Transoral endoscopic thyroidectomy vestibular approach, adaptation of modern surgical technique in a developing country.

Conventional thyroidectomy has been the standard technique for over 100 years but has the drawback of leaving a scar on the neck. As such, the demand for minimally invasive endoscopic thyroid surgery is rapidly growing as patients are becoming more and more worried about scars; it is more appropriate in patients who want to get surgery done because of odd looking swelling over the neck. TOETVA is safe, feasible, effective, and scar-free alternative to conventional thyroid surgery. We are sharing our first clinical experience in TOETVA in Pakistan with effective outcome in terms of surgical complication and patient satisfaction.

Implication of stem cells and platelet rich plasma in otolaryngology, head and neck surgical procedures.

Human body has a set of unspecialized cells called as stem cells that have the ability to generate cells of specialized function. Volume of fractionated plasma extracted from autologous blood is termed as Platelet-rich plasma (PRP) that is rich in several growth factors. Both have shown effective results in the field of regenerative medicine. Physiologically, platelets are the first cells to concentrate at the site of tissue damage, therefore application of PRP in diverse surgical procedures enhances bone and soft tissue healing; this same phenomenon is currently being used in otology, head and neck flap surgery and yielding miraculous outcomes. The perspective role of stem cells in regenerative medicine is wrapped in its loosely arranged DNA with working genes; a similar concept is being worked upon in different ENT procedures with groundbreaking results. But still, the data is scarce and there is a dire need for clinical trials, and large population-level studies to further formulate the guidelines on basis of proven evidence.

Mesenchymal stem cell therapy for treatment of osteoradionecrosis of mandible in head and neck surgery patients - A way forward into the future with promising clinical Outcomes.

Managing osteoradionecrosis is an integral part of complication management in head and neck cancer patients. While essentially an infection, the management of this complication has a considerable task for head and neck surgeons. While various measures have been discussed for the management, stem cells injection therapy is a potential management option. Mesenchymal stem cell therapy provides the local tissue with growth factors and proliferative cells that can aid a radiated tissue in the healing process. The article intends to review the bedrock of the pathology, ranging from pathophysiological and the epidemiological concerns to sparking a potential discussion on the use of mesenchymal stem cell therapy in osteoradionecrosis of mandible in head and neck cancer surgery and thus the ensuing future of the regenerative medicine. Moreover, the article has considered the management option in a developing nation thus explaining the procedural as well as the financial pitfalls and has highlighted the potential loop holes to be addressed in the management of osteoradionecrosis with stem cell therapy.

Prevalence of allergic fungal sinusitis among patients with nasal polyposis.

OBJECTIVE: To determine the frequency of allergic fungal sinusitis among patients with nasal polyps, and to compare Lund-Mackay scores of patients with and without allergic fungal sinusitis. METHODS: The cross-sectional longitudinal study was conducted at a tertiary healthcare centre in Karachi, Pakistan, from December 2016 to November 2018, and comprised patients with sinonasal polyposis undergoing surgery. The patients were categorised as having allergic fungal sinusitis when histopathology showed allergic mucin with fungal hyphae and culture was positive for fungal growth. Lund-Mackay scoring of each patient was noted and mean scores of allergic fungal sinusitis and non-allergic fungal sinusitis patients were compared. Data was analysed using SPSS 25. RESULTS: Of the 114 patients, 61(53.5%) were males. The overall mean age was 37.3±15.3 years. Of the total, 27(23.7%) patients had allergic fungal sinusitis. There was a significant relationship between asthma and allergic fungal sinusitis (p=0.03). The mean Lund-Mackay score was significantly higher for allergic fungal sinusitis patients (p<0.01). Recurrence was seen in 11(9.6%) cases. CONCLUSIONS: About one-fourth of patients with nasal polyps had allergic fungal sinusitis, and such patients showed significantly high mean Lund-Mackay score.

Synchronous primary diffuse large B-cell lymphoma and papillary thyroid carcinoma: A case report highlighting "Lymphoma first approach".

