Serum Galactomannan as a Minimally Invasive Diagnostic Tool for Fungal Skull Base Osteomyelitis.

Multidrug resistant strains and fungi add to treatment conundrums in skull base osteomyelitis (SBO). Deep tissue culture in these patients is challenging due to their advanced age and co-morbidities. Besides, fungal culture positivity is seen only in 60% of invasive aspergillosis. To determine the efficacy of a minimally invasive test-Serum Galactomannan (sGM)-for diagnosing fungal SBO. Prospective observational study. Thirty- three patients, clinically diagnosed with SBO were included in this study. Baseline ESR (Erythrocyte Sedimentation Rate), CRP (C- Reactive Protein), pain score, and sGM were noted for all patients. Antifungal Voriconazole was initiated on patients if the sGM values were more than 0.8. At the 12th week of treatment, all parameters were repeated and compared with the baseline values. A significant reduction was noted in ESR, CRP, and pain scores at the 12th week of treatment compared to the baseline values in patients with raised sGM values who were started on Voriconazole. For a culture-proven fungal skull base osteomyelitis with a cut-off value of sGM > / = 0.8, the obtained sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were 81.82, 36.36, 39.13, 80 and 51.52% respectively. At a cut-off value of sGM > / = 01.6, the values of sensitivity/specificity, PPV, NPV and accuracy were 81.82/72.73%, 60%, 88.89% and 75.76%. Culture-negative patients in SBO with sGM value > 0.8 were more likely to be fungal SBO. An sGM cut-off of 1.6 was observed to give maximum accuracy for diagnosing fungal SBO.

Role of surgery along with antimicrobials in refractory skull base osteomyelitis-A prospective observational study.

INTRODUCTION: Study aimed to ole of surgery along with antimicrobials to improve clinical outcomes in treating refractory cases of skull base osteomyelitis (SBO). METHODS: A prospective observational study in a tertiary care centre with 70 SBO patients meeting eligibility criteria. The study population comprised 35 patients refractory to systemic antimicrobials of at least 4 weeks duration who later underwent surgery in addition to medication (surgical group). They were compared with a medical group that responded to medications alone. The outcome variables studied were the resolution of clinical features (pain, discharge, radiology, and inflammatory markers), culture yield, and total duration of treatment. RESULTS: According to our study, relief of pain was faster in the surgical group (1.66 against 4.57 months) with statistical significance (p < 0.001). Relief of symptoms (p < 0.001), radiological improvement (p = 0.001), and normalising of inflammatory markers (p < 0.001) were better in the surgical group than in the medical group. The duration of treatment was an average of 9.2 months in the surgical group compared to 11.3 months in the medical group (p = 0.019). Microbial culture from deep tissue sampling was positive in 24 surgical patients (68.57%). CONCLUSIONS: The treatment response in selected patients of refractory SBO who underwent surgery along with antimicrobials was better than the group who responded to antimicrobials alone. Surgery provided higher microbial yield resulting in culture-specific antimicrobials. The surgical group observed faster relief of symptoms, reduced hospital stay, and total treatment duration.

Comparison of Video Nasopharyngoscopy and Tympanometry in Suspected Eustachian Tube Dysfunction - A Prospective Study.

Objective Tympanometry is widely used for diagnosing Eustachian tube dysfunction (ETD). However, in clinical practice, it is not uncommon to come across patients with symptoms of ETD with a normal tympanogram. Dynamic slow motion video endoscopy (DSMVE) of Eustachian tube (ET) and Eustachian tube dysfunction questionnaire-7 (ETDQ-7) are other tools to diagnose ETD. Primary aim of the study was to compare DSMVE and tympanometry in diagnosing ETD. Secondary objective was to find an association between DSMVE and ETDQ-7. It was a prospective diagnostic validity study in the department of Otorhinolaryngology at a tertiary care centre. Patients with symptoms suggestive of ETD with intact tympanic membrane (TM) and aged above 12 years were evaluated. The study duration was 17 months. The parameters assessed were tympanic membrane(TM) retraction by otoscopy, DSMVE, tympanometry and ETDQ-7 questionnaire. To test the significance of association and difference between tympanogram and nasopharyngoscopy, Chi-Square t test and McNemar's tests were applied. Out of 107 ears, DSMVE, tympanometry, ETDQ- 7 and otoscopy detected ETD in 51, 31,70 and 57 ears respectively. DSMVE and tympanometry together detected ETD in 29 ears and did not detect in 54 ears. Both these diagnostic methods were not comparable statistically (moderate agreement- Kappa value- 0.542). Comparison of DSMVE with ETDQ-7 was statistically significant (p-value- 0.004). Video nasopharyngoscopy cannot be a stand- alone diagnostic aid for ETD. ETDQ-7 questionnaire showed higher concordance with nasopharyngoscopy than tympanometry. Diagnostic accuracy was more when all four parameters were assessed together.

