Absceso Periamigdalino

Qué es un absceso?

El absceso periamigdalino, es una complicación de una amigdalitis y las bacterias asociadas con mayor frecuencia, son los Streptococcus.

Un absceso es una colección de pus que se forma y se acumula cerca del área infectada. Se produce al extenderse la infección al tejido blando localizado alrededor de las amígdalas (anginas) y es más común en adultos y  raro en niños o adolescentes.

Cuáles son los síntomas del absceso periamigdalino?

Un absceso puede causar una variedad importante de síntomas como dolor severo de garganta, inflamación y obstrucción de la garganta.

Si la garganta está obstruída, entonces habrá dificultad para tragar o deglutir, para hablar (voz en papa caliente) y hasta para respirar. Además puede asociarse a fiebre y calosfríos, otalgia (dolor de oído) del lado afectado y/o trismus (espasmo de los músculos de la mandíbula).

Cuáles son los factores de riesgo para desarrollar un abceso periamigdalino?

Los factores de riesgo para presentar un absceso periamigdalino son haber presentado una infección dental tal como una ginvitis o periodontitis, amigdalitis crónica, tabaquismo, mononucleosis infacciosa, leucemia linfocítica crónica (LLC), presentar depósitos de calcio en las amígdalas (litiasis amigdalina).

Cómo se hace el diagnóstico?

Normalmente el diagnóstico de un absceso periamigdalino se hace en base a la historia clínica y al examen físico del paciente durante la consulta. El diagnóstico suele ser sencillo y normalmente se observa enrojecimiento e inflamación del tejido blando del lado afectado, cerca de la amígdala, lo que sugiere la presencia de un absceso. La úvula (o campanilla), puede verse desplazada hacia el lado contrario de la amígdala donde se encuentra el absceso. Incluso, al presionar el área infectada con un abatelenguas, ocasionalmente puede verse la salida de pus.

Los estudios de laboratorio o de gabinete (rayos X, tomografía computada de cuello o resonancia magnética) se utilizan solo en aquellos casos donde se sospecha que la vía aérea está comprometida (epiglotitis, absceso retrofaríngeo).

8span style="font-family: Verdana, sans-serif;">Cuál es el tratamiento para un absceso periamigdalino?

Existen varias opciones para el tratamiento. Una de ellas consiste en aspirar el pus del absceso en el consultorio (siempre y cuando la vía aérea no esté comprometida) o bien, hacer una incisión con un bisturí en el área afectada para drenar el mismo.

Se administran antibióticos vía intravenosa (I.V.) y se hospitaliza al paciente si éste se encuentra muy enfermo y tiene dificultad para tragar o tiene enfermedades adyacentes tales como Diabetes. Pero si se drena el absceso y el paciente mejora, se pue`e enviar a casa con una lista de “signos de alarma” tales como que exista sangrado, dificultad para respirar o deglutir, babeo constante, fiebre elevada y calosfríos, lo que significaría que el cuadro empeoró y su vida está en peligro.

La amigdalectomía se reserva para aquellos casos donde el paciente presente compromiso de la vía aérea, es decir que tenga dificultad para respirar o para pacientes con historia de amigdalitis crónica o en los casos donde el paciente ya haya presentado previamente otro episodio de absceso periamigdalino.

Cuáles son las complicaciones de un absceso periamigdalino?

Las complicaciones pueden ser muy serias y ponen la vida en peligro si no se trata a tiempo la enfermedad.

Éstas complicaciones son obstrucción de la vía aérea, deshidratación debido a la dificultad para deglutir, absceso profundo de cuello (que puede ser mortal si llega al mediastino, cavidad donde se aloja el corazón), pneumonia, meningitis y hasta sepsis (bacterias en la sangre).

El abseco periamigdalino, debe ser tratado por un médico especialista. En este caso  el Otorrinolaringólogo (médico encargado de las enfermedades del oído, la nariz y la garganta), sería la elección adecuada.

Si Usted presenta dolor de garganta severo, problemas para tragar saliva, dificultad para respirar o hablar, babeo u otros signos potenciales de obstrucción de la vía aérea, acuda con su médico de inmediato!

Peritonsillar Abscess

What is a peritonsillar abscess?

The peritonsillar abscess is the most common complication of tonsillitis and the bacteria most frequently involved in this type of Abscess is the Streptococcus.

