Indications for Adenotonsillectomy in Children

The indications for Tonsillectomy have changed over the years with more understanding about the effects of Obstructive Sleep Apnoea (OSA) in children.
The paper published below is from the Paediatrics and Child health Division of the Royal College of Physicians and The Australian Society of Otolaryngology head and Neck Surgery. It was published in 2008 but still relevant today and to the New Zealand Population.

It emphasises the need to increase the access for adenotonsillectomy for children with moderate to severe OSA.

This is in contrast to what is happening in UK where there has been a 40% planned reduction in Adenotonsillectomy. " The operation has been placed on lists of treatments classed as 'of limited benefit' which are being used by primary care trusts to refuse funding on the NHS."
see http://www.telegraph.co.uk/health/healthnews/9195475/NHS-rationing-leaving-thousands-of-children-suffering-tonsillitis-surgeons.html
So I personally believe we need to be wary of any governmental plan to reduce and control the number of T's and Ads. JG


Final Approved Tonsillectomy Document (3)

Head thrust test- an important test for vertigo.

The head impulse or head thrust test was first described by Halmagyi and Curthoys in 1988.  It has acquired an increasingly important place in the clinical examination of the vertigo patient. It detects severe unilateral loss of semicircular canal (SCC) function clinically; it is more sensitive and specific than the traditional Romberg and similar tests; and it is particularly important in the emergency unit, where it can distinguish between vestibular neuritis and cerebellar infarction, which can both generate similar symptoms suggesting an initial attack of severe acute vertigo.
The result of the head thrust test is definitely normal in a patient with a cerebellar infarction but abnormal in a patient with vestibular neuronitis.

                                                                                                                    Kerber K A , Baloh R W Neurol Clin Pract 2011;1:24-33

see youtube video- Halmagyi Head Thrust Maneuver

Incidental MRI and CT findings in paranasal sinuses and mastoid cells

With increasing numbers of CT and MRI scans being performed, this has lead to an  increase in diagnosis of Sinusitis and Mastoiditis being made and referral to our department.
 Fluid signal in the mastoid can be an incidental finding on T2-weighted magnetic resonance imaging and often is interpreted as mastoiditis by radiologists. 

A recent study examined 28 consecutive cases of such erroneously diagnosed "mastoiditis" and documents the presence or absence of otologic symptoms and clinical signs. They found a very low prevalence of otologic symptoms or pathology and no cases of mastoiditis in these patients, and they determined that magnetic resonance imaging is not an effective screening modality for mastoiditis.

Another study showed 61 % of children had one or more salient findings in their paranasal sinuses or mastoid cells. 48 % had mucosal swelling in their paranasal cavities, 25 % in their mastoid cells. The prevalence was higher among children less than 10 years of age (60 % and 42 %) and among children with current upper respiratory tract infection (71 % and 35 %). There was no correlation to a history of headache, snoring, asthma and allergies, or to gender or place of residence.

CONCLUSION:

Mucosal swelling in paranasal sinuses and in mastoid cells is a frequent incidental finding in adults and more commonly in children. Even major mucosal swelling in a paranasal sinus is not necessarily a sign of infection. In radiological reports the terms "sinusitis" and "mastoiditis" should therefore be used with great caution. The initiation of treatment should be based on clinical symptoms and not on radiological abnormalities alone.

The Northern Cochlear Implant Programme (NCIP)

The Northern Cochlear Implant Programme (NCIP) is a publicly funded programme for profoundly deaf children and adults in the northern region of New Zealand.

They have opened a new web-site with information on referral criteria for adults and children. 

http://www.ncip.org.nz/health-professionals.html#who-can-refer-to-the-ncip






Chris Cairns shares a moment with daughter Isabel, who has just received a cochlear implant and can hear for the first time.(Courtesy of stuff.co.nz and Canberra times)

Whangarei Hospital Adult Hearing Aid Service - Information & Guidelines for Referrers

Whangarei Hospital Adult Hearing Aid Service - Information & Guidelines for Referrers

Please refer patients for hearing aid services to the Audiology service rather than the ENT clinic. I also have added the criteria for the referral.