A Prospective Study of Recovery of Salivary Gland Function After Calculus Removal by Sialendoscopy.

Sialendoscopy is gaining popularity in treating obstructive sialolithiasis as a gland preserving procedure. The study aimed to determine if the salivary glands recovered apart from symptomatic improvement after interventional sialendoscopy for calculus removal. A prospective comparative study was conducted in a tertiary care center on 24 patients diagnosed with sialolithiasis. The eligibility criterion was patients who underwent calculus removal through interventional sialendoscopy. All patients underwent objective and subjective methods of assessments of function of the salivary glands with the help of salivary Technetium (Tc) 99 Scintigraphy, measurement of salivary flow rate, Chronic obstructive sialadenitis symptoms (COSS), and xerostomia index (XI) questionnaires. Assessments were done before the procedure and repeated after 3 months. Categorical variables were expressed using frequency and percentage. Numerical variables were represented using mean and standard deviation. To test the statistical significance of the difference in the mean of the four parameters Wilcoxen sign ranked test was used. According to our study improvement in functionality was noted in all of the subjective and objective parameters assessed namely Tc scintigraphy, salivary flow rate, COSS questionnaire, and XI questionnaire, with a statistically significant p value (< 0.001). Functionality of salivary gland showed improvement within 3 months of calculus removal through sialendoscopy. There was a marked improvement in the symptoms after sialendoscopy. This study demonstrates that removal of obstructing calculus results in rapid recovery of glandular function thereby emphasizing the need for salivary gland preservation. Level of evidence: Level III.

A prospective study comparing itraconazole alone versus systemic steroids alone as adjuncts to topical steroids in the post-operative management of allergic fungal rhinosinusitis.

OBJECTIVES: The objective of this study was to compare the efficacy of itraconazole and systemic steroids as an adjuvant to topical steroids in post-operative patients with allergic fungal rhinosinusitis (AFRS) using both subjective and objective outcome measurements. DESIGN: A prospective comparative study. SETTING: A tertiary care centre. PARTICIPANTS: Sixty patients diagnosed with AFRS were included. Patients with chronic systemic illness and those undergoing revision surgery were excluded. Post-operative patients were divided into two groups of 30 each which received itraconazole 400 mg OD or methylprednisolone in tapering doses over 6 weeks. MAIN OUTCOME MEASURES: The outcomes were measured at the end of 6 weeks-Kupferberg endoscopic staging, absolute eosinophilic count (AEC), serum immunoglobulin (IgE), and Sino Nasal Outcome Test-20 scores. RESULTS: Our study showed no statistical significance in outcomes between the two groups treated with itraconazole and methylprednisolone regarding recurrence, AEC, IgE and quality of life assessment (p < 0.01). CONCLUSION: Itraconazole was comparable to methylprednisolone in preventing disease recurrence in the post-operative management of AFRS. It may be a viable alternative to replacing systemic steroids where the latter may be contraindicated. Itraconazole given at a dose of 400 mg once daily for 6 weeks was a safe dose.

Comparison of the Effects of Azelastine and Fluticasone Nasal Sprays in the Treatment of Allergic Rhinitis.

Allergic rhinitis is a highly prevalent, allergen-induced disease. Intranasal corticosteroids are currently the first-line therapy for these patients. It is uncertain whether intranasal antihistamines have comparable efficacy. This study compares effects of Azelastine and Fluticasone nasal spray in patients with allergic rhinitis. Prospective comparative study including 240 patients with allergic rhinitis was conducted with 120 each in fluticasone and azelastine group. Nasal sprays were given for period of three months along with an oral antihistamine. Follow up was done after three months. Pre and post treatment symptom assessment were done using Total nasal symptom score. The median TNSS in pre and post treatment of group A (fluticasone) is 10(4) and 1(3) which shows statistical significance with p value < 0.001. Median TNSS in pre and post treatment of group B (azelastine) is 9(4) and 1(2) which shows statistical significance with p value < 0.001. The median TNSS in pre and post treatment value between Group A and B shows no statistically significant difference between two groups with p value 0.56 and 0.06 respectively. Intranasal azelastine and fluticasone had comparable efficacy in symptom control in patients with allergic rhinitis. Azelastine due to its lesser side effects, can be safely used in children, patients with glaucoma and cataract. Azelastine may be considered as a safer replacement to fluticasone for long term use in patients with allergic rhinitis. A larger multicentric study with a bigger sample size may be required to confirm the efficacy and safety profile of azelastine nasal spray.

