The Varied Presentations of Sinonasal Region Schwannomas: Apropos of Four Cases

Schwannomas of the sinonasal compartment are rare benign neoplasms of peripheral nerve sheath origin and constitute ~ 4% of all head and neck schwannomas. The presentation may simulate a range of benign and intermediate grade pathologies. Management involves surgical excision via open or endoscopic approach. To describe the clinico-epidemiological characteristics and surgical outcomes in sinonasal region schwannoma patients operated at our institute. The study is a descriptive case series of patients with sinonasal region schwannomas treated at our institution. A retrospective search of electronic database of the Department of ENT and Head and Neck Surgeries and Department of Pathology was conducted from January 2013 to January 2019. The various demographic and clinical details of the patients were extracted. A total of four patients operated for sinonasal region schwannoma were identified. The involved sites were nasal dorsum, nasal cavity, pterygopalatine fossa and infratemporal fossa. The mild, non-specific symptoms resulted in patients ignoring their symptoms for a while initially and presenting late. The nasal dorsum lesion was revealed as a surprise during open rhinoplasty for correction of nasal deformity. Complete excision was achieved in all the cases and no recurrence has been noticed during the follow up (varying from 6 months to 6 years) till date. The diverse clinical manifestations and approaches to the treatment of schwannomas in this specific region are discussed. The surgical excision is the standard of care in dealing with these neoplasms. This series highlights the rarity of this pathology in the sinonasal area, diagnostic surprises and the decision making to choose the correct surgical approach for complete excision. Once excised completely, recurrence is not expected.

Unusual cause of recalcitrant epistaxis

Nosebleeds are among the most familiar presentations to the emergency department as well as otorhinolaryngologic outpatient services. Bleeding from nasal septal branches of the anterior ethmoid artery (AEA) is common and can be effectively controlled endoscopically. However, the bleeding from a pseudoaneurysm involving the nasal septal branches of AEA is extremely rare and can be troublesome to control using endoscopic methods. We report an adult patient presenting with profuse nasal bleeding postroad traffic accident due to the formation of AEA septal branch pseudoaneurysm. The patient required repeated nasal packing, and the diagnosis was revealed using digital subtraction angiography. Since profuse active bleeding precluded endoscopic visualisation, an external approach had to be adopted to ligate the AEA to control the bleeding. We discuss the management options and nuances for this rare cause of the troublesome nasal bleeding.

Unusual cause of dysphagia and dysphonia

Forestier's disease is an idiopathic noninflammatory condition associated with enthesopathy leading to hyperostosis of the vertebrae and peripheral skeletal system. The disease tends to affect elderly individuals and remains asymptomatic in most of the cases. Uncommonly, the patient may present with upper aerodigestive symptomatology, usually dysphagia. In elderly individuals, the disease may closely mimic upper aerodigestive tract malignancy, which should be actively excluded. In our patient, the hypopharyngeal soft tissue distortions created by the bony hypertrophy shifted the clinicoradiological suspicion towards malignant pathology. The current case presents the diagnostic dilemma associated with the disease and the need to keep the possibility of severe cervical bony hypertrophy as a cause of upper aerodigestive symptoms in mind.

A Wolf in Sheep's Clothing: Keratosis Obturans Causing Facial Nerve Palsy - A Case Report with Review of the Literature

Keratosis obturans is a benign disease caused by layered impaction of wax within the external auditory canal. It presents with acute onset of pain and ear blockade. The current report discusses a 24-year-old male patient with recurrent unilateral keratosis obturans associated with facial canal erosion and resulting in facial palsy. A detailed review of the literature is presented. Keratosis obturans can behave aggressively, resulting in significant erosion of the bone and intratemporal structural damage and complications. Timely intervention is vital.

A randomized study to compare palonosetron with ondansetron for prevention of postoperative nausea and vomiting following middle ear surgeries

Background and Aims:

Postoperative nausea and vomiting (PONV) has multifactorial etiology. It is a commonly encountered morbidity after anesthesia specially following middle ear surgery. Various antiemetic medications have been tried with mixed responses. Palonosetron is a newer 5-hydroxytryptamine (5-HT₃) receptor antagonist marketed for PONV prophylaxis. This study was designed to compare the efficacy of palonosetron and ondansetron in preventing PONV after middle ear surgeries.

