An International Journal of Otorhinolaryngology Clinics

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2022 | September-December | Volume 14 | Issue 3

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Aastha Bhatnagar, Anuja V Satav, James Thomas, Shubhangi Prasad, Rajesh Pareek, Lakshmisravya Kakollu

To Study the Effect of Pre-incisional Infiltration of Ropivacaine for Post-tonsillectomy Pain Relief

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:3] [Pages No:79 - 81]

Keywords: Local anesthetic, Pain, Pre-incisional infiltration, Ropivacaine, Tonsillectomy

   DOI: 10.5005/jp-journals-10003-1409  |  Open Access |  How to cite  | 


Aim: To assess the effect of pre-incisional peritonsillar infiltration of ropivacaine on severity of pain after tonsillectomy. Background: Ropivacaine is a local anesthetic drug that has recently been gaining popularity. It is a synthetic drug of long-acting, amide type. It has a high protein-binding capacity of 90–95% that results in a longer duration of action of 6–8 hours. The onset of action, however, is delayed due to a lower lipid solubility as compared to lidocaine. When compared to bupivacaine, ropivacaine is relatively less cardiotoxic, thereby gaining popularity as an agent for epidural analgesia in gynecological procedures and for motor or sensory blocks in orthopedic surgeries. While the contribution of ropivacaine in treatment of pain that occurs after tonsillectomy has been evaluated, the reports are inconsistent, with respect to clinical trials that include lesser number of patients, and the conclusions have been disputable. Therefore, the study was conducted to assess the efficacy of ropivacaine in the management of post-tonsillectomy pain. Materials and methods: Patients were divided into two groups: Group “R”—administered 0.2 mL/kg of 0.75% ropivacaine hydrochloride infiltration into each peritonsillar fossa under general anesthesia but before tonsillectomy, and Group “S”—not administered anything in peritonsillar fossa under general anesthesia before tonsillectomy. Postoperative pain was assessed using a simple descriptive pain scale as subjective indicator for severity of pain. Results: Mild, moderate, and severe pain was reported among 84%, 16%, and 0%, respectively, with ropivacaine infiltration and 32%, 28%, and 40%, respectively, without ropivacaine infiltration. When severity of pain was compared among subjects with and without ropivacaine infiltration using, it was found to be statistically significant as p <0.05. Conclusion: Infiltration of 0.75% of ropivacaine pre-incisionally into the tonsillar bed is an effective measure to manage the postoperative pain in patients undergoing tonsillectomy. Clinical significance: Ropivacaine is an upcoming cardio-safe drug that has a very high threshold to achieve toxicity levels. It significantly helps to reduce immediate postoperative pain following any procedure and pain is one of the main factors causing morbidity in a procedure like tonsillectomy. Thus, there is the need for a research in the field.



Vasundhara P Varute, Anjana A Mohite, Rajashri S Mane, Balasaheb C Patil, Ganesh M Tarlekar, Deepal Kundu, Jyothi Lakshmi

Routine Histopathological Examination in Patients of Adenotonsillectomies: Evaluation of Its Necessity

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:3] [Pages No:82 - 84]

Keywords: Adenoidectomy, Histopathology, Malignancy, Tonsillectomy

   DOI: 10.5005/jp-journals-10003-1367  |  Open Access |  How to cite  | 


Background: Tonsillectomy and/or adenoidectomy is a common otolaryngologic surgical procedure. The histopathological examination (HPE) of excised tissue after these surgeries is controversial. The study aimed to evaluate the necessity of histopathological analysis of excised tonsils. Materials and methods: The prospective study was performed between January 2017 and December 2018 on HPE results of 200 patients including children and adults, who had adenotonsillectomy in the Department of ENT at the tertiary care center, Kolhapur. Results: A total of 400 HPE results from 200 patients (150 children, 50 adults) were included in the study. HPE of all the excised samples was detected with submucosal hyperplastic lymphoid follicles, reactive germinal centers, and bacterial colonies in crypts. No malignancy was detected. Conclusion: Histopathological evaluation of excised tonsils is not necessary in the absence of associated risk factors. Clinical significance: The incidence of malignancy in excised tonsils or adenoids is very rare; therefore, routine histopathological examination is not necessary except in patients with associated risk factors. This will help reduce unnecessary costings and labor.