Comparative study of reliability of inflammatory markers over 18-FDG−PET CT scan in monitoring skull base osteomyelitis / Estudo comparativo da confiabilidade entre marcadores inflamatórios e PET/TC com 18F-FDG no monitoramento da osteomielite da base do crânio

Abstract Introduction The end point of treatment in skull base osteomyelitis is a matter of debate. A treatment based on symptoms alone is fraught with recurrence. There is a need to restrict imaging though more informative. The inflammatory markers like C-reactive protein and erythrocyte sedimentation rate used commonly need a detailed evaluation to optimize its utility. Objectives To compare the diagnostic accuracy of inflammatory markers with a hybrid PET scan in monitoring skull base osteomyelitis. The secondary objective was to obtain a cut-off value of these markers to decide upon antibiotic termination. Methods A prospective cohort study was conducted in a tertiary care center with fifty-one patients with skull base osteomyelitis meeting eligibility criteria. Patients diagnosed with skull base osteomyelitis were serially monitored with weekly markers and PET scan after the initiation of treatment. A hybrid scan was taken at 6-8 weeks of treatment and repeated if required. The follow-up period varied from 6 weeks to 15 months. The outcome measures studied were the values of markers and the metabolic activity of PET scan when the patient became asymptomatic and when disease-free. Results C-reactive protein and erythrocyte sedimentation rate had a statistically significant correlation to disease activity in PET tomography scan as a prognostic marker. Both showed good clinical correlation. A cut off value of ≤ 3.6 mg/L for C-reactive protein and ≤ 35 mm/hour for erythrocyte sedimentation rate were taken as normalized values. Conclusion A consistent normalized value of C-reactive protein and erythrocyte sedimentation rate for 8-12 weeks in an asymptomatic patient may be an indicator of disease control, though not cure. So, relying solely on markers alone for antibiotic termination may cause relapse. It may be used cautiously in a peripheral setting without access to more specific hybrid scans. In a tertiary care, follow-up scans may be done based on the titres, thereby limiting the radiation exposure.

Resumo Introdução O endpoint do tratamento da osteomielite da base do crânio ainda é uma questão de debate. Um tratamento baseado apenas em sintomas é sujeito a altas taxas de recorrência. Por outro lado, embora sejam mais informativos, o uso dos exames de imagem tem sido cada vez mais restringido. Os marcadores inflamatórios como a proteína-C reativa e a velocidade de hemossedimentação, VHS, comumente usados, precisam de uma avaliação detalhada para aprimorar sua utilidade. Objetivos Comparar a acurácia diagnóstica de marcadores inflamatórios em relação à tomografia computadorizada por emissão de pósitrons, PET-TC, no monitoramento de osteomielite da base do crânio. O objetivo secundário foi obter um valor de corte desses marcadores para decidir sobre o momento da interrupção do antibiótico. Método Um estudo de coorte prospectivo foi conduzido em um centro de atendimento terciário com 51 pacientes com osteomielite da base do crânio que atendiam aos critérios de elegibilidade. Os pacientes com diagnóstico de osteomielite da base do crânio foram monitorados semanalmente por meio de exames seriados de marcadores e PET-CT após o início do tratamento. O exame de imagem foi feito em 6 a 8 semanas de tratamento e repetido se necessário. O período de acompanhamento variou de 6 semanas a 15 meses. As medidas de desfecho estudadas foram os valores dos marcadores inflamatórios e a atividade metabólica obtida por PET-CT quando o paciente se tornou assintomático e quando estava livre da doença. Resultados Proteína-C reativa e VHS apresentaram uma correlação estatisticamente significante com a atividade da doença ao PET-TC como marcadores prognósticos. Ambos mostraram boa correlação clínica. Um valor de corte de ≤ 3,6 mg/L para proteína-C reativa e ≤ 35 mm/hora para VHS foi considerado como normalizado. Conclusão Um valor normalizado consistente de proteína-C reativa e VHS por 8 a 12 semanas em um paciente assintomático pode ser um indicador de doença controlada, embora não de cura. Portanto, o uso apenas nesses marcadores para a interrupção do antibiótico pode ser causa de recidiva. Eles devem ser usados com cautela quando não há acesso a exames mais específicos. Em centros de atendimento terciários, o seguimento com exames de imagem pode ser feito com base nos títulos desses marcadores inflamatórios, o que limita a exposição dos pacientes à radiação.

