"Sealing the Gap" : CSF Leakage Demystified-A Comprehensive Analysis of our Experience in CSF Rhinorrhea Management.

CSF (Cerebro Spinal Fluid) rhinorrhoea occurs when the fluid leaks from subarachnoid space into the nasal cavity. The study aims to find out the prevalence and demographic distribution of CSF leak and to describe the site of the CSF leak along with the management. We did a prospective study on 180 patients admitted with head injury in neurosurgery department, along with the patients who came to ENT department with unilateral nasal discharge during the time period from March 2017 to March 2021. A total of 36 cases of CSF leak were obtained during the time period. The etiology in 18 cases was head injury & the other 18 cases were either due to infectious or nontraumatic causes. In our study, 26(72.22%) patients were aged less than 50 years. Incidence was more among males compared to females. The most common etiology was head injury - 18(50%) patients followed by the spontaneous leak- 16 (44.44%) patients with the most common site as the cribriform plate. Endoscopic repair using a hadad flap was done in most of the patients. Trauma due to head injury is the most common etiology in CSF rhinorrhea with more number of patients aged less than 50 years. Most of the leaks can be repaired successfully with the use of endoscope with excellent illumination & localizing the exact site of the leak.

Anatomical Variations of Sphenoid Sinus in South Indian Population: All That You Need for Trans-Sphenoidal Pituitary Surgery.

Pituitary adenomas are one among the most common neurosurgical tumors with an incidence of 10-25% among intracranial neoplasms (Ezzat et al., Cancer 101:613-619, 2004). Surgical management for the same has been practiced since long, and has evolved from trans cranial approach to endoscopic trans sphenoidal method (Hammer and Radberg, Acta Radiol 56:401-422, 1961). Preoperative radiological analysis with CT &MRI is inevitable in planning endonasal trans-sphenoid surgery to avoid complications because of the high variability concerned with sphenoid anatomy. The present study intends to analyze the incidence of various anatomical variations of sphenoid sinus in a cohort of south Indian population as detected by CT& MRI and assess its impact on surgical approach. Retrospective analysis of CT&MRI images of patients who underwent Endonasal Trans-sphenoidal resection of pituitary tumors at JSS Hospital Mysuru from a period of 2009 to 2020 is done. Anatomical variations of sphenoid sinus esp. degree of pneumatization, sellar configuration, septation pattern, inter carotid distance were evaluated. Results were significant and in concordance with other similar studies. Most frequently encountered pnuematization was sellar type and least was conchal type Sphenoid sinus pneumatization is directly linked to safe access to sella. Presence of septae within sinus need to be identified preoperatively to avoid damage and confusion intraoperatively. A meticulous preoperative analysis of sphenoid sinus anatomy will help surgeon in smooth conduct of a complication free surgery.

Assessment of Rhinostomy Parameters in Endonasal Dacryocystorhinostomy.

Epiphora is a bothersome condition seen in chronic dacryocystitis. The mainstay of treatment is surgical, that is creating an opening to establish a drainage pathway. With the advent of endoscope, endonasal DCR has gained popularity. Use of silicone stent in endonasal DCR has added advantage in improving the surgical outcome. And the use of DOS system in improving the success rates of endonasal DCR: (Mohammad et al. in Clin Ophthalmol 8:2491-2499, 2014) a total of 35 patients with chronic dacryocystitis were subjected for endonasal DCR with silicone bicanalicular stent. Patients were followed up at an interval of 1 week, 3 weeks, 6 weeks and 6 months post surgery. DCR ostium parameters were evaluated using DOS system. Silicone stent removal was done at sixth week and evaluated for success. The success rate in our study was 89%. The DOS score of the patient with successful surgery had a score of more than 30 and in the failed cases the score was between 22 and 28. The success rate of the procedure primarily depends on the ostium parameters and the position of the silicone stent. The DOS scoring system can be suitable tool in evaluating the same.

Specific ultralow level chemo-recognition using Graphene-fluorophore supramolecular assembly: Fine-tuning the fluorophore framework.