Original Article

Diptiman Baliarsingh, Vikas Agrawal, Ashutosh Hota, Rajlaxmi Panigrahi

Evaluation of Cervical Lymphadenopathy by Ultrasonography Using Color and Power Doppler and Comparison with Histopathology

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:7] [Pages No:85 - 91]

Keywords: Cervical lymphadenopathy, Color Doppler, Power Doppler, Ultrasonography

   DOI: 10.5005/jp-journals-10003-1412  |  Open Access |  How to cite  | 


To evaluate and determine the efficacy of ultrasound and Doppler for differentiating among various benign and malignant causes of cervical lymphadenopathy. Out of 88 cases, the final tissue diagnosis on the basis of histopathology was found to be tubercular in 35 (40%), reactive/inflammatory in 30 (34%), metastatic in 16 (18%), and lymphoma in seven (8%) cases with cervical lymphadenopathy. In our study, metastatic nodes were present in all neck lymph node levels but most commonly being the involvement of levels I, II, III, and V with most common primary site being oral cavity. Ninety percent of tubercular nodes were less than 3 cm in size, whereas majority of metastatic nodes were more than 3 cm in size with 40% of cases having size greater than 6 cm. Reactive nodes had L/S ratio of 2.1 ± 0.8, tubercular nodes had 1.7 ± 0.5, lymphomatous nodes had 1.6 ± 0.4, and metastatic nodes had 1.1 ± 0.4. Sixty-two percent of tubercular nodes and 44% of metastatic nodes had sharp border. Eighty-seven percent of metastatic nodes and 71% of lymphomatous nodes had absent hilus, while only 28% of tubercular nodes had absent hilus and 90% of reactive nodes had widened hilus. Fourteen percent of tubercular and 6% of metastatic nodes showed intranodal calcification. Seventy-one percent of tubercular and 68% of metastatic nodes had intranodal necrosis with cystic necrosis being commoner, and only 13% of reactive nodes showed intranodal cystic necrosis. Eighty-two percent of tubercular and 75% of metastatic nodes had matting. Twelve percent of metastatic nodes and 28% of tubercular nodes showed peripheral vascularity, whereas 87% of metastatic nodes and 71% of tubercular nodes showed mixed vascularity, and 60% of reactive nodes showed hilar vascularity. In our study of differentiating non-neoplastic from neoplastic lymphadenopathy on the basis of ultrasonography and Doppler with final histopathology, a sensitivity of 92.3%, specificity of 86.9%, PPV of 95.2%, and NPV 80.0% was found.


Original Article

Hemendra Bamaniya, Harbinder S Bhuie, Rajiv K Saxena, Bandana Talukdar

Local Application of 3% Hydrogen Peroxide as Hemostatic Agent in Tonsillectomy

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:3] [Pages No:92 - 94]

Keywords: Coblation, Cold dissection, Primary hemorrhage, Tonsillectomy

   DOI: 10.5005/jp-journals-10003-1407  |  Open Access |  How to cite  | 


Aims and objective: The aim of this study was to assess the hemostatic efficacy of topical application of 3% hydrogen peroxide in tonsillectomy. Materials and methods: The study was conducted in the Department of Otorhinolaryngology, Ananta Institute of Medical Sciences, Rajsamand, Rajasthan, India, for the period of 2 years from July 2016 to July 2018. Eighty randomly selected patients with the clinical diagnosis of chronic tonsillitis with or without adenoid hypertrophy and who underwent tonsillectomy or adenotonsillectomy were included in the study. In group A (n = 40), a gauze piece soaked with 3% hydrogen peroxide was applied to the tonsillar fossa for 5 minutes just after removal of the tonsil. In another 40 patients (group B), a normal saline-impregnated gauze piece was applied to the fossa for 5 minutes. Results were evaluated in terms of duration of surgery, operative blood loss, and the number of ties used to achieve hemostasis. Results: Age of the patients ranged from 4 to 36 years with a mean age of 14.98 years. The number of female patients (57.5%) was more than male patients (42.5%). The average duration of surgery in group A was 27.63 (±9.24) minutes, while in group B, it was 39.3 (±4.13) minutes. The average amount of blood loss in group A was 70.2 (±7.15) mL, while in group B, it was 92.4 (±5.60) mL. The average number of sutures applied in group A was 1, while in group B, it was 2.1. Conclusion: The use of 3% hydrogen peroxide in the tonsillar fossa after removal of the tonsil reduces the duration of surgery, the amount of intraoperative blood loss, and the number of ties used to control bleeding.


