Klebsiella-associated phagedenic ulcers in infants-a report of two cases.

Phagedenic ulcer is usually associated with infections due to staphylococcus, pseudomonas, streptococcus or fusospirochete in immunocompromised individuals. We report, for the first time, two cases of phagedenic ulcers in infants caused by Klebsiella pneumonia species.

A Comparative Study of Interventions of Middle Turbinate Medialization in Endoscopic Sinus Surgery.

The shape and position of middle turbinate play an important role in ventilation and drainage of the osteomeatal complex. The preservation of middle turbinate is one of the major goals of functional endoscopic sinus surgery (FESS). Middle turbinate intervention is essential to prevent obliteration of osteomeatal complex. The aim of this prospective study is to postulate which middle turbinate intervention is most effective and compare the results with conventional technique. In this randomized controlled study, 60 patients were included of the age group of 15-60 years who presented to the Otorhinolaryngology OPD of our institute between November 2017 to June 2019 with symptoms of chronic sinusitis with clinical and radiological evidence and who underwent FESS. The patients were divided into three group, Group A-Bolgerization (n = 20), Group B-Vicryl-conchopexy (n = 20) and Group C-No intervention, Control group (n = 20). The patency of middle meatus and the status of middle turbinate (medialized or lateralized or neither of the two) was ascertained postoperatively. Improvement in symptoms was also evaluated. The middle turbinate was medialized in 90% of Group A and 95% of Group B cases. The middle turbinate was neither medialized nor lateralized in 70% of patients in Group C. 70% of the patients in Group A and 80% of patients in Group B had complete improvement in symptoms with no recurrence of sinusitis compared to Group C in which only 50% of the patients had improvement in symptoms due to development of synechiae. Medialization of the middle turbinate should be considered as one of the essential steps of FESS as it helps in improving the surgical outcome.

Role of Computed Tomography Findings in the Quest of Understanding Origin of Antrochoanal Polyp.

Aetio pathogenesis of antrochoanal polyp (ACP) remains unclear. Correlation of clinical, computed tomography (CT) and histopathological findings is attempted in this study for understanding of their origin. A retrospective chart and image review of 22 patients having ACP was done for clinical, histopathological and CT findings on affected and non affected side for extent of opacificattion, thickness of alveolar bone (AB) in the region of medial wall and the floor of maxillary sinus. Also, widening of accessory ostium was measured and compared. The mean of average thickness of AB medially on affected side was [30.91/11.27] [mean (mm)/SD)] compared to non affected side [55.60/20.74] p = 0.0001 (p < 0.05). The vertical AB thickness at floor on affected side [34.05/14.69] versus [68.14/35.29] p = 0.0001. Ipsilateral side accessory ostium widening on affected was measuring [91.45/57.00] against [55.32/38.96] p = 0.018. The additional CT findings in present study showed reduction in thickness of AB in the medial part and floor of maxillary sinus region. These findings to our knowledge have not been reported in the literature till date. The reduction in bone thickness of AB substantiates theory of antral cyst in origin of ACP. However, their association with embryonic dental lamellae needs further evaluation.

Acquired Angioedema: A Rare Manifestation of Angioimmunoblastic T Cell Lymphoma.

The clinical presentation except age of onset is similar in different types of angioedema. A lymphoproliferative disorder like angioimmunoblastic T cell lymphoma (AITL) rarely presents with symptoms of angioedema. We present extremely rare case of elderly male with recurrent tongue swelling, pruritus with normal levels of complements and C1 esterase inhibitor protein featuring as acquired angioedema, a rare manifestation of AITL. Initial response to corticosteroids may be misleading and occurs as a result of immunosuppression of AITL. High index of suspicion may prompt need for histopathological diagnosis of lymph node biopsy. Definitive chemotherapeutic treatment may achieve long term remission.

Detection of bacteria by 16S rRNA PCR and sequencing in culture-negative chronic rhinosinusitis.

OBJECTIVE: Current studies on the association between bacteria and chronic rhinosinusitis (CRS) have relied solely on microbiological culture, which can sometimes be negative due to prior antibiotic therapy or lack of transport media. The objective of the study was to understand whether bacteria are associated with culture-negative cases. METHODS: We investigated 20 cases of CRS undergoing functional endoscopic sinus surgery by both culture and 16S rRNA gene polymerase chain reaction (PCR) followed by sequencing. The disease severity was assessed using Sino-nasal Outcome Test-22 (SNOT-22) scoring preoperatively. RESULTS: Of the 20 cases studied, only five were culture-positive. Bacteria were detected in all 15 culture-negative cases by 16S rRNA gene PCR. Sequencing indicated that Staphylococcus is the dominant group, followed by Enterobacter and Pseudomonas. In two cases, from which Pseudomonas was detected, SNOT-22 scores were above 80, indicating high disease severity. CONCLUSION: 16S rRNA gene PCR, followed by sequencing, would help the clinician understand the association between bacteria and CRS. Molecular detection and identification of bacteria would help the clinician better predict the outcome and plan further management accordingly. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:2223-2225, 2018.

