Study of the Anatomical Variations of Spinal Accessory Nerve Seen During Neck Dissection.

In our study, thirty one neck dissections in thirty patients were performed as a part of their treatment for head and neck cancers over a period of one year. In this study, we aimed to report anatomical variations of the spinal accessory nerve (SAN) encountered during neck dissection with respect to important reference points and structures in the neck and correlate them with the length of the neck and height of patient. We preserved SAN in all the neck dissections and studied its course and branching in relation to internal jugular vein (IJV), sternocleidomastoid (SCM) muscle, greater auricular point (GAP), mastoid process, clavicle, angle of mandible, length of the neck and height of the patient. In 67.7% patients, the SAN was ventral to the IJV at the level of posterior belly of digastric muscle and in 32.3%, it was dorsal to the vein. In all the cases, SAN was found cephalic to the GAP at the posterior border of the SCM muscle with a mean distance of 1.72 ± 0.54 cm (range 0.90-3.06 cm). The distance between the tip of mastoid process and the point of emergence of the SAN from the posterior border of SCM (Exit Point length) was found to be nearly constant with a mean of 6.35 ± 0.63 cm (range 5.03-8.13 cm). We also found that there is a positive correlation between various parameters and the length of the neck and height of patients. Distance of exit point of SAN from the clavicle, however, is least helpful. We infer that the GAP is one of the most reliable landmarks for the localization of the SAN, followed by distance of exit point from mastoid process and angle of mandible. Also, surgeon should be aware of the variations regarding relationship to internal jugular vein and branching pattern of the nerve. The exit point should be sought for relatively inferiorly in longer necks and taller patients. SAN has great variations and thorough knowledge of these helps to prevent debilitating sequelae and medicolegal repercussions of shoulder syndrome.

Antifungal Resistance Profile of Fungal Isolates from Fungal Rhinosinusitis Patients: A Study from Tertiary Care Hospital.

Objective Fungal rhinosinusitis is on the rise worldwide and it is endemic especially in North India. The main purpose of this study was to determine the antifungal resistance profile of fungal isolates from the cases of fungal rhinosinusitis. Methods Antifungal susceptibility testing of isolated fungi to fluconazole, amphotericin B, itraconazole, and voriconazole was determined by standard CLSI broth microdilution method. Results Sixty-eight fungal isolates of Aspergillus spp . ( n = 49), Rhizopus spp. ( n = 9), Candida spp . ( n = 4), Penicillium spp . ( n = 2), Mucor spp . ( n = 2), Bipolaris spp . ( n = 1), and Alternaria spp . ( n = 1) were obtained from 60 different clinical samples as exudate from nasal mucosa ( n = 28), allergic mucin ( n = 8), nasal lavage ( n = 2), tissue biopsy from nasal polyps ( n = 14), and intraoperative nasal mucosa ( n = 8). Of the 68 isolates, 75% were resistant to fluconazole, 13.23% were resistant to itraconazole, 2.94% to amphotericin B, and none were resistant to voriconazole. Aspergillus flavus (5%) was the only fungi found resistant to amphotericin B, while against itraconazole, A. flavus (7.5%) and A. niger (100%) were found resistant. All the isolates of A. flavus , A. fumigatus , A. niger , and Penicillium spp. were resistant to fluconazole. Conclusion Although amphotericin B stills remains to be the most effective drug, more prospective studies are needed for the requirement of knowledge of the sensitivity pattern for optimal treatment and reduction in morbidity in the long run.

The Hearing Status of Preterm Infant's ≤ 34 Weeks as Revealed by Otoacoustic Emissions (OAE) Screening and Diagnostic Brainstem Evoked Response Audiometry (BERA): A Tertiary Center Experience.

