Unveiling the Allergy-Meniere Connection: Exploring the Impact of Allergen Positivity on Meniere's Disease Severity

Meniere's Disease is a rare ear disorder that can cause severe morbidity to the patient and has no definitive treatment to date. Endolymphatic hydrops is the critical event. Though symptomatology is well understood, the exact etiology of Endolymphatic hydrops attack is still unclear. Twenty-five consecutive patients of Meniere's Disease diagnosed in the Vertigo clinic aged 12 to 70 years were included. Their allergic status was evaluated using a skin prick test. Allergic and non-allergic patients were then identified. Comparison between the two groups was made to identify the effect of allergy on the severity of symptoms using vertigo scales, Functional level scale, Dizziness handicap index, and Pure tone average staging. The prevalence of allergy among Meniere's Disease patients was 56%. The most common allergen found in our study was tyrophagus(n = 8). Polysensitization was more common(n = 12). Airborne allergens were more common than food allergens. There was no significant relationship between the severity scales and the allergen positivity status (p > 0.05). The prevalence of allergy is more among patients with Meniere's Disease. The Endolymphatic sac is allergy prone. The occurrence of endolymphatic hydrops may be due to a cross-reaction of allergen-induced IgE antibodies to self-antigen. Management of the specific allergen may help decrease symptomatology in these patients. Allergen-specific therapies have a promising role in the treatment of allergic conditions and provide a long-term symptom-free period in affected individuals. This can be applied in patients with Meniere's Disease having associated allergic features based on their skin prick test results.

Prevelance of Common Aeroallergens in Allergic Rhinitis and its Correlation with Bronchial Asthma: A Study on 798 Patients by Skin Prick Test

Allergic rhinitis affects 30% of the Indian population (Dey et al. in Int Arch Allergy Immunol 178:60-65, 2019). Patients can be sensitive to single or multiple allergens. Polysensitization is more common (Bousquet et al. in Ann Epidemiol 20:797-803, 2010; Arbes et al. in J Allergy Clin Immunol 116:377-383, 2005). Sensitization to multiple allergens may have a role in the severity and the association of Asthma in such patients. A total of 798 patients with allergic rhinitis (SFAR ≥ 7) were included. Disease severity and associated symptoms were evaluated using questionnaire. Each patient underwent a Skin prick test with an allergen panel of 35 allergens each (Annesi-Maesano et al. in Allergy 57:107-114, 2002) and the results were evaluated to study the association of asthma and severity of Allergic rhinitis. Data consisting of 389 (48.7%) males and 409 (51.3%) females were assessed. A total of 82.2% of the study population of symptomatic patients were sensitized to at least one of the allergens. Seventy patients (8.78%) had associated asthma. Forty-four patients were polysensitized and fifteen were mono sensitized. Among polysensitized patients, 36 patients had sensitization to at least 6 different allergens. Dermatophagoides pteronyssinus was the most common allergen among asthma patients. This study provides a thorough knowledge of locally prevalent aeroallergens which is essential for the prompt diagnosis and treatment of allergic patients. Skin prick test can be a non-invasive vital tool in analyzing patterns of allergen exposure, the prevalence of allergen, sensitizing potential of different allergens in that specific geographic area.

Development of Phonemically Balanced Passage, Oral Passage, and Nasal Passage in the Punjabi Language

The primary aim of the study was to develop phonemically balanced passage, Oral passage and Nasal passage in Punjabi language. Development of the passage: The words in the passage were chosen to represent the way sounds are distributed in spoken Punjabi language, and the relative phonemic distribution of each word inside each paragraph matched how frequently each sound occurs in Punjabi. The paragraph was constructed using words that were rated as extremely familiar and familiar. The developed passages were given to five speech-language pathologists for the purpose of content validation. 100 people with normal hearing between the ages of 18 and 25 were enrolled in the study (50 female and 50 male). Each subject's nasalence was measured using a Nasometer. The individuals were given passages written in Punjabi to read, and their nasalence scores for each text were recorded. The nasalance mean for Punjabi phonemically balanced passage was 36.41 ± 4.61% and 38.57 ± 4.22% in male and female subjects. The Punjabi oral passage mean were 27.36 ± 4.14% and 28.46 ± 4.01% in male and female subjects. The means for Punjabi nasal passage were 46.15 ± 4.09% in male subjects and 47.04 ± 4.91% in the female subjects. The Intraclass correlation coefficient for Female and male subjects for the Punjabi Phonemically balanced passage, Punjabi oral passage, Punjabi nasal passage were 0.904, 0.945; 0.807, 0.909, and 0.956, 0.913 respectively. The developed passages have good test retest reliability and their normative scores can be used for assessment of different resonance disorders.

