Olfaction in Juvenile Nasopharyngeal Angiofibroma: The first study.

BACKGROUND: To study the pattern of olfactory dysfunction/recovery in juvenile nasopharyngeal angiofibroma (JNA). METHODS: Olfactory assessment was undertaken in 30 patients (category1) both pre- & post-operatively and in another 18 (category 2) only postoperative. All patients underwent transpalatal excision and variables of interest included age, radiological stage/parameters & tumor size. RESULTS: Objective olfactory dysfunction was seen in 60% while involvement of olfactory strip was suggested in 50%. Despite some marginal trends only noted between size/age with change of olfaction, Pearson's correlation test did not reveal any significance amongst multiple variables. However a better recovery of olfaction following surgery was evident in Category-2 where Chi-Square test (p < 0.05) significantly revealed this to be a function of postoperative duration. This regenerative course in JNA suggests an optimum period of 4 years for full recovery after surgery. CONCLUSION: In this first study of olfaction in JNA many new trends have been appreciated. In general, deteriorations of olfaction were seen due to 'vascular-concussion' effect in early postoperative phase where post-surgical clearance of airway showed minimal effect in terms of improvement. The hypervascularity of olfactory epithelium with possible hormonal effects may be responsible for the unique pattern of olfactory function and recovery in JNA.

Clinical correlation of molecular (VEGF, FGF, PDGF, c-Myc, c-Kit, Ras, p53) expression in juvenile nasopharyngeal angiofibroma.

BACKGROUND: A molecular surrogate may exist for the clinical behaviour of juvenile nasopharyngeal angiofibroma (JNA). METHODS: In 9-14 cases, a 'correlation' of clinical behaviour with molecular expression (m-RNA expression through RT-PCR) of VEGF, FGF, PDGF, Ras, c-Myc, c-Kit and p53 was undertaken. RESULTS: A comparison of the two extremes of expressions characterized some specific clinical phenotypes for every marker except c-Myc. A higher FGF was associated with post-adolescent presentation, smaller tumour size, enhanced haemorrhage and recurrence. A higher c-Kit was associated with adolescents, rapid growth, skull base involvement and recurrence. Enhanced Ras was associated with post-adolescence, smaller tumour size, skull base involvement and recurrence. Enhanced p53 and PDGF were associated with adolescents, early presentation and rapid progression. Higher VEGF expression was associated with skull base involvement and enhanced haemorrhage. CONCLUSION: This study is currently the only evidence revealing a clinical molecular association in JNA and larger multicentric studies need to be performed to show a statistical significance.

Time trends in recurrence of juvenile nasopharyngeal angiofibroma: Experience of the past 4 decades.

BACKGROUND: An analysis of time distribution of juvenile nasopharyngeal angiofibroma (JNA) from the last 4 decades is presented. METHODS: Sixty recurrences were analyzed as per actuarial survival. SPSS software was used to generate Kaplan-Meier (KM) curves and time distributions were compared by Log-rank, Breslow and Tarone-Ware test. RESULTS: The overall recurrence rate was 17.59%. Majority underwent open transpalatal approach(es) without embolization. The probability of detecting a recurrence was 95% in first 24months and comparison of KM curves of 4 different time periods was not significant. CONCLUSION: This is the first and largest series to address the time-distribution. The required follow up period is 2years. Our recurrence is just half of the largest series (reported so far) suggesting the superiority of transpalatal techniques. The similarity of curves suggests less likelihood for recent technical advances to influence the recurrence that as per our hypothesis is more likely to reflect tumor biology per se.

True bilateral nasopharyngeal angiofibroma: report and review.

This report describes the third case of a true bilateral Juvenile nasopharyngeal angiofibroma (JNA), i.e. two separate JNA arising from both sides simultaneously. The associated multiple recurrences in such a case have not yet been reported. A 21-year-man underwent transpalatal excision and recurred twice. The last 'neo-occurrence' encountered after 2 years was at a different site and was subsequently managed by post-embolization endoscopic resection. A complete report of its clinico-radiological features and management outcome is discussed.

Prevalence of hearing impairement in the district of Lucknow, India.

