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