Information for Referrers (1)

Mycetoma Fungal Sinusitis

Fungal infections of the paranasal sinuses are uncommon and usually occur in individuals who are immunocompromised. However, recently, the occurrence of fungal sinusitis has increased in the immunocompetent population.

 There a number of different types of fungal sinusitis.
Allergic fungal sinusitis
Sinus mycetoma 
Acute invasive fungal sinusitis 
Chronic invasive fungal sinusitis 
Granulomatous invasive fungal sinusitis

Mycetoma Fungal Sinusitis produces clumps of spores, a "fungal ball," within a sinus cavity, most frequently the maxillary sinuses. Generally, the fungus does not cause a significant inflammatory response, but sinus discomfort occurs. The noninvasive nature of this disorder requires a treatment consisting of simple scraping of the infected sinus. An anti-fungal therapy is generally not prescribed. The other types of fungal sinusitis will be discussed in subsequent blogs.

Meningoencepholocoele- Endonasal treatment with nasoseptal flap

Meningoencephalocele is a type of encephalocele characterized by the protrusion of both meninges and brain tissue through a defect in the skull. 

There are two main types of meningoencephalocele. The more common frontoethmoidal type is located at the frontal and ethmoid bones while the occipital type is located at the occipital bone. Hydrocephalus, abnormalities of the eyeball and lacrimal duct  and other findings have been associated with the condition. Some affected individuals have intellectual disabilities .

 The condition is typically congenital  but rarely has been reported to occur spontaneously or after head trauma in older individuals (this occured in our patient shown in the video). The underlying cause of the condition is uncertain, but environmental factors are thought to play a role. 

Treatment depends on the size, location and severity of the defect but mainly includes surgery to repair the defect.
The video shows one of our authors (SS) using a local nasoseptal flap to seal the defect.

Thyroid Nodules management protocols

Nodular disease of the thyroid gland is prevalent. The lifetime risk for developing a palpable thyroid nodule is estimated to be 5-10%, and the condition affects more women than men. Roughly 5% of thyroid nodules are malignant; the remainder represent a variety of benign diagnoses, including colloid nodules, degenerative cysts, hyperplasia, thyroiditis, or benign neoplasms. A rational approach to management of a thyroid nodule is based on the clinician's ability to distinguish the more common benign diagnoses from malignancy in a highly reliable and cost-effective manner.below is the Northland DHB Imaging and management of clinically palpable Nodules.
Nodule V4 Dec 09 (1)

Hyperventilation Syndrome

The ENT clinic gets lots of referrals for patients with dizziness. Often hyperventilation syndrome is forgotten as a diagnosis. As always a good history is important.
Think of this diagnosis if patients symptoms and history are multiple and vague. The patient may have dizziness, vertigo, light-headedness. Below is a presentation by our registrar at a recent teaching session.


 

Hyperventilation syndrome from Jerry Gathercole

Odontogenic Sinusitis

A patient presented to us today with sinus symptoms following dental treatment.
The scan clearly showed a foreign body in the right maxillary sinus.

Odontogenic sinusitis is a well-recognized condition and accounts for approximately 10% to 12% of cases of maxillary sinusitis. An odontogenic source should be considered in individuals with symptoms of maxillary sinusitis with a history of odontogenic infection, dentoalveolar surgery, periodontal surgery, or in those resistant to conventional sinusitis therapy.

 Diagnosis usually requires a thorough dental and clinical evaluation including appropriate radiographs. The most common causes of odontogenic sinusitis include dental abscesses and periodontal disease that had perforated the Schneidarian membrane, irritation and secondary infection caused by intra-antral foreign bodies, and sinus perforations during tooth extraction.

 An odontogenic infection is a polymicrobial aerobic-anaerobic infection, with anaerobes outnumbering the aerobes. The most common isolates include anaerobic streptococci and gram-negative bacilli, and Enterobacteriaceae. 

