Management of Laryngotracheal Trauma During the COVID 19 Pandemic: Our Experience.

Objective To study the outcomes in terms of airway, voice and swallowing as well as the economic impact of the trauma on patients' finances and the constrained health infrastructure due to the pandemic. Materials and methods Study design Retrospective study. Setting: Tertiary care teaching hospital. Subjects and methods: A retrospective study was done of the 19 subjects who sustained acute laryngotracheal trauma during the SARS CoV-2 pandemic and was managed at our institution from January 2020 to September 2021. Results Change in voice was the most common presenting symptom and thyroid cartilage fractures were the commonest cartilage injury noted. It was found that 93% (decannulated) of the patients had good functional outcome and 90% of them required financial support to meet the medical expenses. Conclusion During the COVID 19 pandemic, it was not only, early presentation, timely detection and intervention by the treating team, but also the multidisciplinary teamwork and the support system that facilitated the recuperation and restoration of these traumatized individuals back into society with good laryngeal function.

Lack of Association of Helicobacter pylori in Laryngeal Pathologies.

To study the association of Helicobacter pylori (H. pylori) in patients with laryngeal pathologies. Study design: prospective observational study. Tertiary care teaching hospital. One hundred consecutive patients with laryngeal lesions scheduled for microlaryngoscopy were enrolled in the study. Laryngopharyngeal reflux was assessed using the reflux symptom index and reflux finding score. Tissue samples from the laryngeal lesions were taken under general anaesthesia and were screened for the presence of H. pylori using real time polymerase chain reaction (PCR) for ureA genes and histopathological examination. Of the 100 patients, 14 had a significant reflux symptom index score and 35 had significant reflux finding score. The lesions in the study subjects included both benign and malignant laryngeal pathologies. Vocal cord polyps formed more than half of the laryngeal pathology (57%) studied. Our study could not detect H. pylori in any laryngeal lesions by PCR analysis and histopathological examination. H. pylori may not be associated with laryngeal pathologies.

Unusual Cause of Neonatal Stertor.

We report a case of neonatal respiratory distress caused by an epignathus. This rare tumour, arising from the basisphenoid and protruding from the mouth, is associated with high perinatal mortality. We highlight unique clinico-radiological findings and multidisciplinary approach for a successful outcome. We review oropharyngeal teratomas reported in the literature with current management approaches.

Laryngeal Dysplasia: To Biopsy or Not?

A renal transplant recipient with chronic hepatitis B underwent multiple laser excisions over 4 years for laryngeal keratosis. From the initial histopathology reports of mild to moderate dysplasia, a progression to squamous carcinoma was noted over 4 years. This case report highlights the possible role of immunosuppressants and hepatitis virus in the aetiopathogenesis of laryngeal carcinoma.

A Comparative Study of Outcomes and Quality of Life in Canal Wall up Mastoidectomies and Canal Wall down Mastoidectomies.

Abstract: Chronic Otitis Media (COM) of the squamosal type was primarily managed by performing a canal wall down mastoidectomy; however, the latter era otolaryngologist envisioned benefits in preserving the posterior canal wall. Our primary objective was to assess the disease specific quality of life following canal wall up (CWU) mastoidectomy and canal wall down (CWD) mastoidectomy surgery after a 6 month post-operative period. A prospective observational study was done from September 2017 to August 2018 where the charts of 380 patients from Christian Medical College, Vellore were reviewed. Details of patients above 18 years who had undergone the above surgeries for COM active squamosal disease from the period of January 2014 to December 2016; and had their post-operative follow up (average of 16 months) during the period of study were looked at. The CWU group had a significantly better disease-specific quality of life in the symptoms subscale than the CWD group (p value < 0.01). The CWU group showed a significant air-bone gap closure to 23.3 dB as compared to 27.7 dB in CWD (p value = 0.005). The recurrence rates were 4.5% (9 cases) in the CWU group and 3.9% (7 cases) in the CWD group, which was not statistically significant. Both CWU and CWD methods of mastoidectomy for COM squamosal type give comparable outcomes in terms of recurrence with the CWU group having a better disease-specific quality of life after surgery. Level of Evidence: 2a.

Early Initiation of Voice Therapy After Microlaryngeal Surgery - A Randomized Control Study.

