TRACHOMA

Trachoma is a form of chronic keratoconjunctivitis that is one of the leading causes of infectious blindness worldwide though its prevalence is restricted to the Middle East. It is caused by Chlamydia trachomatis (Serogroup A,B, C)  which is an obligate intracellular parasite. It commonly occurs in children and women in areas with poor sanitary conditions making the spread through direct contact and fomites very easy.

PATHOPHYSIOLOGY:

Chlamydial infections characteristically occur in the upper part of the eyelid and the eyeball. It causes a typical follicular conjunctivitis as seen in other viral infections but the difference is that it has a higher chance of producing scarring because of reinfection.

Trachomatous follicles

Pannus formation

           The process behind the drastic sequel of blindness is the scarring or cicatrisation that occurs in the palpebral conjunctiva that eventually leads to contracture and buckling of the eyelids causing an entropion or rolling in of the eyelid in the margins along with trichiasis, the introversion of eyelashes. All these changes in the usually smooth conjunctiva is going to damage the conjunctiva in the form of abrasion, ulcers and eventually corneal opacities that is going to cause a permanent blindness.

Entropion

CHARACTERISTIC FINDINGS:

•      Trachomatous follicle: Greater than 0.5mm in size and distributed in the upper tarsal plate                      quite unlike the other follicles in viral conjunctivitis
•      Cictrazation of the follicles seen as stellate scars on the tarsal plate
•      Arlt line: A linear scar present in the jumction of upper one third and lower two thirds of the tarsal plate
•      Trachomatous pannus which is an area of vascularization and lymphatic infiltration into the cornea, seen as an area of cloudiness in the upper part of the cornea. It may occur in the form of a progressive or regressive pannus based on the extent of blood vessels
•      Heber pits: Follicles near the limbus.
•      Corneal ulcers or opacities in the later stages

STAGES:

WHO classifies trachoma into the following 4 stages abbreviated as ‘FISTO’

F (follicles) : 5 or more trachomatotous follicles in the upper tarsal plate

I (Intense): Intense inflammation with follicles and papillae such that more than 50% of the tasal   blood vessels are not visible

S (Scarring): Cicatrisation with formation of white fibrous bands seen

T (Trichiasis)

O (Opacity)

SIGNS AND SYMPTOMS:

•      Redness
•      Watery discharge
•      Irritation
•      Photophobia
•      Foreign body sensation
•      Trachomatous ptosis
•      Entropion
•      Trichiasis
•      Pannus formation
•      Visual impairment

TREATMENT:

Tetracycline or Azithromycin ointment should be administered before the onset of scarring. Prophylactic use of these drugs valuable in endemic areas.

BRANCHIAL CYST

                                                              BRANCHIAL CYST

Like any other cyst this is just a fluid filled cavity that arises from the embryological remnants of the pharyngeal clefts, most commonly the second pharyngeal cleft. Obliterated pharyngeal clefts are what makes us one step less close to the Pisces family, as the gills of fish are basically persistent pharyngeal clefts. So when one of our 4 pharyngeal clefts fail to close at the prescribed intrauterine age of 7weeks, voila –you are one step closer to becoming a fish!

HISTORY:

So these pharyngeal arches develop during the 4^th week of embryonic life and develop into various structures in the head and neck. The pharyngeal clefts which are the depressions between each pouch are normally supposed to obliterate, except the first one which develops into the external auditory canal. When the cleft persists, the person develops an epithelium bound cavity that is pretty much harmless and asymptomatic unless a sinus tract develops.

CLINICAL ASPECTS:

A branchial cyst presents mostly as an asymptomatic, unilateral neck swelling in the early adulthood. It may present also as a tender mass when it is associated with an upper respiratory tract infection and so must be distinguished from lymphadenitis. Like any other neck swelling it may produce a mass effect causing symptoms of dysphagia, dysphonia. But the common complaint that mandates a consultation is usually a draining sinus in the skin. Imagine your neck behaving like a leaky faucet, you’ll definitely visit the doctor for that one. The complications of leaving it untreated are increased risk for infections and scarring and a very slight chance of developing a malignancy. But then again surgical treatment also poses serious risk of damage to the vital neck structures.

DIAGNOSIS:

On examination we could find a cystic, fluctuant and transilluminant mass along the lower one third of the anterior border of the sternocleidomastoid that may be associated with a mucoid or purulent discharge if a sinus is present.

