NBI– New Advent in Screening and Diagnosing Cancers of Upper Aerodigestive Tract

Head and neck cancers arise in multiple sites and sub sites, mostly detected so late that the oncological treatment encompasses extensive surgery and post-operative functional defects to the individual causing significant cosmetic changes, difficulties in swallowing, chewing, breathing and speaking. Hence early detection of these tumours in one of the main factors in treatment success.

 Efforts to achieve the earliest detection of malignant disease have led to the development of new endoscopic examination methods. Endoscopic examination has hence become a corner stone for the diagnosis and treatment of cancers of the upper aero digestive tract. However, a laryngoscope with conventional white light (CWL) has technical limitations in detecting small or superficial lesions on the mucosa. Narrow band imaging especially combined with magnifying endoscopy (ME) is useful for the detection of superficial squamous cell carcinoma (SCC) within the oropharynx, hypo pharynx, and oral cavity. 

Narrow band imaging (NBI) is a novel endoscopic technique enhances the diagnostic sensitivity of endoscopes for characterizing tissues by using narrow-bandwidth filters in a sequential red, green and blue illumination system. It exploits the neoangiogenetic pattern of vasculature, hence enabling to differentiate between benign & malignant/ premalignant condition. This filter cuts all wavelengths in illumination except two narrow wavelengths. One of these wavelengths is of 415 nm which corresponds to the peak absorption spectrum of haemoglobin to emphasize the image of capillary vessels on surface mucosa. Superficial lesions are identified by changes in the colour tone and irregularity of surface mucosa during endoscopic examinations.

NBI is a non-invasive technique that can be carried out in the outpatient clinic without need of general anaesthesia. NBI system consists of the same components as conventional video endoscopic systems - light source, camera unit and camera head or chip equipped video endoscope. The blue filter enhance the image of capillary vessels (IPCL - Intraepithelial Papillary Capillary Loops) on mucosal surface. The 540 nm wavelength light penetrates deeper and highlights the sub mucosal vascular plexus. The reflection is captured by a charge coupled device chip (CCD), and an image processor creates a composite pseudo colour image, which is displayed on a monitor, enabling NBI to enhance mucosal contrast without the use of dyes.

Healthy nasopharyngeal mucosa in white light (A) and NBI (B).

Submucosal vessels are visualised with greater contrast.

 Dysplasia in Vallecula in white light (A) and NBI (B). 

Submucosal changes for dysplasia, Carcinoma in situ can be appreciated as brown dots irregularly distributed in a well demarcated area. Hence NBI has proved useful in targeted biopsies of suspected areas and to determine limits of resection.

For follow up post Radiotherapy 

NBI has high sensitivity (91.3 - 100%) and specificity (91.6 - 98%) in Head and Neck cancer follow up patients.

Supraglottic spread (of Glottic carcinoma) well appreciated on NBI.

Dysplastic changes; brown dots on NBI

LIMITS OF NBI: As it is dependent on direct visualisation of mucosa, conditions that prevent direct visualisation can alter the results obtained for example, pooled saliva, sticky mucus, or verrucous lesions where the epithelium has a layer of hyperkeratosis which prevents visualisation of submucosa.   Laryngeal papilloma is another entity where NBI cannot discriminate between benign & malignant lesions.

Laryngeal papilloma

NBI has proved to be a useful screening tool aero digestive malignancy, as well as in the pre-operative, intraoperative and post-operative staging of patients affected by squamous cell carcinoma in the head and neck area. Hence NBI is increasingly being used in otorhinolaryngology as a convenient screening method for detection of new diseases, but also for follow-up of patients after treatment for head and neck malignant tumours, when early detection of possible recurrence is crucial. 

Dr. Honey Ashok
Senior Consultant - ENT, Head Neck Surgery & Head Neck Onco Surgery
MS (ENT), DNB (ENT), Fellowship in Head & Neck Oncosurgery
Department of ENT & Head Neck Surger

Sialoendoscopy –Newer frontiers in minimally invasive ENT treatments

What is sialoendoscopy

New technology aiming to visualize the lumen of the salivary ducts and Treat various inflammatory and obstructive pathologies

How is it done? 

Sialoendoscopy involves the use of miniature endoscopes to enter the small ducts of the salivary system in search of disease

What kind of instruments are used ?  