An abscess is a collection of puss that forms and accumulates near the site of infection. It happens because of the spread of the infection to the soft tissue located around the tonsills. This disease is seen more frequently in adults and rarely in infants or teenagers.

What are the symptoms of a peritonsillar abscess?

The abscess can cause a variety of symptoms like intense throat pain (sore throat), swelling and blockage of the throat. If the throat is blocked, then swallowing, speaking (muffle voice also known as “hot-potato” voice) and even breathing becomes difficult. Also high fever and chills may be present, ear pain on the affected side and/or trismus (muscle spasm in the muscles of the jaw).

What are the risk factors to develop a perintosillar abscess?

There are certain risk factors that make one more prone to a get a peritonsillar abscess such as gum infections (gingivitis or periodontitis), chronic tonsillitis, smoking, infectious mononucleosis, chronic lymphocitic leukemia (CLL) and stones or calcium deposits in the tonsills (tonsilloliths).

Diagnosis?

Usually, the diagnosis of a peritonsillar abscess is based on the history and the physical exam during the consultation of the patient. The diagnosis is usually made easier since swelling and redness on one side of the throat near the affected tonsil suggests the abscess. The uvula (structure that hangs from the middle of the throat), may be shoved away from the swollen side of the oropharynx. Also, sometimes if the doctor touches the tonsil with a tongue depressor, he/she may see puss draining from the site of infection.

Lab studies, such as X-rays, CT (computed tomography) scan of the neck or MRIs (magnetic resonance imaging) are not usually required unless other upper airway diseases are suspected (epiglotitis, retropharyngeal abscess).

What is the treatment for a peritonsillar abscess?

There are several options for the treatment depending on the severity of the case. One of treatments consists of puncturing the abscess with a needle to withdraw the puss into a syringe. Also, an incision and drainage using a scalpel to drain the puss can be used.

Antibiotics will be administered usually through an I.V., if the patient is very ill, have trouble swallowing or have other medical problems such as diabetes, the patient should be admitted to the hospital. But If the abscess drains well, then the patient can be discharged home with a checklist consisting of “alarming signs” such as bleeding, trouble breathing or swallowing, difficulty speaking, drooling, high fever and chills, which would mean that the problem got worse and that the patient's life is in danger.

A Tonsillectomy may be needed in those cases where there is an obstruction of the upper airway, or history of chronic tonsillitis and patients with a previous episode of peritonsillar abscess.

What are the complications of a peritonsillar abscess?

The complications of a peritonsillar abscess can be major and all of them endanger the life of the patient. This complications are airway blockage, bleeding from erosion of the abscess into a major blood vessel, dehydration from difficulty swallowing, a deep neck abscess that could reach the site where the heart is located (mediastine), pneumonia, meningitis and sepsis (bacteria in the bloodstream).

This disease should be treated by a specialist, in this case an ear, nose and throat surgeon (ENT Dr.).

So, if you are experiencing a severe sore throat, difficulty breathing, swallowing or speaking, drooling or other potential signs of upper airway obstruction, call your doctor imme`iately!

Tonsillectomy and Adenoidectomy

What are the tonsils (tonsillitis)?

The Tonsils are an accumulation of lymphoid tissue (tissue that produces antibodies) of ovoid shape, located on the wall of the oropharynx. They have on their surface structures called crypts, which are tubular and extend into the depth of the tonsils.

The abnormal growth (hyperplasia) of the tonsils may cause mouth breathing, abnormal position of the tongue, impaired speech and orofacial growth disturbances.

What are adenoids?

They are a triangular mass of lymphoid tissue (like the tonsils), located in the nasopharynx. This anatomical relationship between the adenoids and nasopharynx, affects the Eustachian tube (the connection between the nose and middle ear) and to the sinuses. So it is very common in children that present adenoiditis, to have otitis media and / or sinusitis infections.

What is the difference between acute tonsillitis and chronic tonsillitis?

In general, the difference lies in the time of evolution of the disease. Arbitrarily determined that if the process is acute, the infection has more than 3 weeks and less than 3 months and chronic, if the infection lasts for more than 3 months.

Acute tonsillitis, is perhaps the most common disease of tonsils and occurs as a sore throat, dysphagia (painful swallowing), fever (not in all cases) and cervical lymphadenopathy (swollen glands in the neck).

