovery
28 Laryngectomy and postoperative radiotherapy
29 Stage IV: T3 N2 M0
30 Stage III
31 Stage II: T2 N0 M0
32 Cochlear implant
33 Stage III: T2N1M0; Surgical excision of growth with supra-omohyoid neck dissection and post operative radiotherapy
34 Fine needle aspiration cytology (FNAC)
35 No. Wait for 3 weeks and treat the URI if needed with antibiotics.
36 Immediate removal of Portex tracheostomy tube
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