A prospective single blinded randomized control trial was conducted to study if early initiation of voice therapy after microlaryngeal produces a better voice outcome in patients with benign vocal fold lesions. METHODS: In this Patients undergoing microlaryngeal surgery for benign vocal fold lesions were recruited for the study and underwent voice evaluation and videostroboscopy preoperatively. Participants were randomised into two groups depending on the duration of voice rest-A (2 days voice rest) and B (5 days voice rest). Following the period of voice rest, voice therapy (tube phonation) was carried out for a month. Postoperative evaluation was done at 6 weeks (over telephone) and 3 months (in person visit) follow up. Outcome measures included the VHI-10, auditory-perceptual voice ratings, acoustic analysis and videostroboscopic vibratory ratings. RESULTS: Of the 50 subjects, 35 completed the follow up evaluation. The overall compliance to absolute voice rest was 43%. Among the various parameters used for voice evaluation, there was no statistically significant difference between the two groups except for jitter, where the improvement in 5 day voice rest group compared to the 2 day voice rest group was statistically significant. CONCLUSION: Prolonged voice rest after microlaryngeal surgery is difficult to comply with. As there was no significant difference between the two study groups, clinicians may prescribe a shorter duration of voice rest followed by early initiation of voice therapy after microlaryngeal surgery.

Transnasal Flexible Laryngoscopy Using Different Topical Preparations and Methods of Application-A Randomized Study.

BACKGROUND: The field of laryngology has grown exponentially since the advent of the transnasal flexible laryngoscopy. Flexible laryngoscopy when performed skillfully using the proper technique, facilitates a good view of the hidden areas of the larynx. OBJECTIVE: To compare the effectiveness of the topical agents in providing a more comfortable experience for the patient, allowing the practitioner to advance the endoscope with less friction, pain and discomfort for the patient using 10% lidocaine spray, 2% lidocaine gel, 4% lidocaine with xylometazoline (1:1) soaked pledgets, or aqueous gel. MATERIALS AND METHODS: A prospective randomized single-blinded clinical trial was conducted in a tertiary care teaching hospital in South India where 376 patients were recruited and allocated into four groups based on the topical preparation used. Following endoscopy, each subject filled a questionnaire grading their experience on a visual analogue scale. The clinician also then answered a questionnaire on aspects of the endoscopy performed. RESULTS: The pain score and the ease of performing the procedure among the different groups were comparable. Those in the 10% lidocaine arm experienced significant burning sensation (P = 0.0001). The other variables such as throat pain (P = 0.783), gag reflex (P = 0.318), unpleasant taste (P = 0.092), globus (P = 0.190), swallowing difficulty after the procedure (P = 0.273), difficulty in breathing (P = 0.744) and willingness to have a repeat procedure (P = 0.883) were also comparable. CONCLUSION: Aqueous gel can be used topically during a flexible nasopharyngolaryngoscopy instead of an anesthetic agent alone or one combined with a nasal decongestant.

Isolated Aspergillus Laryngitis: Spectrum, Management, and Review of Literature.

PURPOSE: Isolated aspergillus laryngitis is rare and often diagnosed after surgical excision or biopsy for a suspected premalignant or malignant pathology. Unlike other systemic or localized aspergillosis, there are no specific guidelines for isolated laryngeal aspergillosis. Our experience of dealing with a wide variety of isolated laryngeal aspergillosis showed that this entity is very responsive to medical therapy, making extensive debridement (as often carried out in surgically accessible aspergillosis) unnecessary as it would invariably lead to long-term dysphonia. MATERIALS AND METHODS: A retrospective analysis of all cases of isolated aspergillus laryngitis that presented to our hospital over the past 5 years was carried out. All patients with confirmed histopathological diagnosis of aspergillus infection were included. RESULTS: Twelve patients (five males and seven females) aged 28-54 years, who were diagnosed with aspergillus laryngitis presented with dysphonia. The most common involved site was the true vocal cords. All patients underwent cautious biopsies either in the operating theatre or in-office using a channeled fiber-optic laryngoscope. On histopathological examination, eight had invasive aspergillus infection while others showed variety of noninvasive involvement including colonization of cysts and carcinoma in situ. The most common species isolated was Aspergillus fumigatus. Appropriate antifungal chemotherapy was prescribed after ruling out systemic involvement. None of the patients showed recurrence or residual lesions on follow-up and reported significantly improved voice. CONCLUSIONS: This study highlights the wide spectrum of presentation of isolated aspergillus laryngitis with Aspergillus fumigatus being the most common organism isolated. Even the invasive variant is a medically treatable condition with voriconazole being the drug of choice. The importance of cautious biopsies and resections for voice preservation is also emphasized. To our knowledge, this is the largest report on isolated aspergillus laryngitis.

