How Does Preoperative Pure Tone Audiometry Relate to the Findings at Surgery to Explain the Hearing Status in Chronic Otitis Media?

Objective: Pure tone audiometry (PTA) guides surgical decision-making in chronic otitis media (COM), and PTA values depend upon the type and extent of COM. Methods: Our cross-sectional study included patients with COM with/without cholesteatoma who were scheduled for surgery. Findings on examination of the middle ear under the microscope and at surgery which could explain the hearing loss were corroborated with preoperative PTA through appropriate statistical methods. Results: The study included 114 patients (mean age: 31.07 years; range: 7-57). Following preoperative PTA, 50% of patients had moderate hearing loss and ~73% had air-bone gap (ABG) <35 dB. Conductive hearing loss affected 109 patients (97.61%); five had mixed hearing loss. At surgery, 27 patients (23.68%) had ossicular discontinuity, with the incus being the most affected. Twenty-one patients in this group had ABG ≥35 dB. Perforations involving the anterior and posterior halves of the pars tensa, and subtotal perforations, demonstrated the maximum mean hearing loss [45.39±8.29 dB HL (p=0.075), 51.08±12.51 dB HL (p=0.26), respectively]. The mean pure tone average in the intact ossicles group was 43.62±8.07 dB HL and that in the absent/eroded ossicles group was 58.15±11.05 dB HL (p<0.0001); the mean ABG was 27.89±4.77 dB and 38.88±6.47 dB, respectively (p<0.0001). Conclusions: Hearing loss was significantly associated with the size but not the site of the central perforation. With ossicular discontinuity, hearing loss and ABG deteriorated significantly. The findings re-establish the relationship between preoperative PTA and the middle ear status which should help surgeons plan surgery and counsel patients regarding hearing outcomes.

Evaluation of the Role of Toluidine Blue Paint as an Adjunctive Method to Biopsy in Suspicious Oral Lesion: A Hospital Based Study.

Early detection is a major step in the success of cancer therapy. Histopathology report is considered as the gold standard in the formulation of management protocol of any malignancy worldwide. But unfortunately, there is a delay in the detection of oral cancer very often due to inconclusive histopathology reports. The main reason behind it is obtaining a biopsy specimen from the non-representative area of the lesion. A hospital-based evaluation of the role of Toluidine Blue dye, used as an adjunctive method prior to biopsy was conducted in a tertiary care hospital on 200 patients presenting with oral lesions persistent for more than 3 weeks. The participants were divided into two equal groups by alternate sampling. In one group biopsy was taken by clinical judgment and in others, Toluidine Blue was used prior to obtaining a biopsy to decide the area to be biopsied. Data was collected using a predesigned proforma and was analyzed with the help of SPSS version 20. Results in two groups were compared with respect to sensitivity, specificity, positive and negative predictive values, false positive and false negative percentages. The Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of wedge biopsy without staining were 73.68, 58.14, 70.00, and 62.50% respectively. These values were 95.08, 82.05, 89.23, and 91.43% respectively when Toluidine Blue staining was done as an adjunctive before the biopsy procedure. These results indicate the promising role of Toluidine blue staining before the biopsy to diagnose oral malignancy more efficiently than obtaining biopsy specimens on clinical assessment only and in avoiding the delay in initiating the treatment in case of oral malignant lesions.

The Anatomic Variations of the Nose and Paranasal Sinuses and Their Effect on Chronic Rhinosinusitis in Adult Patients.