The non-covalent interactions between graphene and aromatic fluorophores have generated highly sensitive fluorimetric turn-on sensors for various significant analytes. Herein, the supramolecular interaction between reduced graphene oxide and 7-Hydroxy-4-Methyl-8-Amino Coumarin is made use of for tracing Cu2+ at sub-zeptomole level with excellent selectivity among a collection of nineteen metal ions. The system enables quantification of the analyte in a commendably wide range, from micromolar to zeptomolar, a feature that almost all-optical sensors lack. Handy solid-state sensor strip fabricated using the above-mentioned supramolecular combination enabled visual recognition of Cu2+ions at the molecular level. Based on the chemo recognition ability of the fluorophore, multiple Boolean logic devices operating at the molecular level are proposed. By screening pertinent coumarin derivatives, it is demonstrated that the selectivity and sensitivity of the sensors of this sort are decided by the number of π- interaction centers of the fluorophores and the strength by which they interact with graphene, respectively, which will enable identification and modification of proper fluorophores for ultra-trace detection of contaminants of environmental relevance from aqueous solutions.

A Study on Surgical Implications and Variations of Suprameatal Spine and Other Landmarks on the Lateral Surface of Temporal Bone.

Mastoidectomy forms the main surgical procedure for eradication of disease in chronic otitis media. Such a surgery which contemplates a complete exenteration of all the tympano-mastoid cavities is rightly considered as a difficult one mainly because a large number of vitally important structures are crowded together in the small field of operation and there is always a risk of damaging them. It is therefore, extremely important that the otologist who would undertake this surgery be thorough with the details of the surgical relations of this region. Out of the various structures seen on the lateral surface of temporal bone one very important structure is the suprameatal spine. It is shown to have great variations in shape and size and has been a mystery to researchers due to the implications it is known to have on mastoid region anatomy. In this study we have evaluated the various types of suprameatal spine, prevalence of each type and the effect of each to other landmarks encountered during surgery and also the effect of mastoid pneumatisation on the same.

Extended Surgical Implication of Tubercle of Zuckerkandl in Total Thyroidectomy.

The primary objective of the study was to assess the Tubercle of zuckerkandl (TZ) during thyroid surgeries and its relationship with RLN and Superior parathyroid (SP). A prospective study was done in, 30 consecutive cases of total thyroidectomy in whom per operatively TZ was identified. The presence of TZ, its laterality, size, relationship with RLN and parathyroid glands were documented. A grading system outlined by Pelizzo was applied in our current study. In majority of the cases the RLN was found to lie medial to TZ (26/30), followed by lateral position (3/30) and one case it was found to be posterior to TZ (1/30). The superior parathyroid was identified in close relation (< 2 cm) to the TZ in 27/30 cases. The distance between the TZ and SP was assessed. We proposed a classification for location of SP based on the distance between SP and TZ and also attempted to relate each class of SP location with TZ grade. There was strong association of Grade of TZ with the class of SP location (p value = 0.00046). TZ is constant surgical landmark with good reliability to identify the RLN and SP. RLN is found medial to TZ in majority of cases with few exceptions. SP is found to be closely associated with TZ in majority of cases and there is a strong relationship of proximity of SP and TZ with respect to TZ grade. Although this required further studies with larger population.

Quest for the Ideal Nasal Pack in Post Operative Cases of Septo-Turbinoplasty: Study in a Tertiary Care Hospital.