Low Dose Intratympanic Gentamicin in Ménière's Disease.

Intratympanic gentamicin has become an accepted standard of care for Ménière's disease. But there still exists controversies regarding the dosing protocol as well as the drug concentration for optimum control of vertigo and hearing preservation. To determine if 20 mg of intratympanic gentamicin administered once a month for a maximum of 2 months can alleviate intractable vertigo caused by definite Ménière's disease with hearing preservation. Once diagnosed with definite Ménière's disease as per AAO-HNS criteria, the patient was given 0.5 ml of 40 mg/ml intratympanic gentamicin. Follow-up was done at 1-month and 6-month post-treatment. If at 1-month review patient continued to have vertigo one more dose of intratympanic gentamicin was administered. Thirty-two patients were included in the study. Seventeen patients (53.1%) received one dose and 15 patients (46.9%) received two doses of intratympanic injection. We achieved an effective vertigo control of 59.4% and complete vertigo control rate of 53.1%. Worsening of symptoms was noted in 1 patient. Hearing was preserved in all patients except for one. Among the patients who attained effective vertigo control, 72.2% had dead labyrinth at 6-month cold caloric status. A single injection of 20 mg intratympanic gentamicin can alleviate intractable vertigo caused by definite Ménière's disease with hearing preservation. Non-responders may be given a second dose after one month. Intratympanic gentamicin is a simple, cheap treatment that can be carried out in an out-patient setting.

Recurrent extramedullary plasmacytomas without multiple myeloma: A case report with review of the literature.

BACKGROUND: Extramedullary plasmacytoma (EMP) is an uncommon presentation and usually occurs in conjunction with multiple myeloma (MM). An EMP without developing MM at any point is an extremely rare presentation, and only seven such cases have been reported in the literature to date. PRESENTATION OF CASE: We present a case of EMP, who presented with multiple recurrent lesions in rare sites like nasal cavity, testis and skin without the involvement of bone marrow at any point of disease course. He was treated with multiagent chemotherapy (DT-PACE) and continues to be in remission at 29 months post-chemotherapy, which is the longest amongst all the cases reported so far. DISCUSSION AND CONCLUSIONS: There are no clearly defined guidelines to treat EMP. Our case had a clinical presentation at very unusual sites and was treated with DT-PACE regimen as against the previous seven reported cases and had the most prolonged period of remission.

Comparative study of reliability of inflammatory markers over 18-FDG-PET CT scan in monitoring skull base osteomyelitis.

INTRODUCTION: The end point of treatment in skull base osteomyelitis is a matter of debate. A treatment based on symptoms alone is fraught with recurrence. There is a need to restrict imaging though more informative. The inflammatory markers like C-reactive protein and erythrocyte sedimentation rate used commonly need a detailed evaluation to optimize its utility. OBJECTIVES: To compare the diagnostic accuracy of inflammatory markers with a hybrid PET scan in monitoring skull base osteomyelitis. The secondary objective was to obtain a cut-off value of these markers to decide upon antibiotic termination. METHODS: A prospective cohort study was conducted in a tertiary care center with fifty-one patients with skull base osteomyelitis meeting eligibility criteria. Patients diagnosed with skull base osteomyelitis were serially monitored with weekly markers and PET scan after the initiation of treatment. A hybrid scan was taken at 6-8 weeks of treatment and repeated if required. The follow-up period varied from 6 weeks to 15 months. The outcome measures studied were the values of markers and the metabolic activity of PET scan when the patient became asymptomatic and when disease-free. RESULTS: C-reactive protein and erythrocyte sedimentation rate had a statistically significant correlation to disease activity in PET tomography scan as a prognostic marker. Both showed good clinical correlation. A cut off value of ≤ 3.6mg/L for C-reactive protein and ≤ 35mm/hour for erythrocyte sedimentation rate were taken as normalized values. CONCLUSION: A consistent normalized value of C-reactive protein and erythrocyte sedimentation rate for 8-12 weeks in an asymptomatic patient may be an indicator of disease control, though not cure. So, relying solely on markers alone for antibiotic termination may cause relapse. It may be used cautiously in a peripheral setting without access to more specific hybrid scans. In a tertiary care, follow-up scans may be done based on the titres, thereby limiting the radiation exposure.

Videonystagmography (VNG) Findings in Patients with Vestibular Migraine: A Hospital-Based Study.

