When bronchoscopy does not suffice for airway foreign body removal: a series of cases requiring tracheotomy.

PURPOSE: To illustrate the importance of tracheotomy in difficult cases of foreign body inhalation and to enumerate the indications of the same. METHODS: A retrospective analysis of 5 cases in which the standard rigid bronchoscopic approach had to be combined with the open surgical approach (tracheotomy) for the removal of the inhaled foreign body for different indications. RESULTS: Combining the two procedures lead to successful removal of foreign body and restoration of airway in all the cases. Tracheostomies whenever performed were temporary. CONCLUSIONS: Foreign body aspiration is an otorhinolaryngologic emergency that can rapidly prove fatal if not well-handled. Though most cases can be dealt with by traditional approaches, a proportion of the cases may prove challenging and need a quick tailoring of response according to the situation at hand. An approach combining tracheotomy with the traditional bronchoscopic approach is one such way and in well-selected cases, can have a significant impact on the outcome; sometimes even in terms of life and death.

Study to Evaluate the Pattern of Nodal Distribution in Papillary Thyroid Cancer.

Among the thyroid cancers, papillary thyroid cancer (PTC) is the most common with lymphatic metastasis. It has the propensity to spread to the level II-VI lymph nodes in a predictable manner. We evaluated the pattern of nodal distribution at different levels of neck in papillary thyroid cancer in this Observational Prospective study. Total 41 patients of PTC (Papillary thyroid cancer) were included in the study. 36 out of them were diagnosed as PTC by FNAC and underwent total thyroidectomy and central neck dissection, while 5 patients were histologically confirmed cases of PTC on previous hemithyroidectomy and underwent completion thyroidectomy and central neck dissection .Patients with T3/T4 stage or N1 underwent lateral neck dissection also. Clinicopathological factors such as age, sex, tumor stage, nodal metastasis and extracapsular invasion, were evaluated. Lymph node metastasis was noted in 21 patients (51.2%) and all these patients had central (level VI) lymph node involvement. Among 21 patients, pathological ipsilateral lateral neck metastasis was noted in 6 patients (28.57%) at level II, 10 patients (47.62%) at level III and 8 patients (38.10%) at level IV. Only 5 patients (23.81%) had metastasis at level V. Extracapsular invasion was observed in 10 (24.4%) patients. We concluded that patients with PTC show higher rates of metastasis at central neck (level VI) and are not easily detected on clinical examination or by USG due to low sensitivity but are sensitive and specific for lateral neck nodes in late stages . Thus, ipsilateral selective neck dissection should be considered with total thyroidectomy and central neck dissection in presence of clinically or radiologically evident lateral lymph nodes (preoperatively) and in T3, T4 stage (late stages) tumors.

Minimally Invasive Parathyroidectomy as the Surgical Management of Single Parathyroid Adenomas: A Tertiary Care Experience.

The aim of our study is to assess the feasibility, safety and adequacy of focused parathyroidectomy for single parathyroid adenoma accurately localized preoperatively by ultrasound neck and Tc99m sestamibi scan. The study was conducted in the department of Otorhinolaryngology of SMS Medical College and Hospital, Jaipur on 116 patients of primary hyperparathyroidism who underwent minimally invasive parathyroidectomy (MIP) for single gland adenoma localized by USG neck and tc99m sestamibi scans. S. Calcium and S. PTH followed up on day 1, 6th week and 6th month. Outcomes were determined on the basis of cure rate, duration of hospitalization, complication rates and disease persistence/recurrence rate. 82 (70.68%) females and 34 (29.31%) males belonging to the age group of 21-67 years (43.02 ± 14) formed the basis of our study. Skeletal (73.27%) and renal (62.93%) were the most common presentations. Accuracy of USG and sestamibi accurately was 93.10% and 96.55% respectively with combined accuracy of 100%. Preoperative serum calcium levels of 10.7-16.03 mg/dl (13.09 ± 2.11) and serum PTH 127-2196 pg/ml (846.57 ± 776.55) were observed. Cure rate of MIP was 99.13%. No permanent complications seen. MIP can be used as the surgical procedure of choice for PHPT caused by single gland adenoma aided by USG and sestamibi scan. The cure rates are equivalent to the bilateral neck exploration (> 95%) with minimal morbidity and complications. Hence, it is a more feasible, safe and effective treatment option.

Association of Neutrophil Lymphocyte Ratio and Platelet Lymphocyte Ratio with Persistent Allergic Rhinitis.