Bacterial Biofilms in Chronic Rhinosinusitis and Their Implications for Clinical Management.

To study the microbiological profile in patients with chronic rhino-sinusitis. To correlate disease severity with the presence of biofilms and host risk factors. To assess outcome of Sinus Surgery 2 weeks post operatively in terms of presence of bacteria and their ability to form biofilm. Prospective study. 50 cases of chronic rhino-sinusitis requiring Functional Endoscopic Sinus Surgery admitted in SDM Hospital, Dharwad, Karnataka were studied using intra-operative mucosal samples for microbiological analysis. The organisms isolated were tested for biofilm forming ability using three in vitro tests. Severity of disease was assessed using SNOT 22 scoring system. Of 50 cases studied, 66% showed presence of chronic rhino-sinusitis with polyposis and had higher SNOT scores compared to those without polyps. Bacterial isolates were obtained from only 17 samples. Staphylococcus species was isolated from 16 samples and Klebsiella pneumoniae from one. 11 Staph spp. isolates showed biofilm forming ability in vitro. Postoperative events in 3 cases yielded biofilm-forming Staphylococcus. Staphylococcus was the most dominant organism isolated and 11 isolates were biofilm formers. Thus the detection of biofilm forming organisms can be considered as a negative prognostic indicator and should forewarn the surgeon about the risk of recurrence.

Improving the Diagnosis of Scrub Typhus by Combining groEL Based Polymerase Chain Reaction and IgM ELISA.

INTRODUCTION: Scrub typhus, an acute febrile illness, caused by Orientia tsutsugamushi, is an important cause of pyrexia of unknown origin in regions of endemicity. This disease is mostly underdiagnosed or misdiagnosed, the reasons for this being a combination of factors which include clinical manifestations that can mimic other infections, lack of easy and reliable diagnostic methods and variation among strains in endemic areas. Hence, easy and reliable methods of diagnosis will contribute to rapid identification and treatment of the infection. AIM: The aim of the study was to compare four different methods of detection of scrub typhus and to identify one single test or a combination of tests detecting maximum number of cases. MATERIALS AND METHODS: One hundred and forty-five suspected scrub typhus cases were included in this study. Duration of fever and presence of eschar in each patient was noted down. Enzyme-Linked Immunosorbent Assay (ELISA) to detect Immunoglobulin M (IgM) antibodies and Polymerase Chain Reaction (PCR) to detect three genes of Orientia, namely, 56 kDa, 16S rRNA, and groEL were done on these samples. The results of each test were analyzed to identify the test picking up maximum number of positive samples. Statistical analysis was performed using Chi-square test. The level of significance was set at p<0.05. RESULTS: These tests showed that IgM ELISA (93%) and PCR (68%) picked up maximum number of positives. Statistical analysis performed using Chi-square test between the diagnostic assays showed that the p - value <0.001 was significant for IgM ELISA. Among the molecular markers, p-value was significant (<0.001) for groEL PCR. Further analysis of eschar positivity and duration of fever also showed that groEL PCR could detect DNA of the bacterium even in cases with 10 days of fever and this PCR was the best among the molecular markers used to detect the infection. CONCLUSION: This study suggests that IgM detection by ELISA and conventional groEL PCR, either in combination or alone, depending on the duration of fever, would enhance the diagnosis of scrub typhus.

Foreign body in upper digestive tract.

OBJECTIVE: Foreign body ingestion is a common clinical problem, encountered in children. METHODS: A total number of 104 patients with ingested foreign body admitted in our hospital are reviewed. Endoscopic removal was done for all foreign objects impacted in esophagus. RESULT: In 84.6% cases, history of having swallowed the foreign body was most common symptom. Majority of patients (61.53%) presented within 24 hours after ingestion of foreign body. Coins were the most frequent offending agents in children (87.5%). Seventy six cases of coins were impacted in the postcricoid region. Complications of retropharyngeal abscess was seen in two cases (1.92%), which was associated with sharp foreign body. CONCLUSION: Early removal of these sharp foreign bodies must be considered to reduce the risk of this complication.

Bronchial foreign bodies.