Papillary thyroid carcinoma (PTC) is the most common type of all thyroid carcinomas and accounts for up to 90% of all thyroid malignancies. It is the most indolent form of the disease and has an excellent prognosis. On the other hand, Primary thyroid lymphoma (PTL) is a rare entity accounting for only about 1% to 5% of all thyroid malignancies and only 2% of extranodal lymphomas. Synchronous PTC and PTL is a very rare condition and only a few cases have been reported in the literature up till now. We report one such case in a 52-year-old lady who was referred to us with goiter and progressively increasing difficulty in breathing.

Training in temporal bone surgery: A review of current practices.

The temporal bone consists of complex anatomy, and the presence of various vital structures in close proximity makes the surgery of temporal bone highly challenging. Such a surgery requires years of training under the direct observation of trainers. Over the course of history, different training models have been adopted by experts to help train the young surgeons in this complex procedure. Cadaveric dissections of the temporal bone remains the gold standard in training of residents as the cadavers present the actual anatomical details which the surgeons encounter while operating on patients. However, due to scarcity of available cadavers, their one-time-only usage and high cost of involved in such trainings, experts have developed newer techniques of training, including three-dimensional reconstruction models and virtual reality simulators. Most of the literature on simulation in training of residents focuses on anatomical understanding and development of the surgical technique. There has been significant improvement in these techniques over time. With the addition of haptic feedback in the newer virtual simulation models, simulation has edged closer to basic modules of temporal bone dissection. the current review article was planned to have an overview of the different techniques in detail that are currently being in used.

Glomangiopericytoma: A rare tumour of sinonasal cavity.

The history of glomangiopericytoma began in 1924 when it was initially diagnosed by Stout and Murray. It is a rare tumour of the respiratory mucosa, with a prevalence of less than 0.5% among all sinonasal tumours. Literature shows female predominance among patients who develop glomangiopericytoma. So far, no accurate aetiology has been discovered, but there are certain risk factors, including trauma, use of corticosteroids and high blood pressure, which are believed to cause glomangiopericytoma. Patients usually present with a history of epistaxis or nasal blockage, though symptoms can get worse if the tumour is not resected timely and can lead to visual disturbance, chronic sinusitis and headache. It has reddish polypoidal appearance on examination. The best modality for the treatment of glomangiopericytoma is endoscopic surgical resection via trans-nasal approach. We present the case of a 70-year-old man, with nasal blockage and epistaxis who underwent endoscopic sinus surgery for this condition.

Management of Laryngotracheal trauma: A review of current trends and future Directions.

Laryngotracheal trauma is rare but can pose serious threats to one's life. Presenting symptoms vary according to the severity of injury. Immediate Airway control is first step in the management, intubation should be considered by a senior member of the trauma team if the injury is minor while tracheostomy should be reserved for more severe injuries. Evaluation by a fibre-optic laryngoscopy and CT scan should be done whenever possible. Reconstruction is done according to the site involved using suture, titanium miniplates and stents. Tissue engineering has added a new horizon in this management but up till now complete laryngotracheal regeneration is very far-fetched, but tissue regeneration at individual sites have shown some positive results. More work needs to be done in this less explored field including laryngeal transplantation.

Changing paradigms in the surgical management of hyperparathyroidism at a tertiary care hospital in a developing country.

We report the presentation, management and outcomes of patients operated for hyperparathyroidism at our hospital. Patient sunder going surgery for hyper parathyroidism from 20 05 to 2 015 were retrospectively reviewed. Preoperative biochemistry, diagnostic scans and surgical procedures were studied. Follow up for cure rates, complications and histology were recorded. Out of 72 patients reviewed 54 (75%) were females and the rest males. The mean age was 48.04±15.5 years. Musculoskeletal complains were the most common (76.4%) among the cases reviewed. Asymptomatic hypercalcemia was seen in 13 (18.1%). The mean preoperative PTH level was 658.95 pg/ml and the mean preoperative calcium was 11.9 mg/dl. Bilateral neck exploration was done in 42 (58.3%) while focused unilateral approach was done in 27 (37.5%) cases. Solitary adenoma was the most frequent pathology in 58 (80.5%) patients. Asymptomatic hyperparathyroidism was less frequently detected in our population owing to lack of screening programme. Our patients are younger with a greater severity of the disease both symptomatically and biochemically compared to the West. In almost two decades, preoperative symptoms, calcium and PTH levels have changed marginally. Bilateral explorations are now giving way to focused less invasive procedures.