Sinonasal and Olfactory Quality of Life in Endoscopic Pituitary Surgery and Time Interval to Olfactory Recovery: A Comparative Prospective Study

Background and Objective

Superior turbinate manipulation is often required in cases of narrow cavities and expanded endonasal approaches with concern for olfaction. The objective of the study was to compare the pre- and postoperative olfactory function in patients undergoing endoscopic endonasal transsphenoidal pituitary excision with and without superior turbinectomy, using the Pocket Smell Identification Test and the quality of life (QOL) and Sinonasal Outcome Test-22 (SNOT-22) scores, irrespective of the extension (Knosp grading) of pituitary tumors. We also aimed to identify olfactory neurons in the excised superior turbinate with immunohistochemical (IHC) stains and correlate them with clinical findings.

Materials and Methods

The study was a prospective, randomized study performed in a tertiary center. Two groups A and B, with superior turbinate preserved and resected, respectively, during endoscopic pituitary resection, were compared using pre- and postoperative Pocket Smell Identification Test and QOL and SNOT-22 scores. The superior turbinate was subjected to IHC staining to identify the presence of olfactory neurons in patients with tumors of pituitary gland requiring endoscopic trans-sphenoid resection.

Results

Fifty patients with sellar tumors were enrolled. The mean age of patients in this study was 46.15 years. The minimum age was 18 years and the maximum was 75 years. Of the 50 patients in the study, 18 were female and 32 were male. Eleven patients had more than one presenting complaint. Loss of vision was the commonest and altered sensorium was the rarest symptom.

Conclusion

Superior turbinectomy is a viable option to gain wider access to sella without affecting the sinonasal function, quality of life, and olfaction. There was doubtful presence of olfactory neurons in superior turbinate. The extent of tumor resection and postoperative complications were unaffected and statistically nonsignificant in both the groups.

Surgical Field Quality in Trans-Nasal Endoscopic Surgeries Using Lignocaine Infusion and Dexmedetomidine Infusion. A Prospective Randomized Control Study

Trans-nasal endoscopic surgery (TNES) is a helpful diagnostic and therapeutic modality in otorhinolaryngology surgeries and requires controlled hypotension for better visualization of the surgical field. Recent literature shows evidence of intravenous Lignocaine infusion to produce the controlled hypotension. The study aims to assess and compare the effects of Lignocaine (LIG) and Dexmedetomidine (DEX) infusion with respect to surgical field quality. 101 Consenting adult patients undergoing elective TNES were double-blinded, randomly allocated in one of the two groups and received either DEX infusion of 0.5ug/kg/hr (n = 51) or LIG infusion of 1.5 mg/kg/h (n = 50) after a loading dose. Surgical field score (SVF) as the primary outcome and secondary outcomes such as variations in hemodynamic parameters, the requirement for rescue agents and total blood loss were recorded. Both the groups were comparable with respect to patient demographics, total duration of anesthesia and surgery. SVF scores were significantly better in the LIG group during the first 105 min of the surgery (p < 0.05). In response to intubation, hemodynamic parameters were lower in LIG group. The requirement of other adjuvant drugs, total blood loss (166.40 ml vs. 251.17 ml) and extubation time were also significantly lower in the LIG group. The study concludes that intravenous Lignocaine gives a better surgical field in the first 105 min of surgery, comparable hemodynamics and decreased blood loss in patients undergoing TNES as compared to Dexmedetomidine infusion. Hence its role as an agent for controlled hypotension during TNES surgery is promising.

As the virus sowed, the fungus reaped! A Comparative Analysis of the Clinico-epidemiological Characteristics of Rhino-orbital Mucormycosis before and during Covid -19 Pandemic

Background

The sudden surge of mucormycosis cases which happened during the second wave of COVID‐19 pandemic was a significant public health problem in India.

Objectives

The aim of this study was to analyse the clinico‐epidemicological characteristics of the mucormycosis cases to determine the changes that had occurred due to COVID‐19 pandemic.

Methodology

A retrospective cross‐sectional study was conducted at the Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India. Patients diagnosed with rhino‐orbital mucormycosis were categorised into the following groups: Pre‐pandemic(May 2019 to April 2020), Pandemic Pre‐epidemic (May 2020 to April 2021) and Epidemic (1 May 2021 to 12 July 2021). The epidemiological, clinical and surgical data of all the patients were retrieved from the hospital records and analysed.

Results

The epidemic period had 370 cases, compared with 65 during pandemic period and 42 in the pre‐pandemic period. Diabetes mellitus was seen in 87% of cases during epidemic period, 92.9% in the pre‐pandemic period and 90.8% in the pre‐pandemic pre‐epidemic period. The proportion of patients suffering from vision loss, restricted extra‐ocular movements, palatal ulcer and nasal obstruction was higher in the pre‐epidemic groups, and the difference was significant (p, <.01). There was no history of oxygen use in 85.9% of patients and no steroid use in 76.5%. The death rates were the lowest during epidemic (10%).

Conclusion

COVID‐19 has caused a statistically significant increase in the number of mucormycosis infections. The mortality and morbidity which showed an increase during the first wave of COVID‐19 decreased significantly during the epidemic period.