Flexible endoscopes which are 0.75 – 1mm in diameter are used. After dilating the passage of the salivary duct, these scopes are passed in .One by one many ducts can be examined.

What are the procedures possible using this technique?

    1. Diagnostic scopy to examine the ducts
    2. Washes t oremove sludge and mucus plugs
    3. Stone removal
    4. Dilation of duct strictures
    5. Biopsies of the gland

How long does it take? 

This may be possible in 30 minutes for a diagnostic examination, to 1-1.5 hours for therapeutic procedures ?

How is it different and advantageous from earlier treatment methods? 

Traditional methods were limited to medications followed by open surgery  for complete removal of the gland. This required long hospital stay, risk of complications e.g. nerve injury , bleeding , pain

With this new method the advantages are:

    1. No Scar
    2. Quick Recovery
    3. Return Home Same Day
    4. No Tissue Damage To Surrounding Areas

When can we use this technology ? 

We can use this technology to diagnose and treat some common problems salivary glands . By far the most common problem is stones , causing sialadenitis

    1. Duct calculi   (stones)        
    2. Strictures
    3. Dryness of mouth        
    4. Foreign Bodies
    5. Mucus plugs / sludge        
    6. Ductal granulomas

This is also used to get biopsies from intraductal lesions, and for complicated auto immune conditions which may involve the salivary glands.

Can this be used for large stones as well ? 

Yes. With newer technologies , a narrow (Holmium)laser fiber can be passed with the endoscope, and  used to break down large stones , which can then be retrieved in a minimally invasive manner.

How long is the recovery process following a sialendoscopy (salivary stone removal)?

It is recommended that a patient rest and relax for the remainder of the day Some pain and discomfort, as well as swelling, is to be expected. Most patients can resume all activities within a day 

Can this technology be used in children 

Yes. Recuurent infection can happen in children, and often requires repeated antibiotics, or even surgery. This procedure can be done safely, even in young children

Dr. Shantanu Tandon
Consultant - Ear , Nose & Throat (ENT)
MS (ENT), Laryngology Fellowship (USA)
Department of Ear, Nose & Throat (ENT)

Causes, Symptoms and Treatments of Allergy

What is an Allergy? 

An allergy is the response of the body's immune system to normally harmless substances. Whilst in most people these substances (called “allergens”) pose no problem, in allergic individuals their immune system identifies them as a’ threat’ and produces an inappropriate response.

What causes an allergic reaction?

When the allergic person comes into contact with the offending substance, his body's immune system rushes to his rescue and begins to produce antibodies to fight off the invader. These antibodies alter the way in which the body reacts, and may produce allergic symptoms. 

How common are allergies? 

It is estimated that at least 20% of the population is likely to develop some kind of allergy. 

In India this value varies from city to city depending on level of industrialization, type of vegetation etc.  Bangalore is gradually becoming the hub of allergies, and the prevalence may be 30% or even more 

 What are the most common allergic symptoms?

Allergy can involve any part of the body. Any system. Any tissue. Most reactions involve the areas cared for by your Otolaryngologist, especially the nose, sinuses, throat, voice box and trachea. 

Many of these allergies, can cause secondary infections of the sinuses and middle ear

Is an allergy a serious illness?

An allergic reaction can vary from a mildly irritating problem to a very serious and life threatening one. Most people usually develop a response of their nasal passage (Allergic Rhinitis). Some may develop a response of their Lower airway (Asthma).

A sudden severe reaction can cause a generalized response called Anaphylaxis - which can cause shutting down of the breathing passage, circulatory collapse, shock and even death.

Are allergies inherited?

While specific allergies themselves are not inherited, the tendency towards allergies is. The more allergic one's family is, the more likely one is to develop allergies.  

At what age is a person most likely to develop an allergy?

It is most common for allergies to begin in childhood, but it is quite possible at any age group

Will I outgrow my allergies?

No. It is common for people to change the way their other allergic symptoms affect them, but the symptoms usually persist. 

What is the 1st treatment for allergies?

First of all, a careful history of the allergic person is taken. The most basic treatment, once an allergen has been identified, is to eliminate the allergen.

Should an ENT treat my Allergies? 

Majority of the problems encountered due allergy affect the ear, nose or throat. Chronic nasal congestion and post nasal drip, seasonal or constant, is often allergic and may be complicated by chronic sinus and middle ear disease.  