XnSome symptoms of chronic tonsillitis are peritonsillar erythema, tonsillar growth and a decreased number of crypts in the tonsils as a result of chronic inflammation, which is evident with a shiny and smooth surface of the tonsils


What is the difference between acute adenoidits and chronic adenoidits?

Acute Adenoiditis is clinically difficult to distinguish from any other infectious disease of the upper airway. You can usually differentiate it if snoring occurs during the infectious episode and disappears once it is cured.

In chronic adenoiditis, nasal discharge is present and presents with a persistent cough, halitosis (bad breath), postnasal discharge, nasal voice and chronic nasal congestion. It may occasionally be associated with otitis media and it is important to differentiate this from a sinus infection.

There is an entity known as recurrent acute adenoiditis, which is defined as the presence of 4 or more episodes of acute adenoiditis in a period of 6 months. If the child with adenoiditis remains asymptomatic between infections, a prophylactic treatment can be considered, especially when these episodes are associated with recurrent otitis media with effusion or no effusion or tracheobronchial hyperreactivity.

When a child presents adenoiditis or recurrent sinus infections, the possibility should be considered that the child is having gastroesophageal reflux disease (GERD).

What are the indications for adenoidectomy?

Adenoid growth that obstructs the nose and forces the patient to breathe steadily through their mouth, sleep disturbances such as sleep apnea, failure to thrive, abnormalities in the way of speaking, or present any severe orofacial/dental abnormalities, that the patient presents with adenoiditis, recurrent otitis media with or without effusion, chronic otitis media or if suspected benign or malignant neoplasm.

Acute tonsillitis

What are the indications for tonsillectomy?

Excessive growth of the tonsils to generate airway obstruction, sleep disorders like sleep apnea, impaired speech, orofacial abnormalities, recurrent or chronic tonsillitis, peritonsillar abscess tonsillitis, acute obstruction of the airway, halitosis and suspected benign or malignant neophasm.

Most frequent causes of acute tknsillitis and adenoiditis?

Infection may be caused by both bacterial and viral agents. Most common Bacteria are group A Streptococcus, Staphylococcus aureus, Haemophilus influenza, Klebsiella pneumonia, and the most frequent viruses are Epstein Barr, herpes simplex, adenovirus and influenza virus.

What is the treatment for chronic tonsillitis and adenoiditis?

Typically, initial treatment for these diseases is antibiotics. Failing this, the next course of action must be an adenoidectomy, tonsillectomy or both at one time depending on the case.

Adenoidectomy is justified in cases where there is persistent nasal obstruction and repeated infections. Benefits include the improvement of nasal ventilation and lower incidences of recurrent infections such as otitis media, sinusitis, and improvement and or even disappearance of snoring and sleep apnea.

Tonsillectomy is performed in the follkwing cases; in cases where there is unilateral tonsillar growth, when there has been a peritonsillar abscess, when there is severe obstruction of the airway in the oropharynx and when there are 7 infectious episodes per year or 3 episodes per year over the course of 3 years or 5 episodes per year in the course of 2 years, accompanied in most cases by a fever equal to or greater than 38 º C and purulent exudate on the tonsils.

Adenoidectomy and tonsillectomy (adenotonsillectomy) are carried out together in the majority of patients, since the tissue is very similar in both structures, and when adenoids gets affected the tonsils get affected too and vice versa. The decision for removing one or both is up to the ENT doctor.

Inverting papilloma

Inverting papilloma is also known as the shneiderian papilloma, in memory of Victor Conrod Shneider who described its histology.

The schneiderian mucosa lines the nasal cavity and the paranasal sinuses and it is embryologically unique in the sense that it is derived from the ectoderm. Also the tumors from this epithelium are very peculiar in their history, evolution and localization. They are associated to the human papiloma Virus (HPV).

The inverting papillomas are found to be growing inwardly and hence the term "Inverted" papilloma. Males are affected 3 times more often than females and the tumor appears between the second and the seventh decades of life.

Anatomically, papillomas can be classified depending on the site of its occurrence. They can either grow from the lateral nasal wall, or paranasal sinuses, or the nasal septum. Usually it presents as a single unilateral mass that can be mistaken with a nasal polyp.

