Medical (ENT) Case of the day

  The picture below shows enlarged and lumpy lingual tonsils. Lingual means tongue. These tonsils sit on the back of the tongue, above the epiglottis (the pale U shaped structure above the lingual tonsils) and cannot be seen when examining a patient through the mouth. This photo was taken using a high definition digital endoscope at HealthHub. Lingual tonsils often enlarge after removal of the palatine tonsils, which we call tonsillectomy. They may get sore/ infected, like tonsillitis. Your GP will not be able to see them so will not believe your symptoms and wonder if you are making it up.

 This is the right side tonsil bed after laser tonsillectomy under local anaesthetic spray. The majority of the tonsil has been vapourised away. The thin ring of white is the extent of thermal damage caused as heat is transmitted through tissue being vapourised. Usually around half a millimetre. No bleeding has occurred. Bleeding of any sort is very rare.

 I spotted this today whilst looking for a cause of mild right sided submandibular pain. It's probably unrelated. When I questioned the 31 year old patient he felt he was increasingly short of breath over the laser year but put that down to inactivity during Covid19, and being a bit of a smoker. In fact the picture clearly shows a subglottic narrowing, perhaps 50% of the breathing tube. He may need surgery.  

 Relatively new laser wavelengths and new technology mean that lasers such as the CO2 and Erbium YAG can be used during nose reshaping (rhinoplasty) surgery when operating on the cartilage at the tip of the nose. These lasers will remove/sculpt, in a way that is more accurate and less traumatic than traditional techniques. A simple experiment on cartilage showed that 5 Watts of superpulse CO2 laser power with a 0.015mm spot size gave a clean predictable cut. When used with a Computerised pattern generator  and a 2mm spot diameter with a 1 msec dwell time, this gives very nice sculpting and cartilage removal effect. This picture shows one of the initial studies. 

 We have performed many laser tonsillectomies using local anaesthetic spray for numbness. Today, number 748 bled a little. I found an area where #tonsilstones were forming in the top of the tonsil. I went too deep in my eagerness to completely remove the involved tissue, and probably hit a small branch of the superior tonsil artery. After bipolar diathermy, Lignospan injection and topical adrenaline the patient stopped bleeding and subsequently went home. It just shows you have to be prepared and test your emergency kit regularly, ready for that 1:750 case. 

 It seems that people are more prepared to put up with recurrent tonsillitis than tonsil stones. It's the perception that they may have bad breath that makes it a socially isolating condition. Laser tonsillectomy under local anaesthetic spray is a very good way of eradicating this problem. The picture shows a tonsil stone sitting on the surface of the tonsil, with a large crack above it, where food enters but can't get back out. This is the cause of tonsil stones. 

Here's my test 4 months after contracting Covid19 moderately badly. As you can see the line at IgM has now disappeared as expected, but the line at IgG, which is the memory antibody, remains strong. Certainly I'm going to deduce from that I'm immune, also to the Kent variant (which I probably had) and the South African one. But how do I get a passport saying this?