Foreign body aspiration is an extremely serious problem in childhood with varied clinical presentation demanding high degree of suspicion on the part of clinician. Surgical emphysema of the neck and chest often complicates tracheostomy and sharp penetrating injuries to the neck perforating viscera of the aerodigestive tract. Rarely if follows chest injuries. But emphysema due to the neck of foreign bodies in the bronchus is quite rare. The authors hereby report four cases of surgical emphysema following foreign body aspiration into the tracheobronchial tree.

Lipoma of the retropharyngeal space.

Lipoma in retropharyngeal space is rare. A case of lipoma in the retropharyngeal space of a paediatric patient is reported with characteristic radiological findings along with surgical management.

Tracheobronchial foreign bodies.

OBJECTIVE: [corrected] Foreign body inhalation is an extremely serious problem in children and sometimes result in sudden death. The current mortality rate from foreign body inhalation is between 0% and 1.8% according to various studies. In spite of this, undiagnosed and unsuspected foreign bodies still occur in the airway. METHODS: Pediatric patients with documented foreign body inhalation, treated in the Department of Pediatrics, Bapuji Hospital, JJM Medical College during 1997-2000 are included in the analysis. Children with or without positive history of aspiration were examined and the diagnosis was made on the basis of history, clinical findings, radilogic evaluation and strong index of suspicion in those children where reasonable appropriate treatment failed to resolve the respiratory symptoms. Bronchoscopy was performed for a suspected foreign body on 165 children. RESULT: A review of 165 pediatric cases of suspected foreign body aspiration revealed, children between 1 and 3 years were found to be very vulnerable for aspiration. Majority of children were boys. Over 70% of the patients had positive history of inhalation. Only 60% of the patients presented immediately, that is within 24 hours after aspiration. Common symptoms were cough and respiratory distress. Physical examination showed abnormal finding in 91% of cases. Decreased air entry was the significant clinical sign. Obstructive emphysema was found in majority of the cases (49.5%). Rigid bronchoscopy under general anaesthesia was the preferred method for removal of aspirated foreign body. In 65 (61.9%) cases foreign body was lodged in the right main bronchus and majority of these were organic in nature, that is 96 (91.43%). CONCLUSION: Tracheobronchial foreign bodies should be strongly suspected in pediatric age group who present with a suggestive history, even when physical and radiographic evidence is absent. The modalities of diagnosis, management and outcome are discussed.

Choanal atresia: transnasal endoscopic technique.

OBJECTIVE: This article attempts to address the controversy between, endoscopic and traditional approaches to neonatal choanal atresia. METHOD: Congenital choanal atresia has been recognized for over 200 years, first described by Roedere in 1775. This condition is uncommon, occurring in approximately 1 in 7000 live births. Unfortunately a single ideal procedure for this condition does not exist. RESULTS: Stankiewicz is credited with the first description of endoscopic techniques for choanal atresia repair. All patients diagnosed to have choanal atresia, treated between 1999 and 2000 were reviewed. Out of four patients two underwent endoscopic repair. CONCLUSION: Transnasal endoscopic technique is followed by stenting with endotracheal portex tubes for 4-6 weeks in the initial surgical procedure of choice.

Perioperative only versus extended antimicrobial usage in tympanomastoid surgery: a randomized trial.

OBJECTIVES/HYPOTHESIS: Antimicrobial prophylaxis is still a matter of debate in ear surgeries. Previous studies have focused on prophylaxis in middle ear surgery alone without inclusion of mastoidectomy. We therefore investigated efficacy of two regimes of antimicrobial prophylaxis in tympanoplasty with cortical mastoidectomy done for mild middle ear disease in chronic otitis media. STUDY DESIGN: Prospective, randomized, controlled, double-blind study. METHODS: Patients undergoing tympanoplasty with cortical mastoidectomy were included and randomized into two study groups. The group I patients received parenteral perioperative antimicrobials; only group II patients received additional extended oral antimicrobials for 8 days more postoperatively. Primary outcomes evaluated were postaural wound infection and graft success, assessed weekly until 1 month. Adverse events and length of hospital stay were evaluated as secondary outcome. RESULTS: Seventy-eight patients were randomized into group I (n = 39) and group II (n = 39). The two groups showed no difference in wound infection rate. The graft success rate in both the group was comparable (94.87% in group I and 97.44% in group II, respectively; P = 1.00). The length of hospital stay was significantly longer (P = 0.00001) in group II (3.05 [0.72], mean [SD]) as compared to group I (2.36 [0.49]). During the first postoperative week, a significantly higher incidence of gastrointestinal disturbances were observed in group II (19 [48.72%] as compared to 1 [2.56%] in group I, P = 0.00001). CONCLUSION: The present study shows that there is no need of extended antimicrobial prophylaxis for tympanoplasty with cortical mastoidectomy done for mild middle ear disease. An indiscriminate use of antimicrobials may lead to increase incidence of adverse events and prolonged hospital stay. LEVEL OF EVIDENCE: 1b.