This distinction has prognostic significance because malignant growth occurs in as many as 15% of cases of papilloma arising from the lateral nasal wall.

Most common symptoms

Usually, the patient manifests unilateral nasal obstruction with or without sinus infection, rhinorrhea and epistaxis (nose bleeds). Occasionally they suffer from headaches, facial pain, anosmia (loss of the sense of smell), and sometimes even nasal deformity or proptosis (eye bulging) if the lamina papyracea is breached.

Here is an interesting fact; 1 out of every 50 patients with nasal polyps presents an inverting papilloma.

Diagnosis

Normally, symptoms give you the most important clue about the disease and most (but not all) inverting papillomas can be found during a physical examination of the nasal cavity usually with an instrument called an nasofibroscope. Later on a CT scan of the nose and the paransal sinuses will provide important elements such as the extent of how the tumor has spread, localization and the degree of bone destruction. In some cases Magnetic Resonance Imaging (MRI) may be needed. Nevertheless a biopsy is necessary to make a definitive diagnosis.

Which is the best treatment?

Surgery is the primary treatment for inverted papillomas, especially the endoscopic endonasal approach (EEA) since this technique allows the surgeon to see and access the tumor, without making incisions on the face, giving the benefit to the patients of no incisions to heal (meaning, no scars) and a shorter recovery time.

Recurrence

Despite a successful surgery there is a recurrence rate of 40% to 80%, and multiple procedures may be needed to control the disease.

Peripheral Facial Palsy (Bell's palsy)

What is Bell’s palsy?

Bell's palsy is a dysfunction that causes edema or inflammation of the facial nerve (VII peripheral cranial nerve, responsible for controlling the movement of the muscles of the face), commonly caused by a viral infection.

Bell's palsy was described for the first time by Sir Charles Bell, a Scottish surgeon, who was dedicated to the study the anatomy and physiology of the nervous system using electricity, and established the difference between the motor and sensitive nerves.

What are the symptoms of Bell’s Palsy?

 

Symptoms may appear with rapid onset (usually within hours) of weakness or palsy on one side of the face, facial droop (usually the eye and the side of the mouth), pain around the jaw or behind the ear of the affected side, Tinnitus (a buzz in the ear), dizziness, increased sansitivity to sound on the affected side, headache, decrease in the ability to taste, difficulty drinking or eating, and decrease of the usual production of saliva and tears forming in the eye on the affected side.

It is extremely important that you seek immediate medical attention because these symptoms can also be seen in a stroke, although Bell's palsy should not be mistaken for a stroke. Also, it is necessary to assess the cause of the paralysis and the severity of illness.

As mentioned before, the most common cause for Bell's palsy seems to be a viral infection, normally related to Herpes simplex (which also causes cold sores), Herpes zoster (causes chickenpox) and Epstein Barr virus (causes mononucleosis).

Risk Factors

The most important risk factors in developing Bell's palsy include a recent upper airway infection, diabetes, chronic ear infection, high blood pressure, Lyme disease, tumors and some say pregnancy (especially during the first trimester).

How to determine the proper diagnosis?

The diagnosis will be based on the symptoms and by looking at the face trying to asses which muscles are affected. If your diagnosis is still in question, your doctor may need to run some other tests, including an Electromyography (EMG) which can confirm the presence of nerve damage and determine its severity. A magnetic resonance imaging (MRI) scan or computerized tomography (CT) scan may be needed on occasion to eliminate other possible sources of pressure on the facial nerve, such as an infection, tumor or skull fracture.

Treatment for Bell’s palsy

The treatment of choice involves 2 drugs, corticosteroids and antiviral medication. Although there are certain controversies regarding the effectiveness of the combination, some clinical studies show that corticosteroids are most effective in the treatment of Bell's palsy due to their anti-inflammatory power, especially when administered during the first 72 hours of the onset of the disease.

The antiviral medication can be administered when a variant of the facial paralysis appears, Ramsay-hunt syndrome, associated to Herpes zoster which can affect the external ear canal and/or the tympanic membrane (ear drum). It may present with hypoacusia (diminished hearing), tinnitus and vertigo.

Also, this medication may be combined with physical therapy to help speed the recovery of the patient.

Surgery is almost never recommended to relieve the pressure of the facial nerve as this is controversial and almost is never undertaken.

