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Styloid process is a long and slender osseous projection protruding downward, forward and slightly medially from the temporal bone and serves as an anchor point for various muscles associated with the tongue and the larynx. The aim of the present study was to record the length and the angle of Styloid process on three dimensional computed tomography in patients with unilateral symptomatic and palpable styloid process and compare the length and the angle of styloid process of symptomatic side to asymptomatic side on three dimensional computed tomography. 3D-CT face reconstruction were perfomed in all 35 patients (17 females, 18 males of age range 25–69 years). The length of the styloid process and its angulation (transverse and sagittal angles) were measured by means of three dimensional and multiplanar reconstruction images. The length of styloid process on symptomatic side had a mean of 33.61 ± 5.08 mm while on asymptomatic side mean was 31.11 ± 5.02 mm. The mean transverse angle on symptomatic sides had a mean of 72.37° ± 4.48° while on asymptomatic side mean was 74.17° ± 4.48°. The mean sagittal angle seen on symptomatic side was 88.11° ± 5.21° while on asymptomatic side was 87.88° ± 5.03°. Symptomatic side has a longer styloid. Length of the styloid process has a statistical correlation with the symptoms and symptomatic side has a longer styloid. Though there was a difference in transverse and sagittal angulation in symptomatic versus asymptomatic side; but it was not statistically significant. On examination of the opposite asymptomatic side, 5 patients had a palpable styloid process therefore we infer that long styloid process may not always be associated with symptoms. Patients with cervicofacial pain should be evaluated for Eagle syndrome by palpation of styloid process in the tonsillar fossa and further by three dimensional computed tomography (3D-CT). 3D CT is an effective tool in evaluating patients with cervicofacial pain and making a diagnosis of Eagle’s syndrome. Therefore, 3D CT should be performed while evaluating patients with these symptoms.

Postoperative pain following tonsillectomy is troublesome, and non-pharmacological methods can be a valuable adjunct to reduce the intensity of pain. Cooling can attenuate the damage done to tissues by hot dissection techniques.Thestudy was aimed to assess the effect of tonsillar fossa cooling on post-tonsillectomy pain. Forty patients aged 8-18 years of American Society of Anaesthesiologists physical status I and II scheduled for elective bilateral tonsillectomy with bipolar electrocautery under general anaesthesia were recruited. After obtaining consent and approval from the institutional ethical committee, they were randomly assigned to one of the two groups. At the end of tonsillectomy, the tonsillar fossa was packed for 10 minutes using gauze soaked in ice-cold 0.9% saline (5–10 ºC) in group T (test) and saline at room temperature in group C (control). The postoperative pain scores using Faces Pain Scale-Revised (FPS–R) and sore throat were evaluated at 15 minutes, 1 hour, 6 hours and 12 hours. All the data were analyzed using appropriate statistical tests. P < 0.05 was considered significant.Pain scores were significantly lower in group T as compared to group C at all time points. (p Cooling of the tonsillar fossa with ice-cold 0.9% saline after hot dissection tonsillectomy is a useful adjunct in reducing postoperative pain without any significant complications.

Tonsillectomy as a surgical procedure has been practiced by ENT surgeons for a very long time. A common indication for Tonsillectomy is Chronic Tonsillitis, among others. The surgery is largely safe irrespective of the method used. Haemorrhage can be a life-threatening complication post Tonsillectomy if it is not identified and treated immediately. Various techniques are used to achieve haemostasis and prevent haemorrhage including surgical tie, cautery, local application of adrenaline or hydrogen peroxide among others. To understand the vasoconstrictive and haemostatic properties of Hydrogen Peroxide in Tonsillectomy bleed. One hundred and thirty-three (133) patients undergoing Tonsillectomy for Chronic Tonsillitis were part of the study. Dissection and Snare technique was performed. 23 patients needed the use of cautery/knot for haemostasis and were then excluded from the study. To avoid bias, dissection of the right tonsil was taken as Group 1 and left tonsil as Group 2. Normal Saline soaked cotton ball was used to give local pressure in the tonsillar fossa in Group 1 and 3% Hydrogen Peroxide soaked cotton ball was used in Group 2. Blood loss and time taken to dissect were taken as parameters of study. In Group 1, it took 14.29 min on an average from first incision to completion. In Group 2, it took 12.15 min on an average from first incision to completion. The time in Group 2 was 14.97% lesser than Group 1. The average blood loss in Group 1 was 56.47 ml and in Group 2 the same value stood at 47.41 ml. The blood loss in Group 2 was 16.04% lesser than in Group 1. There were no complications encountered. Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation 3% Hydrogen Peroxide is a potent agent for antimicrobial activity and haemostasis when introduced in the tonsillar fossa post tonsillectomy. When used in moderation, it is very effective in preventing blood loss. Also, there are no serious complications associated with the use of Hydrogen Peroxide as a haemostatic agent.

Introduction Tonsillectomy is one of the most commonly performed surgical procedures worldwide, with the major drawback of significant post operative pain.There is no consensus regarding topical application or local infiltration of anesthetics post operatively to reduce pain. The present study was performed to evaluate the effect of bupivacaine infiltration in the tonsillar fossae after tonsillectomy. Materials and Methods A double-blinded clinical trial was performed on 75 patients undergoing tonsillectomy between January 2019 and January 2020. All patients underwent tonsillectomy under general anesthesia and were then randomly divided into 3 groups of 25 patients each. For Group I, a swab soaked in normal saline was applied to the tonsillar fossae for 5 minutes just before extubation. In Group II, a swab soaked in 5 ml of 0.5% bupivacaine was placed for 5 minutes, while in Group III, 5ml of 0.5% bupivacaine was infiltrated in the tonsillar fossae. The intensity of pain for each group was measured in the immediate post op period, at6 hours, 24 hours and 1 week by Wong Baker Faces Pain Rating Scale. Results There was a significant difference in the mean level of pain between groups I and III in the immediate post op period, at 6 hours and 24 hours. Although the average pain scores of group III were better than those of group II, the results were significant only in the 6 hour post op period. Conclusion To reduce post-tonsillectomy pain,0.5% bupivacaine can be infiltrated into the tonsillar fossa.