Original Article

Suvamoy Chakraborty, Manu Coimbatore Balakrishnan, Vandana Raphael, Barishisha Kharkongor, Ratan Medhi

Study of Correlation of Clinical Findings and Operative Findings in Thyroid Swellings: A Retrospective Hospital-based Study

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:5] [Pages No:95 - 99]

Keywords: Assessment, Biopsy, Clinical skill, Goiter, Retrospective studies, Risk, Thyroid neoplasms, Thyroid nodule

   DOI: 10.5005/jp-journals-10003-1408  |  Open Access |  How to cite  | 


Introduction: Clinical evaluation plays an important role in diagnosing thyroid malignancy. However, it is largely dependent on the experience of the clinician to have an index of suspicion to detect malignancy and to channel further investigations. Not many studies have been done to signify the use of clinical and intraoperative findings in predicting thyroid malignancy. Objective: The objective of the article was to study the correlation of clinical findings and operative findings in thyroid swellings with histopathological examination (HPE) reports in the Northeastern Indian population in a tertiary care hospital. Materials and methods: The retrospective cohort study was conducted in the department of otorhinolaryngology (ENT). Case records of patients who visited department of ENT with thyroid swellings in the year 2017–2020 were included in the study. Results: A total of 67 patients were included in the study. Clinically, the most common diagnosis was solitary thyroid nodule (STN) made in 54 (81%) patients. In our study, the clinical examination had a sensitivity of 83%, specificity of 32%, positive predictive value (PPV) of 59%, and negative predictive value (NPV) of 63% in diagnosing thyroid malignancy. The intraoperative assessment had a sensitivity of 100%, specificity of 20%, PPV of 59%, and NPV of 100% in diagnosing thyroid malignancy. Conclusion: Clinical evaluation forms the foundation stone for further evaluation of thyroid disorders. Even though a lot of advancements have been made in management of thyroid disorders, clinical evaluation should not be overlooked. With clinical examination having a sensitivity of 83% and NPV of 63% and intraoperative assessment having a sensitivity of 100% and NPV of 100%, it helps in ruling out thyroid malignancy in our study population. However, studies with a large sample size are required to further validate the statement. Clinical significance: Due importance should be given to high-risk clinical and intraoperative features for early diagnosis of thyroid cancer in any population.


Original Article

Shruthi, Praveen Kumar R Bhat

Risk of Thyroid Malignancy in Multinodular Goiter: A Prospective Study

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:3] [Pages No:100 - 102]

Keywords: Follicular carcinoma thyroid, Histopathology, Multinodular goiter, Papillary carcinoma, Thyroid malignancy

   DOI: 10.5005/jp-journals-10003-1413  |  Open Access |  How to cite  | 


Aim: Aim of this study was to estimate the prevalence of thyroid malignancy in multinodular goiter cases and to describe the age, sex distribution, and pattern of thyroid malignancy in multinodular goiter. Materials and methods: A prospective cross-sectional study was carried out on multinodular goiter cases received for histopathologic examination in department of pathology from July 2015 to June 2017. A total of 100 cases were included in the study. Descriptive analysis was performed using frequencies and percentages. Results: Out of hundred patients operated for multinodular goiter, twelve patients had thyroid malignancy. Among 12 malignant cases, nine cases were papillary carcinoma and three were follicular carcinoma. Overall mean age of patients was 40 years. Mean age of patients with coexistent thyroid carcinoma was 39 years. Mean duration of goiter in those who had malignancy was 7.8 years, and that in those who had only goiter was 5.6 years. Overall male/female ratio was 6.14, and thyroid malignancy was seen in only females. Among papillary carcinoma, most common variant was microcarcinoma (four cases) followed by follicular variant (three cases) and conventional type (two cases). Conclusion: There is increased risk of thyroid carcinoma in multinodular goiter. Hence, total thyroidectomy is a better option to treat patients with multinodular goiter. Papillary carcinoma is more common than follicular carcinoma in multinodular goiter. Clinical significance: Total thyroidectomy is a better option to treat patients with multinodular goiter and, if treated conservatively, should be closely followed up.


