Management of Disseminated Rhinosporidiosis: Experience From a Single Tertiary Institution.

Objective: This study aims to present a series of patients with disseminated rhinosporidosis with diagnostic and therapeutic features. Methods: A retrospective study was conducted in a tertiary health care centre in South India from 2007 to 2020 with disseminated rhinosporidiosis. Twelve patients with multiple sites of involvement like the nose, nasopharynx, oropharynx, larynx, lacrimal sac and skin were included in the study. All patients underwent surgical excision, followed by peroral dapsone for one year. Results: The age group was around 30-55 years, with male predominance (11:1). Pond bathing history was present in 50% (n=6). The most common site of lesion was the nose (100%), oropharynx (83.3%), skin (75%), larynx (50%) and less commonly, nasopharynx (41.6%) and lacrimal sac (25%). One patient underwent surgery four times (8.3%), followed by thrice and twice by five (41.6%) and six (50%) patients, respectively. On two years of follow-up, two patients (16.6%) had a recurrence in the nose and larynx whereas eight patients (66.6%) had no recurrence and two patients (16.6%) were lost to follow-up. Conclusion: This original article highlights the rare occurrence of disseminated rhinosporidiosis, the possibility of which should be kept in mind, mainly when two or more sites are involved. The most significant number of disseminated rhinosporidiosis cases in the literature is reported here. Dissemination with the cutaneous and multisite disease is rarely reported and poses difficulty in management. Early diagnosis and intervention prevent the dissemination of spores into various parts of the body.

Endogenous Cu(II) Labeling for Distance Measurements on Proteins by EPR.

In-cell measurements of the relationship between structure and dynamics to protein function is at the forefront of biophysics. Recently, developments in EPR methodology have demonstrated the sensitivity and power of this method to measure structural constraints in-cell. However, the need to spin label proteins ex-situ or use noncanonical amino acids to achieve endogenous labeling remains a bottleneck. In this work we expand the methodology to endogenously spin label proteins with Cu(II) spin labels and describe how to assess in-cell spin labeling. We quantify the amount of Cu(II)-NTA in cells, assess spin labeling, and account for orientational effects during distance measurements. We compare the efficacy of using heat-shock and hypotonic swelling to deliver spin label, showing that hypotonic swelling is a facile and reproducible method to efficiently deliver Cu(II)-NTA into E. coli. Notably, over six repeats we accomplish a bulk average of 57 µM spin labeled sites, surpassing existing endogenous labeling methods. The results of this work open the door for endogenous spin labeling that is easily accessible to the broader biophysical community.

Determining the Best Thyroid Imaging Reporting and Data System: A Prospective Study Comparing the Diagnostic Performance of ACR, EU, and K TIRADS in the Evaluation of Thyroid Nodules.

Background Many different risk stratification systems have been formulated for thyroid nodules, differing in their fine-needle aspiration cytology (FNAC) indication, suggesting a lack of consensus around the world. Purpose This prospective study was conducted to find the best guideline for risk stratification, for a better malignancy yield, and with reduced rates of negative FNACs among three Thyroid Imaging, Reporting, and Data System (TIRADS) guidelines. Materials and Methods A total of 625 thyroid nodules with conclusive FNAC or histopathological diagnosis were included in the study. Various sonographic parameters were recorded. They were classified into categories as per the three guidelines and compared with FNAC diagnosis. The guidelines were evaluated in terms of sensitivity, specificity, predictive values, and diagnostic accuracy. Sensitivity and specificity were compared by McNemar's test. Results American College of Radiology (ACR) TIRADS had the highest diagnostic accuracy (56.8%), specificity (50.75%), positive predictive value (23.92%), lowest rates of negative FNACs (76.08%), and high negative predictive value (97.84 %). Korean (K) TIRADS had the maximum sensitivity (97.75%), highest negative predictive value (98.44%), and gross malignancy yield. European TIRADS was between the two other guidelines in most parameters with specificity like K TIRADS. Conclusion All the three guidelines are very good screening tools, with comparable high sensitivity. ACR TIRADS is better in terms of specificity and reduced rates of negative FNACs. Including the presence of a suspicious cervical lymph node as a criterion and more frequent follow-up might further improve the diagnostic performance of the guideline.

Schwannoma of Nasopharynx-A Rare Case with A Complex Presentation.