Aim: To describe our experience of intraoral surgical management of patients with Eagle’s syndrome. Materials and Methods: Twenty patients with elongated styloid processes were treated between January 2016 to December 2020. Intraoral digital palpation of tonsillar fossa and Lateral skull X-ray was done in those with symptoms suggestive of the diagnosis of eagle’s syndrome and patients with styloid processes longer than 30 mm were treated by intraoral surgical resection.Results: We have included 20 patients in the study. The mean age was 46.6 + 8.4 years with a range of 31 years to 63 years. Female: male ratio was 4:1. 13(65%) cases left side lesion seen 5(25%) cases right side 2(10%) cases bilateral elongated seen. The most common presenting symptom was hemicranial pain on swallowing, 92% of subjects were symptom free by third week. No perioperative complications were encounteredConclusion: Eagle’s syndrome is most frequently a diagnosis of exclusion. Delay in proper management exposes patients to long-term struggle with pain and cancerophobia that cause great deal of emotional distress. The intraoral Styloidectomy approach is a simple minimally invasive approach that provides a satisfactory results.

Objectives: To compare the efficacy of coblation tonsillectomy and dissection tonsillectomy regarding the duration of surgery, amount of intraoperative bleeding, postoperative pain, recovery time and complications. Methods: 50 patients aged 5-30 years with chronic tonsillitis who underwent tonsillectomy operation were randomly divided into two groups. One group underwent coblation tonsillectomy while other group with dissection tonsillectomy. Chronic tonsillitis patients with adenoid hypertrophy and Otitis media with effusion were excluded by diagnostic nasal endoscopy, imaging and audiometry. All patient were examined regularly after surgery for 10 days to assess the postoperative morbidity and efficacy of both coblation and dissection methods. Duration of surgery, amount of intraoperative bleeding, recovery time, postoperative pain& requirement of analgesics, time required to regain normal diet & activityand complication were assessed. Result: Comparing the coblation tonsillectomy to cold dissection group the mean duration of surgery was 9.7 versus 18.4 minutes, the amount of intra operative bleeding 10.62 versus 28.72 milliliter. The difference on the postoperative pain scale, requirement of analgesics, condition of the tonsillar fossa, time required to regain normal diet & activity between two groups were statistically significant. Conclusion: In our study patient underwent coblation tonsillectomy providing a near bloodless field, minimum operating time, less postoperative pain, quicker return to normal diet, normal activity and less use of analgesics than patients underwent dissection tonsillectomy. Postoperative morbidity and complications were lower as compared to conventional cold dissection technique. Bangladesh J Otorhinolaryngol; October 2020; 26(2): 121-127

Tonsillectomy is one of the common surgeries performed by Otorhinolaryngologists and is associated with several morbidities with pain being the commonest, which can cause considerable delay in oral intake and discharge from the hospital. As a commonly performed day care procedure nowadays, pain control is much better than what it used to be previously observed. Therefore newer drugs are being constantly studied inorder to give better analgesia and post operative comfort to the patient with minimal side effects. The main obstacle being finding the best medical method to control pain with minimum side effects, but at the same time making sure that the patient is adequately hydrated and they resume regular eating as soon as possible. Our aim is to study the role of pre-incisional 0.5% bupivacaine versus normal saline infiltration in post-tonsillectomy analgesia. Over a period of 1 year, 30 patients with each group of 15 were compared for the efficacy of 0.5% bupivacaine and 0.9% normal saline in post-operative tonsillectomy pain management. After thorough clinical examination and investigations, all patients underwent tonsillectomy by dissection and snare method. After intubation, 0.5% bupivacaine or normal saline was infiltrated in the tonsillar fossa and pain scores was obtained using Visual Analogue Scale (V.A.S) at 6, 12 and 24 h post operatively. Using Mann–Whitney non-parametric statistical test, inter-group analysis was done which showed highly significant p-value (

Introduction Throat pain is one of the most common complaints that an otolaryngologist encounters in daily practice, there can be numerous aetiologies to it. Eagle Syndrome is one such entity which is characterized by chronic throat pain due to elongation of the styloid process or mineralization of the stylohyoid ligament. The vague symptomatology of this condition often leads to delayed diagnosis and treatment. Case Reports We report 5 cases of Eagle Syndrome. All the patients presented to us with complaints of chronic throat radiating to neck which did not relieve on taking medications, for the same they have been consulting multiple specialities. The diagnosis of Eagle Syndrome was confirmed by palpation in tonsillar fossa and orthopantomogram revealed enlarged styloid process measuring more than 30mm. Upon confirmation, all the 5 patients underwent tonsillo-styloidectomy and on consequent follow ups, they were symptomatically improved. Discussion Eagle Syndrome is a diagnosis of exclusion and should raise high index of suspicion in patients with nonspecific throat and neck pain not responding to any conservative treatment. With an increasing incidence of side effects following injudicious treatment given in such cases, this condition requires attention, as it a rare entity and often misdiagnosed.