Short Anagen Syndrome in an Indian Woman with its Impact on Quality-of-Life.

Short anagen syndrome (SAS) is a recently described entity characterized by idiopathic shortening of anagen phase. The condition is poorly described in Indian population. We describe the 1(st) Indian case with clinico-pathological features of a 30-year-old woman diagnosed with SAS. Case was diagnosed on the basis of clinical examination, trichogram, microscopic examination of the hair shaft, histopathologic examination of scalp, and measurement of hair growth rate.

Chromoblastomycosis presenting as a phagedenic ulcer on the face.

BACKGROUND: Chromoblastomycosis is a chronic fungal infection which presents as a small ulcer, plaques, papulonodular lesion to cauliflower-like warty masses and cicatricial forms. The disease is relatively uncommon, with only a few published case report. METHODS: A 35-year-old female presented with phagedenic ulcer on the face since 15 years. Examination identified a plaque with central perforation on the right side of the face with crusting and oozing and a scar at the periphery with visible underlying turbinates. A biopsy was done and sent for histopathologic examination and culture. Treatment was started with oral fluconazole, 150 mg daily orally, suspecting subcutaneous fungal infection. RESULTS: Biopsy revealed branched, septate, brown-colored dematiaceous hypae in the dermis indicating chromoblastomycosis. Fungal culture revealed Fonsecaea pedrosoi. Patient responded well to treatment, and still she is on treatment. CONCLUSIONS: We believe that this is the first case report of chromoblastomycosis presenting as phagedenic ulcer.

Role of nasal endoscopy in chronic osteomyelitis of maxilla and zygoma: a case report.

Osteomyelitis of the jaws was relatively common before the era of antibiotic therapy and preventive and restorative dentistry. Osteomyelitis is an acute or chronic inflammatory process that can involve cortical and trabecular aspects of bone or bone marrow. Cranial bones are infrequently involved, but spreading of inflammation with involvement of surrounding structures represents important risk, such as cerebral abscess, encephalitis, or meningitis. The mandible is more commonly involved than the maxilla. Dentogenic infections cause 38% of mandibular and 25% of maxillary involvement. Involvement of zygoma is very rare. Factors like viral fevers, malnutrition, malaria, anemia,tobacco chewing, immunodeficiency, osteopetrosis, Paget's disease of bone, and florid cemento-osseous dysplasia (FCOD) result in decreased vascularity of the affected bone, predisposing to the development of osteomyelitis. We present a case of osteomyelitis of left maxilla and zygoma with oroantral fistula in an immunocompetent adult male caused by dentogenic infection. The complete resolution of infection was gained with surgical treatment using nasal endoscope and antibiotic therapy. The aims of this paper are to illustrate diagnostic patterns, to report radiographic findings and surgical treatment using nasal endoscope in a case of osteomyelitis of maxilla and zygoma. The prognosis and cosmetic results are discussed.

Foreign bodies in upper digestive tract.

Foreign body ingestion is a common problem frequently encountered in both children and adults. A total number of 152 patients (104 children and 48 adults) with ingested foreign body admitted in our hospital are reviewed. Location of foreign body was made out by radiological examination. History of having swallowed foreign body was the most common symptom in both blunt and sharp foreign bodies. Endoscopic removal of foreign body was done under general anaesthesia for all cases, except one in which foreign body was removed by open surgical method. Blunt, foreign bodies were common among children, where as meat with bone was common in adults (19/48). Most of blunt foreign bodies in children (83.5%) were impacted in post cricoid region. Where as in adutls, the foreign bodies (37.5%) were seen in upper oesophagus. Retropharyngeal abscess was seen in 2 cases, which was associated with sharp foreign bodies. In all but one, endoscopic removal was successful. In one case denture impacted in post cricoid region was removed by open surgical method. There was no mortality in our series.

Choanal atresia: Experience with transnasal endoscopic technique.

Congenital choanal atresia has been recognized for over 200 years, first described by Roederer in 1775 (Lantz and Brick, Laryngoscope 91, 1981, 1626. Samuel and Fernandes. Laryngoscope 95, 1985, 326). This condition is unconunon, occurring in approximately 1 in 7000 live births. Unfortunately, a single ideal procedure for this condition does not exist. Stankiewicz is credited with the first description of endoscopic techniques for choanal atresia repair. All patients diagnosed to have choanal atresia treated between 1999 and 2000 were reviewed. Out of four patients two underwent endoscopic repair. This article attempts to address this controversy between endoscopic and traditional approaches to neonatal choanal atresia.