A multi-cluster study (survey) was carried out by department of ENT KG Medical University, Lucknow from July 2003 to August 2004 in rural and urban population of Lucknow district to estimate prevalence and causes of hearing impairment in the community. Data included audiological profile and basic ear examination that was analysed through EARFORM software program of WHO. Overall hearing impairment was seen in 15.14% of rural as opposed to 5.9% of urban population. A higher prevalence of disabling hearing impairment (DHI) in elderly and deafness in 0-10 years age group was seen. The prevalence of sensorineural deafness necessitating hearing aids was 20% in rural and 50% in urban areas respectively. The presence of DHI was seen in 1/2 urban subjects and 1/3rd of rural counterparts. The incidence of cerumen / debris was very common in both types of population and the need of surgery was much more amongst rural subjects indicating more advanced / dangerous ear disease.

Olfaction in Primary Atrophic Rhinitis and Effect of Treatment.

OBJECTIVE: To assess olfactory and clinical morbidity in primary (idiopathic)-type atrophic rhinitis and its course following treatment. STUDY DESIGN: Prospective nonrandomized controlled cohort study with follow-up. SETTING: Department of Otorhinolaryngology and Head and Neck Surgery of a university hospital (tertiary heath care center). METHODS: Sixty-one patients with atrophic rhinitis underwent assessment of clinical severity with baseline olfaction with the Brief Smell Identification test, while the improvement of their status following surgical versus nonsurgical treatment was further assessed. RESULTS: Olfaction was universally deranged with bimodal age presentation and female predominance (61%). Clinical improvement was significantly associated with surgical treatment but did not reveal any relation with up-front severity of disease. A near-significant association of age with severity did not reveal significance when stratified by age group. Baseline olfaction or its change following treatment did not reveal any significance with severity of disease or clinical improvement. Radiologic atrophy also did not reveal any significant relation with severity criteria. CONCLUSIONS: Olfactory functions as compared with clinical parameters provided better reflection of underlying (systemic) pathology with environmental interaction, while later it mainly signified localized condition. Accordingly, olfaction was affected early and recovered slowly (or not at all), independent of clinical morbidity, which in turn is affected rather late but recovers early. Olfactory dysfunction at the initial stage may be a surrogate marker of potential worsening clinical condition, since bacteria often superinfect underlying susceptible nasal environment. While surgery mainly improved clinical parameters without affecting olfaction directly, a true improvement would include recovery of both.

Brain Stem and Audio-Vestibular Regulation.

The central pathologies present with perverted auditory perception and compromised postural control. Considering the existing controversy this study involves assessments of 100 cases of post fossa tumefactions in which a detailed clinical and neuro-otological (pure tone audiometry, electronystagmography, brainstem evoked response audiometry) profile is compared with their imaging patterns. The CP angle schwannomas (N = 26) presented with abnormal speech tests (N = 18), abnormal auditory adaptation (N = 7) and ABR with pathologically increased latency of wave V (N = 32), poor formation of wave I (N = 31) along with abnormal inter-wave interval (N = 32). In lesions (N = 32) compressing deeper nuclei, vermis and axial parts of brain stem, a gross truncal ataxia, incoordination, nystagmus, speech defects, subtotal deafness and bilateral ABR abnormalities were observed. The abnormal optomotor activities were seen as saccadic (N = 44) and deformed slow pursuit eye movements (N = 20). Inability to sustain holding function resulted in gaze nystagmus (N = 71), and poor timing manifested as fixation overshoots (N = 42). The midline cerebellar and upper brain stem lesions revealed bilateral OKN abnormalities whereas paramedian pathology showed only ipsilateral distortion. Caloric tests revealed culmination frequency as the most sensitive parameter for assessment of the hypo-reflexia in diffuse cerebellopathies while slow phase velocity in cases of posterior fossa lesion. The caloric hypo-activity appears to be of a better localizing value than the directional preponderance. The slow pursuit tracking revealed Type III curve perhaps due to defective regulation of slow movements in partially intact cerebellum (N = 15), while gross cerebellar dysfunctioning resulted into Type IV curve (N = 5).

Juvenile 'Perinasal' Angiofibroma.