To find out the anatomic variations of nose/paranasal sinuses and how they affect the sinuses in chronic rhinosinusitis (CRS). This observational cross-sectional study included adults with CRS, refractory to optimum medical management, planned for functional endoscopic sinus surgery (FESS). Pre-operative naso-endoscopy and computed tomography (CT) were utilized to estimate the extent of CRS, and to note the anatomic variations of the sinuses. The findings were corroborated within the practical scope of FESS. The anatomic variations were evaluated to establish how they affected the related sinus(es). Most of the 53 patients were young adults presenting with nasal obstruction (77%), discharge (76%) and headache (68%). On diagnostic naso-endoscopy, prominent agger bulge (83% of the nasal sides), prominent uncinate (18%), inferior turbinate hypertrophy (34%), concha bullosa (38%), mucopus and polyp in the middle meatus (51%, 19%; respectively), and gross septal deviation (55%) were noted. The spheno-ethmoid and frontal recesses were predominantly unremarkable. CT revealed inferior turbinate hypertrophy (38% of the nasal sides), agger (100%), and lateralized/collapsed uncinate (8%). Ethmoids and maxillary sinuses were diseased in 50% and 65% respectively, with blocked ostiomeatal complex in 32% and prominent bulla in 48%. Frontal and sphenoid sinuses were least involved (10%, 2%; respectively). Enlarged agger caused maxillary sinusitis (87%), whereas anterior ethmoiditis resulted from enlarged agger (100%), bulla (89%) and frontal cells (51%). Identification of the anatomic variations of the nose/paranasal sinuses through CT and naso-endoscopy (diagnostic, per-operative) is crucial to understand the pattern, extent and severity of the involvement of sinuses in CRS.

Do Benign Mass Lesions in the Superficial Lobe of Parotid Gland Influence Landmark-Based Search for Facial Nerve Trunk At Surgery?

OBJECTIVE: To assess the influence of benign mass lesions in the superficial lobe of parotid on the known anatomic landmarks for identifying the facial nerve trunk. METHOD: Patients with unilateral biopsy-proven benign mass lesions in the superficial parotid were selected for this observational study. During superficial/partial superficial parotidectomy, distance of the facial nerve trunk from each landmark was assessed using spring calliper and correlated with the lesion's volume (measured from the pre-operative imaging). At least two identifiers among tragal pointer (TP), posterior belly of digastric muscle (PBDM) and tympanomastoid suture (TMS) were considered. RESULTS: The study involved 32 patients. The lesions mostly involved the parotid tail (50%) and pretragal region (34.3%), and constituted of pleomorphic adenoma (~66%) and Warthin's tumor (~9%), the rest being various cysts and hamartomas. TP was universally uncovered, while PBDM and TMS were exposed in 26 and 25 patients, respectively. Average distances between the facial nerve trunk and TP, PBDM and TMS were 12.79 mm (SD=2.33), 9.78 mm (SD=1.21) and 7.58 mm (SD=1.33), respectively. Correlation coefficients between the lesion's volume and the distance of facial nerve from a given landmark were -0.11, 0.04 and -0.16 for TP, PBDM and TMS, respectively. CONCLUSION: TP was the most easily available landmark on surgical dissection, while PBDM was the most consistent and the least variable when volumetric data of the benign mass lesions in the superficial lobe of parotid were considered as a factor influencing the distance from the facial nerve trunk.

Chronic Draining Ear and Cholesteatoma Recidivism: A Retrospection from Clinical, Imaging, and Surgical Perspectives.

OBJECTIVE: To evaluate the reasons for persistent draining ear and cholesteatoma recidivism following canal wall down (CWD) tympanomastoidectomy by studying the sensitivity of high-resolution computed tomography (HRCT) scanning in different potential etiologies, corroborating through appropriate surgical intervention, and thereby, to suggest proper preventive measures. METHODS: In this observational study, 32 chronic, refractory draining ears were subjected to revision surgery following a radical or a modified radical mastoidectomy. Besides disease (cholesteatoma/granulations) eradication, pitfalls of the primary surgeries were addressed. Data were interpreted for studying the epidemiologic profile, the clinical presentation at recurrence, the type of primary surgery, the sites of recidivism, the probable causes, and the best possible management at revision. RESULTS: Of the 32 patients/ears, 23 had residual/recurrent cholesteatoma. Major reasons were inadequate disease clearance, contracted/inadequate conchomeatoplasty, no cavity obliteration, and inappropriate bone work. HRCT predicted persistent bridge and lateral semicircular canal dehiscence with 100%, and ossicular integrity and bony overhang with >80% sensitivity. Sinus tympani and oval window niche were the commonest sites of recurrence. At revision, radical/modified radical mastoidectomies were associated with cavity obliteration and appropriate revision of conchomeatoplasty in 28 patients. CONCLUSION: Recurrence of cholesteatoma/granulations is an important cause for chronic drainage from post-CWD cavities. Revision surgery explores the surgical pitfalls, and ensures clearance of disease from hidden areas, adequate bone work, and optimum conchomeatoplasty following cavity obliteration to provide a safe, dry ear with hearing improvement whenever feasible.

