Quality of Life in Non-Ventilated Tracheostomised Patients.

Introduction: Tracheostomy is a lifesaving procedure, often done at short notice to the patient and his kin. Living with a tracheostomy plays a significant role in the psychological and social aspect of the patient's life. Methods: In this study, fifty-two patients who underwent elective tracheostomy and did not depend on assisted ventilation were included. Three international standerized indices namely the Satisfaction with Life Scale, Karnofsky Performance Scale and Living with Tracheostomy Index Scale were used to assess the Quality of Life (QOL). Social, Psychological and Functional domains were assessed by means of questionnaire and specific scoring was allotted. Paired sample T-test was applied to find the level of significance across all domains. A p value of less than 0.05 was considered as the level of significance. Results: Most of the patients fell in the age group of 41-50 years. Domain wise analysis showed, high significant increase in quality of life at final administration of questionnaire with regard to all three domains. The indications of tracheostomy for all the patients in this study was long term mechanical ventilation. The effect of tracheostomy on swallowing and feeding was also noted. A significant amount of patients reported difficulty in communication and strained inter-personal communications. It was observed that patients who could perform their tracheostomy care independently had better self-image and quality of life. Conclusion: All tracheostomy patients had poor quality of life with compromise in Quality of Life across various domains. The functional, psychological and social aspects of quality of life improved over a period of time. Psychological assistance therefore should serve as a prerequisite to the comprehensive management of all patients undergoing tracheostomy. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03162-6.

6 Months of Competency Based Medical Education for Undergraduate Medical Students- Challenges And Road Ahead.

Competency based medical education (CBME) was introduced by National medical Commission (NMC) to improve the medical education to global standards. Lot of infrastructural and curricular reforms have been introduced. This article describes the 6 months experience, challenges and road ahead of CBME curriculum by otolaryngology faculties in a deemed to be university of South India. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03358-w.

Efficacy of Submucosal Diathermy of Inferior Turbinate in Patients with Chronic Rhinosinusitis Undergoing Functional Endoscopic Sinus Surgery.

Aim: To assess the efficacy of submucosal diathermy (SMD) in Chronic rhinosinusitis and inferior turbinate hypertrophy undergoing Functional Endoscopic Sinus Surgery. Materials and Methods: We conducted a Randomized Prospective study in patients undergoing Functional Endoscopic Sinus surgery for Chronic Rhinosinusitis in a tertiary care centre in South India for a period of 2 years. Patients were divided into two groups, Group A underwent FESS and Group B underwent FESS with SMD. The outcome was evaluated using nasal endoscopy score (NES), modified SNOT score and Modified Lund Kennedy scores. Results: A total of 80 patients were included in this study.40 patients were allotted in each group. Male: Female ratio was 48:32. The age distribution ranged from 19 to 44 years with a mean of 29.55 ± 6.90 yrs. Mean NES scores, Modified SNOT and Modified Lund -kennedy scores were estimated pre-operatively and during 1st, 2nd and 3rd month of post-operative periods. The mean pre-operative sores were comparable in both the groups except NES score, which was higher in group B. Both the groups showed significant improvement in post-operative period. Inter group comparison showed significant difference in all scores with group B having better results when compared to group A. Conclusion: This study proves that FESS combined with SMD improves the postoperative clinical outcomes when compared with FESS without turbinate reduction. We conclude that SMD is a simple, mucosal preserving technique with almost no complications and can be safely done along with FESS to improve the outcomes .

Clinical Outcome Following Endoscopic Septoturbinal Surgeries for Rhinogenic Contact Point Headache: A Retrospective Analysis.

To assess the clinical outcome of endoscopic septoturbinal surgeries in patients with rhinogenic contact point headache. Retrospective audit of medical records. Retrospective audit of medical records of patients having undergone endoscopic surgical management for contact point headache between a period of May 2017 to May 2018 were included in the study. Patients who underwent functional endoscopic sinus surgery were excluded from the study. Pre operative pain score were compared with post operative pain score at interval of 1 month for 3 months consequently and at 1 year interval using Visual Analog scale (VAS). The difference between preoperative (mean 6.82) and post operative VAS pain scores after 1 month (mean 3.36), 2 months (mean 4.50), 3 months (mean 5.48), 1 year (mean 5.01) was statistically significant (p < 0.001). Contact point headache is an important clinical entity that might be missed during evaluation and management of refractory headache. Surgical management under endoscopic guidance can help to ensure removal of mucosal contact point and aid in the treatment of refractory headache as noted in our study.

Expression of Marker PAK1 in Sinonasal Polyposis.