Nasopharyngeal tumors are rare, and schwannomas originating from this location are extremely uncommon. Schwannomas are tumors arising from the Schwann cells of peripheral nerve sheath which are neuroectodermal in origin. These are benign, slow growing, well-encapsulated tumors and are mostly seen in the head and neck region. We present a rare case of schwannoma with nasopharynx as its epicenter in an elderly female patient who presented with complaints of hematemesis, bilateral nasal obstruction and stertorous breathing. Diagnostic nasal endoscopy revealed a smooth mucosa covered globular mass occupying bilateral choana. Contrast-enhanced computed tomography of Nose and paranasal sinuses revealed a homogenous mass occupying the entire nasopharynx extending into the nasal and oropharyngeal cavities. The patient underwent Trans-nasal Endoscopic excision under general anesthesia. Nasopharyngeal tumors have a wide range of presentation and a high index of clinical suspicion combined with imaging modalities is required for diagnosis and pre operative planning. Some tumors can cause life-threatening airway obstruction due to delayed presentation and should be managed efficiently and meticulously, with endoscopic excision being a viable approach for cases confined within the nasopharynx.

Site of Tracheostomy and Its Influence on The Surgical Outcome and Quality of Life After Tracheal Resection and Anastomosis in Patients with Tracheal Stenosis.

Introduction With the advances in critical care, the incidence of post intubation tracheal stenosis is increasing. Tracheal resection and anastomosis have been the gold standard for the management of grades III and IV stenosis. Scientific evidence from the literature on the determining factors and outcomes of surgery is not well described. Objective This study was aimed at determining the influence of tracheostoma site on the surgical outcomes and postoperative quality of life of patients undergoing tracheal resection anastomosis. Methods Thirteen patients who underwent tracheal resection and anastomosis during a period of 3 years were followed up prospectively for 3 months to determine the degree of improvement in their quality of life postsurgery by comparing the pre and postoperative validated Tamil/vernacular version of RAND SF-36 scores and Medical Research Council (MRC) dyspnea score. Results As per preoperative computed tomography (CT), the mean length of stenosis was found to be 1.5 cm while the mean length of trachea resected was 4.75 cm. We achieved a decannulation rate of 61.53%. There was an estimated loss of 3.20 +/- 1.90 cm of normal trachea from the lower border of the stenosis until the lower border of the stoma that was lost during resection. Analysis of SF-36 and MRC dyspnea scores revealed significant improvement in the domains of physical function postoperatively in comparison with the preoperative scores ( p < 0.05). Conclusion Diligent placement of tracheostomy in an emergency setting with respect to the stenotic segment plays a pivotal role in minimizing the length of the resected segment of normal trachea.

Site of Tracheostomy and Its Influence on The Surgical Outcome and Quality of Life After Tracheal Resection and Anastomosis in Patients with Tracheal Stenosis

Abstract Introduction With the advances in critical care, the incidence of post intubation tracheal stenosis is increasing. Tracheal resection and anastomosis have been the gold standard for the management of grades III and IV stenosis. Scientific evidence from the literature on the determining factors and outcomes of surgery is not well described. Objective This study was aimed at determining the influence of tracheostoma site on the surgical outcomes and postoperative quality of life of patients undergoing tracheal resection anastomosis. Methods Thirteen patients who underwent tracheal resection and anastomosis during a period of 3 years were followed up prospectively for 3 months to determine the degree of improvement in their quality of life postsurgery by comparing the pre and postoperative validated Tamil/vernacular version of RAND SF-36 scores and Medical Research Council (MRC) dyspnea score. Results As per preoperative computed tomography (CT), the mean length of stenosis was found to be 1.5 cm while the mean length of trachea resected was 4.75 cm. We achieved a decannulation rate of 61.53%. There was an estimated loss of 3.20 +/- 1.90 cm of normal trachea from the lower border of the stenosis until the lower border of the stoma that was lost during resection. Analysis of SF-36 and MRC dyspnea scores revealed significant improvement in the domains of physical function postoperatively in comparison with the preoperative scores (p < 0.05). Conclusion Diligent placement of tracheostomy in an emergency setting with respect to the stenotic segment plays a pivotal role in minimizing the length of the resected segment of normal trachea.

One More Chance to See the World: A Rare Case Report on Sphenoid Mucocele Causing Vision Loss.