To know the prevalence of hearing loss in preterm infants & to evaluate the sensitivity & specificity of otoacoustic emission (OAE) in detecting hearing loss in preterm infants ≤ 34 weeks. A total of 70 preterm babies from 28 to 34 weeks of gestational age were enrolled in the study. Detailed prenatal, perinatal, postnatal & family history and physical examination of the babies were carried out. First OAE was done at discharge or two weeks after birth, whichever was earlier and the second OAE assessment was done at 36-40 weeks of corrected age. Diagnostic brainstem evoked response audiometry (BERA) was done in all infants at 36-40 weeks of corrected age, at the time of second OAE. Neonates with hearing impairment were advised for early hearing aid amplification and were referred to the rehabilitation center for further management. The sensorineural hearing loss (SNHL) in either one of the ears was identified in 13 (18.57%) preterm babies. Bilateral profound SNHL was found in 5 (7.14%) babies. Auditory neuropathy profile was found in 7 (53.8%) out of 13 babies who had hearing loss. The sensitivity, specificity, positive and negative predictive values of second TEOAE compared with diagnostic BERA was 46.15%, 85.96%, 42.85%, and 87.5% respectively. Neonatal jaundice (p = 0.009) and history of exchange transfusion (p = 0.019) were found to be significant risk factors of hearing loss in our study. Other risk factors like mode of delivery, birth asphyxia, low APGAR score, meningitis, ototoxic drugs, and seizures were not associated with hearing loss. The prevalence of hearing loss in preterm infants < 34 weeks is very high. OAE alone is not an ideal screening test for high-risk neonates ≤ 34 weeks because of its low sensitivity. OAE combined with diagnostic BERA should be done in all high-risk infants preterm neonates ≤ 34 weeks to identify cases of auditory neuropathy spectrum disorders.

Regulatory and Educational Initiatives to Prevent Food Choking Injuries in Children: An Overview of the Current Approaches.

Choking injuries are one of the major causes of death among children ages 0-3, and most of these injuries are related to food. This work provides an overview of the current recommendations for food choking prevention and educational targets as a basis for developing a unified common set of knowledge for primary prevention policies development. Guidelines published by professional membership organizations and national governments in the English language were considered. All of these guidelines provide lists of hazardous food items and recommendations for food preparation to minimize choking hazard. Together with recommendations for food preparation, also recommendations aimed at stakeholders (food manufacturers, health care providers, and public authorities) are provided, underlining that this severe public health problem should be further addressed by adopting integrated public health interventions. Our overview stressed the importance of developing educational and primary prevention policies to sensitize adult supervisors and to regulate dangerous food products in the market.

Anthropometric analysis of linear parameters of the Indian nose: A cross-sectional study and comparison with literature.

BACKGROUND: Many studies have been done to find out the accepted "ideal" appearance and proportions of the nose. However, much of this work has been limited to the facial architecture of the North American Caucasian population. Therefore, most beauty standards are driven by Western influences. AIMS AND OBJECTIVES: To measure different standard linear parameters of Indian faces and compare them with the studies found in the literature, in an endeavor to help in preoperative planning in rhinoplasty while maintaining their ethnicity. METHODS: This was a hospital-based cross-sectional study of 500 subjects. A total of 21 standard measurements were noted directly from the faces, and 11 proportional values calculated. Mean values with standard deviations were statistically used for comparisons with studies in the literature. RESULTS: There were significant differences between male and female subjects of our study in 16 variables. The proportional indices calculated also revealed significant differences statistically in 6 out of 11 measurements between male and female subjects. Significant differences were found in most of the parameters when our data were compared with Indian American, North American white population, Korean, Chinese, and African American. CONCLUSIONS: Facial measurements in the Indian population are different from those of other races, such as nasal index: (al-al × 100/n-sn), sn-prn x 100/ al-al index, and sn-prn x 100/n-Sn index, and it is important to have own set of parameters to act as standards guiding esthetic nasal surgeries while maintaining ethnicities. Our study is an attempt at the same. However, because of the huge diversity of the Indian population, it requires larger studies from different regions to achieve the final aim to create standards for cosmetic rhinoplasties.

A Study on Neck Nodes in Oral Cancers, with Special Reference to Skip Metastasis.