Tele-Otolaryngology at a Tertiary Care Center in North India During COVID-19 Pandemic Lockdown: A Validated Patient Feedback Questionnaire Based Study

Providing medical care using the telecommunication networks holds the promise of increased access and efficiency of healthcare particularly during global emergencies like the Coronavirus disease 2019 (COVID-19) pandemic. Most of the hospital setups worldwide have put telemedicine into practice ever since the onset of the COVID-19 pandemic. This study aimed at assessing the effectiveness of Tele-otolaryngology (TO) at a tertiary care centre during the pandemic lockdown. A validated patient feedback questionnaire was developed and distributed to 2577 patients who utilised the TO mobile health service at our institute. Patient feedback-based assessment of TO effectiveness during COVID-19 lockdown was carried out. The validated questionnaire in English and Hindi was statistically robust with Cronbach’s alpha value of 0.808 and 0.886 respectively. 1751 patients completed their feedback to the questionnaire. 97.5% utilised WhatsApp for TO consultation. 15.2% patients were detected of Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection with TO guidance. Up to 75% patients had a positive response to the questionnaire and 91.1% opined of savings achieved either with travel time, cost incurred or the treatment time. With respect to patient health status, 71.5% recovered, 20.1% had no change and 8.4% deteriorated with a mortality rate of 1.65%. Telehealth in otolaryngology during the COVID-19 pandemic lockdown was indispensable in managing exigencies. Redesigning of clinical protocol and technical constraints, clinician training and a validated patient feedback questionnaire would effectively bestow upon the global emergencies.

Endoscopic management of congenital nasal meningoencephaloceles: a short series of 15 paediatric cases

PURPOSE

To retrospectively analyse surgical management of clinico-radiologically proven nasal meningoencephalocele amongst children and results of repair with single-layer septo-mucosal flap at a tertiary skull base surgery centre in north India.

METHODS

Fifteen children with clinic-radiological nasal meningoencephaloceles with or without CSF rhinorrhoea were included. Radiological scans included CT scans and MRI scans for all cases to delineate soft tissue and bony architecture. All children underwent endoscopic excision of encephaloceles and repair of the skull base defect.

RESULTS

The authors were successful in fourteen cases. Successful cases included 4 children less than 6 months of age who underwent single-layer rotated septo-mucosal flaps, thereby avoiding donor site morbidity.

CONCLUSION

As endoscopic excision of nasal encephalocele is an established management approach, the authors take the concept of minimally invasive surgery a step further by successfully managing these lesions with single-layer repair. Vascularized septo-mucosal flap seems to be the only determining factor for a successful repair for congenital meningoencephalocele. However, a prospective study comprising a larger subset of patients would substantiate the assumption.

Investigation of the Paediatric Tracheostomy Decannulation: Factors Affecting Outcome

Introduction:

Evidence for factors determining paediatric tracheostomy decannulation vary extensively; therefore, this prospective observational study aimed to investigate these factors.

Materials and Methods:

In total, 67 consecutive paediatric patients (<12 years old) who referred to the Department of Otolaryngology, (Postgraduate Institute Medical Education and Research),(Chandigarh), India, for decannulation were included and evaluated for contributing factors in this study. Parental counselling was performed, and informed consents were obtained from them. The patients underwent detailed work up including X-rays of airway/soft tissue neck (STN) and endoscopic assessment under anaesthesia for evaluating airway patency. Decannulations were attempted post assessment and followed up one month to classify decannulation as success or failure regarding the removal of the tracheostomy tube.

Results:

Totally, 61 patients out of 67 cases were successfully decannulated, whereas six children failed the decannulation. Moreover, the duration of tracheostomy (Pearson’s Chi-square 35.330, P=0.013), indication of tracheostomy (Pearson’s Chi-square 21.211, P=0.000), STN X-Ray (Chi-square 43.249, P=0.000), and bronchoscopic findings (Chi-square 67.000, P=0.000) were significantly associated with the outcome of decannulation. However, decannulation outcome had no significant correlation with various factors, such as the duration of intubation preceding tracheostomy, duration of ventilation, tracheal swabs, and antibiotic therapy.

Conclusion:

The STN X-ray is an independent predictor, and it is recommended for paediatric tracheostomy decannulation. Moreover, bronchoscopic assessment should be performed in children having doubtful infra-stomal airway. Duration of tracheostomy significantly affects decannulation outcome. However, intubation duration preceding tracheostomy and duration of assistive ventilation have no direct effects on the outcome of decannulation. In children, gradual decannulation should be preferred and one month follow up is adequate for deciding decannulation outcome.