Original Article

Naina Narasimhadevara, P Shrinath D Kamath

Role of Bupivacaine Infiltration into Tonsillar Fossa in Post-tonsillectomy Analgesia

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:5] [Pages No:103 - 107]

Keywords: Bupivacaine infiltration, Palatine tonsil, Tonsil, Tonsillectomy

   DOI: 10.5005/jp-journals-10003-1434  |  Open Access |  How to cite  | 


Aim: To assess pain with local infiltration with bupivacaine into tonsillar fossa post tonsillectomy by measuring pain on the subjective and objective pain scales. Materials and methods: A prospective comparative double-blind study was done on 70 patients undergoing tonsillectomy/adenotonsillectomy. Patients were divided into two groups: Group I received infiltration into the tonsillar fossa following tonsillectomy with 0.5% bupivacaine, and group II received normal saline. Objective pain analysis was done using the behavioral observational pain scale (BOPS) and subjective scoring using visual analog scale (VAS). Results: Overall pain was comparatively less in group I when compared with group II up to 12 hours postoperatively. Conclusion: Post-tonsillectomy infiltration of bupivacaine into the tonsillar fossa following tonsillectomy reduces pain significantly up to 12 hours. Clinical significance: Reduction of pain in the early postoperative period significantly improves patient satisfaction and early oral intake and reduces the need for analgesics.



Yee Hau Tan, Nik Hisyam Amirul Nik Hishammuddin

A Rare Cause of Unilateral Tonsillar Enlargement

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:2] [Pages No:108 - 109]

Keywords: Case report, Globus sensation, Hoarseness, Intratonsillar abscess, Tonsillar disease

   DOI: 10.5005/jp-journals-10003-1410  |  Open Access |  How to cite  | 


Intratonsillar abscess is a rare entity of tonsillar disease. It is defined as focal areas of neutrophils and necrotic debris within the parenchyma of the tonsil. To date, only 48 cases have been reported including the case report and case series so far from our literature review. It was found to mainly occur in young age of less than 20 years old. It is important not to be overlooked as one of the differential diagnoses of unilateral tonsillar hypertrophy especially in the elderly age-group. The treatment modalities may vary among centers for which there is no gold standard treatment for the intratonsillar abscess. This is a case report of intratonsillar abscess in a 68-year-old man. In this case, incision and drainage were performed with 1 week intravenous antibiotic coverage. Patient had complete resolution of symptoms after 5 days of treatment. The purpose of this study is to discuss on the rarity of the intratonsillar abscess in elderly male and treatment modality in intratonsillar abscess.



Cosimo Galletti, Francesco Ciodaro, Francesco Freni, Galletti Bruno

Pneumoparotid and Subcutaneous Emphysema in a Man with Psychiatric Disorders

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:4] [Pages No:110 - 113]

Keywords: Computed tomography scan, Head and neck region, Parotid gland, Parotid swellings, Parotitis, Salivary gland

   DOI: 10.5005/jp-journals-10003-1411  |  Open Access |  How to cite  | 


Pneumoparotid is an uncommon clinical presentation of parotid swelling. An incompetent Stensen's duct may cause pneumoparotid. Infectious complications and subcutaneous emphysema are mentioned in the literature. We present a 45-year-old man with numerous episodes of distressing distension of the left parotid region. Bedside inspection is carried out and fluctuant left-sided sore parotid enlargement with crepitation at the palpation is noted. A head–neck computed tomography (CT) study with oral medium contrast is performed marking heavy emphysema of subcutaneous layer that is extension gone from temporal region to the upper thoracic outlet, also is noted an important ectasia of Stensen's duct, salivary glands, and left parotid. Medical treatment with antibiotic therapy and support measures are administrated with a complete resolution of subcutaneous emphysema. Pneumoparotid could be correlated with auto-insufflation behavior common in psychiatric conditions and some professions, it is essential besides medical treatment, a psychosocial follow-up in addition.