To analyse the distribution of Neck metastases (NM) and to study frequency of skip metastases in oral squamous cell carcinoma (SCC) of oral cavity. From September 2012 to April 2013, 30 previously untreated patients with SCC of oral cavity underwent primary surgical treatment in our institution. From pathological report of Neck dissection specimen prevalence and distribution of NM were ascertained. All patients were classified according to American Joint Committee on Cancer 2005 TNM classification. Overall frequency of NM was 36.7%. Frequency of occult metastases was 33.3%. N+ metastases found in 37% cases. The overall frequency of NM in level IV and V was 9.5%. Isolated level III involvement was found in 3.3%. No isolated level IV and V involvement was found. Skip metastases to level III LN was 6.7%. We did not find any skip metastases to level IV in our study. Neck nodes at greater risk for metastases were level I and II (50 and 28.6%). Level III (11.9%), IV (7.14%), V (2.38%). The risk of skip metastases to level IV was nil in our study.

Is Acoustic Radiation Force Impulse (ARFI) Ultrasound Elastography Valuable in the Assessment of Cervical Lymphadenopathy?

Cervical lymphadenopathy frequently poses a diagnostic challenge as neither clinical nor imaging assessment can reliably differentiate between benign and malignant lymphadenopathy. Non-invasive differentiation between the two may help to reduce the number of FNAC or biopsy. The purpose of this study was to evaluate whether the new ARFI technique (Virtual Touch Quantification), in conjunction with gray scale sonography and Doppler, can help in the characterization and differentiation of benign from malignant cervical lymphadenopathy. Fifty adult patients with cervical lymphadenopathy were included in the study and sonoelastography was done. Sonoelastographic findings were compared to the gold standard histopathology or cytopathology. ARFI measurements in benign and malignant enlarged lymph nodes were compared using the Student t test and ROC curve was used to arrive at the Youden index, sensitivity, specificity, PPV, NPV and diagnostic accuracy. Sonographic patterns indicative of malignancy includes heterogenous echopattern, short axis/long axis ratio > 0.5, absent echogenic fatty hilum and mixed vascular pattern. Sensitivity, specificity, PPV, NPV and accuracy in differentiation between the benign and malignant lymph nodes using ARFI elastography was 79.17, 100, 100, 83.9 and 89.9% respectively. ROC curve analysis of SWVs for differentiation between the malignant and benign lymph nodes gave a cut-off value of 2.8 m/s with an area under curve of 0.892. ARFI imaging technique quantifies the tissue stiffness of the cervical lymph nodes non-invasively and aids in characterisation and differentiation of benign from malignant cervical lymphadenopathy in conjunction with conventional sonography.

Primary Ewing's Sarcoma of the Temporal Bone: A Rare Case Report and Literature Review.

Ewing's sarcoma is a malignant, round cell tumor arising from the bones and primarily affecting children and adolescent, accounting for 3 % of all childhood malignancies. Although the long bones and the trunk are typically affected, rare cases of it involving isolated bones throughout the body have been reported. Involvement of the skull bones is rare, constituting 1-6 % of the total Ewing's sarcoma cases but those affecting the cranial bones are rarer still, constituting only 1 %. We describe an 8 months old infant having Ewing sarcoma, of the petrous and mastoid parts of temporal bone along with the occipital bone, whose clinical presentation mimicked mastoiditis with facial nerve palsy. We discuss the clinical and therapeutic course of an extensive primary Ewing sarcoma of the temporal bone, which was treated without performing surgery and review this entity's literature in detail.

Myeloid Sarcoma Presenting as Nasal and Orbital Mass: An Initial Manifestation of an Acute Myeloid Leukaemia.

Myeloid sarcoma is an extramedullary manifestation of Acute Myeloid Leukaemia and sometimes is the only indicator of the disease. The incidence varies between 3-9.1% of acute leukaemia cases. The blast infiltration is seen most commonly in skin, lymph node, gastrointestinal tract, bone, soft tissue though can involve any body site usually as a solitary lesion and is rarely seen in nasal cavity. We present two cases of myeloid sarcoma presenting as a nasal mass in a six year old girl and other as orbital mass in 32-year-old as an initial manifestation of acute myeloid leukaemia. Histopathological examination along with immunohistochemistry clinched the diagnosis of myeloid sarcoma. Examination of bone marrow aspirate revealed blasts which fulfilled the criteria for acute leukaemia. These cases are usually misdiagnosed because often lymphoma and granulocytic sarcoma is not considered in initial list of differential diagnoses. These rare cases are being presented here as early recognition and diagnosis will ensure rapid treatment of the condition and improve the survival.