Mucocele of the sphenoid sinus is one of the rare diseases which an ENT surgeon can encounter in a clinical setup. It can often present as a chronic headache. It can remain undiagnosed unless a symptom due to the compression effect of the mucocele, such as diminution of vision, ophthalmoplegia, or any intracranial complication, occurs. Early diagnosis and emergency surgical intervention are imperative to prevent complications. Although late presentation can have a risk of permanent vision loss, improvement in vision postsurgery does not necessarily depend on the duration of symptoms. Here, we present a rare case scenario where, even after the delayed presentation, the patient had a significant vision improvement postsurgery.

Endoscope-Assisted Removal of Post-Traumatic Orbital Epidermoid Inclusion Cyst: A Useful Adjunct.

Orbital epidermoid cysts are uncommon lesions within the bony orbit with varied symptomatology related to both the eye and the sino-nasal system. They are often slow-growing cystic masses which may cause facial asymmetry and visual loss due to pressure symptoms. Cross-sectional imaging such as computed tomography and magnetic resonance imaging are contributory and useful for assessment of the size and actual extent and should be mandatory before planning any surgical intervention. Open approaches and needle aspiration have been traditionally described; however, the use of the rigid nasal endoscope in the intraorbital compartment is a useful adjunct for exploration of the extent of the lesion and for complete surgical clearance. In this report, a 69 years old female with an old post- traumatic orbital epidermoid cyst which was removed completely using an endoscope via transorbital route was presented with the review of literature.

Kaposiform Haemangioendothelioma of the Sublingual Gland in an Adult.

Kaposiform haemangioendotheliomas (KHE) are extremely rare, borderline malignant, locally aggressive vascular tumours. KHE is usually found in the retroperitoneum, over the extremities, the soft tissues of the trunk, mediastinum and the head and neck regions. We present a very rare case of KHE of the sublingual gland in an adult, which was not associated with Kasabach-Merritt phenomenon and was resected completely without any recurrence. To the best of our knowledge, this is the first reported case in the literature of a KHE arising from the salivary glands in an adult.

Veillonella atypica causing retropharyngeal abscess: A rare case presentation.

Veillonella species are obligate anaerobes which are part of the human oral, gut and vaginal microbiota. The genus Veillonella consists of 16 characterized species. Very few infections due to Veillonella atypica have been reported till date. Here we present a case of retropharyngeal abscess due to this organism in a 55-year-old lady.

Plasma Cell Granuloma of the Maxillary Sinus-A Case Report and Review.

Plasma cell granuloma is a rare, benign, space occupying lesions occurring after recurrent infections. It most commonly involves young adults with lungs being the most common site. They are usually rounded masses with bony expansion and destruction without any life threatening complications and surgery being the best choice of treatment. Here we reported a 33 year-old female with plasma cell granuloma of the maxillary sinus treated with surgery and no recurrence has been noted.

Role of endotracheal tube size on nasal and laryngeal morbidity during awake fiberoptic nasotracheal intubation: A Randomized controlled trial.

Background and Aims: Awake fibreoptic nasotracheal intubation is associated with adverse airway and hemodynamic complications. The aim of this study was to evaluate the role of endotracheal tube size on nasal and laryngeal morbidity during awake fibreoptic-guided nasotracheal intubation. Material and Methods: Eighty patients recruited to undergo awake fibreoptic intubation were randomly allocated to Group C (standard size endotracheal tube) and Group S (small size endotracheal tube followed by exchange to standard size using Airway Exchange Catheter under general anesthesia). Nasal morbidity was assessed by incidence of epistaxis, olfactory acuity, and mucociliary clearance. Patient discomfort during intubation was assessed using grimace score and hemodynamic parameters were recorded. Postoperatively, the incidence of nasal and laryngeal injury was recorded using nasendoscopy and telelaryngoscopy, respectively. Results: Demographic profile between the two groups was comparable. Epistaxis was noted in 47.5% of patients in group C as compared to 12.5% in group S. Postoperative olfactory acuity was decreased [2 (1-4) vs 4 (2-5)] and saccharin clearance time was prolonged (314 s vs 134 s) in Group C as compared to Group S. (P-value <0.001) Higher grimace score [2 (1-3) vs 1 (0-2)] and increased hemodynamic response was demonstrated in Group C. (P-value <0.001) Incidence of nasal injury [2 (1-4) vs 1 (0-2)] and laryngeal injury [1 (0-2) vs 0 (0-2)] was more in Group C as compared to Group S. Conclusion: Awake fibreoptic nasotracheal intubation with small size endotracheal tube followed by exchange to standard size under general anesthesia reduces nasal, laryngeal, and hemodynamic complications.