Picardo Naina, Nithish Raj, John AJ Prakash, Abi Manesh

Lemierre's Syndrome in COVID Pandemic: Is there an Association?

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:3] [Pages No:114 - 116]

Keywords: Klebsiella, Lemierre's syndrome, Neck swelling, SARS-CoV-2, Type 2 diabetes

   DOI: 10.5005/jp-journals-10003-1401  |  Open Access |  How to cite  | 


Background: Lemierre's syndrome is an uncommon life-threatening condition characterized by septic thrombophlebitis of the internal jugular vein (IJV), anaerobic sepsis, and metastatic infections. Case description: A 57-year-old diabetic male presented to the emergency department with progressively increasing left-sided neck swelling. A contrast-enhanced computed tomography of the neck revealed an air-containing abscess showed a long-segment thrombus in the left internal jugular vein with septic embolization to the right upper lung. He was also positive for SARS-CoV-2 infection. He underwent emergency drainage of the abscess along with culture appropriate antibiotics. Two days postprocedure, he developed atrial fibrillation and received anticoagulation treatment for 3 months. Discussion: This case report adds to the growing body of literature of co-occurrence of Lemierre's syndrome in SARS-CoV-2 infection and discusses the possible associations between the two. Besides, it also highlights Klebsiella pneumoniae as an uncommon pathogen causing Lemierre's syndrome.



Deeksha Thakur, Satish Nair

Mental Nerve Schwannoma

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:2] [Pages No:117 - 118]

Keywords: Immunohistochemistry, Mental nerve, MRI, Schwannoma, Surgery

   DOI: 10.5005/jp-journals-10003-1426  |  Open Access |  How to cite  | 


Schwannomas are benign, painless, slowly growing tumors that arise from Schwann cells that surround the neural sheath. Clinical symptoms and signs are often nonspecific and inconclusive. Diagnosis is confirmed by fine needle aspiration cytology, histopathological examination, and immunohistochemical positivity for S100. They show a good prognosis overall with minimal rates of recurrence and transformation to malignancy.



Meng Hon Lye, Intan Kartika Kamarudin, Norhafiza Mat Lazim

Spontaneous Tonsillar Hematoma: A Rare Presentation of Immune Thrombocytopenia

[Year:2022] [Month:September-December] [Volume:14] [Number:3] [Pages:3] [Pages No:119 - 121]

Keywords: Adenotonsilitis, Immune thrombocytopenia, Spontaneous tonsillar hematoma

   DOI: 10.5005/jp-journals-10003-1433  |  Open Access |  How to cite  | 


Aim: We report a case of spontaneous tonsillar hematoma in a 15-year-old male with adenotonsillitis and underlying immune thrombocytopenia (ITP). Introduction: Immune thrombocytopenia is an acquired autoimmune disorder characterized by isolated thrombocytopenia without other discernible etiology. Reported intraoral manifestations included petechiae, purpura, ecchymosis, and hematoma at trauma-prone site. Spontaneous tonsillar hematoma is rarely encountered. Case description: A 15-year-old male with underlying ITP presented with fever and sore throat for 2 days with odynophagia, dysphagia, and a change of voice. Examination revealed two large hyperemic masses occupying the oropharynx. Flexible endoscopy showed bilaterally enlarged tonsils. The patient developed spontaneous bilateral epistaxis requiring nasal packing. A blood test showed elevated leukocytes count and thrombocytopenia. Contrast-enhanced computed tomography (CECT) scan revealed adenoid and palatine tonsils hypertrophy with bilateral cervical lymphadenopathy causing oropharyngeal airway narrowing. He was admitted for observation and started on intravenous antibiotics, corticosteroids, and co-managed with the medical team. Nasal packing was removed after 4 days following platelet transfusion. Patient was discharged after 7 days with full resolution of symptoms. Conclusion: High index of suspicion should be practiced when encountering patients with erythematous oropharyngeal mass. The bleeding disorder should be excluded if the hematoma is suspected. Clinical significance: Spontaneous tonsil hematoma is a possible manifestation of ITP. Symptomatic ITP should be managed with a multidisciplinary team approach for the best outcome.


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