It´s very important to understand that, after the apparition of the paralysis of the facial muscles, the sooner you present yourself to your doctor to get a treatment, the better chances you have of recovering up to 90% or greater of the movement of your face. After the first 72 hours, the possibilities of a total recovery diminish. So, go to your doctor as soon as possible!  

OTITIS MEDIA (ENGLISH)

Otitis media is one of the most frequent causes for a consultation with an Otolaryngologist. This disease is more common in young children due to the more horizontal position of the Eustachian tube (tube that connects the middle ear to the nose), compared to in an adult.

The function of the Eustachian tube is to drain the fluid produced in the middle ear to the nasopharynx. If for any reason, it is blocked, the liquid will tend to accumulate and may cause an infection.

What causes Otitis Media?

There are several reasons why the Eustachian tube can clog, such as allergies, infections of the upper airway, including sinus infections (sinusitis), excess mucus and saliva produced during teething, adenoiditis (growth of the adenoids), exposure to tobacco smoke and other irritants, gastro-esophageal reflux disease and even feeding in a bad position (lying face up) while feeding from a bottle.

There are certain risk factors increasing the likelihood of a child suffering from acute otitis media such as attending day care, changes in altitude, cold climate, exposure to smoke, not being breastfed, and frequent upper airway infections.

What are the most common symptoms of Otipis Media?

In a young child, the most common manifestations are inconsolable crying, fever (greater than or equal to 38 ° C) or have trouble with sleeping. In older children or adults otalgia (ear pain) may occur, sensation of a clogged ear, malaise, hypoacusia (diminished hearing) of the affected ear.

We can also find a variant to otitis media which is otitis media with effusion, which is the sudden discharge of a yellowish or greenish liquid, thick, sometimes with blood, accompanied by an improvement in ear pain that can signify the rupture of the tympanic membrane.

How to diagnose a patient with otitis media?

The diagnosis is made when the doctor examines the ear with an otoscope or an ear endoscope. What is seen in these cases is known as "doming" of the tympanic membrane which includes fluid or bubbles behind the tympanic membrane, blood or puss and in some cases, a tympanic membrane perforation may be seen.

Otoscope

What is the best treatment for otitis media?

In Otitis Media, one of the most important things in treatment is to relieve the pain. Depending on the origin of Otitis Media, antibiotics and pain killers (paracetamol, ibuprofen, etc) may be given and antihistamines and analgesics either orally or topically.

In general, all children under 6 months, with fever or symptoms as described above (and especially if there is no improvement thereof), should be seen by their physician to determine the best treatment for them.

The trend now is to try to determine if the cause of an ear infection is due to a virus or a bacterial infection since antibiotics have no effect on virus infections. For this reason, you should not prescribe antibiotics for EVERY ear infection.

However, all children under 6 months which present with an ear infection, should be given antibiotics.

If a treatment does not seem to be taking effect within the first 48 to 72 hours of starting the medication, consult your doctor again as he/she may have to change treatment or add other medications.

When to consider surgical treatment?

If an infection does not go away with the usual medical treatment, or if a child presents with repeated infections over a short period of time, thoughts should be considered for inserting ventilation tubes.

This procedure consists of introducing into the tympanic membrane, a very minute tube, which allows entry of air into the middle ear so the liquid which accumulates in it can drain through the eustachian tube easily.

These ventilation tubes usually fall out by themselves. If this does not happen within 6 months after placement, they should be removed by the physician.

If the cause of otitis media is adenoid hyperplasia (growth of the adenoids) then, an adenoidectomy (surgical removal of the adenoids) should be considered.

Usually ear infections are a minor medical problem, which improves without any complications, however, it should be noted that during infection, that children may have a minor and temporary hearing loss. This is due to the presence of fluid in the middle ear.

What are some of the complications of otitis media if not treated properly?

Sometimes, an otitis media, can worsen and may evolve into serious infections such as mastoiditis (infection of bone found behind the ear) or meningitis (infection of the coverings of the brain).

Other complications include a perforated tympanic membrane, chronic and recurrent ear infections, adenoid hyperplasia and of the tonsils, otitis media with effusion, formation of a cholesteatoma (secondary to a chronic infection), delayed language development (as they do not understand the words properly when there is fluid in their ears).

As always, the most important thing is prevention. If you think your child may be having this disease, look for a consultation with your doctor.