Introduction Chronic rhinosinusitis with nasal polyposis involves mucosal lining of nose and paranasal sinuses. Numerous studies studied the mechanism leading to sinonasal polyposis. We attempted study the inflammatory mechanisms responsible for the recruitment and activation of leukocytes. Aim To study and compare the expression of the immunohistochemistry marker PAK1 in sinonasal polyposis and normal nasal mucosa. Material and Methods Prospective observational study done by comparing two groups of 30 each with Group A comprises Sinonasal polyposis and Group B comprises normal nasal mucosa. The specimens were subjected to PAK1 immunohistochemical staining. Results Immunihistrochemical staining showed higher intensity stain in sinonasal polyp when compared to normal nasal mucosa. Conclusion The upregulation of PAK1 in sinonasal polyposis when compared to normal nasal mucosa may indicate an increased cellular proliferation and turnover in the background of chronic inflammation.

Role of Primary Aetiology of Intubation in Acquired Laryngotracheal Stenosis: An Institutional Audit and Review of Literature.

Aetiology of acquired laryngotracheal stenosis (ALTS) is complex and heterogenous. The aim of this study is to discuss the role of primary aetiology of intubation in the development and outcomes of Post intubation Laryngo tracheal stenosis (PILTS). A retrospective review of patients diagnosed and managed as PILTS from May 2008 to January 2017 was conducted. Demography, primary aetiology of intubation, grade of stenosis, length of the stenotic segment, treatment and outcomes of these patients were recorded and analysed. Based on aetiology of intubation, patients were divided into Poisoning (I), Neurogenic (II) and Rest of aetiologies (III) group respectively. Group I had 28/52 patients (53.8%) followed by group II, 15/52(28.8%) and group III, 9/52(17.3%) respectively. Organophosphorus compound poisoning (OPP) (44.2%) was the commonest cause overall followed by Brain injury (23.1%) and Acute Respiratory Distress Syndrome (ARDS) (11.5%). Trachea (46.15%) was the commonest subsite involved in this study. 24/28(85.7%) of patients had advanced (either grade 3 or 4) subglottic stenosis. The average length of stenotic segment in the study was 18.5 ± 9.2 mm (7-34 mm). 39/52(74.9%) of patients underwent open surgical approaches like cricotracheal resection and anastomosis, Laryngotracheal reconstruction or Shian-Yan Lee technique. 48/52(92.3%) patients were decannulated successfully. There was no significant association between primary etiology of intubation and outcomes. We conclude that OPP and neurological disease patients are more susceptible to airway injury. The authors emphasize that clinicians should be aware of these facts and manage these susceptible patients accordingly.

Changes in Otolaryngology Residency During COVID-19 Times.

Impact of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) on resident training programs is little known and even lesser studied. Residents work simultaneously in Corona virus induced disease (COVID) and non-COVID environments. Partial to complete shutdown of elective services have affected resident training significantly. This article describes changes brought about in Otolaryngology training program in a medical college hospital located in south India.

A comparative study of sequential vs. simultaneous type I tympanoplasty in patients with bilateral chronic otitis media - Mucosal type.

BACKGROUND: Patients with bilateral chronic otitis media - mucosal type have been conventionally treated with sequential tympanoplasty. Bilateral simultaneous tympanoplasty is usually not preferred because of the theoretical risk of iatrogenic sensorineural hearing loss. With the advent of modern surgical instruments and surgical techniques, the risk is expected to be lower. This study compares the clinical outcomes in type I tympanoplasty performed simultaneously and sequentially. MATERIALS & METHODS: This randomized prospective study was carried out in a tertiary care hospital between August 2015 and July 2017. A total of 30 patients were divided into two groups of 15 each. This study analyzed the graft uptake, pure tone audiogram findings pre- and post-operatively, duration of surgery and number of hospital visit for each patient and the outcomes were compared between both the groups. RESULT: Patients undergoing bilateral simultaneous tympanoplasty had significantly lesser mean duration of surgery and number of hospital visits than the patients undergoing sequential tympanoplasty. Graft uptake and postoperative wound infections were similar in both the groups. Postoperative hearing improvement was significantly better in the bilateral simultaneous tympanoplasty group. However, further studies are needed to authenticate this observation. None of the patients had a postoperative deterioration of hearing or sensorineural hearing loss. CONCLUSION: Bilateral simultaneous tympanoplasty is not only feasible but also better than sequential tympanoplasty, especially in terms of operating time, follow-up and overall financial implications on the patient.

Outcomes of Middle Turbinate Flap in the Reconstruction of Non-tumorous Ventral Skull Base Defects - an Institutional Review.