Pediatric Otolaryngological Emergency: An Experience from a Tertiary Care Teaching Institution at Kolkata, India.

Otolaryngological conditions constitute a major share of emergency medical problem among children. The present study was conducted to assess the patient profiles, incidences morbidities, mode of presentation and managements of different otolaryngological emergencies among pediatric patients presented in a tertiary care hospital. Descriptive cross-sectional study by analysing retrospectively collected information pertaining to the patients attended ENT emergency service department of a tertiary care hospital, Kolkata. Data were collected using predesigned proforma and were analysed with the help of SPSS version 20. About 39.0% of total ENT emergency attendance was contributed by pediatric age group. The male female ratio was 1:1.33 with average age of 58.95 ± 34.42 (mean ± SD) months. Half of the attendees had ear problem and almost one-third reported complaints related to nose. The major complaints at the time of presentation were earache (32.3%), nasal foreign body (24.0%) and aural foreign body (13.3%) closely followed by aero-digestive tract foreign body (12.0%). Inflammatory conditions affected the ears more, foreign bodies found most commonly in nose and miscellaneous condition such as impacted wax was found to be related to ear in significantly higher proportion. Conservative management was provided to 96.25% of patients. Foreign body insertion was found to be associated with lower age group. Most of the emergencies were managed conservatively which might be done at subdivision or district level to reduce the undesirable burden on the tertiary care medical colleges.

Estimation of partitioning of airflow in septal surgery: A prospective study with reference to the NOSE scale.

Improper patient selection for septal surgery often has been found to result in therapeutic failure, and there needs to be an objective assessment of nasal obstruction before the surgery and for postoperative follow-up that can be applied in the routine otolaryngology practice. The purpose of this study is to assess the usefulness of a cost-effective device for objective measurement of the nasal airway partitioning in selecting patients for septal surgery and for postoperative outcome evaluation. A hospital-based, prospective, observational study was carried out in a tertiary-care teaching institution involving 74 patients waiting for septal surgery. Each patient was exposed to subjective assessment of nasal obstruction by the Nasal Obstruction Symptom Evaluation (NOSE) scale and objective measurement by Nasal Partitioning Ratio (NPR) using a new device, Nasal Airway Partition Meter (NAPM), once before and twice after surgery. Overall, average NOSE score and NPR values were 66.42 ± 9.42 and 0.57 ± 0.18, respectively, at preoperative assessment (correlation coefficient 0.441). Sixty of the 74 patients had high values for both NPR and NOSE scores (Group 1), but in the remaining 14, NPR values were found to be lower despite high NOSE scores (Group 2). Postsurgery, the NOSE score and NPR values were significantly reduced in Group 1. In contrast, participants in Group 2 showed no alteration in the values of both the parameters after the same operative maneuver. However, 2 patients in Group 1 had NOSE score and NPR values unaltered, while 1 patient in Group 2 had a reduced NOSE score after surgery. Therefore, the validity of the new equipment was calculated to be 96.7% sensitive and 92.9% specific to identify patients who needed to undergo septal surgery for their nasal obstruction. It can be deduced from the present study that NAPM can be a cost-effective device for clinicians to objectively measure nasal airway obstruction and screen patients for septal surgery.