The extranasopharyngeal angiofibroma is a separate clinical entity but those involving infratemporal fossa and cheek resemble juvenile nasopharyngeal angiofibroma (JNA) and hence have been labelled as juvenile perinasal angiofibroma (JPA) in this paper. This paper presents a 7th case of JPA and attempts to review the world literature on JPA, along with a proposal of staging the disease. A 16 year male presented with a painless compressible facial swelling since 7 months without any epistaxis or nasal obstruction. Initially a vascular lesion was suspected but JNA without nasal extension was strongly suspected on imaging. A deep trucut biopsy confirmed the histopathology. The vascular enhancement was significant and the tumour was excised through open approach (Weber Fergusson). JPA that can be regarded as a variant of JNA that fails to extend medially. Imaging demonstrates classical JNA findings with a clear nose/nasopharynx. A deep trucut biopsy under control in inpatient settings may sometimes help. JPA presents most commonly in Stage II where an open facial approach preferably following selective preoperative embolization is indicated. Hence with painless compressible (or non-compressible) cheek swelling suspected to be of a vascular etiology, a high degree of clinical suspicion for JPA needs to maintained in order to prevent a misdiagnosis.

Current molecular profile of juvenile nasopharyngeal angiofibroma: First comprehensive study from India.

OBJECTIVE: An attempt is made to analyze the molecular behavior of juvenile nasopharyngeal angiofibroma (JNA). STUDY DESIGN: Case Series METHODS: Quantification of mRNAs expression was undertaken through real-time polymerase chain reaction in JNA (9-24) samples for VEGF-A, basic fibroblast growth factor (b-FGF), platelet-derived growth factor PDGF-A, KIT proto-oncogene receptor tyrosine kinase (c-Kit), Avian myelomatosis viral oncogene homolog (c-Myc), Harvey rat sarcoma viral oncogene homolog (H-Ras), tumor suppressor gene TP53, and androgen receptor and interleukin 6 (IL-6). The ß-catenin expression was evaluated by western blot in 16 samples. Nasal polyp was taken as control. RESULTS: A significantly increased (P < 0.01) expression of c-myc, VEGFA, bFGF, PDGFA, c-kit, and TP53 was seen, along with enhanced expression of ß-catenin. A massive enhancement of H-Ras expression was seen for the first time. Androgen receptor expression was no different, whereas IL-6 despite showing upregulation trend was not significant. CONCLUSION: The enhanced expressions of various markers suggest their potential role in JNA. Although the biological significance of c-kit, c-myc, and one of the novel markers H-Ras has yet to be defined, their significant expression may have a therapeutic importance. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:E100-E106, 2017.

Comparative efficacy of steroid nasal spray versus antihistamine nasal spray in allergic rhinitis.

This prospective randomized case controlled study was conducted to determine the efficacy of antihistamine (azelastine) nasal spray and compare it to steroid (beclomethasone) nasal spray on the symptoms of allergic rhinitis. Seventy five symptomatic patients of allergic rhinitis were included in this study. Diagnosis was made on the basis of history and physical examination. The patients were divided into three groups randomly. Group A was treated with Azelastine nasal spray, Group B was treated with Beclomethasone nasal spray and Group C was control group and only treated with steam inhalation. Efficacy of the treatment was assessed in the terms of Total Rhinitis Symptom Complex (TSC) scores and individual symptom score which was calculated on the basis of Okuda's grading system. Base line total symptom complex (TSC) scores were reduced in group A and group B by 84.0% after 4 week treatment whereas in group C it was reduced by only 38.0%. Decrease in mean score for sneezing was 95.0% in group A and group B whereas it was only 28.3% in group C. Similarly decrease in mean score for rhinorrhoea in azelastine group was 94.4% and in beclomethasone group was 95.3% in comparison to steam inhalation group where it was 25.0%. Only the beclomethasone reduced nasal stuffiness score significantly by 95.0%. No significant adverse effects of the drugs were observed. The present study establishes the relative efficacy and tolerability ofazelastine nasal spray as compared to beclomethasone nasal spray in symptomatic patients of allergic rhinitis.

Aneurysmal bone cyst of paranasal sinuses.

Aneurysmal hone cyst is rare in paranasal sinuses. It may be uni or multilocutar It occurs alone or with other benign bone lesions. The exact pathogenesis of it is still unknown. The aggressiveness of the disease needs early diagnosis and proper management to prevent recurrence. This report describes a case of aneurysmal bone cyst involving the ethmoid and maxillary sinuses which was successfully managed.

Inverted papilloma of nose with orbital involvement and malignant transformation.

We report two cases of inverted papilloma of nose with malignant transformation and orbital involvement in 60 year and 73 year male patients from Nepal. Medial maxillectomy and orbital exenteration were done in both cases. Histo- pathological examination showed areas of squamous cell carcinoma in inverted papilloma in both of the cases.The dilemma of diagnosis and treatment is discussed with review of literature.