Role of Oncofetal Protein CR-1 as a Potential Tumor Marker for Oral Squamous Cell Carcinoma

Cripto-1 (CR-1) is an oncofetal protein with its role as a key factor in early process of carcinoma has been evaluated in cases of various cancers. However, very few studies have reported its role in oral cancer, which is the sixth most common cancer around the world, particularly with high prevalence in developing countries. Oral squamous cell carcinoma (OSCC) is the most predominant (90%) of all the histological types of oral cancer. Late detection, associated with increased morbidity and mortality, is mainly attributed to non-availability of a suitable biomarker for the disease. In the present pilot study, we have evaluated the role of soluble CR-1, in serum as a potential tumor marker for OSCC. CR-1 was estimated using sandwich ELISA in serum samples of 50 biopsy proven OSCC patients (pre and post treatment) along with age and gender matched healthy controls. Immunohistochemistry was also done in corresponding tumor tissue sections to check the expression of CR-1. Pre-treatment CR-1 was found to be 2.25-fold higher in serum of OSCC patients as compared to control (p < 0.0001***), which was reduced to 1.6 folds post treatment (p = 0.0006***). CR-1 levels were comparatively higher in early stage of disease. Upon IHC 80% of the cases were found to be positive for CR-1. This study provides evidence that serum levels of CR-1 are elevated in patients of Oral Squamous Cell Carcinoma, which decrease post treatment. Also, the association of expression of protein with tumor progression predicts CR-1 as a molecule that can be further evaluated as a potential tumor maker in OSCC.

Evaluation of Multimodality Management of Adenoid Cystic Carcinoma of the Head and Neck

Adenoid cystic carcinoma is a relatively rare tumour arising from salivary glands of head and neck region. Surgery and radiotherapy form standard treatment modalities in the management of this tumor. In this analysis we present results of multimodality treatment in our cohort of patient. This retrospective analysis evaluated results of treatment in forty patients diagnosed with adenoid cystic carcinoma of the head and neck. Evaluation was done to identify prognostic factors affecting the disease free survival. A median disease free survival of 34 ± 2.42 (Median ± SE) versus 10 ± 5.45 months was seen in patients undergoing surgery followed by post operative radiotherapy versus radiotherapy alone (P = 0.01). A radiotherapy dose more than 60 Gy was associated with a better disease free survival compared with patients receiving less than 60 Gy (P = 0.01). Positive surgical margins and perineural invasion were associated with a poor treatment outcome (P = 0.02) Patients with c-kit positive status showed a poor local control rate (P = 0.05).

Frontal pyomucocoele as forehead swelling in a five-year-old girl

Mucocoeles are slow-growing, locally aggressive, mucus-containing cysts, lined by epithelium, which, when infected, are called pyomucocoeles. We present the case of a five-year-old girl who presented with a frontal pyomucocoele requiring decompression and adequate antibiotics.

Cladosporium sphaerospermum causing brain abscess, a saprophyte turning pathogen: Case and review of published reports

Emergence of saprophytic fungi thriving in dead plant material and soil as opportunistic human pathogens is of great concern. Cladosporium species are environmental saprophytes reported to cause various superficial and invasive fungal infections worldwide. C. sphaerospermum, a predominantly indoor fungus has been reported from cases of meningitis, subcutaneous and pulmonary fungal infections in the past. Herein we report the first case of cerebral abscess due to C. sphaerospermum in an immunocompetent host who was successfully managed by combined medical and surgical therapy.

Direct-acting Antiviral Agents in Hepatitis C Virus-infected Renal Allograft Recipients: Treatment and Outcome Experience from Single Center

Hepatitis C virus (HCV) infection in renal allograft recipient is associated with increased morbidity and mortality. At present, only few studies related to treatment and outcomes of HCV-infected renal allograft recipients with DAAs have been published. We aimed the study to assess the efficacy and safety of sofosbuvir-based regimens in HCV-infected renal allograft recipients. We analyzed data of 22 eligible HCV-infected renal allograft recipients (14 genotype-3, 6 genotype-1, one each genotype-2 and 4) who were treated with DAAs at our institute. DAA regimen included sofosbuvir and ribavirin with or without ledipasvir or daclatasvir for 12–24 weeks. Patients were followed up for 24 weeks after completion of treatment. A rapid viral response of 91%, end of therapy response of 100%, and sustained viral response at 12 and 24 weeks of 100% with rapid normalization of liver enzymes were observed. Therapy was well tolerated except for ribavirin-related anemia. A significant decrease in tacrolimus trough levels was observed and most patients required increase in tacrolimus dose during the study. Treatment with newer DAAs is effective and safe for the treatment of HCV-infected renal allograft recipients.

Pindborg Tumor Presenting as a Nasal Polyp: Immunohistology and Ultrastructural Features of a Rare Case, With Review of the Literature

Calcifying epithelial odontogenic tumor, also known as Pindborg tumor, is a rare benign odontogenic tumor. This tumor predominantly involves the mandible, though the maxilla can also be involved in some cases. The involvement of maxillary sinuses, however, has been previously reported in only 8 case reports English literature. These patients chiefly presented with nasal obstruction along with epistaxis or proptosis in rare cases. However, a primary presentation as nasal polyp is unheard of. We present a rare case of calcifying epithelial odontogenic tumor presenting as a nasal polyp, posing a diagnostic difficulty.

Apoplexy in an intradural clival chordoma causing intraventricular bleed

Background:

A few cases depicting apoplexy in a chordoma have been reported. Rarely, this intratumoral bleed may spillover into intracerebral or intraventricular regions.