Recurrent Dermatofibrosarcoma Protuberans of the Parotid: A case report and review of literature.

In 1924, Darier and Ferrand described Dermatofibrosarcoma Protuberans as a progressive and recurring dermatofibroma. It is a locally aggressive sarcoma originating from dermal and subdermal tissue of the skin. It usually begins as a small plaque that grows over a period and later manifests as multiple small subcutaneous nodules. It is more commonly found in females as compared to males and typically occurs in between 2nd and 5th decades of life. Most frequently involved regions of the body are torso and proximal ends of extremities and very rarely head and neck region is the site of involvement. The mainstay of treatment of this entity is surgery. The rate of recurrence of this disease is very high in about 50% of the cases and it may also express rare distant metastasis. It is a radiosensitive tumour and radiation may play a role in reducing risk of recurrence. We present a case of a 35 years old male with recurrent Dermatofibrosarcoma Protuberans of right parotid gland.

Frequency of Sensorineural hearing loss in chronic suppurative otitis media.

Chronic suppurative otitis media (CSOM) is defined as chronic otorrhea (i.e., lasting > 6-12 weeks) through a perforated tympanic membrane. It is generally associated with some degree of conductive hearing loss. However, recurrent ear infections due to perforated eardrum result in absorption of toxins and macromolecules into the cochlea leading to sensorineural hearing loss (SNHL). We planned to determine the frequency of sensorineural hearing loss in chronic suppurative otitis media. A descriptive cross-sectional study was conducted at Aga Kgan University Hospital, Karachi, from October 2013 to March 2014. Average threshold of speech frequencies was calculated via pure tone audiogram for both diseased and normal contralateral ear.A mean of >25db in diseased ear was labelled as positive case for SNHL. SNHL was reported in 64(52%) patients and the frequency was found to increase with increasing duration. Patients with CSOM should be counselled regarding the risk of developing SNHL if left untreated.

Ethical Dilemmas in the Management of Head and Neck Cancers in the Era of the COVID-19 Pandemic.

Coronavirus disease 2019 (COVID-19) has emerged as an unforeseen challenge for head and neck cancer care providers. A similar challenge is also faced by other oncological fields, but the severity of this challenge is highest in otolaryngology because of the need for additional precautionary measures and curbs on the possibility of aerosol forming interventions related to the upper aerodigestive tract. In this narrative review, provision of ethical and consistent care on moral and professional grounds to head and neck cancer patients during the pandemic are discussed for professionals who provide head and neck oncology care.

Comparison of Endoscopic Versus Microscopic Tympanoplasty.

Introduction: Tympanoplasty is a common surgery for chronic otitis media and has conventionally been performed with a microscope for decades. The trend of endoscopic minimally invasive surgeries has been increasing worldwide for the last few decades. Few studies have discussed the outcomes of tympanoplasty with microscope and tympanoplasty with endoscope . This study aims to compare results of tympanoplasty done with microscope vs endoscope in terms of graft take rate and improvement in conductive hearing loss. Materials and Methods: We did a retrospective review of 120 patients (54 male and 66 female) who underwent Type I tympanoplasty at Liaquat National Postgraduate Medical Center from January 2019 to January 2020. We included 60 patients who underwent tympanoplasty with microscope and 60 patients who underwent tympanoplasty with endoscope. Postoperative graft uptake and hearing improvement were studied. Results: Overall mean preoperative hearing loss was 30.24 (±9.61) dB as compared to mean postoperative hearing loss, which was reduced to 19.36 ( ±8.54) dB, and the difference was significant (P-value <0.001. No statistically significant difference was found for air-bone gap closure between the two groups (P-value 0.78). Out of 120 patients, overall successful graft uptake was seen in 109 (90.8%). In tympanoplasty with microscope, graft take was 90.0%, compared to 91.6% in endoscope group. There was no significant difference in graft take in the two groups. Conclusions: The tympanoplasty with endoscope is comparable to tympanoplasty with microscope in terms of graft uptake and hearing improvement.