Eagle syndrome occurs when an elongated styloid process or calcified stylohyoid ligament causes recurrent throat pain or foreign body sensation, dysphagia, or facial pain. Diagnosis is usually made on physical examination by digital palpation of styloid process in tonsillar fossa. Aim: To study the significance of chronic throat pain and elongated styloid process. Matrials and Methods: 60 patients with chronic throat pain (excluding other causes) were assessed by palpation of styloid process was recorded according to age, gender of patients. The prevalence of elongated styloid process in age groups and gender determined correlation and significance of chronic throat pain, along with palpable styloid process in tonsillar fossa and length of styloid process in tonsillar fossa and length of styloid process was determined..Results: The maximum number of patients having chronic throat pain were between 40-49 years age group. The male to female ratio was 0.62:1. The prevalence of elongated styloid process was seen more in 50-70 years of age. There was a higher prevalence of elongated styloid process with moderate to severe pain. 76% patients with elongated styloid process had tonsillar fossa tenderness. 96.4% of patients with elongated styloid process had palpable styloid process in tonsillar fossa. Conclusion: There is a significant correlation between patients having chronic throat pain and elongated styloid process. X ray Skull-Towne’s view is very cost effective as a baseline radiological investigation to diagnose elongated styloid process in patients with chronic throat pain for which cause is unknown. Keywords: Eagle syndrome, Chronic throat pain, X ray skull-Towne’s View.

Pain and hemorrhage are common morbidities after tonsillectomy. Although many studies have focused on post-tonsillectomy pain, inadequate researches are available on wound healing. Hence, there is a definite need for a novel technique to facilitate the healing process and thereby improving the post-tonsillectomy recovery.This prospective and randomized study was conducted on 60 adult patients who underwent tonsillectomy. They were divided into two groups of control and amniotic membrane (AM). Human amniotic membrane was applied over the tonsillar bed as a biologic dressing. Post-tonsillectomy pain and bleeding were evaluated. Also, the healing rate was assessed on days 5, 10 and 15 post-operatively.The pain score in the AM group was lower than that in the control group during the first week after surgery (P 0.0001). Moreover, the AM group returned faster to their normal diet in comparison with the control group (P 0.0001). With respect to the healing rate, there were no significant differences between the groups on day 5 (P 0.05), whereas a significant difference was seen on days 10 and 15 post-surgery (P 0.0001). There was no significant difference between the two groups in terms of post-operative bleeding (P ≅ 1).We observed that the use of AM graft as a biologic dressing might be beneficial in reducing post-operative pain and promoting the wound healing process. The results represent a further step toward developing a new technique for coverage of tonsillar fossa with sheeting or wearing grafts.

Objective Parapharyngeal space contains intricate vascular anatomy (external and internal carotid arteries) that might be inadvertently injured during the dissection in this plane. None of the bony landmarks can be used during the transoral robotic surgery (TORS) radical tonsillectomy as these landmarks lie lateral to the internal carotid artery (ICA) and external carotid artery (ECA) in transoral approach. Our study aims to identify the safe surgical limits during the dissection of parapharyneal space in TORS radical tonsillectomy and to correlate the same with radiological study. Material and methods Fifteen cadavers (30 head and neck regions) and 50 CT-Angiogram of neck (100 head and neck regions) were included in the anatomical and radiological study respectively. The vertical midpoint of anterior tonsillar pillar (palatoglossus muscle) was taken as the reference point and all the measurements were done at the level of reference point both for anatomical and radiological study. Distance between tonsillar fossa and ECA, distance between tonsillar fossa and ICA, relation between ECA and styloglossus and relation between ICA and stylopharyngeus at reference level were studied. Results The mean distance of ECA from the tonsillar fossa at the reference point was 18.2 mm in the anatomical study and 16.2 mm in the radiological study. The mean distance of ICA from the tonsillar fossa was 23.4 mm and 23.3 mm in the anatomical study and radiological study. There was no significant difference between the anatomical and radiological findings for both the mean distance between ECA and ICA to the tonsillar fossa (p value was 0.45 and 0.30 respectively). ECA was located posterolateral to styloglossus in 24 cases (80.0%) and 79 cases (79.0%) in the anatomical and radiological study respectively. ICA was found posterolateral to stylopharyngeus in 21 cases (70.0%) and 69 cases (69.0%) in the anatomical and radiological study respectively. Conclusion The muscular plane between styloglossus and stylopharyngeus can be used as an envelope to locate the ECA and ICA that lie medial to these critical vascular structures during TORS. We propose to divide the parapharyngeal space into two compartments (anterior and posterior) based on the surgical perspective of inside-out anatomy. The anterior compartment houses styloglossus muscle with ECA posterolateral to it and the posterior compartment has stylopharyngeus and ICA posterolateral to it.

The objective of this study is to evaluate the effect of tonsillar fossa closure after tonsillectomy on the amount of intra-operative blood loss, post-operative pain and bleeding. Sixty patients enrolled in this single blind case control study held at Basrah Teaching Hospital in the period from July 2017 to November 2018. Patients age was between 7 to 50 years, of them 28 (46.7%) females and 32 (53.3%) males. One of tonsillar fossae was selected for closure and the other was left open as a control side, the duration of dissection, the amount of bleeding for each side, the level of post-operative pain on (0, 3, 7, 10-14) days was estimated utilizing Visual Analogue Score (VAS) together with any evidence of post-operative bleeding. There was statistically significant reduction in the level of post-operative pain in the sutured side compared to the control for all the follow-up periods. No significant differences in the amount of intra-operative blood loss between both sides were found. None of the patients experienced post-operative primary or secondary hemorrhage. In conclusion, Closure of tonsillar fossa has beneficial effect in reducing the level of post-operative pain after tonsillectomy with no effect on post-operative bleeding. No difference was noted regarding the amount of intra-operative bleeding.