Common investigations include Ultrasound scans or Contrast CTs or a Sinogram if a sinus tract is present. For histological examination, samples may be collected by FNAC or biopsy and the lining the epithelium could be found as stratified squamous or ciliated columnar and occasionally keratin debris might also be found.

TREATMENT:

Initially antibiotics are administered to control the infection followed by surgical excision. Stepladder incisions are made to completely excise the sometimes tortuous path of the cyst. Off late, for cosmetic reasons, retroauricular and endoscopic approaches are preferred. Latest non-surgical advancement is the use of a sclerosing drug called PICBANIL to cause fibrosis of the cyst.

                                                          A CAN OF WORMS

                                Oral myiasis                                      

Those little nubbins gathered around her tooth are a happy family of freshly hatched maggots. Quite a large family I should add for there was one hundred of them all having a grand gingival feast. Must have literally been a can of worms situation for the dentist on opening the mouth and de-rooting a kidney-tray worth load of worms. This thankfully rare condition is named Myiasis. A condition that arises from extremely poor oral hygiene as in our case or even from minor dental caries (sweet-tooth alert!). Anything rotten in your mouth – Huzza, you’ve just sent out scented invitations to the Fly family…Our common guests being the Musca and the Chrysomia family. This is rare treat for them- a much wanted deviation from their usual meals like measly sheep, cow and goats.  Once their eggs begin hatching there’s no stopping their hungry little hatchlings. They eat and burrow and keep eating till you should be happy you have your maxillofacial bones left. And then again we shouldn’t forget our bacteria, always right on time add zing to any chaos anywhere, anytime. With these readily accessible pathways already paved by our larvae it’s will only be a cakewalk for the bacteria to gain access to the bloodstream and cause fatal sepsis. Unless of course proper intervention is made in the right time with enough disinfectants like turpentine oil and antibiotics like Ivermectin to ward off the infestation and to ensure proper oral hygiene to prevent recurrence. If you think the ick-factor is over –you are wrong. Our patient is a mentally challenged cripple thrown out of her family for ‘maintenance issues’. If that is not the greater ick-factor, then what is?

                                      DENTAL BRACES FOR THE 1ST TIMER!

                                                    Its All in the moves!!

Anyone whose worn braces might know the embarrassment of dental embracement. But the perks of orthodontic correction both cosmetic and medical, quite overshadows even the dire nine months involved. Common malocclusions or misalignment of the teeth include over bite, under bite, crowding etc. If not for aesthetic reasons these problems must be addressed early to avoid risks of poor oral hygiene in the future.

THE PROCESS:

   Willy wonka in his braces with the headgear

The recent advancements in this field have made quite a dramatic improvement in improving the visual appeal. If you’ve seen little Willy Wonka you’ll know. Now the technology has so radically improved to the point of invisible ceramic braces next to the regular steel braces. The basic architecture of any brace includes:

        So during you first visit to the dentist, an impression of your teeth is made following which all the these paraphernalia are made in a customized manner to suit your dentition. Initially the brackets are fixed to each of your teeth via adhesives and laser and the arch wire is passed through the brackets and tightened to position by means of alastics. Now the arch wire is going to provide the necessary strain on teeth because it has a property to maintain its shape thereby eventually pulling the teeth along to proper alignment.

MECHANISM INVOLVED:

Now as simple as that sound one might wonder why this requires such a lengthy time span. For that well have delve deeper into the molecular mechanics of the process. So fundamentally what happens during orthodontic correction is just a highly regulated injury and repair process. The keystone to this process being an intervening biologically active tissue, the periodontal ligament playing that role here.

 So initially when traction is applied to the tooth, we are actually injuring the periodontal ligament. This triggers release of inflammatory cytokines like IL-1, IL-6, TNF-α which cause necrosis of the surrounding soft tissue followed by the recruitment of osteoclasts that initiate alveolar bone resorption in the direction of the force. This is marked by the loosening of the tooth and its movement in the desired direction. The next step is reparative phase carried out by the osteoblasts and fibroblasts which deposit new bone and connective tissue required for the anchorage of the tooth in the new position. So finally the teeth are aligned to according to the bend of the arch wire. Constant impetus is provided by repeated visits to the dentist to keep the wire tightly wound. So putting your teeth in a tight spot is will eventually give you a beautiful curve on your face to put all matters straight.

That’s for today !