OBJECTIVE: Middle turbinate (MT) flap, based on the branches of sphenopalatine artery is one of the commonest mucosal flaps used in endoscopic skull base surgery. The objective of this study is to analyze the outcomes of the MT flap in the reconstruction of non-tumorous ventral skull base defects. METHODS: A retrospective review of patients was done from 2010-19. Patients who underwent reconstruction for non-tumorous ventral skull base defects using middle turbinate (MT) flap were included in the study. The parameters assessed include patient demography, primary etiology, site of the defect, size of the defect, graft materials used, outcomes and postoperative complications. RESULTS: A total of 13 patients who met the study criteria were included. Three (23.07%) of the patients had meningo-encephalocele, while the remaining 10 (76.93%) had CSF fistula. Isolated foveal defect (53.8%) was the most common site involved, followed by isolated cribriform, combined cribriform-foveal and combined foveal-planar defects. Graft materials used were fascia lata, fat and septal cartilage. MT flap was successfully harvested in 11 (84.6%) patients, with successful outcome in 10/11 patients. Hypoplastic MT was present in two patients, who subsequently required Hadad flap for defect closure. No major complications were reported in the postoperative period. CONCLUSION: The MT flap is effective in the reconstruction of selective skull base defects. Appropriate surgical technique and expertise are required for successful harvest. Further studies are required to analyze its outcomes in various skull base defects.

A Retrospective Analysis of Peroperative Risk Factors Associated with Posttonsillectomy Reactionary Hemorrhage in a Teaching Hospital

Introduction: Tonsillectomy is one of the most common otolaryngology procedures performed worldwide. It is also one of the first procedures learnt by residents during their training period. Although tonsillectomy is viewed relatively as a low-risk procedure, it can be potentially harmful because of the chance of posttonsillectomy hemorrhage. Objective: The objective of the present study is to analyze the effects of peroperative factors and experience of the surgeon on the incidence and pattern of posttonsillectomy reactionary hemorrhage. Methods: A retrospective review of medical charts was performed from 2014 to 2017 in a tertiary care hospital. A total of 1,284 patients who underwent tonsillectomy and adenoidectomy were included in the study. The parameters assessed were experience of the surgeon, operating time, intraoperative blood loss, difference in mean arterial pressure (MAP) and pulse rate. Results: A total of 23 (1.79%) out of the 1,284 patients had reactionary hemorrhage. Out of those 23, 16 (69.5%) patients had been operated on by trainees, while 7 (30.5%) had been operated on by consultants (p = 0.033, odds ratio [OR] = 0.04). Operating time, intraoperative blood loss, difference in MAP and pulse rate were significantly higher in the reactionary hemorrhage group, and showed a positive association with risk of hemorrhage (p < 0.05; OR >1). Re-exploration to control the bleeding was required in 10 (76.9%) out of the 23 cases. Conclusion: The experience of the surgeon experience and peroperative factors have an association with posttonsillectomy hemorrhage. Close surveillance and monitoring of the aforementioned peroperative factors will help in the identification of patients at risk of hemorrhage (AU)

Deep Neck Space Infection: Study of 52 Cases.

Deep neck spaces are still common in developing countries like India, even though its less prevalent in developed nations. It can lead to serious complications like jugular vein thrombosis and dissemination of infection if not diagnosed early and intervened. This is a retrospective chart review of 52 patients from 2014 to 2017 in a tertiary care hospital. Only patients with infection deeper to the superficial fascia of neck were included. Submandibular space infection was the most common and precipitating factor being dental infection. Most common comorbid condition was diabetes mellitus. Klebsiella pneumoniae was the most common isolated organism and few patients had mixed culture with anaerobes. Injectable cephalosporin with metronidazole was the most effective antibiotic combination against such infections. Low threshold for early surgical intervention reduce hospital stay and enable quick recovery of patients. Usage of over the counter antibiotics masks the conditions and complicate diagnosis and treatment of this condition.

A Short Term Comparison of Cartilage with Temporalis Fascia Graft Tympanoplasty in Paediatric and Adolescent Population.

To compare the anatomic and functional outcomes of the cartilage and temporalis fascia graft materials in type 1 tympanoplasty in paediatric and adolescent population. A total of 55 patients aged <18 years who required type 1 tympanoplasty were selected. 30 patients underwent cartilage palisade tympanoplasty and 25 using temporalis fascia grafts. The age, the side of the operated ear, the operative technique, pre- and post operative pure tone and impedance audiological results, and the status of the graft were noted. Graft was considered taken up if there was successful closure of tympanic membrane perforation. At the end of 6 months, the graft take rate for cartilage was 90% and for temporalis fascia it was 80% (p > 0.05). ABG closure ratio in cartilage group was 58.54 ± 23.10% and in temporalis fascia group was 56.46 ± 27.4% (p > 0.05). Pre operatively all patients had type B tympanogram in both the groups. While post operatively either type A or C curve was seen in 80% patients of cartilage and 68% patients of temporalis fascia group. Hearing outcomes and graft success rates were high in both fascia and cartilage graft groups but not significantly different.

