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Laser Tonsil Cryptolysis: Perspectives in Airborne Personnel

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Laser Tonsil Cryptolysis: Perspectives in Airborne Personnel Pol J Aviat Med Psychol 2013; 19(2): 25-30 REVIEW ARTICLE LASER TONSIL CRYPTOLYSIS: PERSPECTIVES IN AIRBORNE PERSONNEL Rafał CHMIELEWSKI Military Ins tute of Avia on Medicine, Department of Otolaryngology, Warsaw, Poland Source of support: Own sources Author’s address: R. Chmielewski, Military Institute of Aviation Medicine, Department of Otolaryngology, Krasińskiego 54/56 Street, 01-755 Warsaw, Poland, e- mail: [email protected] Background: Laser tonsil cryptolysis is a relatively new, minimally-invasive method of chronic caseous tonsillitis and oral malodor treatment. Recently, several reports were published presen- ting this technique and its clinical outcomes. This review article presents the techniques and the clinical results of the treatments reported in published articles available in the PubMed database. Keywords: laser cryptolysis, chronic caseous tonsillitis, tonsil stones, tonsilloliths, bad breath, halitosis INTRODUCTION Odors are one of the most important signals we quality. The goal of this article is to present the collect from our environment, as it may provide results of the treatment of oral malodor reports warning of dangers, information on surround- due to chronic palatine tonsillitis by means of laser ing objects, revoke memories of the past as well cryptolysis as well as the applicability of this meth- as encourage or discourage us from interacting od in the treatment of airborne fl ight personnel. with other people. Aircraft pilots and, even more Tonsils are covered with multilayer epithelium than that, fl ight attendants, are occupations that forming tonsillar crypts within the parenchyma. involve direct contact with clients. It is quite easy Each palatine tonsil has 10 to 20 crypts. These to imagine the negative impact of oral malodor in spaces become anaerobic chambers that promote the deck crew on the relationships with the pas- the growth of the biofi lm of particular bacterial sengers and thus on the overall opinion of fl ight strains. As the biofi lm grows and matures, it dilates Figures: 3 • Tables: 1 • References: 10 • Full-text PDF: h p://www.pjamp.com • Copyright © 2013 Polish Avia on Medicine Society, ul. Krasińskiego 54/56, 01-755 Warsaw, license WIML • IndexaƟ on: Index Copernicus, Polish Ministry of Science and Higher Educa on © The Polish Journal of Aviation Medicine and Psychology 2013 | Volume19 | Issue 2 | 25 This is an open-access ar cle distributed under the terms of the Crea ve Commons A ribu on Non-commercial License (h p://crea vecommons.org/licenses/by-nc/3.0), which permits use, distribu on, and reproduc on in any medium, provided the original work is properly cited, the use is non-commercial and is otherwise in compliance with the license. Review Article the crypt, leading to formation of tonsil stone and this assessment is to establish whether the smell infl ammation in its vicinity. is consistent with the usual smell of patient’s Tonsil stones have several equivalent names in mouth. The intensity of halitosis is expressed in both English and Polish nomenclature. In English, a three-point scale: severe (when oral malodor they may be called tonsilloliths or cryptic tonsils. can be smelled during conversation with the pa- A common Polish name is “detryt”. One of fi rst tient), moderate (when strong, unpleasant odor modern articles providing an attempt to analyze is smelled on the glove at a distance of 10 cm or tonsil stones defi ned them as purulent content while smelling the air exhaled by the patient) or with dead bacteria and infl ammatory cells within mild, when no odor is smelled at patient’s mouth the tonsillar crypts following an infection [10]. and the odor of the glove is detected only upon The largest tonsil stone described in the literature placing it immediately close to the nostrils. weighed 44 grams [9]. A new look on the structure Recently, a specifi c Halitosis Associated Life- and physiology of tonsil stones was provided by quality Test questionnaire (HALT) has been devel- Stoodley who, having meticulously studied their oped and validated in psychological and clinical contents, compared them to biofi lm deposits on terms by Kizhner et al. [4]. The test has been de- the teeth. The biofi lm develops in tissue hollows veloped from scratch based on patient interviews and fi ssures and consists of the matrix and bacteria and the review of the literature. The questionnaire in slow-metabolism forms, capable of leaving hi- contains 20 halitosis-specifi c questions (Tab. 1.). bernation in favorable external conditions. These The authors compared the results of subjective consist mostly of anaerobic Gram-negative bacte- organoleptic assessments with HALT results ob- rial strains. tained upon subsequent visits and then following Tonsillar complaints and symptoms reported 3 months of conservative treatment laser cryp- in the literature include a feeling of a presence of tolysis