It is often advisable to approach an ENT doctor to treat such problems

Some ENT’s also run allergy clinics, and are equipped to do proper allergy testing and should be preferred.

Such specialists are also capable of offering specialized examination of the ear, nose and throat. When required, such specialists may also suggest surgical treatment, such as polyp removal, placement of middle ear ventilating tubes, straightening of the nasal septum, and treatment of sinus infections. 

In isolated cases of skin allergies, dermatologists may be referred to for treatment of allergies

Should I do any tests for allergies?

 Although the diagnosis of allergy usually based on clinical history, various tests can help

Blood test – help in assessing the severity of the problem 
Skin prick Test – this helps identify the cause of allergy, and helps us decide how to avoid these allergens

How can I prevent allergies?

Allergic rhinitis can be prevented by avoiding exposure to allergic triggers. Here are some useful tips:

House dust mite:

    1. Minimize allergen ‘reservoirs’ like carpets, sofas and curtains
    2. Regular clean these fabrics in hot water
    3. De clutter your home and damp dust regularly.
    4. Open windows after bathing and cooking

Pet dander:

    1. Wash pets regularly and always wash your own hands after touching it.
    2. Dander settles on carpets and soft furnishings. Keep the house ventilated and also vacuum regularly.

Mould spores:

    1. Keep your home dry by closing any cracks and leaks. Also use an exhaust fan in damp areas
    2. Dry all clothes outside whenever possible.
    3. A HEPA air purifier can help trap allergen particles

What if the allergen cannot be eliminated?

Drug treatment has long been a cornerstone of allergy treatment. Antihistamines and/or decongestants (for the nose) and bronchodilators (for asthma) counteract the symptoms caused by the main chemical released by the body's immune system in an allergy attack. There are other drugs, both pills and nasal sprays, which can prevent the release of these inflammatory chemicals or suppress the immune reactions themselves. 

When can I stop taking medications that I have been using to treat allergy problems?

As symptoms are relieved, you may taper off of these medications. Oral steroid such as Prednisone should be slowly tapered down, following instructions from your prescribing doctor. Prescribed and over the counter allergy medications approved by your doctor can be continued if you find you can prevent or relieve allergy problems

Dr. Shantanu Tandon
Consultant - Ear , Nose & Throat (ENT)
MS (ENT), Laryngology Fellowship (USA)
Department of Ear, Nose & Throat (ENT)

7 things you should know about Skin Prick Test

What is a Skin Prick Test?

A Skin Prick Test is a diagnostic procedure done to identify the allergy causing agents (called allergens) that trigger various kinds of allergic diseases. Also known as a scratch test, this test helps to check allergic reactions to various kinds of allergens like - Fungi, Mites, Pollen, Dusts, Epithelia, Insects, and Food.
Thus this test helps confirm what particular substance one touches, breathes or eats is causing the symptoms of concern.

Where can this test be done?

The test is generally performed in a doctor’s office where the doctor himself or a trained nurse performs the test and the results are interpreted by an allergist or a general physician. In adults, the test is usually done on the forearm, whereas for children (not done for children under the age of 10) it is mostly done on the upper back.

How long does it take to get the results?

A Skin Prick Test usually takes about 20 to 30 minutes. In certain tests allergic reactions develop within 15 minutes of exposure to an allergen detecting a specific range of allergies, while some tests detect delayed allergic reactions, which develop over a period of several days.
A positive skin test is when a visible allergic reaction develops corresponding to a specific allergen. Bigger wheals usually indicate a greater degree of sensitivity. A negative skin test means that you probably aren't allergic to a particular allergen.

Does it hurt?

Skin Prick is a Non-invasive Test and is not painful. This type of testing uses needles (lancets) that barely penetrate the skin's surface. There is no bleeding and only a mild to moderate discomfort is felt at the site of prick.
One may have symptoms such as itching, a stuffy nose, red watery eyes, or a skin rash if one is allergic to the allergens used in the test.

How is the test done?