Fibroepithelial Polyp: A Rare Presentation In Sinonasal Cavity.

A fibroepithelial polyp is a benign polypoidal lesion of mesodermal origin. It can present in any area of the body with an epithelial surface. These are relatively more common in skin and genitourinary tract and has been reported very rarely in head and neck region. We report here a rare presentation of fibroepithelial polyp in sinonasal cavity presenting with the symptoms of unilateral nasal obstruction. The patient underwent endoscopic surgical excision and recovered completely. In patients with unilateral sinonasal growing masses fibroepithelial polyp should be considered as one of the possible diagnoses. Sinonasal fibroepithelial polyps have good prognosis after being treated surgically.

Frequency of Thyroid Gland Invasion by Laryngeal Squamous Cell Carcinoma: The Role of Subglottic Extension.

Introduction Management of the thyroid gland during laryngectomy has been controversial. The primary tumor may invade the thyroid gland by direct invasion or lymphovascular spread. Hypothyroidism and hypoparathyroidism are potential risks when lobectomy or total thyroidectomy are performed simultaneously. Objective To report the frequency of thyroid gland involvement by primary laryngeal squamous cell carcinoma in patients undergoing laryngectomy and to identify possible risk factors for thyroid gland involvement so that judicious excision of thyroid gland can be attained. Methods We performed a retrospective review of 9 years. Data was collected from medical records of patients dated from December 2009 to October 2018. All patients with laryngeal cancer who underwent laryngectomy with lobectomy or total thyroidectomy were included in the present study. Results We reviewed 151 laryngectomy records. A total of 130 surgeries included the thyroid gland with the excised specimen and were available for analysis. There were 124 males and 6 females. The mean age was 59.4 years old. The glottis was the most common subsite involved, in 70 patients, followed by 38 transglottic, 16 supraglottic and 03 subglottic tumors. On histology, 12 out of 130 excised thyroid glands were involved by squamous cell carcinoma. Only subglottic involvement ( p = 0.01) was significantly associated with thyroid gland invasion (TGI). Type of laryngectomy, subsite of the primary tumor, thyroid cartilage involvement, neck nodal metastases, and perineural and lymphatic invasion by the primary tumor were not associated with TGI. Conclusion Only subglottic involvement is associated with TGI; therefore, preoperative and intraoperative assessment is necessary prior to considering excision of the thyroid gland.

The Efficacy of Bethesda System for Prediction of Thyroid Malignancies- A 9 Year Experience from a Tertiary Center.

INTRODUCTION: The best initial investigation for thyroid nodule is fine needle aspiration (FNA). Bethesda System is an international standardized system of reporting thyroid nodules and recommends subsequent management. Every institution should assess the risk of malignancy in each category to avoid unnecessary thyroid surgeries, with this aim we conducted a review at our center to calculate risk of malignancy in each category. MATERIALS AND METHODS: Retrospective 9-year (2009-2018) review of thyroid FNAs done at a tertiary care Centre. The FNA was stratified according to The Bethesda System. Histopathology reports of the operated cases were used to evaluate the cytology for diagnostic accuracy. RESULTS: There were 495 patients who underwent thyroidectomy. The mean age of the cohort was 42.51 +/- 13.2 years and 387 (78.2%) were females. The frequency of Bethesda categories I, II, III, IV, V, and VI were 9.1%, 55.6%, 16.4%, 6.5%, 9.3%, and 3.2% respectively. Malignancy rate in operated thyroid nodules were 37.8%, 8.4%, 33.3%, 50.0%, 89.1%, and 100% for Bethesda categories I to VI, respectively. The sensitivity, specificity, negative predictive value and positive predictive value and their 95% CIs were calculated as 81.30 (73.28 - 87.76%), 77.06 (72.12 - 81.51%), 91.64 (88.3 - 94.1%) and 57.14 (51.79 - 62.33%). The overall diagnostic accuracy was 78.22 (74.12 - 81.95%). CONCLUSIONS: All the Bethesda categories showed greater malignancy risks than other reported studies. Knowledge of local rates of malignancy is important to accurately predict the risk of malignancy even when reported with internationally accepted nomenclature like the Bethesda System.