Case Description:

The authors report an intradural variety of clival chordoma presenting with apoplexy and spillover of blood into lateral ventricle. Clinical presentation, radiological scans, and relevant literature is also described.

Conclusions:

In a stable case of clival chordoma, intratumoral bleed or apoplexy may cause rapid neurological worsening and warranting urgent surgical intervention.

Comparison by objective parameters in patients with chronic rhinosinusitis managed medically and surgically (with and without powered instruments)

Objective:

To compare mucociliary clearance time and quality of life in patients who underwent sinus surgery using conventional and powered instruments, and in patients who were treated nonsurgically.

Methods:

A total of 151 patients with chronic rhinosinusitis were included. Fifty-four patients were treated conservatively, 48 patients were managed surgically by using conventional instruments and 49 patients were managed by using a microdebrider. Kupferberg nasal endoscopy grades, 20-item Sino-Nasal Outcome Test scores, Lund-Mackay scores, and mucociliary clearance time were analyzed.

Results:

On comparison among the groups, it was found that there was a significant difference between group A (nonsurgically treated) compared with group B (surgery by conventional means) or group C (surgery with microdebrider) in nasal endoscopic grades, Lund-Mackay scores, 20-item Sino-Nasal Outcome Test scores, and mucociliary clearance time. However, in comparison between groups B and C, there was no statistically significant difference.

Conclusion:

Mucociliary clearance time tended to recover after starting treatment for chronic rhinosinusitis both after conservative treatment and after surgical treatment. Surgery provided better improvement in different objective scores in chronic rhinosinusitis. There exists no statistical difference in parameters independent of the instrument used for surgery.

Successful endoscopic endonasal repair of nasal meningoencephalocele in a 21-day-old neonate

Introduction:

Indications of surgical intervention in congenital nasal meningoencephaloceles includes presence of cerebro spinal fluid rhinorrhea having a risk of causing meningitis, episodes of prior meningitis and bilateral nasal obstruction causing respiratory difficulty in these obligate nasal breathers. Many authors would like to wait till the patient attains the age of 2 to 3 years for repair of the defect due to surgical feasibility. However, early intervention prevents further episodes of meningitis in the future. We present the youngest patient of nasal meningoencephalocele successfully repaired via endoscopic approach.

Case Report:

A 21 days old neonate was referred to us with a nasal meningoencephalocele with active cerebrospinal fluid rhinorrhoea. Radiological investigation showed a cribriform plate defect on the right side. Repair was done by endoscopic route by multi-layered closure of the defect which was augmented with a mucoperichondrial flap from the septum. Patient was asymptomatic in the post-operative follow up period and did not have any episode of meningitis till date.

Conclusion:

Early repair by transnasal endoscopic route is a feasible surgical option for congenital anterior skull base defects with meningoencephaloceles to prevent further episodes of meningitis. This is feasible even in the neonatal period due to improved technique and instrumentation now available for endoscopic nasal surgeries.

Ochroconis humicola coexisting with esthesioneuroblastoma: an incidental coloniser or allergen?

Ochroconis humicola, a fish pathogen, is rarely reported to cause disease in human. We report its first isolation from nasal tissue of a human immunodeficiency virus-positive young female patient. Histopathologically, the nasal mass was diagnosed as esthesioneuroblastoma. She presented with right-sided nasal obstruction and bleeding for two and half months. Computed tomography scan showed the nasal mass filling the whole right nasal cavity, maxillary, ethmoid and sphenoid sinuses. The direct microscopy of the nasal tissue and mucin demonstrated the presence of septate hyphae. On culture, O. humicola was isolated from the same tissue and the fungus was identified by morphologic, physiologic and molecular data including sequencing of ITS and 28S rDNA regions. No antifungal was prescribed, and the whole mass was resected out by endoscopic surgery. The patient was treated further by radical radiotherapy. After 1 year of follow-up, patient is stable with no recurrence of tumour. The role of this fungus was not clear, as it may be bystander or producing allergic fungal rhinosinusitis.

Schwannoma of the nasal septum: an unusual finding

Schwannomas of the nasal cavity are rare benign tumors, and those that arise from the nasal septum are even rarer. When they do occur, they usually become symptomatic early because of the close confines of the nasal cavity. We describe a case of nasal septal schwannoma that was noteworthy in that the patient-a 28-year-old woman-waited 8 months after the onset of symptoms to seek medical care. Her symptoms included complete right-sided nasal obstruction, occasional epistaxis, and hemifacial pain. The tumor was completely removed via an endoscopic approach. We discuss the clinical presentation, differential diagnosis, and treatment of this rarely encountered neoplasm.

Endoscopic repair of CSF rhinorrhea: necessity of fibrin glue

OBJECTIVE

The aim of this study is to compare the efficacy of cerebrospinal fluid (CSF) repair with and without fibrin glue in pediatric patients with CSF rhinorrhea treated endoscopically.