Allergic Fungal Rhinosinusitis: A Study in a Tertiary Care Hospital in India.

The study was conducted to study the occurrence and clinical presentation of allergic fungal rhinosinusitis (AFRS), characterize the same, and correlate with the microbiological profile. Clinically suspected cases of fungal rhinosinusitis (FRS) depending upon their clinical presentation, nasal endoscopy, and radiological evidences were included. Relevant clinical samples were collected and subjected to direct microscopy and culture and histopathological examination. 35 patients were diagnosed to have AFRS. The average age was 28.4 years with a range of 18-48 years. Allergic mucin was seen in all the AFRS patients but fungal hyphae were detected in only 20%. 80% of cases were positive for IgE. All the patients had nasal obstruction followed by nasal discharge (62.8%). Polyps were seen in 95% (unilateral (48.57%) and bilateral (45.71%)), deviated nasal septum was seen in 28.57%, and greenish yellow secretion was seen in 17.14%. Direct microscopy and septate hyphae were positive in 71.42% of cases. 91.4% of cases were positive by culture. 5.7% yielded mixed growth of A. flavus and A. niger. Prompt clinical suspicion with specific signs and symptoms along with timely sampling of the adequate patient specimens and the optimal and timely processing by microscopy and culture and histopathological examination is a must for early diagnosis and management.

Teeth in Rare Locations with Rare Complications: An Overview.

Ectopic presence of teeth within the dentate region is common in clinical practice. However, the presence of teeth in non-dentate areas such as the nasal cavity or the maxillary sinus is rare. These may remain asymptomatic for years, may be misdiagnosed as foreign bodies, or may present with some serious complications involving the nose and paranasal sinuses. Complications such as nasal obstruction, epistaxis, headaches, rhinolith formation, epiphora, sinusitis and oro-antral fistula have been well described in literature, however, very few cases of antro-cutaneous fistulas have been reported. We discuss three cases of ectopic eruptions of teeth, all occurring in children. The clinical and radiographic findings of the cases, possible etiology, complication, diagnosis and treatment are discussed.

Impact of endoscopic sinus surgery on olfaction and use of alternative components in odor threshold measurement.

BACKGROUND: One of the major causes of olfactory disturbances is chronic rhinosinusitis (CRS), and the main surgical modality to treat CRS is functional endoscopic sinus surgery (FESS). It, therefore, is essential to assess the effect of this surgery on olfaction. Also, it is necessary to find new ways of measuring olfaction so as to reduce dependability on standard tests available. OBJECTIVES: To study the prevalence of olfactory impairment in patients with CRS and to evaluate the impact of FESS on olfaction. The study also aims at investigating the use of other odorants in place of butanol-1 in the Connecticut Chemosensory Clinical Research Center test. SUBJECTS AND METHODS: Forty patients of CRS without nasal polyposis were included in the study to analyze the prevalence of olfactory dysfunction and examine the influence of FESS at 1 and 3 months after surgery. Computed tomography scores (Lund Mackay scores) were calculated preoperatively, whereas other tests, viz., visual analog scale scoring, nasal endoscopy (Lund Kennedy scoring), and composite olfactory testing with odor thresholds of butanol-1, peppermint, lemon, clove, and ethyl acetate were carried out before surgery and after surgery at 1 and 3 months. RESULTS: Of 40 patients, 70% had symptoms of hyposmia or of anosmia before surgery, which dropped to 22.5% at 1 month after surgery and to 10% at 3 months after surgery. Nasal endoscopy and visual analog scale scores improved significantly. Odor threshold and odor identification scores also improved compared with the preoperative levels. A significant positive correlation was found between the threshold scores of butanol-1 and other odorants, both before and after surgery. CONCLUSION: Significant improvement was observed in olfaction after FESS, both in patient responses and in objective testing. The olfactory results with peppermint, lemon, clove, and ethyl acetate were close to those with butanol-1, and, hence, these other odorants can be used in place of butanol-1 in measuring the odor threshold.