Vestibular migraine (VM) is a disorder where vestibular symptoms are causally related to migraine. It is one of the common causes of recurrent vertigo in the general population. It has often remained as an under-recognized condition with largely unknown pathophysiology. Accurate diagnosis is essential in vestibular pathologies as it determines the management in each case. The aim of this reasearch was to compare vestibular functions of patients with VM and healthy controls using VNG and to study the VNG patterns of patients diagnosed with VM. This study is a retrospective analysis of subjects who have undergone videonystagmography (VNG) testing from October 2018 to October 2020 done in a tertiary referral hospital. Those patients satisfying diagnostic criteria for vestibular migraine were subjected to VNG testing. Group 1 consisted of 35 vestibular migraine patients, and group 2 consisted of 35 age and sex-matched healthy controls. Statistical comparison of parameters of these groups were made.We found that the mean age of VM patients in the study was 40 ± 9.9, and the females were predominantly affected (Female: Male = 2.8:1). Statistically significant difference was obtained between VM patients and healthy controls in vertical smooth pursuit and in the positional tests using the Dix Hallpike test on the right side (p value < 0.05). We conclude that a careful study of VNG patterns can serve as a valuable tool in hard to diagnose cases of vestibular migraine.

Comparison between Sialendoscopy and Conventional Methods in the Treatment of Sialolithiasis.

BACKGROUND: Sialendoscopy is gaining in popularity in treating calculus disease. The delicacy of the instrument and the diameter of the salivary ducts are factors that limit the ability to achieve complete success. There is also continued speculation regarding the utility of the procedure, especially among clinicians who are masters of conventional methods like sialadenectomy and sialodochotomy. OBJECTIVE: To assess the efficacy of sialendoscopy over conventional methods in treating sialolithiasis. METHODS: A prospective case control study was conducted in a tertiary care centre; this study involved 50 patients of sialolithiasis, and it extended over a 36-month period. All had undergone treatment, either by conventional methods or interventional sialendoscopy. All patients with nonpalpable calculi smaller than 6 mm underwent interventional sialendoscopy. Failed sialendoscopies and larger nonpalpable calculi were removed through sialadenectomy. The outcome variables studied included calculus removal, postoperative symptoms, and gland preservation. RESULTS: The success rate in terms of calculus removal by sialendoscopy was 88%, versus 100% by sialadenectomy. The salivary gland was preserved in 88% of the cases in the sialendoscopy group. Only 12% of patients were symptomatic. CONCLUSION: Sialendoscopy was effective in removing calculi of various sizes; it was definitely superior to conventional methods. Sialadenectomy should be reserved for cases either not suitable for sialendoscopy or in which there was an intervention failure.

Correlation of Lateral Cephalogram and Flexible Laryngoscopy with Sleep Study in Obstructive Sleep Apnea.

Objective. To study the correlation between lateral cephalogram, flexible laryngoscopy, and sleep study in patients diagnosed with obstructive sleep apnea (OSA). Background. Screening tools should be devised for predicting OSA which could be performed on an outpatient basis. With this aim we studied the skeletal and soft tissue characteristics of proven OSA patients. Methods. A prospective study was performed in patients diagnosed with obstructive sleep apnea by sleep study. They were evaluated clinically and subjected to lateral cephalometry and nasopharyngolaryngoscopy. The findings were matched to see if they corresponded to AHI of sleep study in severity. An attempt was made to see whether the data predicted the patients who would benefit from oral appliance or surgery as the definitive treatment in indicated cases. Results. A retropalatal collapse seen on endoscopy could be equated to the distance from mandibular plane to hyoid (MP-H) of lateral cephalometry and both corresponded to severity of AHI. At the retroglossal region, there was a significant correlation with MP-H, length of the soft palate, and AHI. Conclusion. There is significant correlation of lateral cephalogram and awake flexible nasopharyngolaryngoscopy with AHI in OSA. In unison they form an excellent screening tool for snorers.

Nasogastric and percutaneous endoscopic gastrostomy tube use in advanced head and neck cancer patients: a comparative study.

To compare the efficacy of percutaneous endoscopic gastrostomy (PEG) and nasogastric (NGT) tube administration of enteral nutrition in head and neck cancer patients undergoing curative treatment, the authors conducted a prospective study to compare nutritional outcomes, complications, and patient satisfaction. PEG patients sustained significantly less reduction in nutritional parameters, measured at 6 weeks post insertion, as compared with NGT patients. There was also a statistically significant difference between the two groups in patient's quality of life scores and complications. Comparison could not be done at 6 months because all patients were converted to PEG feeding due to the earlier findings. The authors conclude that PEG is more efficacious than NGT as a channel for nutrition in advanced head and neck cancer patients over a short duration.