MATERIALS AND METHODS

This was a retrospective study carried out in the Departments of Otolaryngology and Neurosurgery at a tertiary care center between December 2005 and July 2010.

RESULTS

The 27 patients with CSF rhinorrhea included in the study were divided into Group A: 13 patients who underwent endoscopic endonasal CSF repair using fibrin glue (Tisseel, Baxter, Vienna, Austria) by an endoscopic rhinologist and Group B: 14 patients who underwent endonasal CSF repair without fibrin glue. There was no statistically significant difference in endoscopic CSF repairs with or without fibrin glue (P = 0.48) in all the variables studied. CSF repair without fibrin glue appeared more cost saving as compared to repair with glue.

CONCLUSION

CSF repairs with and without fibrin glue are equally effective and CSF repair without fibrin is costs saving.

Primary hydatid cyst presenting as a mass in the supraclavicular region: an unusual case report and literature review

Hydatid disease, also known as echinococcosis or hydatidosis, is an infectious disease caused by the cestode Echinococcus. Echinococcus granulosus is the most common Echinococcus species affecting human beings. It may affect any organ and tissue in the body, in particular the liver and lung. Musculoskeletal or soft tissue hydatidosis accounts for about 0.5%-5% of all echinococcal infections in endemic areas, and is almost always secondary to the hepatic or pulmonary disease. Even in regions where echinococcosis is endemic, hydatidosis of cervicofacial region is extremely rare. Herein, we present an exceptionally rare case with an unusual localization of primary hydatid cyst in the right supraclavicular region of the neck without involvement of the lungs or pleura.

Esthesioneuroblastoma: Good Local Control of Disease by Endoscopic and Endoscope Assisted Approach. Is it Possible?

To present a short report on nine patients of esthesioneuroblastoma, managed endoscopically or endoscope assisted. To describe the technique and discuss the results at an average of 36.7 months of follow up. A retrospective study in a tertiary care centre. The present communication describes a series of 9 cases harbouring esthesioneuroblastoma, 6 managed endoscopically and 3 endoscope assisted between January 2005 and December 2009. All the nine patients remained free of disease at the primary site by endoscopic and radiological evaluation on an average of 36.7 months of follow up. One of the patients developed cutaneous and systemic metastasis for which she received chemotherapy and another one died during post-operative period due to unrelated causes. None of the patients showed recurrence or residual disease locally. Endoscopic and endoscope assisted approach provides a cosmetically better and surgically comparable outcome for local control of disease in early stages of esthesioneuroblastoma in expert hands without significant complications.

How to decannulate tracheostomised severe head trauma patients: a comparison of gradual vs abrupt technique

Tracheostomy is a common surgical procedure performed in patients with severe head injury to facilitate prolonged airway and ventilatory support. Decannulation is the procedure of removing the tracheostomy tube either gradually by downsizing the tube or abruptly in a single sitting. This prospective study was done to evaluate gradual vs abrupt techniques for successful decannulation in tracheostomised severe head trauma patients in Post Graduate Institute of Medical Education and Research (PGIMER), a central government tertiary centre in Chandigarh, India. A total of 118 patients, recruited over one and half years duration were arbitrarily divided into 2 groups: Gradual and Abrupt. Particulars were taken. Time since tracheostomy, timing of decannulation, Glasgow Coma Scale, amount of secretions, breath holding time, CXR and STN radiographs and cough reflex were all assessed. Follow up was done at one month to classify those who were re-tracheostomised or re-intubated as decannulation failures. Sixty-eight patients were decannulated gradually and 50 abruptly. Of the various factors assessed, only cough reflex, number of suctioning required per day, X-ray STN and use of antibiotics for more than 7 days were found to be statistically significant. One hundred and fourteen patients, 67 out of 68 in the GD group and 47 out of 50 in the AD group, had successful outcome. The study showed that success or failure of decannulation is independent of mode of decannulation.

Traumatic chiasmal syndrome

A case of closed head trauma, harbouring bitemporal hemianopsia is presented. The MRI evaluation describes chiasmal contusion as the cause behind visual deficits. Chiasmal injury may occur even in the absence bony chip impingement and features of hypo-pituitarism. Such a situation warrants MRI evaluation of optic pathways.

Comparison of efficacy of amphotericin B and itraconazole in chronic invasive fungal sinusitis

Management of invasive fungal sinusitis includes both surgery and antifungal chemotherapy. To compare the efficacy of amphotericin B and itraconazole used alone in the management of chronic invasive fungal sinusitis. A prospective randomized unblinded study was conducted in the Department of Otolaryngology, Postgraduate Institute of Medical Education and Research, Chandigarh, India during December 2006 to June 2008. 26 immunocompetent patients were randomly divided into two groups-group A-received amphotericin B and group I-received itraconazole in conventional doses. The response to treatment was judged on the basis of symptomatic and radiologic resolution. Seven patients had complete cure (5/16-gr I; 2/10-gr A); Eleven patients had persistent disease (7/16-group-I; 4/10 in group A); four relapses were noted (3/16 in group I and 1/10 in group A); 3 deaths occurred; one patient was lost to follow up. Relative risk analysis did not show any statistically significant difference between the two drugs as regards their efficacy. Itraconazole and amphotericin B both have been found to be equally efficacious in the management of invasive fungal sinusitis. Itraconazole however, has fewer side effects compared to amphotericin B.