Socio-demographic Correlates of Rhinosporidiosis: A Hospital-Based Epidemiologic Study in Purulia, India.

The present paper attempts to explore the socio-demographic profile of patients with rhinosporidiosis in an endemic area. A cross-sectional study was carried out in a tertiary-care hospital in Purulia district, India, including consecutive patients with histologically-proved rhinosporidiosis. Their socio-demographic profiles were obtained through a pre-designed proforma with given epidemiologic parameters. Data was statistically analyzed with inputs from literature review. Of the 39 patients included, 87 % were fresh/new cases. The age-group of 10-20 years was mostly involved, with multiple peaks around 50. About 82 % were from rural background, commonly involved in cattle farming and agriculture, with a universal habit of pond-bathing. There was a male preponderance; however women were being increasingly affected. Nasal cavity was the predominant site involved; nasal obstruction and epistaxis were the primary complaints. About 13 % had recurrent lesions that were statistically related to higher age-group (≥15 years) and occupation (agriculture, labor). Rhinosporidiosis is predominantly the disease of young rural adults engaged in field activities and habituated to pond-bathing. A bimodal age distribution was noticed. The present article provides an update on the socio-demographic perspectives of rhinosporidiosis in an endemic zone. It also summarizes the factors that would identify the vulnerable population and help formulate preventive measures.

Diffuse Idiopathic Skeletal Hyperostosis Involving Cervical and Lumbar Spine Presenting with Dysphagia: A Case Report.

INTRODUCTION: Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a very rare cause of dysphagia when it occurs in the cervical spine. It can also affect the lumbar region where it causes deformity. CASE REPORT: In this article, a rare case of Diffuse Idiopathic Skeletal Hyperostosis involving both the cervical and lumbar spine, presenting with dysphagia and spinal stiffness leading to a stooping posture, is reported. CONCLUSION: Cases of simultaneous involvement of cervical and lumbar vertebrae by Diffuse Idiopathic Skeletal Hyperostosis, presenting with symptoms of both area involvement, are rarely reported in the English literature. When investigating a case of dysphagia, a high level of suspicion is required to diagnose such a condition.

Sporotrichosis of Maxillary Sinuses in a Middle Aged Female Patient from Rural Area of Eastern India.

Sporotrichosis is commonly a chronic infection caused by Sporothrix schenckii, a saprophytic fungus and is usually limited to cutaneous and subcutaneous tissues. Disseminated systemic, osteoarticular or pulmonary sporotrichosis have been reported but nasal sinusitis by this fungus is extremely infrequent. Earlier report from southern India documented a case of maxillary sinusitis by Sporothrix schenckii. Here we report a similar case of bilateral maxillary sinusitis in a middle aged female from a village of Bihar, a state in eastern India. She underwent endoscopic maxillary sinus surgery for nasal symptoms and diagnosed to have sporotrichotic infection of maxillary sinuses. The diagnosis was done by mycological and histopathological examination and patient improved under antifungal chemotherapy.

Extracalvarial Meningioma in the Parapharyngeal Space: Presentation, Diagnosis and Management.

Extracalvarial meningioma in the cervical region presenting as a parapharyngeal mass lesion is seldom encountered in clinical practice and poses great challenge in its diagnosis and surgical management. In this report, we present a case of extracranial meningioma in a middle-aged person who presented with a large, gradually progressing cervical swelling with multiple cranial nerve pareses. The difficulties in diagnosis and surgical management of this unusual neoplasm in the setting of partial encasement and thrombosis of the internal jugular vein have been discussed, along with the computed tomography and magnetic resonance imaging providing details of its extent and character. The report emphasizes the need to consider extracalvarial meningioma as a less common but important differential diagnosis of parapharyngeal space neoplasms.

Postoperative hypofunctioning of the thyroid gland after total laryngectomy.