Aim: To demonstrate the efficacy of a new novel anterior tonsillar fossa approach in management of elongated styloid process syndrome. Material and Method: We operated upon 20 patients with confirmed, symptomatic elongated styloid process. None of these patients gave a previous positive history of trauma or any other procedure relating to tonsillar area. All these patients had undergone treatment or were under treatment for neuralgia/TMJ dysfunction syndrome. Diagnosis was confirmed by clinical examination followed by radiological findings. Results: 12 patients underwent bilateral styloidectomy (60%) and 8 patients, underwent unilateral styloidectomy (40%). The length of stolid process ranged from 34mm to 62mm (mean 44 mm). Post operative follow up period ranges from 6 months to 12 months.17 patients (85%) were asymptomatic & had complete remission of symptoms over a follow up period of 12 months. 2 patients had partial remission of symptoms & 1 patient was lost to follow-up. Conclusion: Our anterior tonsillar fossa approach to elongated styloid is safe & adequate in effective surgical management & more so with an additional advantage of not requiring tonsillectomy which is often performed in trans-pharyngeal technique.

Bilateral second branchial cleft fistulae are very rare and usually arise from the incomplete obliteration of the branchial apparatus during the embryonic period. Here, we present the clinical characteristics and surgical treatment of a case with bilateral second branchial cleft fistulae coexisting with bilateral pre-auricular fistulae. A 32-year-old man with complaints of a mucus-like discharge that was occasionally secreted on both sides of his neck at 2 years of age when swallowing or pressing the upper area of the two openings. He underwent surgical treatment. The fistulae tracts were traced ascending to the area adjacent to the internal and external carotid arteries, passing the glossopharyngeal and hypoglossal nerves, and opening into the tonsillar fossa finally. The correct diagnosis and definitive surgical excision should be made by a doctor who is familiar with the history, clinical examination, and anatomic structure of the different types of branchial anomalies.

Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo (p Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Simple Summary Transoral robotic surgery (TORS) with spontaneous healing is associated with improved quality of life as compared to traditional open surgery in small pharyngeal tumors. Improved surgeon experience allows very large or very complex resections, such as in a previously irradiated field where spontaneous healing is functionally insufficient or is at high risk of postoperative complications. We demonstrated very satisfactory feasibility and postoperative outcomes with a free flap microvascular reconstruction in this category of patients. TORS and free flap reconstruction has a place as a standard of care in a number of complex situations. Abstract We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.

Branchial cleft anomalies are embryonic remnants of the branchial arches and are described as the second most common congenital neck mass. Depending on their extent, these anomalies are classified as a cyst, sinus, or fistula with branchial cysts being the most common. Branchial cysts deriving from the second branchial arch are by far the most common, accounting for approximately 95% of all cases. Complete second branch arch fistulas with both an internal and external opening are a rare variant of this anomaly, and even less have been well-documented on computed tomography (CT) imaging in the literature. We present here a case of a 20-year-old female with CT findings consistent with a complete second branchial arch fistula extending from the tonsillar fossa to the external lateral neck.

Introduction The management of parapharyngeal space (PPS) tumors is surgical, but the approach remains a challenge. Attention should be paid to avoid intra-operative bleeding, cranial nerves damage, and external scars. Presentation of case The authors report a case of a 23-year-old female, with complaint of progressive, painless swelling just below the right angle of the mandible of 6-month's duration. Magnetic resonance imaging images reported the presence of an oval-shaped expansive lesion (maximum diameter 3 cm), from the lower polar region of the parotid gland while fine needle aspiration cytology (FNAC) was not diagnostic. We performed a Trans Oral Robotic surgical excision of the tumors with Da Vinci Robot. Discussion Thanks to a detailed magnification, the authors were able to reach the PPS region through the tonsillar fossa saving the palatine tonsil without any significant bleeding or nerve lesions. The histological examination confirmed the diagnosis of pleomorphic adenoma of parotid gland. The decision on which surgical approach to be used is determined by site, size vascularity, histology of the tumor, and knowledge of radiological images. Conclusion There is not only 1 surgical approach for PPS tumors but the surgeon must know all the different options and possible outcomes. Transoral Robotic Surgery approach with Da Vinci could represent a valid option with a good knowledge of Robot surgical instruments and a detailed preoperative plan.

Eagle's syndrome is a rare disease responsible for polymorphic head and neck symptoms, often resulting in delayed diagnosis. The diagnosis of Eagle's syndrome is based on the presence of suggestive clinical signs associated with pain on palpation of the styloid process in the tonsillar fossa, a positive lidocaine test and elongation of the styloid process on 3D CT scan. The most commonly proposed curative treatment is styloidectomy, which allows complete resolution of symptoms in the great majority of cases. This procedure can be performed via a transoral approach or a transcervical approach. After briefly reviewing the embryology and anatomy of the styloid diaphragm region, the authors describe the transcervical styloidectomy technique performed in their department. This simple technique is based on anatomical imperatives designed to limit the operating time and avoid damage to neurovascular structures.

Transoral robotic surgery (TORS) allows surgeons to access tumors of the upper aerodigestive tract through a natural body orifice – the mouth. This technique has been most commonly applied for neoplasms of the tonsillar fossa and base of tongue. The reason for this site predilection is two-fold: neoplasms of the tonsil and base of tongue represent one of the most common subsites of cancer in the head and neck, and neoplasms in this area are amenable to exposure and resection with the currently available robotic instrumentation. The use of this technique, however, forces the surgeon to view the anatomy from a different vantage point. Head and neck surgeons are accustomed to approaching tumors of the oropharynx from lateral to medial. The transoral approach forces surgeons to consider the anatomy from the oral cavity and oropharynx medial perspective. This chapter discusses the evaluation and workup of patients with tonsillar neoplasms being considered for surgical treatment, the relevant anatomy, operative goals, robotic surgical technique, and clinical considerations of transoral robotic surgery for neoplasms of the tonsillar fossa.