ABPA Concomitantly Occurring with Invasive Sinus Aspergillosis: A Short Report on Two Patients

Allergic bronchopulmonary aspergillosis (ABPA) is a pulmonary disorder that is caused by hypersensitivity to Aspergillus fumigatus with resultant systemic immune activation, chronic asthma, recurrent pulmonary infiltrates, and bronchiectasis. First described by Hinson et al. (Thorax 7:317-333 [1]) in 1952, this disease occurs in 1-2% of patients with persistent asthma and in 2-15% of patients with cystic fibrosis (Greenberger, Front Biosci 8:s119-s127 [2]). Although the diagnostic criteria for ABPA have been laid down (and include bronchial asthma, immediate skin test reactivity to A. fumigatus, elevated total serum IgE level, pulmonary infiltrates, central bronchiectasis, peripheral blood eosinophilia, and positive serum precipitins [IgG] against Aspergillus antigen), none of these are specific for ABPA (Shah, Curr Opin Pulm Med 13(1):72-80 [3]). There is still no consensus on the number of criteria needed for diagnosis, and patients in different stages of ABPA may not fulfill all these criteria (Greenberger, Front Biosci 8:s119-s127 [2]; Chakrabarti et al., Mycoses 45:295-299 [4]). An high-resolution CT (HRCT) scan showing central bronchiectasis and high attenuation mucus is presently the investigation of choice for the diagnosis of bronchiectasis in patients with ABPA (Shah, Front Biosci 8:e138-e146 [5]). ABPA has also been reported in association with allergic fungal rhinosinusitis in English literature (Shah, Curr Opin Pulm Med 13(1):72-80 [3]). We are reporting two patients with invasive aspergillosis of the nose, paranasal sinuses and orbit, who were diagnose and managed successfully for ABPA, a previously unreported entity.

Allergic fungal sinusitis: innocence under suspicion

The objective of this investigation was to explore the possibility of treating patients harboring invasive intracranial aspergillosis (InIA) at an early stage. Nineteen patients (age range 18-42 years) from a total of 114 cases of InIA seen from January 1999- December 2009 were included in this investigation. These individuals, all of whom had a past history of treated allergic fungal sinusitis (AFS) were evaluated as to their immune status, clinical presentations, time-intervals and radiological findings. Past records of seven patients indicated skull base erosion and extension of the paranasal (PNS) masses into intracranial cavity, but none had neurological deficits or symptoms suggestive of raised intracranial pressure. All 19 patients had undergone endoscopic clearance of PNS during their first presentations. Both AFS and InIA were found simultaneously in seven patients, while the time-interval between the two forms was as long as 10 years for two patients. Overall mortality was (8/19; 42%) with all deaths attributable to fungal meningo-encephalitis. As InIA carries a high mortality rate, it seems prudent to evaluate and treat these patients early in the course of their illness. The appearance of the invasive form of the disease in patients with a past history of AFS is not uncommon. The allergic form of disease may not be considered as a separate entity from InIA as both the pathologies may exist in same patient.

Fine needle aspiration cytology in lesions of the nose, nasal cavity and paranasal sinuses

OBJECTIVE

To assess the spectrum of lesions in the sinonasal region diagnosed on FNAC.

STUDY DESIGN

This is a retrospective audit of sinonasal lesions diagnosed on FNAC over a period of 12 years (1998-2009).

RESULTS

Out of a total of 79,851 FNACs, 158 (0.2%) were from the sinonasal region. FNAC was non-diagnostic in 20 (12.6%) cases. Infective/inflammatory lesions comprised of 30 (19%) cases including non-specific inflammation (19), fungal infection (7), tuberculosis (2), actinomycosis (1) and filariasis (1). Benign cysts (24; 15.2%) included epidermal inclusion cysts, mucocele and aneurysmal bone cyst. Benign bone tumors (4) comprised of giant cell tumor, fibrous dysplasia, chondroma, and osteoblastoma. Other benign tumors included lipoma (6), hemangioma (5), schwannoma (2), meningioma (1), pleomorphic adenoma (1), sebaceous adenoma (1) and other skin adnexal tumors (3). Malignant epithelial tumors (24; 15.2%) included squamous cell carcinoma (10), basal cell carcinoma (5), poorly differentiated carcinoma (4) and metastatic carcinoma (5). Two cases of chordoma and one case each of dermatofibrosarcoma pertuberance and hemangiopericytoma were seen. Sarcomas included sarcoma, not otherwise specified (4), rhabdomyosarcoma (3), osteosarcoma (2), chondrosarcoma (2), leiomyosarcoma (1), malignant fibrous histiocytoma (1), fibrosarcoma (1) and malignant peripheral nerve sheath tumor (1). There were cases of malignant small round cell tumor (11), non-Hodgkin lymphoma (3), plasmacytoma (2) and malignant melanoma (2).