Surgical and dental treatment of the odontogenic pathological conditions combined with medical therapy is indicated

Submandibular Gland stones

Saw this patient today with a huge submandibular duct stone easily visible in the floor of the mouth. Must have been there a long time as it is over 3cm in length. Our poor patients just don't go to the doctor!
It was easy to remove with a little local anaesthetic and a snip with scissors along the direction of the duct.

Submandibular calculi are common because stasis in the duct is encouraged both by the submandibular glands lying below the opening of the duct on the floor of the mouth, and the large mucous content of the secretions of the submandibular gland. They may be found anywhere along Warthin's duct, including its course within the gland. They vary in size from several millimetres to centimetres in diameter. Those in the distal part tend to have an elongated 'date stone' shape.

They should be differentiated from a stenosis of the duct orifice due to repeated trauma and fibrosis, e.g. following irritation from a sharp tooth, or a bite of the cheek. They can be palpated, and 80% are radio-opaque on x-ray.

• the majority of salivary calculi (80% to 95%) occur in the submandibular gland, whereas 5% to 20% are found in the parotid gland
• sialothiasis rarely affects the sublingual gland and the minor salivary glands are rarely (1% to 2%) (1)
• sialolithiasis can occur at any age - however most cases occur in patients in their third to sixth decade. Sialothiasis rarely occurs in children

Topical chemotherapeutic treatments for non melanoma Skin Cancer

With our aging population we have lots of patients who have had multiple skin cancers, who we sometimes call 'frequent flyers' . They require many costly surgical removals in the hospital. There is good evidence to suggest that prevention by the use of chemotherapeutic treatments is a very cost effective alternative to surgical procedures.
Our ENT House surgeon has just presented an excellent resume of medical options particularly comparing Efudix (5FU) and Aldara (Imiquimod) and when they are best used. I hope GP's will find it helpful.

Topical chemo therapeutic treatments for non melanoma skin cancer 

Adenoidectomy in Children with Otitis media with effusion.

A recent randomised controlled trial in UK, MRC multicentre Otitis Media Group (2012) has shown that adenoidectomy leads to longer term hearing benefits than grommets alone.
-In the no-treatment group over a 2 year period  only one in five of the children had complete remission.
-The tympanostomy tube group nearly all returned to near normal hearing levels in the short term.
-But adjuvent adenoidectomy provided a prolonged advantage by preventing recurrence of OME after extrusion in one in four children.

Of course a study like this still doesn't have all the answers.

• The question is would all children benefit from adenoidectomy with grommet insertion. 
• Does the size of the adenoids matter or the history of UTIs. 
• One has to weigh up the risks of adenoidectomy. 
• Would just putting in longer lasting grommets be the option in-spite of the probable  higher drum damage from larger grommets. 
• The availability of resources may be the main obstacle to adjuvant adenoidectomy as a first-line intervetion.

In Northland we tend to do an Adenoidectomy on all children who are booked for their second lot of grommets as well as children with significant nasal symptoms with their first set of grommets. Resources are certainly a factor though.

LPR and GERD-The difference

I was asked today what the difference was between Gastroeosphogeal Reflux(GERD) and Laryngopharyngeal reflux (LPR). This is a presentation I gave some years ago which explains it.
LPR is probably one of the commonest presentations to our clinic and if a good history is taken can be treated initially without referral. Many patients have a fear of 'throat cancer' but with simple advice and treatment can be reassured. If a patient complains of 'TRUE' dysphagia they should certainly be referred immediately.

Laryngopharyngeal Reflux from jeremygathercole

Sublingual Immunotherapy for allergic rhinitis

The private ENT service, would like to offer sublingual immunotherapy to Northland patients. Unfortunately there is no funding for this in Public.

It is a treatment modality, that modifies the immune response by producing blocking antibodies to both antigen specific IgG/IgA. It also reduces the T helper cells , reactive plasma cells,and reduces antigen presentation in the inflammatory response.