A case of cystic schwannoma in the neck masquerading as branchial cleft cyst.

One-third of schwannomas occur in head and neck region, mostly in the parapharyngeal region. Cystic change is seen in only 4% of schwannomas. The diagnosis of such tumors remains a challenge due to the rarity of these lesions and limited utility of fine needle aspiration cytology. When cystic, branchial cleft cyst is an important differential diagnosis more so due to radiological resemblance. We present a case of 42-year-old male with left sided neck mass masquerading as branchial cleft cyst clinically and radiologically. Multiple sections examined from the cystic areas of the mass revealed lymphoid aggregates beneath the cyst wall in addition to the schwannomatous areas.

Public health implications of obstructive sleep apnea burden.

OBJECTIVE: To assess the implications of obstructive sleep apnea (OSA) burden among Indian children. METHODS: MonteCarlo simulations were performed in order to estimate the number of OSA related obesity cases among Indian children (1-14 y of age) and the number of cases of stroke, coronary heart disease (CHD) and type 2 diabetes, considered as main adverse outcomes of OSA related childhood obesity, according to untreated and treated [adenotonsillectomy (AT) alone and AT associated to continuous positive airway pressure (CPAP)] pediatric OSA. Data used to perform MonteCarlo simulations were derived from a review about current literature exploring OSA related obesity. RESULTS: The analysis on the number of adverse outcomes according to treated and untreated obesity related to OSA showed that treatments reduce the number of obesity cases, resulting in a great reduction of the amount of stroke, CHD and type 2 diabetes cases. However, the cost for treating adverse outcome was higher in patients treated for obesity related to OSA compared to those not receiving any treatment. CONCLUSIONS: The reduction in the number of adverse outcomes due to treatment of obesity related OSA implicates the urgent need for public health policies in providing screening for OSA among children population: an early detection and a consequently prompt reaction to pediatric OSA could improve the burden of OSA related obesity.

Endoscopic, radiological, and symptom correlation of olfactory dysfunction in pre- and postsurgical patients of chronic rhinosinusitis.

The aim of the present study was to correlate olfactory dysfunction determined with psychophysical testing with nasal endoscopy, computed tomography (CT) scan, and patient's self-assessed olfactory deficit in patients of chronic rhinosinusitis (CRS) before and after sinus surgery. It was a prospective cohort study comprising of a total of 40 consecutive patients of CRS. All of them were given Connecticut Chemosensory Clinical Research Center Test for olfactory evaluation, nasal endoscopy, CT scan, and a graded questionnaire for perceived olfactory ability preoperatively on the same day after failing maximal medical management for 3 weeks. All investigations except CT scan were repeated 3 months postsinus surgery. For metrics, Visual Analog Scale (VAS) score, Lund Kennedy nasal endoscopy score, and Lund MacKay CT score were used. Spearman's correlation coefficients were determined between olfactory scores and endoscopic, CT, and VAS scores. Significant positive correlation was found between subjective VAS scores and composite odor scores both preoperatively (r = 0.89, P < 0.001) and 3 months postoperatively (r = 0.54, P < 0.001). Significant negative correlation was established between olfactory scores and CT (r = -0.71, P < 0.001). With nasal endoscopy also, the correlation results of odor scores were significant (r = -0.39, P = 0.01 in preoperative period and r = -0.47, P = 0.002 in postoperative period). Hence, it could be concluded that severity of olfactory disturbance determined by olfactory tests correlates well with nasal endoscopic findings, presence of CT opacification, and the patient's self-perceived olfactory insufficiency in CRS both before and after sinus surgery and can guide us well to determining the olfactory burden.

Physical activity patterns among school children in India.

OBJECTIVE: To assess the prevalence of physical activity and its relation with socio-demographic variables and eating habits among school-aged children in India. METHODS: The study incorporated secondary analysis of anthropometric measurements and questionnaires on lifestyle and dietary habits of 1,680 school children aged between 3 and 11 y, obtained while carrying out the OBEY-AD project. The inventory contained questions about several variables concerning to physical activity, educational background, lifestyles and eating habits for both children and parents. Questions were organized along specific contents, which could be informative topics, picture choices and multiple answers choices. RESULTS: Prevalence of inactivity was 21% and exhibited significant variations between cities. Physical activity was significantly associated to socio-economic status and consumption of fruits and vegetables. No association could be revealed with children's BMI. CONCLUSIONS: Health-promotion interventions aimed at improving healthy lifestyles in Indian children should focus on population strata with low socio-economic status.