CONCLUSION

A variety of non-neoplastic and neoplastic conditions can involve the sinonasal region. FNAC is a reliable diagnostic procedure in a good number of cases, especially in the light of clinico-radiological data.

CSF rhinorrhea-feasibility of conservative management in children

PURPOSE

To study the role of conservative management in CSF rhinorrhea in pediatric population.

STUDY DESIGN

A retrospective study in a tertiary care center.

METHODS

Cases with a diagnosis of CSF rhinorrhea discharged after conservative management but required skull base repair for recurrence of CSF rhinorrhea or meningitis were included in the study between periods 2000 and July 2010.

RESULTS

12 cases of CSF rhinorrhea managed were treated conservatively, 7 patients again required rehospitalisation for recurrence of CSF rhinorrhea or meningitis. Male:female ratio was 4:1. The age ranged from 3 years to 14 years. Duration of recurrence of the CSF leak or meningitis varied from 6 to 121 months. Presenting symptoms included headache, rhinorrhea, or recurrent meningitis. The time from the initial injury to surgical exploration ranged from 163 to 3650 days. All patients were under regular follow-up and doing well except one had recurrence of the leak 2 months after surgery requiring revision surgery following which the patient had no recurrence.

DISCUSSION

The management of CSF fistulae is still a matter of debate and there will be a risk of recurrent meningitis on conservative management. Most comprehensive study to date indicates there is a 9.8% annual risk of developing meningitis. Duration of recurrence of the CSF leak or meningitis varied from 6 months to 121 months. The overall incidence of meningitis as a result of skull base defect and CSF leak ranges from 9% to 50% with a reported cumulative risk of 85% in 10 years if no repair is performed. As seen in our series CSF repair can resolve with conservative management but there is a risk of intermittent CSF leak or meningitis due to an incompletely healed or tenuous mucosal regeneration which should be addressed surgically. The patients with traumatic CSF leak who were treated with conservative management alone had a 25-29% risk of subsequent meningitis.

CONCLUSION

Conservative treatment of CSF leaks may lead to recurrent meningitis or leaks, therefore surgical closure of defects at the skull base should be considered treatment of choice to prevent ascending meningitis.

Ear surgery without microscope; is it possible

Our experience of endoscope usage in otological surgery is presented. We included 17 patients with secretory otitis media for grommet insertion, 49 cases of myringoplasties and 6 cases of ossiculoplasties operated between May 2005 and 2008. All the procedures were performed through transcanal route. The success rate regarding perforation closure was 91.5% and average air-bone gap improved from 22.24-12.28 db in myringoplasty group and from 27.5-13 db in ossiculoplasty group. Secretory changes subsided in 16 out of 17 patients in secretory otitis media group. Endoscopic surgery offers many advantages over microscopic surgery which have been discussed.

Diagnosis of adult rhabdomyoma by fine needle aspiration cytology: a report of 2 cases

BACKGROUND

Adult rhabdomyoma (ARh) is a rare, benign tumor originating in striated muscle cells. Ninety-three percent of the tumors occur in the head and neck region and sometimes mimic malignant tumors clinically. The preoperative correct diagnosis of this tumor is important as it can help in deciding on management.

CASES

We report two cases of ARh diagnosed by fine needle aspiration cytology (FNAC). Case 1 was a 43-year-old male who presented with a recurrent tumor in the region of the floor of the mouth. Case 2 was a 37-year-old male who presented with soft tissue swellings in bilateral submandibular regions. On cytology in both cases, the smears showed numerous large tissue fragments of tumor cells, which were large, polygonal cells with abundant, vacuolated cytoplasm and bland, eccentrically placed nuclei. Characteristic cross-striation and intracytoplasmic inclusions were not conspicuous on cytosmears. However, a primary cytodiagnosis of ARh could be offered based on characteristic morphologic features.

CONCLUSION

ARh has characteristic cytomorphologic features, which are described in detail in the present report, and they can help in diagnosing this tumor on FNAC.

Vascular malformation of the jejunum presenting as obscure gastrointestinal haemorrhage: detection with multidetector CT angiography

Vascular malformation of the small bowel is an uncommon cause of gastrointestinal haemorrhage. Phlebectasia or venous ectasia is a rare benign vascular anomaly of the gastrointestinal tract. We report a 39-year-old Egyptian man presenting with multiple jejunal phlebectasia, liver haemangioma and port-wine naevus. Despite recurrent melaena, the results of various routine investigations, including repeated endoscopic procedure, were negative. The site and aetiology of bleeding was detected using multidetector computed tomography (MDCT) angiography and was further confirmed by double-balloon enteroscopy. This report emphasises the potential of MDCT angiography in the diagnosis of small intestine lesions presenting as obscure bleeding.