Before any allergy testing, the health care provider will need some information about:
    1. Details of the past allergic reactions experienced
    2. Family history of specific allergies
    3. Past illnesses
    4. Work and home environment
    5. Lifestyle and habits
    6. Food and eating habits
Procedure
    1. In adults the test is performed on the forearm.
    2. The test site is first cleaned and disinfected.
    3. The forearm is then marked using a water soluble skin marker.
    4. A drop of each allergen is then placed corresponding to a number on the grid.
    5. Then a sterile needle (lancet) is used to prick in the middle of each drop of allergen using light pressure. There is no bleeding in the process and the needle only allows the allergen to penetrate into the skin.
    6. The site is then cleaned and the patient is asked to wait for some time.
    7. If one is allergic to a particular allergen being tested, allergic reaction in the form of a raised, red, itchy bump (called a “wheal”) develops on the corresponding site within 15 minutes or so.
    8. The results are then recorded and the grid marks are cleaned with alcohol solution.
    After interpreting the results the allergist or the physician will then recommend treatment options for your allergy. The treatment plan can include medications, changes to be made in the work or home environment or dietary changes and immunotherapy if required.

 

What are the necessary precautions for the test?

  1. Certain medicines like antihistamines can interfere with the skin test and must be discontinued at least 10 days to 2 weeks before the test, after consulting with the doctor.
2. Certain medications may also increase the risk of an allergic reaction during the test. These must 3. Also the patient should always come accompanied with at least one person for this test.

Are there any risks involved?

Since a very tiny amount of the allergen is used, the reaction is also very small and fades away within a few hours.
The reaction can at the most manifest as a few itchy bumps.
    1. Patients with Asthma have a tendency to develop some severe allergic reaction or an asthmatic attack within the next 24 hours. Therefore, they must always keep the doctor informed about their condition and always carry their inhalers and medication while going for this test.
    2. Skin Prick Tests are usually not done on pregnant women, people on certain medications, or those with very bad eczema.
    3. Rarely, these allergy skin tests can produce a severe, immediate allergic reactions like a whole-body allergic reaction (called anaphylaxis), which can be life threatening.
    4. This usually only occurs with intradermal testing / food allergen testing. So it's important to have the skin tests performed at a centre where appropriate emergency equipment and medications are available and the health care provider is prepared to handle all such emergencies.

Dr. Honey Ashok
Senior Consultant - ENT, Head Neck Surgery & Head Neck Onco Surgery
MS (ENT), DNB (ENT), Fellowship in Head & Neck Oncosurgery
Department of ENT & Head Neck Surgery

Prof. Dr. C V Harinarayan receives the prestigious Dr. B C Roy National Award

Sakra World Hospital is proud to congratulate Prof. Dr. C V Harinarayan for receiving the prestigious Dr. B C Roy National Award on 1^stJuly 2016 from the Hon’ble President of India, Shree Pranab Mukherjee.                                                                   

B.C.ROY Natianal Award is given annually by the Medical Council of India for doctors of highest accomplishments in the medical field. The B. C. Roy award for the year 2009 was conferred to Prof.  Dr. C V Harinarayan - Director, Institute of Endocrinology, Diabetes, Thyroid and Osteoporosis Disorders, Sakra World Hospitals, Bangalore for his accomplishments in the field of endocrinology and metabolic bone diseases. His work on metabolic bone diseases is quoted in many textbooks of medicine.

From his studies he showed that low vitamin D status of Indian population is the cause of bone disease in patients with primary hyperparathyroidism. It is hard to believe that in a sun drenched country like India we have vitamin D deficiency. Later this fact was confirmed by many scientific workers across the country. His land mark population study from south India by his group is the FIRST and ONLY study till date to document the low dietary calcium intake and low vitamin D status in agricultural labourers residing in villages. Subsequently his group documented that by ampoule model of previtamin D synthesis and showed that we as Indians can synthesize enough vitamin D on exposure to sunlight from 11 am to 2 pm, by exposing 10 to 15% of body surface area for 15 to 30 minutes.

His work was the first to show that renal tubular damage is the major cause of metabolic bone diseases in patients with flurosis (Ranked top 10 publications - year 2006 by Internet). The work with BARC, Mumbai helped to indigenously develop intact IRMA radioimmunoassay for parathyroid hormone in India (make in India concept). With all this in background his group developed the “Clinical Practice Guidelines for the management of Postmenopausal osteoporosis (2012-13) – Executive summary and Recommendations” for Indian Menopause society. He was instrumental in developing the Department of Endocrinology, SVIMS, Tirupati, (for nearly two decades) with a good dedicated endocrine laboratory infrastructure.