Post tonsillectomy hemorrhage (PTH) is a common complication of tonsillectomy. Our objectives were to: 1) Examine the postoperative course of patients presenting to St. Christopher's Hospital for Children (SCHC) with PTH; 2) Compare patients with and without a blood clot visualized in the tonsillar fossa at time of presentation to determine if outcomes regarding return to the operating room (OR) differ.This was a retrospective chart review conducted at an academic, tertiary, pediatric hospital in an urban setting. Pediatric patients who underwent a tonsillectomy with concurrent adenoidectomy and were admitted for observation following secondary post tonsillectomy hemorrhage were reviewed. The effects of age, gender, indication, and clinical exam findings on admission on the rate of eventual return to the OR for control of hemorrhage were also analyzed. Chi-square analysis and Fisher's exact test were used to compare the significance of categorical frequencies.The rate of blood clot presence in our cohort was 50.9% (28/55). Return to OR rates were defined as patients who began actively hemorrhaging following admission for observation, further stratified by presence or absence of clot on admission physical exam. There was a statistically significant higher rate of return to OR in patients who presented with a clot (46.6%) on clinical exam versus no clot (18.5%) after resolved post tonsillectomy hemorrhage (p .027). Furthermore, patients with a blood clot present were significantly more likely to require OR sooner (21.31 h from admission) than those without a clot (100.75 h from admission) (p .012). There was no statistically significant higher rate of blood clot presence or rate of return to OR in groups based on age, gender, or indication.Pediatric patients presenting after resolved secondary PTH with a blood clot visualized in the tonsillar fossa are more likely to require return to the OR for hemostasis and cautery than are those without a blood clot, and this is more likely to occur within 24 h of admission. Thus, patients with a blood clot on initial presentation may benefit from admission for a 24-h observation period, while a similar observation period may be unproductive for patients without a blood clot.Patients who present with a resolved secondary PTH and a blood clot present on clinical exam require return to the OR more often than patients presenting without a blood clot. While previously controversial, we feel that this demonstrates that a 24-h observation of a patient with a clot on exam is reasonable.

OBJECTIVE Tonsillectomy is one of the most common surgeries performed in the pediatric population. Although different forms of instruments and various methods are used to perform tonsillectomy, none of them is still recognized as the best global technique. This study aimed to compare the outcomes of the new Bipolar Loop tonsillectomy versus bipolar diathermy technique. METHODS This study is a pilot randomized clinical trial and was conducted on 40 pediatric patients who were the candidate of tonsillectomy. Patients were divided into two groups of Bipolar Loop or bipolar diathermy. Operation time, intraoperative bleeding, tonsillar fossa wound, postoperative complications, and duration of return to normal diet were evaluated in the current study. RESULTS In both of the Bipolar Loop and bipolar diathermy groups, no significant difference was found in terms of sex, age, and weight. The average amount of the operative time, intra-operative blood loss, and postoperative pain loss were significantly less in the Bipolar Loop group (P

The accessory submandibular salivary duct is an infrequent anatomical variation, with an extremely rare, intraluminally located stone. We present a distinctive case of the largest accessory submandibular sialolithiasis ever reported in the literature. A 54-year-old male presented with a slow-growing mass in the right submandibular area. An examination revealed a large calcified mass in the ipsilateral tonsillar fossa. A preoperative CT scan demonstrated the continuation of the pathologic calcification between two areas. The submandibular gland, together with the entire stone in the accessory duct, was safely removed using the external approach in order to prevent neurovascular injuries that could otherwise arise from its distorted location.

Setting Post-tonsillectomy pain in adults can be severe and is often poorly controlled. Pain can lead to decreased oral intake, bleeding, longer hospital stays, emergency department visits, dehydration, and weight loss. Due to persistent pain despite scheduled medications, other methods for pain control are needed. Local/regional anesthetic options have been previously studied in this population. Unfortunately, neither the injection of local anesthetics into the tonsillar fossa nor the postoperative topical application of local anesthetics to the tonsillar bed has demonstrated efficacy in large systematic reviews. Patients Here we report on the post-tonsillectomy pain experience of three patients who were treated with perioperative nerve blocks placed in the pterygopalatine fossa. This represents an as-yet unexplored option for post-tonsillectomy pain control. Intervention After induction of general anesthesia, before surgical incision, a 25-gauge spinal needle was advanced into the pterygopalatine fossa using a suprazygomatic, ultrasound-guided approach. Ropivacaine and dexamethasone were deposited into the pterygopalatine fossa. Results All three patients experienced excellent pain control for the duration of their recovery and required ≤10 mg of oxycodone over the two weeks after surgery. Conclusions Our case series of three patients provides proof of concept that use of nerve blocks in the pterygopalatine fossa can be useful for the control of post-tonsillectomy pain. Further study is needed to confirm these initial results.

Lipomas are benign soft tissue tumors; the most common ones present in subcutaneous planes distributed throughout the body. However, there are few sites which are unusual location for lipomas. Here, we discuss the presentation of 4 cases of head and neck lipomas at unusual subsites. Though its prevalence is high in the body, lipomas are rarely seen in upper aerodigestive tract and these lesions can cause severe deglutition and respiratory distress problems in addition to cosmetic deformities. In the head and neck, most common location of lipoma is the cheek, followed by the tongue. Tonsillar lipomas are very rare. The mainstay treatment for lipomas is complete surgical excision and recurrence following complete removal is rarely known. We are here discussing a series of 4 cases of lipomas, presenting at uncommon subsites in head and neck region. These include lesions over neck, tongue, palate and tonsillar fossa. Lipomas are benign mesenchymal tumors, that are initially non bothersome. However, with increasing size they can cause severe aerodigestive problems with functional compromise and need complete surgical excision.