Allergic Rhinitis in Children: A Randomized Clinical Trial Targeted at Symptoms.

Allergic rhinitis (AR) underlies many symptoms and complications which severely affect children's quality of life. This two-arm study aimed at evaluate the efficacy and safety of the medical device Narivent(®) versus topical corticosteroids in the symptomatic management of allergic rhinitis in paediatric patients. A randomized study was conducted. Forty subjects with a diagnosis of allergic rhinitis were randomized to receive one puff of Narivent(®) into each nostril twice daily for 30 days (n = 20) or to receive one puff of topical intranasal corticosteroid into each nostril twice daily for 30 days (n = 20). In both treatment arms, severity of major symptoms related to AR, including nasal congestion, rhinorrhoea, sneezing and nasal itching, was assessed subjectively on a 0-100 mm visual analogue scale. Nasal congestion, rhinorrhoea and sneezing improved significantly after 30 days of treatment with Narivent(®). Similarly, in topical steroids group severity of all subjective symptoms decreased significantly. Narivent(®) appears to be efficacious in treating nasal congestion and other major symptoms in children with AR over a 30-day period, showing comparable results to intranasal corticosteroids therapy but with a better safety profile.

Functioning thyroglossal cyst and concurrent ectopic thyroid in the floor of the mouth without an orthotopic thyroid gland.

We report the case of a 20-year-old man with a constellation of anomalies - a functional thyroglossal cyst and concurrent ectopic thyroid in the floor of the mouth, without an orthotopic thyroid gland. To our knowledge, this is the third such report in the otolaryngology literature. It is important to be aware of the possibility of concurrent ectopic thyroid and thyroglossal cyst in the absence of an orthotopic thyroid gland. The majority of reported cases of thyroid ectopy occur at the base of the tongue. The occurrence of an ectopic thyroid in the floor of the mouth is both unusual and not amenable to clinical examination. Even if there is good uptake on nuclear imaging, the ectopic thyroid may be hypofunctioning. We discuss the importance of thyroid imaging, as well as the need for preoperative imaging and an appropriate management strategy in the treatment of patients with this triad of anomalies.

The role of current audiological tests in the early diagnosis of hearing impairment in infant.

This study aims to compare the various audiological tests that are currently available as screening tools for infant hearing assessment. In developing countries, which have limited resources, it is imperative to design a screening programme that is easy to perform, gives accurate results, has good patient acceptability and is cost effective. Fifty infants, 3-12 months of age, were subjected to BOT for hearing, transient-evoked oto-acoustic emissions (TEOAEs), automated auditory brainstem response (AABR) test, auditory brainstem evoked response (ABR) testing and auditory steady state response (ASSR). The sensitivity and specificity of the various tests was calculated, with ABR test as the gold standard. We also compared them for average time taken, cost factors, ease of performance, number of repeat tests required and patient acceptability. All the screening tests, TEOAE, AABR and behavioral observation test had reasonably high sensitivity. Specificity was highest for behavioral observation testing (67.7 %) and AABR (64.5 %), but low for OAE test (48.3 %). The cost and time taken for each test was least for the behavioral observation test, which also did not require any repeat testing. TEOAE and AABR incur a recurring cost of approximately one dollar per test. However, in 12 and 28 % of the babies had to be called back for repeat testing, respectively. ASSR, as a diagnostic test, has a 100 % sensitivity and high specificity but scores down on the cost involved, time taken and the number of repeat tests required. Overall parent acceptability was the highest for behavioral observation test, as it was non-invasive and easy to perform. Behavioral observation combined with TEOAE/AABR, can be fairly accurate as screening tests for hearing loss in infants. Considering its ease of performance and low cost, behavioral observation could be used as a screening test for detection of hearing loss in infants, in those countries/places where universal neonatal hearing screening is not yet available.