Material and Methods:

One hundred patients of ASA class 1 or 2, aged 18 years and above, weighing between 40 and 90 kg scheduled for elective middle ear surgeries were randomly assigned into palonosetron group (n = 50) and ondansetron group (n = 50). Palonosetron was administered in dose of 1 mcg/kg maximum up to 75 mcg and ondansetron in dose of 0.1 mg/kg maximum up to 8 mg. Intraoperative monitoring of QTc interval was also done to see any significant change after the antiemetic administration. The incidence of nausea, vomiting, and side effects were recorded over 2, 12, and 24 hours postoperatively. All parameters were compared between the two groups as mean ± standard deviation and as count (%). Two sided P values of <0.05 were considered significant.

Results:

The incidence of PONV (P = 0.002), nausea (P = 0.0002) and vomiting (P = 0.006) was significantly lower in palonosetron group than in ondansetron group in 2- to 12-hour period. QTc interval prolongation, a known side effect of ondansetron was not found in palonosetron group intraoperatively.

Conclusion:

Palonosetron was found to be superior to ondansetron up to 12 hours after the surgery with no significant effect on QTc interval.

Idiopathic Isolated Nasal Amyloidosis: Report of a Rare Case with Review of Literature

Deposition of amyloid in localized form is rare and most often involves head and neck region. Localized amyloidosis carries good prognosis with surgical debridement offering symptomatic benefit. We present an adolescent male presenting with localized sinonasal amyloidosis managed previously with conservative surgical debridement. The patient was symptomatic from early childhood and the previous histopathological reports were non-specific inflammation. A repeat biopsy revealed features of amyloidosis and retrospective review of past slides revealed the same. On explaining the course of the disease and prognosis, the patient opted for regular follow up. A pertinent comprehensive literature review of the condition is discussed.

Submandibular Duct Re-routing for Drooling in Neurologically Impaired Children

Drooling is a challenging situation to manage especially in neurologically impaired pediatric population. Numerous surgical procedures have been described in literature but none of them is standardized. We evaluate the effectiveness of bilateral submandibular duct rerouting and sublingual gland excision in drooling paediatric patients. Prospective interventional study was conducted from November 2007 to September 2009 in twenty-eight pediatric patients with drooling who had failed conservative treatment modalities. Patients underwent bilateral submandibular duct transposition and sublingual gland excision. Patients were assessed pre-operatively, at 7, 30 and 90 days after surgery for drooling severity, frequency as per Thomas-Stonell and Greenberg classification and also number of bibs changed per day. Result was categorized using Wilkie and Brody criteria for assessing effectiveness of the surgery. Twenty-eight patients were successfully operated. All patients were followed-up for a duration of at least 3 months. The success rate achieved in term of control of drooling was 95.2 % at 3 months follow up. Statistically significant difference (p < 0.001) was noted in pre-operative and postoperative mean values for severity and frequency of drooling and also bibs/day. Transient, minor complications (n = 5/28, 17.8 %) were encountered following this surgical procedure. Bilateral submandibular duct rerouting and sublingual gland excision in drooling paediatric patients is a simple and effective surgery with minor operative morbidity. Concomitant sublingual gland excision bilaterally helps in reducing the incidence of ranula formation significantly.

Laryngopharyngeal reflux: Current opinion

The increasing importance of LPR is being recognized day by day in ENT practice. LPR has a significant negative impact in the quality of lives of the patients. Although its impact is similar in some respects to that of laryngopharyngeal disease, LPR has a more significant impact on patient's social functioning and vitality.([23]) All ear, nose and throat practitioners need to be sensitised to the presence of LPR and the need for starting treatment wherever required. Lot of hitherto symptoms of unknown aetiology are being increasingly of treating patients with atypical reflux symptoms such as hoarseness (unexplained cause), globus, throat clearing, cough, etc., with antireflux therapy.([24]).