Introduction: Orofacial and cervical pain are a frequent reason for neurology consultations and may be due to multiple pathological processes. These include Eagle syndrome (ES), a very rare entity whose origin is attributed to calcification of the stylohyoid ligament or elongation of the temporal styloid process. We present a series of five patients diagnosed with ES. Methods: We describe the demographic and clinical characteristics and response to treatment of 5 patients who attended the headache units of 2 tertiary hospitals for symptoms compatible with Eagle syndrome. Results: The patients were 3 men and 2 women aged between 24 and 51, presenting dull, intense pain, predominantly in the inner ear and the ipsilateral tonsillar fossa. All patients had chronic, continuous pain in the temporal region, with exacerbations triggered by swallowing. Four patients had previously consulted several specialists at otorhinolaryngology departments; one had been prescribed antibiotics for suspected Eustachian tube inflammation. In all cases, the palpation of the tonsillar fossa was painful. Computed tomography scans revealed an elongation of the styloid process and/or calcification of the stylohyoid ligament in 3 patients. Four patients improved with neuromodulatory therapy (duloxetine, gabapentin, pregabalin) and only one required surgical excision of the styloid process. Conclusions: Eagle syndrome is a rare and possibly underdiagnosed cause of craniofacial pain. We present 5 new cases that exemplify both the symptoms and the potential treatments of this entity. Resumen: Objetivos: El dolor orofacial y cervical es un motivo de consulta frecuente, que puede deberse a múltiples procesos patológicos. Entre ellos se encuentra el síndrome de Eagle, entidad muy infrecuente cuyo origen se atribuye a una osificación del ligamento estilohioideo o una elongación de la apófisis estiloides. Presentamos una serie de cinco pacientes con dicho diagnóstico. Material y métodos: Se describen las características demográficas y clínicas de cinco pacientes atendidos en las Unidad de Cefaleas de dos hospitales terciarios por un cuadro compatible con síndrome de Eagle, y su respuesta a distintos tratamientos. Resultados: Se trata de 3 varones y 2 mujeres, de entre 24 y 51 años, con dolor de localización predominante en un oído y la región amigdalina ipsilateral, de cualidad sorda y de gran intensidad. En todos ellos el patrón temporal era crónico y continuo, con exacerbaciones desencadenadas por la deglución. Cuatro pacientes habían realizado múltiples consultas en servicios de otorrinolaringología, y uno de ellos había recibido tratamiento antibiótico ante la sospecha de tubaritis. En todos los casos la palpación de la fosa amigdalina resultó dolorosa. En tres de los pacientes se demostró elongación de la apófisis estiloides y/o calcificación del ligamento estilohioideo mediante tomografía computarizada. Cuatro mejoraron con tratamiento neuromodulador (duloxetina, gabapentina, pregabalina) y sólo uno precisó cirugía con escisión de la apófisis estiloides. Conclusiones: El síndrome de Eagle es una causa de dolor cráneo-facial poco frecuente, y posiblemente infradiagnosticada. Aportamos cinco nuevos casos que permiten delimitar tanto la semiología como los posibles tratamientos.

Objective Fine needle aspiration (FNA) cytology has been successfully utilized in the preoperative diagnosis of oral masses. Lymphoma involving other sites has also been diagnosed frequently on FNA. Oral cavity lymphoma (OL) is rare and is clinically indistinguishable from other lesions of the mouth. A complete excision of these may be difficult. Our experience with FNA diagnosis of 11 OLs along with histopathological correlation is reported herein in a tertiary health care setting. Methods In this retrospective study, clinico pathological characteristics of patients with final diagnosis of non-Hodgkin's lymphoma (NHL) were reviewed over a 7 year period. Routine cytological giemsa staining was performed in all cases along with immunocytochemistry (ICC) wherever possible. The gold standard for diagnosis of NHL was based on: (1) Histopathology and immunohistochemistry and/or (2) Flow cytometry (FC). Results A total of 11 cases were diagnosed as NHL. All showed B cell immunophenotype. Two of them were diagnosed as follicular lymphoma on histopathology. Male to female ratio was 7:4 and ranged in age from 37 to 70 years. The most common site was tonsillar fossa (N = 5), followed by hard palate (N = 3), soft palate (N = 2), and buccal mucosa (N = 1). Size ranged from 1 to 6 cm. Conclusions Diagnosis of OLs may be hampered by its rarity and difficulties in obtaining sufficient cellularity in oral FNA but there is need for immediate and accurate diagnostic procedures, including immunohistochemical analysis to avoid delay in treatment. FNA along with ICC helps in early diagnosis of this rare entity and can also provide sample for FC.

This is a brief report of a 17-year-old male who presented to the emergency department with odynophagia and a foreign body sensation in the throat after choking on a chicken wing. A soft tissue neck radiograph was performed which revealed a 4.6 centimeter linear object in the vallecula read by the radiology department as a chicken bone. The otolaryngology team was consulted and performed a nasopharyngeal laryngoscopy which did not reveal a foreign body in the upper aerodigestive tract. On physical examination, the right tonsillar fossa was tender to palpation. Upon further review of the radiograph, the right stylohyoid ligament was noted to be elongated and calcified. Thereafter, the diagnosis of Eagle syndrome was made. This case provides an important teaching point for providers by pointing out a syndrome that can mimic other disease processes. In addition, it emphasizes the importance of providers reviewing their own films.