Comparison of the Efficacy of Septoplasty with Nonsurgical Management in Improving Nasal Obstruction in Patients with Deviated Nasal Septum - A Randomized Clinical Trial

Abstract Introduction In the current era, the major indication for septoplasty is nasal obstruction due to deviated nasal septum (DNS). Even though septoplasty is a commonly performed surgery, its effectiveness in relieving nasal obstruction in DNS has not been proven. Objective The present study involved the measurement of both objective (nasal patency) and subjective (quality of life measures) outcome measures for the evaluation of the efficacy of septoplasty as compared with medical management. Methods Patients with DNS presenting with nasal obstruction were included and randomized into a septoplasty group or into a nonsurgical management group, with 70 patients in each group. The improvement in nasal obstruction was assessed subjectively by the visual analogue scale (VAS), and the sino-nasal outcome test-22 (SNOT-22) and the nasal obstruction symptom evaluation (NOSE) questionnaires and was measured objectively by assessment of nasal patency by peak nasal inspiratory flow (PNIF) at 0, 1, 3, and 6 months of treatment in both groups. Results The average VAS, SNOT-22 and NOSE scores for the septoplasty versus the nonsurgical group before treatment were 6.28 versus 6.0, 19.5 versus 15, and 14 versus 12, respectively, and at 6 months post-treatment, the scores were 2.9 versus 5.26, 10 versus 12, and 8 versus 10 (p= 0.001), respectively. The average PNIF scores at 0 and 6 months were 60/50 l/min and 70/60 l/min, respectively, in the septoplasty group (p= 0.001); the scores at 0 and 6 months in the nonsurgical management group were 60/60 l/min and 70/70 l/min, respectively (p= 0.001). Conclusion Surgical correction of DNS by septoplasty improves nasal obstruction better than nonsurgical management at 6 months postsurgery.

Comparison of the Efficacy of Septoplasty with Nonsurgical Management in Improving Nasal Obstruction in Patients with Deviated Nasal Septum - A Randomized Clinical Trial.

Introduction In the current era, the major indication for septoplasty is nasal obstruction due to deviated nasal septum (DNS). Even though septoplasty is a commonly performed surgery, its effectiveness in relieving nasal obstruction in DNS has not been proven. Objective The present study involved the measurement of both objective (nasal patency) and subjective (quality of life measures) outcome measures for the evaluation of the efficacy of septoplasty as compared with medical management. Methods Patients with DNS presenting with nasal obstruction were included and randomized into a septoplasty group or into a nonsurgical management group, with 70 patients in each group. The improvement in nasal obstruction was assessed subjectively by the visual analogue scale (VAS), and the sino-nasal outcome test-22 (SNOT-22) and the nasal obstruction symptom evaluation (NOSE) questionnaires and was measured objectively by assessment of nasal patency by peak nasal inspiratory flow (PNIF) at 0, 1, 3, and 6 months of treatment in both groups. Results The average VAS, SNOT-22 and NOSE scores for the septoplasty versus the nonsurgical group before treatment were 6.28 versus 6.0, 19.5 versus 15, and 14 versus 12, respectively, and at 6 months post-treatment, the scores were 2.9 versus 5.26, 10 versus 12, and 8 versus 10 ( p = 0.001), respectively. The average PNIF scores at 0 and 6 months were 60/50 l/min and 70/60 l/min, respectively, in the septoplasty group ( p = 0.001); the scores at 0 and 6 months in the nonsurgical management group were 60/60 l/min and 70/70 l/min, respectively ( p = 0.001). Conclusion Surgical correction of DNS by septoplasty improves nasal obstruction better than nonsurgical management at 6 months postsurgery.

'Shifting from anxiety to the new normal': A qualitative exploration on personal protective equipment use by otorhinolaryngology health-care professionals during COVID-19 pandemic.