Primary laryngeal carcinoma is a common cancer, predominantly affecting males. Hypothyroidism is an undesirable sequela of both surgery and radiotherapy, the two most commonly used modalities of treatment. For advanced cases, standard treatment protocol includes total laryngectomy and neck dissection along with pre- or postoperative radiotherapy. Hemithyroidectomy is also routinely performed as an integral part of total laryngectomy. In the present study, assessment of the function of the remaining half of the thyroid gland has been done in cases of total laryngectomies in combination with uni- or bilateral neck dissection and pre- or postoperative radiotherapy. This prospective, observational study was carried out for a period of 5 years in the Otolaryngology Department of R.G. Kar Medical College and Hospital, Kolkata, India, involving a dynamic cohort of patients with advanced laryngeal carcinoma (stage T3 or T4a) who underwent total laryngectomy (including hemithyroidectomy) and bilateral or unilateral neck dissection for primary laryngeal cancer along with preoperative and postoperative radiotherapy. Assessment of the thyroid function was based on the measurement of serum thyroid-stimulating hormone and free thyroxine levels. The results revealed that 23.8%, 45.2%, and 73.8% patients developed either clinical or subclinical hypothyroid state at 6, 12, and 24 weeks, respectively, after the surgery. The estimation of relative risk (RR) was found to be most prominent among the group belonging to the "preoperative radiation with bilateral neck dissection" group at all levels of assessments, but all of the RRs were found to be insignificant per their 95% confidence intervals. Superiority of any method could not be established or refuted firmly due to the small sample size of the study. We presume that in the future, a study with a larger sample size, involving a meta-analysis of multicentric data, would be the most suitable method to throw some light on this issue.

Supernumerary nostril with congenital cataract.

Supernumerary nostril is a very rare congenital anomaly. It can be unilateral or bilateral, and it sometimes occurs in the presence of other congenital deformities. Behind the external opening of a supernumerary nostril is a small accessory nasal cavity, which may or may not communicate with the normal nasal cavity on the same side. We describe a new case in which the supernumerary nostril with a small accessory nasal cavity, which did not communicate with the normal nasal cavity on the same side, appeared in a young girl who also had microcornea and congenital cataract. The accessory nasal cavity was successfully removed surgically. We believe that this case may represent the first reported case of a supernumerary nostril with a congenital cataract on the same side. We also discuss the hypotheses that have been proposed to explain supernumerary nostrils.

Use of fluoroscopic guidance to remove a migrating esophageal foreign body.

Ingested foreign bodies that migrate extraluminally are rare. In such cases, exploration of the neck via an external approach is the recommended procedure to remove the object. However, locating such a foreign body can be a difficult task. We report what we believe is the first adult case of fluoroscopically guided localization of an accidentally ingested foreign body that had migrated into the soft tissues of the neck. We also review the other methods used to locate a migrating foreign body.

Primary malignant melanoma of the external auditory canal extending into the preauricular area and scalp.

Malignant melanomas in the head and neck region are uncommon. When they do occur, they usually represent a metastasis. To the best of our knowledge, only 11 cases of primary malignant melanoma of the external auditory canal have been previously reported in the English-language literature since 1954. We describe a new case, which occurred in a 72-year-old woman who presented with a large, lobulated, pigmented mass with ulcerated bleeding on its surface. The patient was scheduled for surgery, but during preoperative preparations she developed signs of rapid dissemination and metastases to the liver and lungs, and she died of multiple organ failure within 3 weeks of presentation. Apart from the rarity of malignant melanoma of the external auditory canal, this case included other extraordinary features that make it noteworthy. Our experience with this case underscores the importance of early diagnosis and prompt initiation of treatment for patients with this potentially fatal malignancy.

Unusual presentations of adenoid cystic carcinoma in extra-salivary gland subsites in head and neck region: a case series.