depending on the study group. The results a foreign body, metallic taste in mouth, pharyn- of the HALT test were assessed to be signifi cantly geal constriction or compression, cough, chok- correlated with the results of the organoleptic ing, and – most of all – bad breath, also known as test and that HALT allowed for correct assessment oral malodor or halitosis. By itself, oral malodor of the treatment outcomes in both groups, thus may be caused by numerous causes. Oral causes constituting a reliable tool for the assessment of are estimated to account for about 90% of cases. the quality of life in patients complaining of bad In 8%, the etiology of the disorder is in the nose breath. and throat or associated with the respiratory sys- Tab. 1. HALT questionnaire – adapted from (Kizhner tem, while the remaining 2% include other causes, et al., 2011). such as gastrointestinal disorders, renal or hepatic Q1. Mainly mouth breathing insuffi ciency of metabolic disorders, including dental caries, gingivitis, disorders within paranasal Q2. Frequent tonsillar infections sinuses, lung or esophagus (mainly the Zenker’s Q3. Frequent sinus infections diverticulum) [7]. Q4. Worrying about or self-conscious about your mouth breath In recent years, the range of diagnostic meth- Q5. Miserable or tense due to halitosis ods was widened by an objective method to assess Q6. Diffi culty chewing or limiting certain food due to halitosis oral malodor: halitometry. The method consists in Q7. Change of taste the measurement of volatile sulfur compounds Q8. Problems speaking (or mouth covering) due to halitosis (VSC) in the exhaled air. According to the manu- Q9. Appearance aff ected due to halitosis facturer of the device, VSC values that exceed the Q10. Depressed due to mouth breath limit of normal are those of > 150 ppb. Hitherto, Q11. Problems concentrating due to halitosis researchers used only subjective assessments of Q12. Embarrassed due to halitosis patient’s oral odor, which negatively aff ected the Q13. Spending time related to halitosis? scientifi c value of the assessment. A subjective as- Q14. Talking from afar due to halitosis sessment technique, known as Finkelstein’s tonsil Q15. Avoid going out due to halitosis smelling test, was described by Finkelstein and Q16. Communication problems due to halitosis widely adopted by the researchers [3]. The meth- Q17. Mentioned about halitosis od consists in the assessment of the odor of secre- Q18. Suff er fi nancial loss due to halitosis tion from the palatine tonsil. The tester presses the Q19. Suff er social/personal loss due to halitosis tonsil with a gloved fi nger for further organoleptic Q20. Reduced life satisfaction due to halitosis assessment by the tester themselves, the patient, and individuals close to the patient. The goal of 26 | 2013 | Volume19 | Issue 2 | www.wiml.waw.pl R. Chmielewski - Laser tonsil... OPERATIVE TECHNIQUE The premise of laser cryptolysis is minimally- Local anesthesia is usually suffi cient to elimi- invasive treatment of cryptic tonsils and halitosis nate the gag refl ex, either infi ltrative or topical. while preserving its immune function. Another im- A CO2 laser beam (some authors have also used portant factor is that the procedure is performed diode lasers in cases with single crypt retention) in an outpatient setting under local anesthesia. is applied onto the surface of the tissue surround- This shortens the duration of the procedure and ing the tonsillar crypt in combination with a 2 mm signifi cantly reduces associated costs. Yet another rotation scanner to vaporize the sequential layers. benefi t is that the treatment can be repeated if Shrinking tissue in the crypt mouth region causes complete improvement has not been achieved. an outward movement of the crypt edges, leading to marsupialization, i.e. wide opening of the crypt. Fig. 1. A schematic illustration of a tonsillar stone in a dilated palatine tonsillar crypt. Author’s diagram based on Y. P. Krespi & Kizhner, 2013. Fig. 2. A schematic illustration of laser (L) vaporization of the palatine tonsil crypt mouth region. Combination of the laser beam with the scanner facilitates superfi cial vaporization of following epithelial layers until complete opening of the crypt. The immediately adjacent tonsil tissue shrinks (arrows pointing sideways), additionally opening the mouth of the crypt. Author’s diagram based on Y. P. Krespi & Kizhner, 2013. © The Polish Journal of Aviation Medicine and Psychology 2013 | Volume19 | Issue 2 | 27 Review Article Fig. 3. Removal of a tonsil stone from a widely open crypt following laser cryptolysis. Author’s diagram based on Y. P. Krespi & Kizhner, 2013. As the laser beam reaches the bottom of the crypt, to the cryptolysis procedure were qualifi ed for the it facilitates its full emptying and shallowing. Co- study. The assessment of oral malodor was subjec- agulation of the crypt bottom is necessary to make tive and performed according to the Finkelstein’s the procedure eff ective and to prevent formation tonsil smelling test as developed by the author.
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