To compare the efficacies and post operative outcomes of patients with nasal packing with merocel, intranasal splints and merocel along with intra-nasal infant feeding tubes following septo-turbinoplasty, in patients with nasal obstruction secondary to septal deviation and inferior turbinate hypertrophy. A prospective study was done in 60 patients of symptomatic deviated nasal septum with inferior turbinate hypertrophy. Septoturbinoplasty was performed. Patients' nasal cavity was packed for 48 h after being randomly divided into 3 groups: (1) packing using merocel, (2) intra-intra nasal septal silicone splint, (3) packing using truncated merocel along with infant feeding tube. Patients were given a questionnaire 24 h post operatively and their reponse was analysed to compare nasal blockage, epistaxis, epiphora and headache. Pain on pack removal was recorded after 48 h. We found that merocel with infant feeding tube had better tolerance than plain merocel in almost all cases, with symptoms of nasal blockage, epiphora, headache and pain on pack removal being lesser than with plain merocel, and comparable to the results produced by nasal splints. Also the epistaxis control in merocel with infant feeding tube was better than with nasal splints. Truncated merocel with infant feeding tubes provides a suitable and cheap replacement for nasal splints which may not be affordable to a lot of patients, or may not in available in many settings. The results are superior to plain merocel and the control of post operative bleeding is better than with intra nasal splints.

Evaluation of Dynamic CT Scans and Analyzing Its Efficacy Accuracy in Staging of Laryngeal CA: A Prospective Analysis of 30 Patients and Review of Literature.

Laryngeal and hypopharyngeal cancer is the most common cancer in the head and neck. It is the most commonly reported human malignancy, with more than 100,000 cases reported annually worldwide. Thus, exact staging of the tumor is of utmost importance in the decision making of the management of these patients. CT can directly evaluate penetration of tumor into the laryngeal soft tissues and cartilages; whereas laryngoscopy and contrast laryngography can only infer deepseated abnormalities from changes in surface contour of the laryngeal cavity. The main aims of our study were: (1) To assess whether dynamic CT scans increase the diagnostic efficacy for laryngeal and hypopharyngeal cancers and its extent in surrounding structures. (2) To assess the importance of phonation CT scans in evaluation and diagnosis of vocal cord paralysis/fixity and involvement of subglottic region and pre epiglottic space.

Laryngectomy With or Without Partial Pharyngectomy: A Systematic Review.

Complications following the total laryngectomy with or without partial pharyngectomy with neck dissection for laryngeal and pyriform fossa malignancies like aspiration, pharyngocutaneous fistula wound infection, flap necrosis, haematoma, chyle fistula and carotid blowout can cause serious implication on the final outcome of the treatment, which leads to increased postoperative morbidity, hospital stay and hospital cost. A prospective study in the Department of Otolaryngology and Head-Neck Surgery, JSS Hospital, Mysore, from November 2014 to July 2016. 30 patients undergoing Total laryngectomy with or without partial pharyngectomy for laryngeal and pyriform fossa were included in this study. The presentation, diagnosis, and management of the complications that were occurred, were discussed. The age of the patients vary between 32 and 76. Also, male preponderance was seen with approximately M:F ratio 3:1. Out of these 30 patients, 6 patients developed complications. The most common complication was pharyngocutaneous fistula (2 patients, 6%), which was developed after the 7th day. It was managed conservatively in both patients, wound infection was a second complication (2, 6%). Other complications were drain failure (1, 3%) and chylous fistula (1, 3%). The Most common complications after total laryngectomy with or without partial pharyngectomy with neck dissection in our study were wound infection and pharyngocutaneous fistula. Assessment of risk factors, early recognition of complications per operative protocols with improvised techniques are necessary to reduce incidence of complication after total laryngectomy with or without partial pharyngectomy with neck dissection.

Contrasting Surgical Management of CSF Leak from Lateral Recess of Sphenoid Sinus and Its Surgical Outcomes: Our Experience.

CSF leak from Lateral Recess of Sphenoid (LRS) sinus accounts for 35% of all CSF rhinorrhoea cases. There are various surgical techniques described for repair of LRS CSF leak. This study describes the experience of LRS leak repair in a tertiary care center with three different surgical techniques. Study comprises of 3 cases of LRS CSF leak that presented to J.S.S. Hospital, during the time period of July 2018-January 2019, who underwent endoscopic CSF leak repair. All three cases underwent endoscopic endonasal transpterygoid approach to the leak site. The closure technique opted for all three cases were different. For the first case free mucosal flap from ipsilateral middle turbinate was used, for the second ipsilateral nasoseptal flap (NSF) was used and contralateral NSF was used for the third. All the cases were followed up for a minimum of 3 months. In all the 3 cases the CSF leak site was located in the lateral recess of Sphenoid sinus. Encephalocele was noted in two cases, which were cauterised and closure was done as planned. Crusting was more in cases that underwent closure using free mucosal flap. Healing and take up was similar for both the ipsilateral NSF and contralateral NSF. The endoscope has revolutionized the management of CSF leak from the lateral recess of sphenoid sinus. These defects can be managed efficiently using multilayer closure of defect. For large defects, the Posterior nasoseptal flaps can be used. In addition, contralateral PNSF has lower chances of being devascularized due to injury to pedicle while drilling the pterygoid plates.