Adenoid cystic carcinoma (ACC) is an uncommon malignant epithelial tumor occurring in head neck region, accounting for approximately 10% of all salivary gland neoplasms. Extra-salivary gland involvement of other head neck subsites by ACC may present in unusual modes creating clinical dilemma. Here we present some cases with extra-salivary gland ACC. In this series six cases with extra-salivary gland ACC were included. Three patients presented with external auditory canal and temporo-mastoid region involvement of whom two cases also had intracranial extension. In one case tongue was the site of involvement where it was confused with benign neurogenic tumour. Palatal erosion with formation of oro-nasal fistula was the the manifestation of ACC involving palate. On the other hand sinonasal bleeding mass which came out as ACC on histopathological examination did not cause any palatal erosion and was removed successfully via lateral rhiniotomy. In all these cases patients were treated with post-operative radiotherapy and were closely followed up for early detection of any distant metastasis. The experience about the various unusual manifestations of ACC and the therapeutic challenge poised by the cases is discussed here.

Dysphagia due to forestier disease: three cases and systematic literature review.

Forestier disease or diffuse idiopathic skeletal hyperostosis (DISH) is an uncommon cause of dysphagia. Due to rarity of this condition there is neither any demographic data nor any consensus about the investigation and treatment modalities. Here an effort is made in the present article to compile the information regarding the demographic and clinical features, investigation modalities and different methods of treatment from all the available case reports of dysphagia due to Forestier disease in the English literature till date. Three cases of the same condition are also reported in the present paper. Three cases of dysphagia due to Forestier disease treated in the ENT department of R.G. Kar Medical College and Hospital are reported herewith. A systematic review of literature is also done. All the case reports of dysphagia due to Forestier disease are obtained by World Wide Web search (WWWS) using 'Forestier Disease', 'DISH' and 'dysphagia' as the key words. Data regarding age, sex, duration of the symptom, associated symptoms, investigations done, level of vertebrae involved and different modalities of treatment with result are collected and analyzed systematically. We found total 73 cases of dysphagia due to Forestier disease. The condition commonly affects males (M:F 5.64:1) in older age group (94.52% cases are 60 years or above), often presented to the treatment facility after a long time of initiation of the symptom. Barium swallow X-rays and lateral neck X-ray were the most common investigations done to arrive at a diagnosis as per result of systematic review. Surgical removal of the causative osteophytes were the definitive treatment, but if surgery is contraindicated, conservative measures like switchover to liquid and semisolid food and proper swallow training also improve the condition to some extent. Dysphagia due to Forestier disease mostly affects older male, often has a chronic course. It can be diagnosed with simple investigations like neck X-ray or barium swallow X-rays. The definitive treatment is surgical, but if contraindicated the problem can be palliated with simple measures like swallow training and change of food.

Migration of a fish bone from the upper aerodigestive tract to the skin of the neck: a case report.

We describe an unusual case of a migratory foreign body (fish bone) in the neck of a 45-year-old woman. The 2.1-cm bone migrated from the esophagus and traversed through the entire soft tissue of the neck, and it almost extruded through the skin of the neck. With the patient under local anesthesia, the foreign body was easily extracted through an incision over the skin.

Huge hibernoma of the neck with extension into the mediastinum.

Hibernomas are benign tumors made up of brown fat. They are rarely encountered in otolaryngologic clinical practice, as they are usually located in the interscapular area, axilla, thigh, mediastinum, and retroperitoneum. We report an extremely rare case of a very large hibernoma in a 45-year-old man who presented with a 4-year history of neck swelling. Radioimaging was suggestive of a mass in both parapharyngeal spaces; the lesion was more prominent on the left side. The mass extended from C2 into the retropharyngeal space and superior mediastinum. Fine-needle aspiration cytology failed to yield a diagnosis. On surgical exploration, a tumor measuring 17 × 16 × 5 cm was removed and sent for histopathologic examination. Light microscopy was suggestive of a hibernoma. Staining with oil red O confirmed the diagnosis. To the best of our knowledge, a large hibernoma with such massive extension has not been previously reported in the literature.