Media Coverage 

We got featured in various newspaper dated on the 2nd July, 2016 titled as, "President of India, Shri Pranab Mukherjee presents Dr. BC Roy National Award to Prof.Dr.C.V.Harinarayan". 

66 year old cured from a rare Benign Phosphaturic Mesenchymal Tumour (PMT)- only 12 such cases repo

Doctors at Sakra World Hospital have successfully treated a very rare case of sino-nasal vascular tumour on a 66-year old male in the city. The Phosphaturic Mesenchymal Tumour (PMT), Hemangio Pericytoma of Ethmoid Sinus was found in a 66-year-old male patient who was confined to a wheel-chair. Only 12 such rare cases of the tumour has been reported worldwide till date according to medical journals.

He is a writer and was bed-ridden for the last 6 months, who had undergone a hip replacement surgery after a fall in the bathroom two years ago. He should have completely recovered post-surgery but unfortunately his condition kept deteriorating. Visits to multiple hospitals neither identify the core issue nor treated his condition. His condition further worsened that he was confined to a wheelchair and had to be carried around even for his ablutions. Being the sole bread winner of the house he could not afford to be in this situation, over and above he was also diabetic, hypertensive and had a CABG (Coronary artery bypass grafting) done in past.  

The patient was referred to Prof.Dr.C.V. Harinarayan, Director Diabetes, Endocrinology and Osteoporosis, who identified the problem to be the loss of phosphorus from the body.  According to Dr. Harinarayan, ‘Phosphorus along with calcium, phosphate, vitamin D etc. are important components for the formation of the bones. In normal conditions the phosphorus is reabsorbed into the body by the kidneys, but in this case it was excreted resulting in soft bones.  Such a condition occurs due to the presence of a Phosphaturic Mesenchymal Tumour which is a rare benign tumour which inappropriately produces a substance known as FGF23 (Fibroblast Growth Factor 23) which decreases the rate of reabsorption of phosphorous in the body.’

Based on the above biochemical assessment a Positron Emission Tomography (PET) scan was conducted in order to locate the position of the tumour. The scan revealed a tumour at the base of the skull, very close to the eyes and base of the brain (Posterior Ethmoidal Sinus). The size and position of the tumour made it very complicated and required highly-skilled and experienced doctors to handle.

Based on the assessment and location of the tumour, the team at Sakra World Hospital performed a specialised CT scan and generated a 3D image of the tumour and decided on the complex procedure.  ‘Being a vascular tumour, the risk of blood loss could have been very high and any mishap could have led to serious damages to the eyes and the brain. The navigation assisted endoscopic procedure along with the CT scan helped in successfully performing the surgery with minimal blood loss and without any incisions,’ said, Dr. Honey Ashok, Senior Consultant - ENT, Head Neck Surgery & Head Neck Onco Surgery.

The patient showed signs of recovery within just a few hours of the surgery and laboratory tests showed a steady rise in phosphorus levels. The patient was discharged the very next day with advice for regular follow up. Now his FGF level has returned to normal.

“The past one year of my life has been a very difficult with what had taken place. Being confined to a wheel-chair and not being able to perform even the daily chores made me miserable. Visited many doctors and hospitals and unfortunately no one could locate the problem. I am thankful that Dr. Harinarayan and team who could not only locate the problem, but also through their expert advice and experience treat the same. I am able to walk again and can complete all my pending jobs,” says the cured male patient.

Media Coverage

Sinusitis Symptoms Diagnosis Treatment and Recovery

What should know about Sinuses & Sinusitis?

Sinuses are connected system of empty spaces in the facial bones, filled with air. They have different names, depending on their location: ethmoid, frontal, maxillary and sphenoid sinuses. Sinuses have a skin lining and a layer of mucus which filters and humidifies the air we breathe,

Sinusitis is an inflammation or swelling of the tissue lining the sinuses. But when they become blocked and filled with fluid, germs (bacteria, viruses, and fungi) can grow and cause an infection.

Conditions that can cause sinus blockage include the common cold, allergic rhinitis (swelling of the lining of the nose), nasal polyps (small growths in that lining), or a deviated septum (a shift in the nasal cavity).