Allergic rhinitis is a disease that affects approximately 15-25% of the World population. It is characterized by itching, sneezing, and nasal or postnasal drip. Generally, diagnosis is based on clinical findings and patient history. Laboratory tests that can be used in the diagnosis and clinical course of AR are still limited and should be improved. Neutrophil-lymphocyte ratio (NLR) and Platelet Lymphocyte Ration(PLR) are novel markers for the evaluation of inflammation. This study aims to investigate whether NLR and PLR, would be useful in diagnosis and monitoring the severity of disease in allergic rhinitis. It is a 1 year cross sectional study which assesses 140 patients, 70 belonging each to case and control group. NLR and PLR ratio was measured and compared in case and control groups. Mean NLR was 1.92 in patient group and in control group it was 1.54 (P value < 0.001). Mean PLR was 1.33 in patient group and in control group it was 0.88 (p < 0.001). Mean NLR in mild cases was 1.68 and in moderate to severe cases was 2.15 (p value 0.002). Mean PLR was 1.49 in moderate to severe disease and in mild disease it was 1.18 (p value 0.006). To conclude NLR and PLR were significantly higher in moderate to severe allergic rhinitis and not so in mild cases. Hence in allergic rhinitis NLR and PLR can be used as a marker of severity of disease according to symptoms of the disease.

Primary Hyperparathyroidism in a 21 Year Old Patient of Turner Syndrome : A Rare Case Report.

Turner syndrome is the most common chromosomal anomaly in females. The typical features include short stature, amenorrhoea, short webbed neck, shielded chest and many comorbidities like osteoporosis, cardiac anomalies, diabetes and hypothyroidism. Primary hyperparathyroidism caused by parathyroid adenoma is rarely reported in patients of turner syndrome. The exact cause is not known at present. We report a case of a 21 years old patient of Turner syndrome who had symptoms of renal stones and hypercalcemia. USG neck and sestamibi scans revealed left inferior parathyroid adenoma. Surgical excision of the involved gland was done which led to normalization of S. calcium and PTH levels. Although hyperparathyroidism is extremely rare in patients of Turner syndrome, any symptoms of renal stones, pathological fractures and hypercalcemia should raise the suspicion of parathyroid adenoma. Surgical management should be planned as early as possible.

A Descriptive Observational Study of GJB2 and GJB6 Mutations in Familial Autosomal Recessive Non-syndromic Hearing Impairment.

Mutations in the genes, GJB2 and GJB6 play an important role in autosomal recessive, non-syndromic hearing loss. This study is aimed to detect the association of mutations in GJB2 and GJB6 genes in familial autosomal recessive non-syndromic hearing impairment cases. We included 26 families with at least two affected individuals having congenital bilateral, non-syndromic sensorineural hearing loss. Blood samples were drawn, DNA was extracted, and sent for multiplex PCR and Sanger sequencing. Of the 26 families analyzed, GJB2 mutations were detected in 9(34.6%) and GJB6 mutations were not detected in any of the families. GJB2 mutations are a major cause of congenital, non-syndromic hearing loss in this study population. This study also suggests that GJB6 mutations do not contribute to autosomal recessive non-syndromic hearing loss in the Indian population.

Post Covid-19 Sinonasal Candidiasis: A Crisis Within the Pandemic.

The aim of this study was to find out the association of sinonasal candidiasis and Covid-19 infection. A prospective observational study was conducted at a tertiary care centre from April to September 2021, involving all patients with invasive candidiasis of the paranasal sinuses having a history of Covid-19 infection. A total of 18 patients of covid associated sinonasal candidiasis among the 475 cases of fungal rhinosinusitis were studied. All patients had involvement of nose and sinuses and 2 patients had orbital involvement with no loss of vision, while 3 had intracranial extensions and 1 had pulmonary involvement. Mandible was involved in 1 patient alone, while the maxilla and palate were involved in 5 patients. 15 patients were hypertensive, 12 diabetics and 1 had aplastic anaemia. Cultures showed that 8 patients had C. parapsilosis, 5 had C. albicans, 3 had C. tropicalis and 2 had mixed fungal infections. All patients underwent surgical debridement and antifungal administration. They were followed up for a minimum of 3 months. There was only one mortality (with aplastic anaemia), rest 17 were disease free at the time of writing this article. This is perhaps the first case series of post covid sinonasal candidiasis in the world. Invasive sinonasal candidiasis is a newer sequela of COVID-19 infection. Uncontrolled diabetes and over-zealous use of steroids at the time of Covid-19 are few of the known risk factors. Early surgical intervention and anti-fungal treatment should be sought for management.

Anterior and Central Skull Base Fibrous Dysplasia: A 12 Years' Experience.

Fibrous dysplasia, specially of anterior and central skull base region, is a rare disorder. This article discusses about our experience in this pathology. A tertiary care institute based retrospective type study was conducted over a period of 12 years. Demographics, radiology, intraoperative details, pathology and follow up were taken into consideration and the data was analysed. Sixteen patients with complaints of proptosis, diplopia, nasal obstruction and/or facial deformity, underwent endoscopic sinus surgery. Subtotal resection was done in 5 patients. Ethmoid bone involvement was seen in 12 patients. Post operatively, diplopia persisted in one patient and one patient had epistaxis. All patients were followed up for 2-10 years with no other complications reported. Anterior and central skull base involvement is rare in fibrous dysplasia. However, it can be removed effectively by endoscopic approach. Overall safety of patient has more concern rather than complete removal of disease.

Giant Parathyroid Adenoma: Are They Different?