Our role would be to guide patient selection, and supervise the first dose.

The ideal patients are those patients symptomatic to a small number of antigens, ideally two or one.Once the patient is referred, we would confirm the allergic symptoms, perform a skin prick test, then reconfirm the allergens by performing a RAST test.There must be a perception that this an additional measure in treating a difficult condition.

Sublingual Immunotherapy, is given in the form of a liquid.There is also a tablet for Grass (Oralair),and next year there is hoped to be a tablet for Dust Mite.

Treatment for grasses,begins in winter,and ends in Feburary.

There is a cost for treatment which must be borne by the patient/parents-of $4/day.CS

Home management of BPPV

Benign positional vertigo is a condition in which a person develops a sudden sensation of spinning, usually when moving the head. It is the most common cause of vertigo. here is a good article to read :http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002393/

I find these diagrams very useful for patients with BPPV to treat themselves at home. They are simple to follow and either option is useful.

·    Modified Epley Procedure THIS is for left ear benign paroxysmal positional vertigo. For right ear, start with the head turned to the right and perform in opposite direction.  1. Start by sitting on a bed with your head turned 45 degrees to the left. Place a pillow behind you so that on lying back it will be under your shoulders.  2. Lie back quickly with your shoulders on the pillow, neck extended and head resting on the bed. In this position, the affected (left) ear is underneath. Wait for 30 seconds.  3. Turn your head 90 degrees to the right (without raising it) and wait again for 30 seconds.   4. Turn your body and head another 90 degrees to the right and wait for another 30 seconds.  5. Sit up on the right side. Repeat this three times daily until you are free from positional vertigo for 24 hours.   Source: A. Radtke et al, Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure, Neurology 2004, 63:150-152    Modified Semont Manoeuvre THIS is for left ear benign paroxysmal positional vertigo. For right ear, start with the head turned to the left and perform in opposite direction.  1. Sit upright on a bed with your head turned 45 degrees toward the right ear.  2. Drop quickly to the left side, so that your head touches the bed behind your left ear. Wait 30 seconds.  3. Move head and trunk in a swift movement toward the other side without stopping in the upright position, so that your head comes to rest on the right side of your forehead. Wait again for 30 seconds.  4. Sit up again. Repeat this three times daily until you are free from positional vertigo for 24 hours.  You may experience bad vertigo, as well as nausea and vomiting, during the first few times on these exercises. Ask your doctor if you need medications or anti-vomiting drugs.    Source: A. Radtke et al, Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure, Neurology 2004, 63:150-152

Dental disease in Northland

Dental infection and secondary neck abscesses are regrettably very common emergency admission for our department. Northland experiences some of the highest dental disease rates in New Zealand. For the last year the hospital dental services are available 24hrs. a day for managing acute abscesses and we are available for extensive neck involvement.

This picture is a case I was involved with. The sad thing is that this is largely a preventable disease. It interested me that this man had never brushed his teeth for as long as he could remember.
When we see patients with other problems we will always discuss and educate them about smoking, but how often do we comment on their teeth and the importance of prevention of dental disease. I appreciate the big factor is cost, but I would encourage all of us to spend time in our consultation to look and advise on the patients teeth. For more reading go to Oral health for all Northlanders

Chronic cough as a complication of treatment with statins: a case report.

Chronic cough as a complication of treatment with Statins see original reportother causes in the differential include

A cough lasting 8 weeks or more (chronic cough)

Some of the most common causes of chronic cough include:

• post-nasal drip syndrome, when mucus drips down your throat from the back of your nose
• allergies
• asthma
• smoking
• COPD (emphysema and chronic bronchitis)
• acid reflux ( gastro-esophageal reflux disease (GERD)or laryngopharyngeal reflux (LPR))
• some high blood pressure medications
• or a combination of these causes

others more serious causes such malignancies ohttp://fauquierent.blogspot.co.nz/2012/07/chronic-cough-due-to-statins.htmlr TB also require investigation

Bilateral vocal cord palsy

I saw a 60 year old patient a week or so ago with a long history of stridor on exercise. She had had a total thyroidectomy 10 years previously and noted the problem since then. Her voice had also changed. She got breathless on exercise and could not walk that far. She had had multiple treatment for asthma over this time. Her astute GP asked us to see her and check her vocal cords, suspicious of recurrent larygeal nerve injury. See endoscopic video(there is probably slight movement of the right vocal cord, but they are lying in a para-median position giving her a poor airway but reasonable voice.)