Risk factors for Sinusitis

1. Swelling inside the nose caused by common cold or allergies
2. Deviation of the nasal septum
3. Nasal polyps
4. Conditions that make an infection more likely, such as immune system deficiencies or medications that suppress the immune system.
5. In children, the contributing factor for sinusitis includes allergies, illnesses from other kids at day care or school, pacifiers, drinking from a bottle as they lay on their back and smoke in the environment.
6. The main risk factors for adults are infections and smoking.

Symptoms of Sinusitis

1. A feeling of pain or fullness in your face- over the cheekbones, between or above the eyes
2. A nasal obstruction or blockage
3. Pus in the nasal cavity
4. Fever
5. Nasal discharge or discoloured postnasal drainage
6. You may also have, Headaches, Bad breath, Fatigue and Dental pain

How to diagnose sinusitis?

Having a history of the above symptoms are strong indicators of sinusitis. During a medical screening doctors may press your sinuses for tenderness, and tap your teeth to see if you have an inflamed paranasal sinus.

You may also need other tests like Nasal Endoscopy where we use a tubular camera to see inside your nose and sinus drainage areas.

Can Sinusitis cause any complications?

Though uncomfortable and painful, in most patients sinusitis is not dangerous. In some cases the infection from the sinus can easily spread around the eye, the bones, blood or into the brain.  The complications are more common among children, so if your child has swelling or redness of the eyelid or cheek, then it should be immediately reported to the doctor.

Surgical treatment for Sinusitis

FESS or endoscopic sinus surgery can be considered if antibiotics and other medicines don't clear the sinus.

An endoscope is used to visualize and widen the passageway of the sinuses. It is also used for cleaning out the mucus or pus and restoring the ventilation of all nasal sinuses. Most people can get back to their normal activities within 5 to 7 days.

Doctors may additionally do a procedure called “septoplasty” to straighten the nasal septum or "turbinectomy" to shrink the swollen tissues of the nose.  

Newer Surgical treatment – Balloon Sinuplasty

A modern approach for treating sinusitis is a minimally invasive technique called Balloon Sinuplasty. In this process a balloon is placed over a wire catheter to dilate the sinus passageway. The idea is to restore the normal drainage in the sinus passageway. This opens up swollen, inflamed sinuses much like a heart surgeon opens blocked blood vessels to the heart with a balloon angioplasty.

Advantages of Balloon Sinuplasty

The Balloon Sinuplasty can be performed either in the hospital or at a doctor’s clinic considering how the procedure is relatively easy. Though performed under general anesthesia, it is slowly being performed under local anesthesia by many doctors

Computer Navigation Assisted Sinus Surgery

Computer Assisted Surgery is a new technology used during nasal and sinus procedures.

These systems use a computer specialized software, and electromagnetic tracking technology similar to a global positioning system (GPS) in a car, that allows the driver to see the exact location on a virtual roadmap. This tells us the exact position of the surgical instruments

Sinuses are irregular structures with a variable anatomy and in close proximity to the eyes, brain and multiple arteries and nerves.  With the ability to track instruments, surgeons can more safely perform delicate procedures without damaging these critical surrounding structures. This helps surgeons to be accurate, thorough and safe.

What to expect after Sinus surgery?

• It is normal to have some blood tinged discharge after sinus surgery

• Straining or nose blowing soon after surgery

• You will often be stated on a Nasal Saline Spray to moisturise & make your nose more comfortable. 

• You will be taught sinus which will clean out the debris left behind in your sinuses after surgery. This is important and improves results  

Recovery after a Sinus Surgery

Immediately after surgery, most patients will find some improvement. Like any surgery though, the body takes a few weeks to heal completely. That’s when most patients will realise full improvement. 

Blog by: 

Dr. Shantanu Tandon
MS (ENT), Laryngology Fellowship (USA)
ENT and Head Neck Surgery

10 facts about Snoring and Sleep Apnea you should know

1) WHAT IS SNORING?
A block of airflow through any part of the breathing passage in the mouth and/or nose causes turbulence & vibrations of the soft tissue. The sound that these vibrations cause is called snoring.

2) WHAT CAUSES SNORING?
When we are awake the upper part of the airway to the lungs is held wide open by muscles. However, when we are asleep these muscles can become rather slack allowing the airways to narrow, causing turbulence & vibrations. 