Variable extent of emperipolesis in the evolution of Rosai Dorfman disease: Diagnostic and pathogenetic implications

This study examines variation of morphologic features, including emperipolesis, during the evolution of a case of Rosai Dorfman Disease (RDD). A 44-year-old male patient with RDD affecting the salivary glands, cervical lymph nodes, nasal and maxillary sinus mucosa had a waxing and waning course over two and a half years, with episodic sudden increase in size followed by involution and then a static course with moderate sized swellings. Multiple aspirations and biopsies were performed, which form the basis of this study. Four classical cases of RDD on aspirates and another four on biopsy were analyzed for comparison, with quantification of the number of lymphocytes engulfed by histiocytes (emperipolesis). Three nasal biopsies and one salivary gland excision of the index case, performed during acute exacerbation, showed chronic inflammation and foamy histiocytes without emperipolesis, the aspirate showing emperipolesis nil in 45%, 1-3 lymphocytes in 15%, 4-10 in 36% and > 10 in 4%. Two aspirations and one lymph node biopsy done from static phase showed classical features of RDD with extensive emperipolesis, the aspirate from left cervical lymph node showing emperipolesis nil in 2%, 1-3 in 5%, 4-10 in 35% and > 10 in 58% while right cervical lymph node aspirate showed emperipolesis nil in 9%, 1-3 in 21%, 4-10 in 29% and > 10 in 41%. A biopsy performed from involuting cervical lymph node showed extensive apoptosis and vasculitis without foamy histiocytes or emperipolesis. For comparison, eight classical RDD cases showed abundant emperipolesis with mild variation. Emperipolesis is variable in RDD depending on disease activity, which has differential diagnostic relevance and demonstrates the natural history of this rare disease.

Changes in ventilatory function following surgery for bilateral abductor paralysis

Management of bilateral vocal fold immobility continues to remain a challenge for the Otolaryngologist who attempts to create a balance between creation of an adequate airway and preservation of voice. The flow volume loop obtained by spirometry provides an ideal objective assessment tool to evaluate the results of surgery for this condition. Our experience in using peak inspiratory flow rate (PIFR) and forced inspiratory flow with 50% of vital capacity (FIF(50)) in the lung in assessing the results of surgery is described. Seventeen patients were included in the study. The surgical procedures performed included laser posterior cordectomy with partial arytenoidectomy, endoscopic arytenoidectomy and posterior cordectomy-Kashima's technique. Twelve out of 17 patients were successfully decannulated, a success rate of 70.6%. All patients except one showed an increase in mid-inspiratory flow rates and peak inspiratory flow rates. The mean increase in FIF(50) was 0.44 l/sec (52.6%) and the mean increase in PIFR was 0.41l/sec (39.77%). No statistically significant difference in improvement of inspiratory flow rates was observed between the three surgical procedures used in the study.

Large pedunculated fibrovascular polyp of oesophagus in a young woman

A 25-year-old female patient with a history of progressive dysphagia of one year duration was detected to have intraluminal polypoidal mass in the oesophagus on barium contrast study and computed tomography. Direct laryngoscopy and flexible endoscopy confirmed the origin from pharyngo-oesophageal junction. Lateral cervical oesophagotomy and excision of a polypoidal mass of 15x6.5x3 cm size was done. Histopathology revealed fibrovascular polyp (FVP) arising from submucosa of oesophagus. FVP is a benign tumour-like condition which can attain an enormous size inside the lumen of the oesophagus. It predisposes the patient to aspiration due to incomplete vocal cord adduction and asphyxia due to possible laryngeal inlet block and thus, threatening life. Complete surgical excision through lateral oesophagotomy is the standard treatment and provides cure in the majority of cases.

A technique for the orientation of endoscopically resected laryngeal lesions

Endoscopic resection is a widely accepted method of treating early laryngeal malignancies. Accurate histological assessment of resected laryngeal specimens can be difficult due to their small size and potential damage and distortion caused by standard orientation and processing techniques. A new technique is described which employs dehydrated cucumber to mount laryngeal specimens for orientation and processing. This technique is quick, easy, cheap and reliable, allowing accurate histological assessment of potentially malignant lesions. Better orientating and processing of laryngeal specimens can optimise treatment decisions based on histological results.

Unilateral pseudohypacusis in children

Pseudohypacusis is a condition where there is hearing loss without any organic etiology. Though this condition has been reported long before, the literature exists mainly in the form of case reports. An interesting aspect of pseudohypacusis is of patients presenting with unilateral pseudohypacusis. In children, there often exist underlying psychological factors related to the occurrence of this condition. This condition is usually suspected when there is discrepancy in audiometric testing. The authors hereby report a child of unilateral pseudohypacusis presenting with psychological stressors, along with an overview of the management of such conditions.