Bilateral vocal fold (vocal cord) immobility (BVFI) is a broad term that refers to all forms of reduced or absent movement of the vocal folds. Bilateral vocal fold (cord) paralysis (BVFP) refers to the neurologic causes of bilateral vocal fold immobility (BVFI) and specifically refers to the reduced or absent function of the vagus nerve or its distal branch, the recurrent laryngeal nerve (RLN). Vocal fold immobility may also result from mechanical derangement of the laryngeal structures, such as the cricoarytenoid (CA) joint.


According to Benninger's findings in a series of 117 cases BVFI can be attributed to the following causes: surgical trauma (44%), malignancies (17%), endotracheal intubation (15%), neurologic disease (12%), and idiopathic causes (12%).^[1]

History

The importance of a complete history cannot be overstated. The history should include the following:

• Chief symptom, as related to airway, voice, or swallowing
• Onset of symptoms (acute, subacute, chronic)
• Changes in the voice and airway over time
• Related events such as intubation, surgery, or other medical conditions that can affect vocal cord mobility
• Tobacco use

In children, obtaining a history of birth trauma, central nervous system abnormality, intubations, or surgeries is important.

Treatment options

Procedures for bilateral vocal fold (cord) paralysis (BVFP)

• Tracheostomy
• Reinnervation techniques (experimental)^[11]
• Electrical pacing (experimental)
• Permanent procedures

  • Posterior cordotomy (unilateral or bilateral)
  • Arytenoidectomy (endoscopic or external, partial or complete)
  • Cordopexy, lateralization of the vocal cord

 I have asked the specialist Laryngologists in Auckland to review her and suggest treatment options for her.

Laryngopharyngeal reflux (LPR)

Laryngopharyngeal reflux(LPR) is one of the common presentations to our clinic. We probably see a patient with this diagnosis every single clinic.

A patient may have some or all of the following symptoms:

• Hoarseness
• Chronic (ongoing) cough
• Frequent throat clearing
• Constant mucus or phelgm in the throat
• Dry or sandpaper like sensation in the throat
• Pain or burning sensation in the throat
• Feeling of a lump in the throat (globus pharyngeus)
• Problems swallowing
• Bad/bitter taste in the mouth (especially in morning)
• Asthma-like symptoms
• Ear pain and/or persistent ear infections
• Post-nasal drip
• Large lingual tonsils

Note that these symptoms are not the same as GERD, with little heartburn and reflux. 
This condition was not taught to us when I was a student and patients would often be labelled as stressed.(Globus Hystericus). Because we now know that reflux is the trigger it is usually relatively easy to treat with proton pump inhibitors.


 It is important though to exclude other more serious pathologies by performing a flexible endoscopic examination. Many patients have the fear of cancer and are reassured by examination. 

Public Health services question the Indications for adenotonsillectomy in Children

At a recent Medical Executive meeting the following topic was presented.

4.1             Atlas of Healthcare Variation 

·        Originally scheduled for publication by 30 June, now delayed till later in July.

·        Atlas will highlight variation in health service provision and outcomes between different geographic areas of New Zealand.

·        Information to be displayed in maps, graphs and tables, and displayed on the HQSC (Health Quality and Safety Commission) website.

·        Atlas to be organised into ‘domains’ with 10 domains to be published each year.