Covid 19 Pandemic-Training of Healthcare Workers in Obtaining a Nasopharyngeal Swab: Our Experience.

To describe the training of healthcare workers (HCW) in nasopharyngeal swabbing during the COVID 19 pandemic. STUDY DESIGN: Retrospective study. SETTING: Tertiary care teaching hospital. SUBJECTS AND METHODS: One hundred and seventy eight health care workers were trained from May 2020 to January 2021. Three modules were designed to train the health care workers in the technique of obtaining a nasopharyngeal swab specimen.Training consisted of an instructional video on how to perform nasopharyngeal swabs and live demonstration followed by hands-on supervised training. The trainees included 30 doctors, 101 nurses, 31 respiratory therapists, 3 physiotherapists, 9 interns and 4 lab technicians. There were 39 male and 139 female trainees. After attending all 3 modules of training, they were confident and efficient in taking a non-traumatic nasopharyngeal swab. Good knowledge and adequate training is key to a good nasopharyngeal sampling for SARS CoV-2 testing.

Role of Narrow Band Imaging in Laryngeal Lesions: A Prospective Study from Southern India.

To assess the utility of Narrow Band Imaging (NBI) as a diagnostic tool in evaluating laryngeal pathology in patients presenting with hoarseness. Study design: Prospective cross sectional diagnostic study. Methods: 200 patients with voice change were recruited and laryngeal findings documented with high definition flexible endoscopy with both white light and narrow band light and the representative still images recorded for analysis. The NBI intraepithelial papillary capillary loop (IPCL) patterns was compared with the histopathology report. Of the 200 patients evaluated, 84 lesions were biopsied which included both benign and malignant lesions. The sensitivity obtained was 73.3% [54.1-87.7% with 95% CI] and the specificity was 87% [75.1-94.6% with 95% CI] for detecting malignant lesions. NBI can be considered as a useful diagnostic tool in evaluating laryngeal pathology and can be used to detect early premalignant and malignant lesions.

Voice Change Following Adenotonsillectomy in Pediatric Population: Myth or Reality?-A Pilot Study.

Modifications in the structure of pharynx following adenotonsillectomy are presumed to cause changes in the voice characteristics of patients. Data on effect of tonsillectomy/adenotonsillectomy on changes in voice among Indian children are sparse. This study was thus conducted to study the effect of adenotonsillectomy/tonsillectomy on childrens' voice. It was a prospective observational study of children aged 4-15 years undergoing tonsillectomy with or without adenoidectomy. Measures of voice were noted preoperatively, 1 and 3 months post-operatively. Subjective evaluation was done using Paediatric Voice Outcome Survey (PVOS) questionnaire administered to participants' parents. Objective evaluation was done by recording and analyzing using PRAAT voice analysis software which is an open-software tool. Statistical analysis was done using the statistical software SPSS 17.0 version. There were 31 children between 4 and 14 years of age 65% being male. Adenotonsillectomy was done in 83.5%. There was statistically significant difference in the subjective scores (PVOS) pre-operatively and 3 month postoperative score (p value = 0.001). However, there was no statistically significant difference between any other pre op and post op parameters. Though the only significant post tonsillectomy voice changes noted was subjective by parents 3 months later, it does raise concern whether this could be a reality and not a myth. Further studies with larger number of patients, including involving the subjective evaluation (PVOS) by another person in addition to patients' parent need to be undertaken to address this issue.

Sublingual dermoid causing stertor in an infant.

Sublingual dermoids are uncommon lesions in the floor of mouth. The most common age of presentation is early adulthood, but presentation in infancy has also been reported. This report highlights the clinical presentation and treatment challenges in infants. An 8-month-old infant presented with inability to close mouth, intermittent stertor and snoring. MRI suggested a sublingual dermoid which was confirmed on histopathology of the surgically enucleated specimen. Sublingual dermoids are uncommon lesions of the floor of mouth. The age of presentation of a sublingual dermoid depends on the initial size of the lesion. Large sublingual dermoids in neonates can present with respiratory embarrassment and need early surgical intervention. Surgical enucleation via an intraoral approach is the treatment of choice with external approach reserved for very large cysts below the mylohyoid. Large sublingual cysts can present with anaesthetic challenges and may need fibreoptic intubation.

Infraorbital nerve schwannoma: a rare cause of upper jaw swelling.