Prediction of obstructive sleep apnea in patients presenting to a tertiary care center

The objective of this prospective observational clinical study is to derive and validate a diagnostic model for prediction of obstructive sleep apnea (OSA) in subjects presenting with non-sleep-related complaints in a tertiary care center in north India. We included 102 subjects (group I, range 31-70 years) presenting to the hospital with non-sleep-related complaints. None of the subjects had any significant comorbid illness such as respiratory or congestive cardiac failure. All subjects underwent detailed evaluation including polysomnography (PSG). Various parameters were compared between the cases (apnea-hypopnea index, AHI > or =15/h) and controls (AHI <15/h). Using multivariate logistic regression analysis, a diagnostic model for prediction of OSA was derived. Subsequently, using similar selection criteria, 104 subjects (group II, range 32-68 years) were included for validation of the newly derived diagnostic model. Body mass index [BMI; OR (95% CI), 1.14(1.1-1.2)], male gender 5.0(1.4-27.1), relative-reported snoring index (SI) 2.8(1.7-5.0), and choking index (ChI) 8.1(1.4-46.5) were significant, independent predictors of OSA. Diagnostic model was computed as score = [1.61 x (gender)] + [1.01 x (S1)] + [2.09 x (ChI)] + [0.1 x (BMI)] where, gender: 0 = female, 1 = male and SI, ChI, BMI are actual values. The diagnostic model had an area under the receiver operator characteristics curve of 89.6%. A cutoff of 4.3 for the score was associated with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 91.3, 68.5, 70.5, and 92.3%, respectively. Misclassification rate with the application of the diagnostic model on group II subjects was 13.5% (14/104). Sensitivity, specificity, PPV, and NPV of the model for predicting OSA in this group were 82, 90.7, 89.1, and 84.5%, respectively. BMI, male gender, SI, and ChI are independent predictors of OSA. Diagnostic model derived from these parameters is useful for predicting presence of OSA and screening subjects for PSG.

Validation of the modified Berlin questionnaire to identify patients at risk for the obstructive sleep apnoea syndrome

BACKGROUND & OBJECTIVES

Awareness regarding obstructive sleep apnoea (OSA) among general public as well as practicing physicians is low in India. The present study was undertaken to test the utility of modified Berlin questionnaire for risk categorization of OSA in Indian setting.

METHODS

The modified Berlin questionnaire was administered in 180 middle aged adults (of 320 screened), of whom, 104 underwent overnight polysomnograhy, in a cross-sectional study at a tertiary care, referral center in north India. Questionnaire addressed the presence of frequency of snoring, wake time sleepiness, fatigue, obesity and hypertension. Subjects with persistent and frequent symptoms in any two of these three domains were considered in high risk category for obstructive sleep apnoea. Overnight polysomnograhy was performed to measure apnoea and hypopnoea index (AHI).

RESULTS

Questions about the symptoms demonstrated internal consistency (Cronbach alpha correlations 0.92-0.96). Of the 180 respondents to the screening questions, 80 were in the high risk and the rest were in low risk group. For 104 subjects who underwent polysomnograhy, risk grouping was useful in prediction of AHI. High risk category predicted an AHI >5 with a sensitivity of 86 per cent, specificity of 95 per cent, positive and negative predictive values of 96 and 82 per cent respectively. These results were comparable to Berlin questionnaire study done in the western population for validation.

INTERPRETATION & CONCLUSION

On the basis of the findings of present study it is concluded that administration of modified Berlin questionnaire prior to a polysomnography study can identify high risk subjects and can thus avoid unnecessary polysomnography studies especially in resource-limited settings. To identify subjects at risk for OSA syndrome in general population, this questionnaire can be applied. However, the findings of the present study need to be confirmed further in a large number of subjects in a community-based setting.

Thyroxine replacement therapy reverses sleep-disordered breathing in patients with primary hypothyroidism

BACKGROUND AND PURPOSE

Anecdotal reports suggest that sleep-disordered breathing (SDB) is common among patients with primary hypothyroidism. This study was undertaken to determine the prevalence of SDB and to evaluate the effect of thyroxine replacement therapy on SDB in patients with primary hypothyroidism.