·        First 3 domains will be :

-         Maternity, ie vaginal deliveries, c-section rates

-         Surgical Procedures of Potentially Questionable Usefulness, ie tonsillectomies/grommets

-         Life Expectancy, and other demographic variables

Now I wasn't at this meeting and although have requested more detail, non is forthcoming. Having researched what the Atlas of Healthcare Variation is, it appears to have been directly "borrowed" from the NHS in UK.
For those GP's and Specialists who like me are concerned by the statement that "Tonsillectomies/grommets may be of questionable usefulness", I direct you to a Joint Position paper of the Paediatrics and Child Health Division of the Royal Australian College of Physicians and The Society of Otolaryngology, Head and Neck Surgery(July 2008).


It states
Conclusion 2
Current Suboptimal rates of adenotonsillectomy for OSA in Australia and New Zealand
     The incidence of adenotonsillectomy in Australia and New Zealand for OSA is significantly below that expected. The analysis suggests that only 1 in 7-10 children who could benefit from adenotonsillectomy is being treated.


I wont go onto discuss the indications for grommets but there is plenty of similar research to confirm its usefulness. Unfortunately there are going to plenty of more pushes to save money in our health service and worryingly many may be directed towards children. (editor)

Fauquier ENT Blog: Stem Cells Restore Toddler's Congenital Hearing Loss

Fauquier ENT Blog: Stem Cells Restore Toddler's Congenital Hearing Loss

Medical Management of Chronic sinusitis

We see a lot of patients with  chronic sinusitis who have often not had a full course of medical management before being referred to our department.  Many patients will come right with adequate treatment and will avoid a surgical option.

SymptomsCommon symptoms include facial pain / pressure / fullness; nasal obstruction / blockage; purulent nasal or post nasal discharge; hyposmia or anosmia; fever (acute sinusitis only); dental pain.

Physical SignsOften minimal. Mucosal swelling/inflammation; postnasal drip; facial tenderness and
swelling. Post nasal mucous alone is not typical of sinusitis.
Look for nasal polyps, deviated nasal septum or enlarged turbinates.
Examination ideally done after decongestion (Otrivine spray or Co-phenylcaine Forte
Spray in multidose container).

Differential DiagnosisAllergic rhinitis: atypical facial pain; headaches (migraine or tension).
Gastro-oesophageal reflux: TMJ pain; dental pain.

 Chronic sinusitis (continuous symptoms > 3 months)
Management

•  Supportive treatment 
•  - increase fluids, analgesia (paracetamol, NSAIDS) steam inhalations, decongestants i.e. otrivine / drixine nasal sprays or oral pseudoephedrine (maximum 5 days only), and most importantly nasal saline irrigation (Sinus Rinse or Narium commercial preparations are OTC products or use saline irrigation using syringe or straw inhalation). see video here
•  First line antibiotic 4 weeks
• First line antibiotics – amoxycillin, cotrimoxazole, doxycyline.
•  Topical nasal steroid 3 months.

 If no improvement second line antibiotic for further 1 month plus oral steroid minimum 2 weeks – Prednisone 20mg/day for 1 week then Prednisone 10mg/day for further week.

RadiologyPlain x-rays not indicated.
CT Scan indicated for recurrent or chronic sinusitis if no response to medical management as above.

See Healthpoint for full management options and referral criteria

How to do a punch biopsy

Skin biopsy is one of the most important diagnostic tests for skin disorders. Punch biopsy is considered the primary technique for obtaining diagnostic full-thickness skin specimens.

   A patient who is referred to our ENT clinic is expected to have both a punch biopsy done as well as a photo. This 5 minute procedure will save the patient a trip to Hospital as well as allowing us to fast track a patient with a malignancy such as a squamous cell carcinoma. We appreciate there is a cost involved but it will provide in most cases an accurate diagnosis which will help both the patient and the specialist staff at the hospital.


You need
Local anaesthetic with adrenaline, ideally with a dental syringe and needle which is very quick and easy to use.
A punch. 2mm in most cases is sufficient, although you can use a 3mm. They cost about 8.00NZ$.
A small pair of fine forceps and iris scissors
An alcohol swab and a couple of gauze swabs.
Send specimen in formalin to the laboratory


I have not had problems with people on anticoagulants as the bleeding is minimal.