Highlights • The average dose to 95% of initial PTV volume was 70.7 Gy for standard plans vs. 58.5 Gy for adaptive plans. • MRI-guided adaptive approach resulted in decrease dose to normal tissue compared with standard plans. • NTCP of post-treatment dysphagia, feeding tube, and hypothyroidism were reduced using the adaptive approach., Purpose We aim to determine the feasibility and dosimetric benefits of a novel MRI-guided IMRT dose-adaption strategy for human papillomavirus positive (HPV+) oropharyngeal squamous cell carcinoma (OPC). Materials/methods Patients with locally advanced HPV+ OPC underwent pre-treatment and in-treatment MRIs every two weeks using RT immobilization setup. For each patient, two IMRT plans were created (i.e. standard and adaptive). The prescription dose for the standard plans was 2.12 Gy/fx for 33 fractions to the initial PTV. For adaptive plans, a new PTVadaptive was generated based on serial MRIs in case of detectable tumor shrinkage. Prescription dose to PTVadaptive was 2.12 Gy/fx to allow for maximum dose to the residual disease. Any previously involved volumes received minimally a floor dose of 50.16 Gy. Uninvolved elective nodal volumes were prescribed 50.16 Gy in 1.52 Gy/fx. Dosimetric parameters of organs at risk (OARs) were recorded for standard vs. adaptive plans. Normal tissue complication probability (NTCP) for toxicity endpoints was calculated using literature-derived multivariate logistic regression models. Results Five patients were included in this pilot study, 3 men and 2 women. Median age was 58 years (range 45–69). Three tumors originated at the tonsillar fossa and two at the base of tongue. The average dose to 95% of initial PTV volume was 70.7 Gy (SD,0.3) for standard plans vs. 58.5 Gy (SD,2.0) for adaptive plans. The majority of OARs showed decrease in dosimetric parameters using adaptive plans vs. standard plans, particularly swallowing related structures. The average reduction in the probability of developing dysphagia ≥ grade2, feeding tube persistence at 6-month post-treatment and hypothyroidism at 1-year post-treatment was 11%, 4%, and 5%, respectively. The probability of xerostomia at 6-month was only reduced by 1% for adaptive plans vs. standard IMRT. Conclusion These in silico results showed that the proposed MRI-guided adaptive approach is technically feasible and advantageous in reducing dose to OARs, especially swallowing musculature.

Background and objective: Tonsillectomy is the surgical procedure of removing the tonsils. Various methods of tonsillectomy have been practiced aimed at decreasing or eliminating intraoperative and postoperative morbidity. This study was conducted to determine the different outcomes of tonsillectomy surgery in both coblation and dissection techniques. Methods: A prospective control study was conducted with a total sample size of 66 patients. Each patient underwent tonsillectomy by using ArthroCare Coblator on the right side and dissection method on the left side. Children between the age of 3-12 years old were selected with indications of recurrent tonsillitis and/or kissing tonsil causing snoring and/or sleep apnea. Children with peritonsillar abscess, malignancy, bleeding disorder were excluded. Operative time and blood loss, postoperative pain, bleeding and healing process were compared between two methods. Operations performed by the same surgeon. Results: The intraoperative time was significantly shorter (P

Objective We analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical-transoral robotic oropharyngectomy course with free flap reconstruction. Methods Patients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre-operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery. Results Three patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous-cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications. Conclusions In our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations. Level of evidence 4.

Introduction: Tonsillectomy in children is associated with some major complications originating from intense post-tonsillectomy pain which can distress patients, cause swallowing difficulties and discomfort, and also lead to aspiration. Thus, this study aimed to investigate the effect of using pre-operative ketamine injection on post-tonsillectomy pain intensity in children. Methods: This double-blind clinical trial was carried out on 60 patients undergoing elective tonsillectomy. To this end, all the patients were anaesthetized by the same method. In the first group, 2 cc of ketamine (0.5mg/kg) solution was topically injected into the soft tissue of tonsillar fossa (peritonsillar space); in the second group, a similar administration was performed but with normal saline. For all the patients, incision was made 5 minutes after injection with the Blast Dissection Snare method. Moreover, the patients’ pain intensity and analgesics consumption were measured 30 minutes, and 1, 2, 4, and 6 hours after surgery. Finally, the collected data were analyzed using the SPSS software. Results: The present study was conducted on 60 patients, 37 males and 23 females, with the mean age of 9.3±3.4 years. In this respect, repeated measures analysis of variance of patients’ pain scores collected in five post-operative stages showed that pain intensity in both groups was at the highest level immediately after operation; it gradually decreased during measurement stages. However, at each measurement, the pain intensity experienced in the ketamine-treated group was significantly lower than that for the placebo group. Conclusion: It was concluded that pre-incision topical injection of ketamine can serve as an effective method to control post-tonsillectomy throat pain.