PATIENTS AND METHODS

Fifty consecutive newly diagnosed, untreated symptomatic patients with primary hypothyroidism (age: 34+/-11 years; males: 21 [42%]) were prospectively studied. Physical examination, anthropometry, fasting blood glucose and serum lipids were performed in all patients at baseline. Polysomnography was done at baseline in all patients and was repeated after adequate thyroxine replacement in those who had SDB.

RESULTS

SDB defined as apnea-hypopnea index (AHI) > or =5 was present in 15 patients (30%) at baseline and was reversible in 10 of the 12 patients evaluated following thyroxine replacement therapy (P=0.006). Thyroxine replacement therapy was associated with improvement in findings that reflect a compromised upper airway, such as macroglossia (4 [33%] vs. 1 [8%]; P=0.083), myoedema (5 [42%] vs. 1 [8%]; P=0.046) and facial puffiness (10 [83%] vs. 1 [8%]; P=0.003).

CONCLUSIONS

Reversible SDB is common among patients with primary hypothyroidism. Changes in upper airway anatomy resulting from hypothyroidism probably contribute to the development of SDB in these patients.

A stepped approach for prediction of obstructive sleep apnea in overtly asymptomatic obese subjects: a hospital based study

BACKGROUND AND PURPOSE

Prevalence of obstructive sleep apnea (OSA) is high in obese subjects, many of whom may not be overtly symptomatic. Polysomnography (PSG) is a costly and time-consuming investigation. Since it is not feasible to subject all obese individuals to PSG, it is useful to define predictors of OSA among these subjects.

PATIENTS AND METHODS

One hundred and eighteen obese subjects [body mass index (BMI)> or =25 kg/m(2)] presenting to the hospital with non-sleep related complaints were included, of which 53 subjects with PSG evidence of OSA [apnea-hypopnea index (AHI)> or =15/h] were defined as cases and 65 subjects without any evidence of OSA (AHI<15/h) were defined as controls. Anthropometry, biochemical investigations, blood gas analysis, pulmonary function tests, and PSG were performed for all subjects.

RESULTS

Waist hip ratio (WHR) (as percentage of a standard) [odds ratio (95% CI): 1.07 (1.00-1.14); P = 0.049] male gender [odds ratio (95% CI): 3.97 (0.99-15.81); P = 0.046] and neck circumference (NC) [odds ratio (95% CI): 1.23 (1.03-1.47); P = 0.023] were found to be independent predictors of OSA. Overnight oxygen desaturation data were evaluated in patients selected as having OSA on the basis of these clinical markers, and the best cut-off for level of desaturation (10%) was defined. The stepped approach had a specificity, sensitivity, positive and negative predictive value of 89.2, 88.5, 86.8 and 90.6%, respectively, for the diagnosis of OSA.

CONCLUSIONS

Male gender, WHR and NC are independent predictors of OSA in overtly asymptomatic obese subjects. A stepped approach to diagnose OSA should be used, as it is accurate and cost-effective.

Sleep disordered breathing in chronic obstructive pulmonary disease

We prospectively studied sleep disordered breathing in 50 consecutive patients (39 males) with chronic obstructive pulmonary disease (COPD) with chronic respiratory failure (CRF) (n=33) and without CRF (n=17) by performing polysomnography. Patients with CRF had a lower mean nocturnal oxygen saturation (SaO2 %) (88.6+/-6.7 vs. 96.3+/-0.8; p=0.0001) and a lower minimal nocturnal SaO2 (73.6+/-12.0 vs. 84.3+/-7.3; p=0.002) compared to those without CRF, suggesting that patients with CRF tend to have more severe drops in nocturnal SaO2. Patients with CRF also had a lower FEV1 (% predicted) (p=0.01) and PEFR (% predicted) (p=0.031) compared to those without CRF suggesting an indirect relation to the oxygen saturation. Other pulmonary functions were comparable between both the groups. Among patients with and without CRF, the total sleep time (minutes); the rapid eye movement (REM) stage (% of total sleep time); the non-rapid eye movement (NREM) stage (% of total sleep time) were comparable (p=NS). Only three of the 50 patients with COPD had a significant (>5) apnea-hypopnea index (AHI) (total no. of apneas + total no. of hypopneas/ total sleep time [(hours) = AHI] and these three patients had a mean BMI = 27.7 which was higher than the mean BMI of the whole group (21.1). The AHI was comparable in patients with and without respiratory failure. Multiple regression analysis revealed a positive correlation between AHI and the neck circumference (r=0.41; p=0.005) and BMI (r=0.31; p=NS). There was a small but statistically insignificant negative correlation between AHI and neck length (r= -0.28; p=NS). We conclude that, BMI per se contributes to the AHI and nocturnal desaturation in patients with COPD.