An expedient sequential one-pot four component synthesis of novel steroidal spiro-pyrrolidine heterocycles in ionic liquid.

A facile one-pot synthesis of novel steroidal dispiro-indenoquinoxaline pyrrolidines via multicomponent-[3+2]-cycloaddition of azomethine ylides in ionic liquid is described. The structure of cycloadduct is confirmed by IR, (1)H NMR, (13)C NMR, high resolution mass spectroscopy and elemental analysis.

Determination of theophylline in rabbit plasma by triple quadrupole LC/MS.

AIM AND BACKGROUND: A simple, sensitive and rapid method was developed for quantitation of theophylline in rabbit plasma utilizing Triple Quadrupole LC/MS. MATERIALS AND METHODS: An aliquot of 0.1 mL of plasma sample was extracted with ethyl acetate using Heidolph Vortex. The chromatographic separation was performed by using HyPURITY ADVANCE™ C18 Column (3 × 50 mm) with a mobile phase of 80% methanol and 20% 2 mM ammonium acetate buffer followed by MS/MS detection. The analyte was quantitated in positive ionization mode. Multiple reaction monitoring (MRM) using the transition m/z 181.1→124.2 and m/z 180.2→110.1 was performed to quantify theophylline with internal standard (IS, Phenacetin), respectively. The method had a total chromatographic runtime of 3 min and linear calibration curves over the concentration range of 50.418-5062.063 ng/mL. The lower limit of quantification (LLOQ) was 50.418 ng/mL Sodium heparin (3.50%) used as an anticoagulant to prepare rabbit plasma and samples were maintained at 10°C in the auto sampler during the assay period. Inter and intraday batch precision and accuracy of the method were determined by using six quality control samples. RESULTS: Average accuracies for the assay were 89 to 106%, inter and intra-day coefficients variation (CV) of <9% and the recovery is 39.30% for theophylline and 57.00% for Phenacetin. CONCLUSION: Currently we are extensively using this method in our laboratory for quantitative analysis of theophylline in rabbit plasma samples and proved to be simple, accurate and precise.

Chemometric investigation of complex equilibria in solution phase II: Sensitivity of chemical models for the interaction of AADH and FAH with Ni(II) in aqueous medium.

A detailed study of the species formed in the complex equilibria involving adipic acid dihydrazide (AADH)/2-furoic acid hydrazide (FAH) with Ni(II) using pH titration with glass electrode is performed. The results of modeling studies and effect of errors on the equilibrium constants of AADH/FAH with Ni(II) refined by the non-linear least squares program MINIQUAD75 are reported. Based on the expert system approach developed in our laboratory for the species formed from secondary formation data (n and n (H)), several preliminary chemical models were tested. For the four species identified (MLH, ML, ML(2)H, ML(2)), an exhaustive search of a different combination of models (15) was performed. Then other suspected minor species (ML(2)H(2), ML(3) and ML(3)H) were tested. The final best fit chemical model was found to contain ML(3)H to an extent of 3% along with the other four major species. In order to ascertain the accuracy of the stability constants and consequently distribution of the species, a detailed error analysis is attempted. As the existing least squares procedures cannot suppress the systematic errors, three-dimensional plots of the simultaneous effects of pH and TLO:TMO (1.5:1 to 5:1) on the percentage of species are drawn which are of immense use in arriving at optimum conditions for the preparation of a complex of definite stoichiometry.