Current grading systems may not allow clinicians to reliably document and communicate adenotonsillar size in the clinical setting. A validated endoscopic grading system may be useful for reporting tonsillar size in future clinical outcome studies. This is especially important as tonsillar enlargement is the cause of a substantial health care burden on children.To propose and validate an easy-to-use flexible fiberoptic endoscopic grading system that provides physicians with a more accurate sense of the three-dimensional relationship of the tonsillar fossa to the upper-airway.50 consecutive pediatric patients were prospectively recruited between February 2015 and February 2016 at a pediatric otolaryngology outpatient clinic. The patients had no major craniofacial abnormalities and were aged 1 to 16years. Each patient had data regarding BMI, Friedman palate position, OSA-18 survey results collected. For each child, digital video clips of fiberoptic nasopharyngeal, oropharyngeal and laryngeal exams were presented to 2 examiners. Examiners were asked to independently use the proposed Endoscopic tonsillar grading system, the Brodsky tonsillar grading scale, the Modified Brodsky tonsillar grading scale with a tongue depressor, and the Parikh adenoid grading system to rate adenotonsillar hypertrophy. Cohen's Kappa and weighted Kappa scores were used to assess interrater reliability for each of the four grading scales. The Spearman correlation was used to test the associations between each scale and OSA-18 scores, as well as Body Mass Index (BMI).50 pediatric patients were included in this study (mean age 6.1years, range of 1year to 16years). The average BMI was 20. The average OSA-18 score was 61.7. The average Friedman palate position score was 1.34. Twelve percent of the patients had a Friedman palate position score≥3, which made traditional Brodsky grading of their tonsils impossible without a tongue depressor. All four scales showed strong agreement between the two raters. The weighted Kappa was 0.83 for the Modified Brodsky scale, 0.89 for the Brodsky scale, 0.94 for the Parikh scale to 0.98 for the Endoscopic scale (almost perfect agreement). The Endoscopic scale showed the most consistent agreement between the raters during the study. There was a moderate association between the Parikh adenoid grading system with OSA-18 scores (Spearman's ρ=0.58, p0.001) compared to a low association of the tonsillar grading systems with OSA- 18 scores. None of the scales correlated with patient BMI.The proposed Endoscopic tonsillar grading system is as reliable of a method of grading tonsillar size as conventional grading systems. It offers the advantage of allowing for critical evaluation of the tonsils without any anatomic distortion which may occur with the use of a tongue blade. This new validated endoscopic grading system provides a tool for communicating the degree of airway obstruction at the level of the oropharynx regardless of Friedman palate position and may be used in future outcomes projects.

Objective To evaluate and compare the efficacy of postoperative control with digital photographs and physical examination for children who underwent tonsillectomy? Methods In this prospective study, 86 children (46 boys (53.5%) and 40 girls (46.5%) were enrolled for postoperative clinical visit and for obtaining photographs of the tonsillar bed with a digital camera at clinic control. Results No difference in tonsillar fossa healing was observed between the two methods 2 weeks after surgery. Conclusions Digital photographs proved to be a safe method for postoperative control of pediatric patients who underwent tonsillectomy. Adding control with outpatient follow-up will be useful for minimizing postoperative complications.

Eagle's syndrome is characterised by focal pain in the tonsillar fossa on wide mouth opening or head rotation and various accompanying symptoms. While the syndrome is difficult to diagnose, shortening the styloid process via a transoral or transcervical surgical approach has been shown to be the most effective treatment. The aim of this article was to document our experience with a transoral robotic approach to treat Eagle's syndrome and to present the outcomes of four patients. We reviewed the cases of four patients with Eagle's syndrome who underwent transoral robotic surgery (TORS). The average age of patients was 53.75 years, and there were equal numbers of males and females. The styloid processes were reconstructed in 3D from the preoperative CT scans and were measured as an average of 4.18 cm (range 3.3-5.1). The mean set-up time and operation times were less than 10 minutes and 30 minutes, respectively. All patients were completely relieved of symptoms, and were able to restart an oral diet on post-operative day 1. No patient suffered intraoperative or postoperative complication, including cranial nerve injury, haemorrhage, or deep neck infection. In our experience, transoral excision of the styloid process via a robotic approach can be considered as a feasible treatment option for Eagle's syndrome.La sindrome di Eagle è caratterizzata da dolore a livello della loggia tonsillare all’apertura della bocca o alla rotazione della testa, e da vari altri sintomi associati. Nonostante la sindrome sia difficile da diagnosticare, è stato osservato che l’accorciamento del processo stiloideo per via transorale o trancervicale è il trattamento più efficace. L’obiettivo di questo studio è stato quello di portare la nostra esperienza con la chirurgia robotica transorale nel trattamento della sindrome di Eagle, presentando i risultati di quattro pazienti. Abbiamo dunque revisionato i casi di quattro pazienti con Sindrome di Eagle sottoposti a chirurgia robotica transorale (TORS). L’età media dei pazienti era 53.75, e i due sessi erano rappresentati in ugual misura. I processi stiloidei sono stati ricostruiti in 3D a partire dalle scansioni TC preoperatorie e sono stati misurati: la media è risultata pari a 4.18 cm (range 3.3-5.1 cm). I tempi medi di preparazione e di intervento sono risultati pari a 10 e 30 minuti rispettivamente. Tutti i pazienti hanno avuto una completa risoluzione dei sintomi e tutti hanno ripreso la dieta orale in prima giornata postoperatoria. Non c’è stata nessuna complicanza intraoperaatoria o postoperatoria, come emorragie, infezioni o lesioni di nervi cranici. Dalla nostra esperienza si evince che l’accorciamento del processo stiloideo con chirurgia robotica transorale può essere una valida opzione per il trattamento della sindrome di Eagle.

OBJECTIVE The aim of this study was to evaluate the effect of suturation (tonsillary fossa closure) plus Surgicel application on postoperative bleeding and pain after tonsillectomies performed using a classical dissection method. STUDY DESIGN A prospective, randomized, double-blind, clinical trial was performed on 760 patients undergoing tonsillectomy or adenotonsillectomy during a 5-year period. METHODS After excluding patients with hemorrhagic disorder, chronic disease, and peritonsillar abscess, both tonsils were removed via classic dissection technique (cold knife or blunt dissection) and then electrocauterized for hemostasis. The tonsillar fossa randomly assigned to the treatment protocol (Group 1) was closed by sutures, following Surgicel application. The other side was unaltered and acted as the control (Group 2). Pain was evaluated every day for 10 days postoperatively, and bleeding was reported at any time. RESULTS A total of 760 patients (393 males, 367 females) between the ages of 4 and 35 years (mean age 13.46 ± 7.98) were included in the study. Bleeding was observed in 31 patients: 8 from Group 1; and 23 from Group 2 (95% confidence interval [CI], P