3) WHAT CAN PREDISPOSE TO SNORING ISSUES?
•    WEIGHT: Excess fat, especially around the neck area, squashes the airway 
•    SMOKING: causing nasal lining to swell and produce excess catarrh. This results in nasal congestion 
•    ALCOHOL/SLEEPING TABLETS: causes a decrease in the tone of the muscles that keep the breathing passage open leading to airway collapse

4) WHAT MEDICAL CONDITIONS CAN CAUSE SNORING AND SLEEP APNEA?
Conditions causing the nose to become blocked
•    Recurrent cold or allergies      
•    Nasal polyps     
•    Deviated nasal septum
Conditions causing the throat to get choked up
•    Large tonsils
•    Large uvula and soft palate 
•    Bulky back of the tongue

5) IS SNORING A SERIOUS PROBLEM?
Snoring may seem to be just a personal problem affecting only our partner and family. It can also be a social problem, especially when we travel. But Snoring may also be a sign of a more serious condition called SLEEP APNEA or OSA (Obstructive Sleep Apnea) which can lead to high blood pressure, heart disease, lung problems and diabetes amongst a whole list of other medical problems!

6) WHAT IS OSA (OBSTRUCTIVE SLEEP APNEA)?
Obstructive Sleep Apnea occurs when there are repeated episodes of complete or partial blockage of the upper airway (Apnea) during sleep. During such episodes, the brain wakes up and ensures that breathing resumes (usually with a loud gasp, snort, or body jerk). These episodes can interfere with sound sleep. They can also reduce the flow of oxygen to vital organs and cause irregular heart rhythms.

7) ARE THERE ANY TESTS TO CHECK IF I HAVE OSA?
•    Polysomnography (Sleep Study): This is an overnight test which monitors our sleep pattern, sleep breaks, heart and lung activity while sleeping oxygen levels etc. 
•    Sleep Endoscopy: A thin flexible camera is used to look for obstruction while the patient is asleep

8) CAN I DO SOMETHING MYSELF TO TREAT THIS PROBLEM?
Sometimes snoring can be treated with changes in lifestyle, such as: 
•    Weight loss
•    Quitting smoking
•    Reducing the use of alcohol, sedatives and sedating antihistamines
•    Changing your sleep position to the side and/or elevating your head and neck

9) WHEN SHOULD I MEET AN ENT DOCTOR?
In most cases, a person with OSA is not aware of these repeated awakenings because they occur below the level of consciousness. One should consider meeting an ENT doctor if:
1.      Complaints of snoring from partner/friends/ family
2.      Feeling of daytime tiredness, sleepy feeling,
3.      Poor quality sleep with problems of memory, concentration, and mood changes.

10) WHAT CAN BE DONE TO TREAT THIS?
•    CPAP machine
•    surgical procedures  
•    Newer minimally invasive radiofrequency reduction procedures​

ENT- Image Based Case Study for Air Gun Injury

A 34 year old Bangalore patient, Mr X had an accidental air gun injury in which the bullet directly went through the eye and into the nose and sinuses. Multiple metal pellets got lodged between the eye and the paranasal sinuses. An eye specialist treated him said that he had initial vision problems which occurred due to the trauma. Some pellets remained in the junction where the optic nerve crosses near the nasal sinus, and posed a possible risk in the future.

Recently, the patient visited Dr. Shantanu Tandon, Consultant - Ear, Nose & Throat (ENT) at Sakra World Hospital for a thorough examination.  

An endoscopic removal of these multiple pieces of the bullet was planned by Dr. Tandon. The challenge was that, these pellets were small, and surrounded by blood and tissue, and thus difficult to identify .The pieces had spread to different areas & were also very close to the eye. Dr Tandon used a surgical navigation system to assist the endoscopic surgery.

With the help of this excellent navigation technique, the doctors could get a sense of where the bullet pieces were lodged and how far they were from delicate nerves, eye and the brain . This aided in retrieving the pieces without any significant blood loss, shorter surgery time and patient recuperated in 2 ½ days.

What makes this surgery beneficial for patients:  Endoscopic sinus surgery is the most popular method for treating “Sininasal Diseases”. However, there are some pitfalls with this technique that can result in serious complications. Under the assistance of a navigation system, surgeons can overcome such problems.

Air gun Injury through the eye into the nose and sinus

Case Study by :

Dr. Shantanu Tandon
ENT and Head Neck Surgery
Sakra World Hospital