Primary hyperparathyroidism is a common endocrinology anomaly which involves head and neck region. The diagnosis and treatment of parathyroid adenoma however still remains a challenge. Giant parathyroid adenomas are rare and involve more surgical expertise. Retrospective study was carried in Departments of ENT and Endocrinology, SMS Medical College and Hospital, Jaipur. Records of patients operated between 2010 and 2019 were evaluated and analysed for size and site of parathyroid adenomas, biochemical parameters, intra-operative findings and postoperative course. Tumours with size > 3 cm were termed as giant parathyroid adenomas and this is a rarity in literature. Records of 79 patients were found to be complete. Out of these 9 had giant parathyroid adenomas: 4 left inferior, 2 right inferior, 1 ectopic location (superior mediastinum) and 1 each in left and right superior glands. The size, symptomatology and biochemical parameters are discussed in light of available literature. Giant parathyroid adenomas are a rare entity and their behaviour are same as of non giant parathyroid adenomas. In the view of literature published on pub Med, this is found to be largest case series on parathyroid Adenoma considering size more than 3 cm.

COVID-19, Diabetes and Steroids: The Demonic Trident for Mucormycosis.

Coronavirus disease 2019 (COVID-19) has been found to be associated with mucormycosis in few parts of the world, especially India. It is important to look for reasons for this upsurge of cases so that other countries may take proper steps to prevent it. A prospective clinico-demographic study was conducted in SMS Medical College, Jaipur, India from April to May 2021. All patients (235) with COVID associated mucormycosis (CAM) were studied in detail with reference to their diabetic status and steroid intake during treatment of COVID-19. Steroid usage was in 84.3% of patients with methylprednisolone being the most commonly used steroid (66.8%). Majority of the patients had taken steroids for 7-14 days. Diabetes was found in 204 patients and 42.1% of patients were newly diagnosed during/after COVID-19 treatment. The HbA1c levels of diabetic patients ranged from 6.0% to 16.3%. This is perhaps the biggest study in the world shows that the triad of COVID-19, diabetes and steroid usage is a major contributing factor towards mucormycosis. Proper steps should be taken to prevent CAM.

Rhino-Orbital Cerebral Mucormycosis in Non-Diabetic Patients with COVID-19.

Rhino-orbital Cerebral Mucormycosis (ROCM), a rare invasive fungal infection, affects diabetic and immunocompromised individuals. Recent reports have raised the alarm for invasive ROCM associated with SARS-CoV-2 infection. SARS-CoV-2 infection causes immune cell dysregulation, cytokine dysregulation, and is associated with invasive fungal infections. Immunosuppressive treatment of COVID-19 with corticosteroids increases the risk of opportunistic infection. We present a series of 3 cases of invasive ROCM with different outcomes in immunocompetent nondiabetic patients who all received corticosteroids at doses higher than those recommended by the World Health Organization, and who received oxygen during their SARS-CoV-2 treatment course. Immune dysregulatory effects of COVID-19 and high-dose corticosteroids may both have caused predisposition to ROCM in these cases. Additionally, health system stress caused by responding to COVID-19 surges may have predisposed patients to exposure to mucormycosis-causing fungi through use of non-sterilized water for oxygen humidification. In light of these cases, we encourage guideline-based corticosteroid dosing in the management of COVID-19 as well as vigilance for invasive mucormycosis and prompt treatment in corticosteroid-treated patients.

Laryngeal foreign bodies among adults.

Impacted foreign body of the larynx in the middle-aged man is a rare occurrence. Occupational and habitual surroundings make them prone to foreign body aspiration and impaction in the larynx. Proper history helps in establishing the diagnosis. We report 2 cases of unusual laryngeal foreign body in middle-aged adults who presented with complaints of sudden onset of change in their voice without any respiratory difficulty with accurate history of aspiration. Foreign bodies were successfully removed by direct laryngoscopy under general anesthesia.

Rare impacted foreign bodies of larynx.

This paper presents our experience with three cases of very unusual impacted foreign bodies in larynx and all without any Classical signs and symptoms of foreign body inhalation. Review of literature reveals that these conditions are rare and reported infrequently. Correct diagnosis and adequate approach is necessary as foreign bodies that do not obstruct the airway and which are stuck in place may be relatively asymptomatic but could be life threatening.

Spindle cell sarcoma of larynx.

Spindle cell carcinoma of larynx is rare tumors constituting only 0.6% of laryngeal neoplasm with predominance in elderly males (average 63 yrs). These tumors were described under various names: pseudosarcoma, Carcinosarcoma, fibromyxosarcoma, mixed sarcoma, polypoidal sarcoma. Immunohistochemistry and electron microscopy suggest that spindle cell carcinoma are true neoplasm and spindle cells are part of the neoplasm and not benign reactive fibroblast.

Foreign body in bronchus: An unusual presentation.

Exogenous foreign bodies in the trachea bronchial tree are not uncomion particularly in children. Children who are not given proper individual attention at an early age are more hable to ingest or inhale foreign body.