Background: The novel coronavirus pandemic has influenced the working practice of health-care professionals who come across symptomatic and asymptomatic COVID patients in their day-to-day practice. Especially, among HCWs in otorhinolaryngology, with the risk of exposure being high, hence were mandated to use personal protective equipment (PPE). Materials and Methods: The change in perceptions and patterns of PPE use throughout the COVID-19 pandemic was studied in detail through interviews conducted among 15 key informants, and the data were analyzed using health belief model in our study. Results: A health belief model explains the trajectory of PPE use by otorhinolaryngology health care providers during the COVID-19 pandemic. The course of usage of PPE by otorhinolaryngology health-care professionals during the COVID-19 pandemic was explained through the health belief model. During the initial days of the COVID-19 pandemic, intense perceived severity and susceptibility to COVID infection led to PPE use, and otorhinolaryngology HCWs resorted to higher grade PPEs which gave optimal protection; but in course of time with a better understanding of the natural course of illness, minimal PPEs without compromising HCW safety were used with minimal discomfort. Perceived severity of COVID infection on self and family, health knowledge, influence of peers, and support from the institution encouraged them in using PPEs. Conclusion: We found that various aspects of health belief model such as the perceived susceptibility, perceived severity of the disease, perceived barriers and benefits in PPE use, self-efficacy, health-related knowledge, and the cues to action influence PPE use among otorhinolaryngology HCWs. The key findings can be applied in behavior change models to promote the use of PPE in the hospitals, especially during the time of pandemic.

Middle turbinate angiofibroma in an adolescent boy.

Bleeding nasal mass in adolescent boys has customarily been attributed to Juvenile nasopharyngeal angiofibroma. However, little is known regarding the extranasopharyngeal origin of angiofibroma, as highlighted in this case report of a 15-year-old boy who presented with recurrent epistaxis and nasal obstruction. On constructing a working diagnosis of nasal haemangioma, the patient was taken up for endoscopic excision under general anaesthesia. Intraoperative endoscopic findings and histopathological examination revealed the diagnosis of middle turbinate angiofibroma, which is an extremely rare extranasopharyngeal angiofibroma. Consequently, this represents the third described case of a juvenile angiofibroma arising from the middle turbinate.

Naso-Bronchial Rhinosporidiosis.

Rhinosporidiosis is a chronic mucocutaneous granulomatous disease caused by Rhinosporidium seeberi, commonly affecting the nose and nasopharynx. Endobronchial involvement is of rare occurrence but can pose challenging problems for diagnosis, surgical excision and anaesthetic management. We report a 40-year-old man with a history of recurrent nasal rhinosporidiosis who presented with unilateral nasal obstruction, cough, shortness of breath and a radiological feature of left lung collapse. Eight years since the last surgery, he presented with a recurrent lesion in the nose with concurrent endobronchial involvement. The patient underwent excision of the nasal and the endobronchial lesion successfully under general anaesthesia without any complication and good symptomatic improvement. The clinical presentation and the management of endobronchial rhinosporidiosis are discussed here. The surgical difficulties faced during the procedure are highlighted.

Intact Parathyroid Hormone Levels in Predicting Postoperative Hypocalcaemia After Total Thyroidectomy in South Indian Population: Cross Sectional Study.

Hypocalcaemia being one of the most common complications after total thyroidectomy may not be avoidable in all cases. This study evaluated the effectiveness of intact Parathyroid hormone (iPTH) measured at 1-h after total thyroidectomy in predicting postoperative hypocalcaemia in early postoperative period in South Indian population. Patients who underwent total thyroidectomy in our institute from 2016 to 2018 were included. Preoperative calcium and iPTH levels were measured. Patients' iPTH level was measured 1 h after surgery and serum calcium level was measured at 24 h after surgery. Patients were also monitored clinically for any symptoms and signs of hypocalcaemia. A total of 57 patients were studied. The malignant causes accounted for 75.4% with papillary carcinoma thyroid being the most common cause. 65.7% of patients who underwent total thyroidectomy and 100% of patients who underwent total thyroidectomy with neck dissection developed hypocalcaemia. 70% of patients with low iPTH developed hypocalcaemia and none of the patients who had normal iPTH developed hypocalcaemia. This relation was statistically significant with p value of 0.018 (< 0.05). The positive predictive value is 70% and negative predictive value is 100%. Though our study supports the hypothesis that iPTH is effective in predicting hypocalcaemia after total thyroidectomy in the early postoperative period, a larger sample study is needed to further support this. It can be used to consider patients for early discharge or to prophylactically start oral calcium and Vitamin D supplementation based on iPTH levels at 1 h after surgery.