INTRODUCTION: Schwannoma of the infraorbital nerve is a rare entity, with lesser than a dozen cases reported in literature and only one from India. REPORT: This article reports a 23-year-old male presenting with a painless swelling in the cheek, which was eventually diagnosed as infraorbital nerve schwannoma. He underwent a complete excision of the tumor via a Caldwell Luc approach and continues to be disease free on 3 year follow-up. CONCLUSION: Despite its rarity, infraorbital nerve schwannomas should be considered in the differential diagnosis, of upper jaw swelling. We recommend the Caldwell Luc approach as safe, effective and cosmetically acceptable, for anteriorly based infraorbital schwannomas, and review literature on this unusual entity.

Chronic pharyngitis: role of atypical organisms: a case control study from South India.

BACKGROUND: Bacteria including Chlamydophila pneumoniae, Mycoplasma pneumoniae, and anaerobic bacteria such as Fusobacterium necrophorum have been implicated as etiological agents of chronic pharyngitis in Western literature. Because there are no data regarding this from India, the authors undertook this study. STUDY DESIGN: Prospective case-control study. SETTING: Tertiary-level medical college and hospital. METHOD: In total, 343 consecutive adults with persistent throat pain and/or irritation (duration ≥3 months) were screened for known causes of pharyngitis by a thorough clinical and endoscopic examination. In 71 patients, the evaluation performed was unable to determine any cause, and these were considered cases. An enzyme-linked immunosorbent assay test to detect IgA and IgG antibodies to C pneumoniae and M pneumoniae was performed on 66 of these cases and 62 controls. The posterior pharyngeal swabs taken from both the cases and controls were subjected to aerobic and anaerobic culture. RESULTS: Individuals with chronic pharyngitis had a 3.43 times odds of being seropositive for C pneumoniae as compared with controls (P = .001; odds ratio = 3.43). Aerobic organisms and M pneumoniae did not seem to be significant etiological agents for chronic pharyngitis. On the contrary, isolation of Fusobacterium spp was found to be significantly more in controls as compared with cases. CONCLUSION: This study suggests an association between IgA antibodies to C pneumoniae and chronic pharyngitis. Further studies using more specific tests combined with long-term follow-up are needed to confirm these findings.

Iatrogenic pseudoaneurysm: a rare complication of sinonasal surgery.

OBJECTIVE: We report 2 patients with iatrogenic pseudoaneurysms, which developed following sinus surgery. METHOD: Case reports and a review of literature of the management of iatrogenic pseudoaneurysm. RESULTS: For one patient who presented with massive epistaxis, the only lifesaving option available was to perform an urgent angiogram followed by selective embolization of the feeding vessel. In the second patient who presented with persistent nasal obstruction and discharge and no epistaxis, a traumatic aneurysm of the internal carotid artery was demonstrated on magnetic resonance imaging scan that was later confirmed by angiography; he, however, declined further treatment. CONCLUSION: Iatrogenic pseudoaneurysms that develop following a vascular injury, though rare, can cause life-threatening epistaxis or a thromboembolism. In this report, we describe 2 different manifestations of iatrogenic vascular malformations following sinus surgery. The role of angiography and subsequent endovascular therapy in the management of these lesions is emphasized.

A case of Turner syndrome with hyperparathyroidism in an adult.

Turner syndrome is a hereditary chromosomal anomaly that affects girls and women. A result of gonadal dysgenesis, its primary characteristics are short stature, osteoporosis, neck webbing, and cardiac defects. Turner syndrome may also involve the auditory system and kidneys. We report the case of a woman with Turner syndrome who presented late in adulthood with severe osteoporosis and hypercalcemia. She was subsequently diagnosed with primary hyperparathyroidism secondary to a parathyroid adenoma. After excision of the adenoma, the woman's serum calcium level normalized. To the best of our knowledge, only 4 other cases of Turner syndrome with hyperparathyroidism have been reported in the literature.

Outcome analysis of benign vocal cord lesions by videostroboscopy, acoustic analysis and voice handicap index.

Benign vocal cord lesions affect vibratory vocal fold function resulting in significant dysphonia. A prospective study of 30 patients with benign vocal fold lesions was undertaken at our centre to compare the pre and post operative voice using videostroboscopy, voice analysis and voice handicap index. The vibratory pattern of the cord improved as evidenced by the stroboscopic parameters-symmetry, mucosal wave and glottic closure (p<0.05). Voice analysis showed a trend towards normalcy but the values obtained did not attain statistical significance. Voice handicap index showed a reduction in the total and the subscales scores. Videostroboscopy along with acoustic analysis and voice handicap index are useful tools in the objective and subjective assessment of the effectiveness of treatment in patients with benign vocal cord lesions. Their routine use in a voice clinic is recommended.