Below is a video of how to do it. (the patient has given permission to show this video)

Skin cancer surgery

The incidence of skin cancer continues to rise with the baby boomers reaching older age and the lack of sun protection when young.

In Northland we have limited Dermatology services so if the lesion is too large for a GP to remove, referral can be made to General surgery, ENT and occasionally Ophthalmology services, depending on the site.
Ideally all patients should have a photo and punch biopsy of the lesion before referral. The real importance for this is for those patients with a SCC and patients who are immunocompromised can be triaged for urgent treatment. I shall be posting a video on how to do a punch biopsy  shortly. Just a reminder that it is best not to punch biopsy a suspected melanoma. All melanomas should be sent to General surgery.

The ENT service has recently produced an Audit on the last 6 months of head and neck skin cancer cases. ---102(91%) cases with clear margins and 10(8.0%) with positive margins.(requiring a second procedure). These results are satisfactory compared with international series.

At a meeting today between the General Surgery and ENT departments it appears that at present waiting times are not too bad.  We shall keep an eye on this. Another area of concern is those patients having multiple lesions removed, require input from someone with knowledge and interest in preventative skin care. Cytotoxic creams and lotions are showing very good results in skin cancer prevention. Management are looking into this for us.

Allergic Rhinitis and skin prick testing

The most common allergic symptoms are congestion, runny nose, postnasal drip, watery eyes, and itching of the eyes or throat. Ear infections and sinus infections are often aggravated by allergies.

Skin testing for allergies is used to identify nasal allergens. It is performed by applying an extract of an allergen to the skin, scratching or pricking the skin to allow exposure.

•  A drop of extract for each potential allergen -- such as pollen, animal dander, or dust mite -- is placed on the skin and pricked into the epidermis. The subsequent wheal is measured.
• All adults and children over about 6-7yrs should have allergy testing if they have symptoms of allergic rhinitis. This is available at the local pathology lab and some practices. 
• The video above demonstrates this simple investigation.

Sublingual gland removal for plunging ranula

A plunging ranula is an extravasation of saliva from the sublingual gland due to trauma or obstruction of the duct. Fluid from the obstructed gland dissects between the fascial planes and myelohyoid muscle to the submandibular space. 


The exact prevalence of plunging ranula is not known, however, these lesions appear to more common in Maori and Pacific Islanders. Some plunging ranulas either accompany a swelling in the floor of mouth or are associated with a history of treatment of intraoral ranula. On the other hand most plunging ranula in New Zealand there is no clinical evidence of an oral connection, and are sometimes difficult to diagnose.

Treatment involves surgical removal of the sublingual gland and exposure of the pseudocyst. See video above

Endoscopic treatment of Pharyngeal pouch

We recently treated a patient with a Pharyngeal pouch.

His symptoms were  dysphagia, regurgitation, aspiration, chronic cough and slight weight loss.
Usually there are no clinical signs but there may be a lump in the neck that gurgles on palpation. There may also be halitosis from food decaying in the pouch.


A pharyngeal pouch(Zenkers diverticulum) represents a posteromedial pulsion diverticulum through Killian's dehiscence. It is a herniation between the thyropharyngeus and cricopharyngeus muscles that are both part of the inferior constrictor of the pharynx.

The aetiology is unknown but malfunction of the upper oesophageal sphincter probably contributes. They occur in the elderly.

The diagnosis is confirmed with a Barium swallow.

traditionally we have treated these by an external operation which involves exposing the pouch in the neck and excising it. As we don't see too many of these it can be a difficult procedure with some risks. 

Recent endoscopic techniques are now favoured so we asked a specialist colleague to come from Auckland to show us how it is done. 

The video shows the dividing wall between the pouch and the oesophagus being divided. We used a harmonic scalpel which seals and cuts the bridge which includes the cricopharyngeus muscle creating a single large cavity.