Level I Nodal Positivity as a Factor for Involvement of the Submandibular Gland in Oral Cavity Carcinoma: A Case Series Report.

Introduction The routine practice of neck dissection in the surgical management of oral carcinoma has evolved into a more functionally conservative approach. Over time, the rationale for removal of the submandibular gland has been questioned. Routine extirpation of the submandibular gland can aggravate the xerostomia experienced by many patients, significantly affecting their quality of life. Objective The objective of the present study was to determine the incidence of submandibular gland metastases in oral cavity carcinoma and to identify possible factors that may affect their involvement. Methods A total of 149 cases of oral carcinoma presenting at a private tertiary care hospital in Karachi, Pakistan, over the course of 1 year were reviewed retrospectively. Results Histopathological data showed that the submandibular gland was involved in 7 (4.7%) cases. Involvement of level I lymph nodes was found in all of the cases. Direct extension of primary tumor was noted in two cases when the primary tumor was in the floor of the mouth. Conclusion The results suggest that preservation of the submandibular gland during neck dissection for oral carcinoma can be practiced safely when there is no evidence of direct extension of the primary tumor toward the submandibular gland or when there is no clinical or radiological evidence of neck disease in level I. Presence of pathological lymph nodes in level I requires caution when contemplating preservation of the submandibular gland.

Ewing Sarcoma of Larynx: A Rare Case in a 5-Year-Old Boy.

Ewing Sarcoma of the head and neck region is an extremely rare entity. Treatment usually involves surgery, chemotherapy and radiotherapy in varying sequences. We present the third case to date of Ewing sarcoma of the larynx in a paediatric population. A 5-year-old boy presented to emergency room with acute respiratory distress. Computerized tomography scan showed a mass in the supraglottis; he was intubated using videolaryngoscope and tracheostomy was avoided, mass was removed by cold dissection. Final histopathologic examination revealed Ewing sarcoma. Further workup showed no systemic metastasis. Patient was advised adjuvant therapy which the family refused. Currently he is doing fine on 2 years of follow-up.

Malignancy Rate in Thyroid Nodules with Atypia or Follicular Lesion of Undetermined Significance.

Introduction Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is one of the six diagnostic categories of the Bethesda System for Reporting Thyroid Cytopathology. The prevalence of malignancy among Bethesda category III cytology is variable, ranging from 5% to 37% in the literature. Objective To determine the rate of malignancy in thyroid nodules reported as Bethesda category III. Methods A total of 495 patients underwent surgical intervention for thyroid nodules from January 2015 to December 2017. The present study included 81 cases reported as Bethesda category III, and their medical records were reviewed. Results Out of 495 fine-needle aspiration cytology samples, 81 (16.4%) samples were labeled as AUS/FLUS. Among these 81 patients, the mean age was 43.0 years (± 13.9), with only 11 (14%) patients older than 55 years of age. Most of our patients were female ( n = 69; 85.2%), and the rest were male. The rate of malignancy based on the final histology was of 33.3% ( n = 27). The majority were 17 cases (21%) of papillary carcinoma, followed by follicular carcinoma ( n = 6) (7.4%). Conclusion The risk of malignancy can be higher than it is commonly believed, and guidelines should be based on the data from the institutions themselves for a better assessment of the outcomes.

COVID-19: Implications, Reactions and Future Directions.

Humanity has faced several foes over the centuries, a formidable one amongst them is the current pandemic of COVID-19. The symptoms of COVID-19 are more or less related to the nose and throat. Therefore, patients more often present to Ear Nose Throat (ENT) clinics with symptoms including cough, sore throat, fever and shortness of breath. In the management of head and neck pathologies, as the airway is a direct source of infection, the impact of COVID-19 holds special significance. This review has attempted to explain the various aspects of the disease itself, its diagnosis, the use of personal protective equipment (PPE) to provide an overview of the evolving recommendations in head and neck patients, the future outlook and the limitations faced in developing countries specifically for ENT patients.