Fire during the use of Nd-Yag laser

Fire during the use of Nd-Yag laser is a very rare complication. A case report of laser fire during the use of Nd-Yag laser for congenital subglottic stenosis is reported. The probable causes for the fire, management and short review of literature are dealt with. This case report highlights the importance of following the safety protocol during laser surgery.

Extranasopharyngeal angiofibroma arising from the nasal septum

Extra nasopharyngeal origin of angiofibroma is very rare. The nasal septum is a very rare site of extra nasopharyngeal angiofibroma with only two cases reported in the medical literature. We report here a case of a vascular mass arising from the nasal septum of an 8 year old boy. Histopathology confirmed it to be a case of angiofibroma. A review is also made of the other reported cases of angiofibroma arising from the nasal cavity. The likely theory of origin of the tumor and the management is also discussed.

Computers in Otorhinolaryngology : New horizons

There has been an explosion in the computers and information technology in the past couple of years. Otorhinolaryngology has also seen a number of new applications of computers. This article aims to familiarize the reader with different uses of computers as applied to the field of Otorhinolaryngology. It deals with the role in medical literature search, patient and doctor education, medical record Keeping, telemedicine, internet and E-mail. creating virtual environments and its role in FESS, skull base tumors and plastic surgery.

Laryngeal chondroma

Chondroma of thyroid cartilage is a rare condition. Two cases of laryngeal chondroma diagnosed clinically and confirmed histopathologically are presented. Surgical excision was undertaken in both the cases.

Allergic fungal sinusitis: clinicopathological characteristics

Allergic fungal sinusitis is a comparatively new disease entity in paranasal sinus mycoses. It is not a very rare condition, but diagnosis is difficult to establish. Of 28 consecutive cases of allergic nasal polyposis during a 2-year period, 11 patients had allergic fungal sinusitis and the diagnosis was based on the presence of type I hypersensitivity, eosinophilic mucus without tissue invasion of fungi on histopathology and detection of septate hyphae on direct microscopy. On culture, Aspergillus flavus was isolated from nine patients and A. fumigatus and A. niger from one patient each. Among patients with allergic fungal sinusitis, five had asthma, four had proptosis, of whom two had impaired vision, and all 11 patients had nasal obstruction. Eight patients described a history of recurrence. All patients underwent surgical clearance of the diseased sinuses and were given post-operative topical steroids to prevent recurrence.

Differential regulation of two types of intracellular calcium release channels during end-stage heart failure

The molecular basis of human heart failure is unknown. Alterations in calcium homeostasis have been observed in failing human heart muscles. Intracellular calcium-release channels regulate the calcium flux required for muscle contraction. Two forms of intracellular calcium-release channels are expressed in the heart: the ryanodine receptor (RyR) and the inositol 1,4,5-trisphosphate receptor (IP3R). In the present study we showed that these two cardiac intracellular calcium release channels were regulated in opposite directions in failing human hearts. In the left ventricle, RyR mRNA levels were decreased by 31% (P < 0.025) whereas IP3R mRNA levels were increased by 123% (P < 0.005). In situ hybridization localized both RyR and IP3R mRNAs to human cardiac myocytes. The relative amounts of IP3 binding sites increased approximately 40% compared with ryanodine binding sites in the failing heart. RyR down-regulation could contribute to impaired contractility; IP3R up regulation may be a compensatory response providing an alternative pathway for mobilizing intracellular calcium release, possibly contributing to the increased diastolic tone associated with heart failure and the hypertrophic response of failing myocardium.