A Retrospective Analysis of Peroperative Risk Factors Associated with Posttonsillectomy Reactionary Hemorrhage in a Teaching Hospital.

Introduction Tonsillectomy is one of the most common otolaryngology procedures performed worldwide. It is also one of the first procedures learnt by residents during their training period. Although tonsillectomy is viewed relatively as a low-risk procedure, it can be potentially harmful because of the chance of posttonsillectomy hemorrhage. Objective The objective of the present study is to analyze the effects of peroperative factors and experience of the surgeon on the incidence and pattern of posttonsillectomy reactionary hemorrhage. Methods A retrospective review of medical charts was performed from 2014 to 2017 in a tertiary care hospital. A total of 1,284 patients who underwent tonsillectomy and adenoidectomy were included in the study. The parameters assessed were experience of the surgeon, operating time, intraoperative blood loss, difference in mean arterial pressure (MAP) and pulse rate. Results A total of 23 (1.79%) out of the 1,284 patients had reactionary hemorrhage. Out of those 23, 16 (69.5%) patients had been operated on by trainees, while 7 (30.5%) had been operated on by consultants ( p = 0.033, odds ratio [OR] = 0.04). Operating time, intraoperative blood loss, difference in MAP and pulse rate were significantly higher in the reactionary hemorrhage group, and showed a positive association with risk of hemorrhage ( p < 0.05; OR >1). Re-exploration to control the bleeding was required in 10 (76.9%) out of the 23 cases. Conclusion The experience of the surgeon experience and peroperative factors have an association with posttonsillectomy hemorrhage. Close surveillance and monitoring of the aforementioned peroperative factors will help in the identification of patients at risk of hemorrhage.

Laryngopyocele in a case of bilateral mixed laryngocele: an impending airway emergency.

Laryngopyocele is a rare complication involving the laryngocele which can present with acute airway compromise. A 31-year-old man presented with acute onset respiratory distress and dysphagia. He had swelling on either side of upper aspect of the neck with tenderness on left side. Videolaryngoscopy using 70° rigid Hopkins rod telescope showed a swelling in the left pyriform sinus pushing the ipsilateral vocal cord. However, glottic space was adequate. Contract-enhanced CT scan of the neck confirmed left-sided mixed laryngopyocele with contralateral mixed laryngocele. Patient underwent excision of both the lesions in a single stage by transcervical approach. Laryngopyocele in a case of bilateral mixed laryngocele presenting as an impending airway emergency has not been reported in literature. The diagnostic and therapeutic challenges are discussed here along with review of literature.

An unusual presentation of chronic sclerosing sialadenitis of submandibular gland (Kuttner's tumour).

Kuttner's tumour, also known as chronic sclerosing sialadenitis, is a localised form of IgG4 disease which presents as asymptomatic submandibular gland swelling. The diagnosis is usually based on histopathology and immunohistochemistry. A 33-year-old woman presented with acute-onset pain and swelling in the right submandibular region. Clinical examination showed an enlarged submandibular gland, and CT showed a calculus in the Wharton's duct. After treating the acute phase with antibiotics, the patient underwent submandibular gland excision and calculus removal. Histopathology of the specimen showed areas of periductal sclerosis, acinar atrophy and intense lymphoplasmacytic infiltrates with occasional eosinophils. The IgG4 to IgG plasma cell ratio was >40%, suggestive of an IgG4-related disease. The authors have chosen to report this case because of the unusual presentation of IgG4 disease as acute sialadenitis.

Clear cell, giant myoepithelioma of tongue base: a diagnostic and surgical challenge.

Clear cell variant is a rare histological type of myoepithelioma seen in parotid and soft palate. This article describes clear cell variant of myoepithelioma in the tongue base, which has not been reported in the literature so far. A 34-year-old man presented with dysphagia and foreign body sensation of throat. Video laryngostroboscopy using a 70° rigid telescope showed a smooth globular mass in the oropharynx arising from the tongue base. Based on clinical and radiological findings, the lesion was considered as benign. Fine needle aspiration cytology was not attempted fearing risk of bleeding, aspiration and airway compromise. Hence, an excisional biopsy followed by definitive histopathological examination without frozen section was planned. The patient underwent coblator-assisted excision and subsequently sent for histopathological analysis. There were cuboidal cell nests with abundant clear cytoplasm which stained positive for p63 by immunohistochemistry. This helped in establishing the diagnosis of clear cell myoepithelioma.

Endoscopic cartilage versus temporalis fascia grafting for anterior quadrant tympanic perforations - A prospective study in a tertiary care hospital.

OBJECTIVE: Management of anterior perforations of tympanic membrane is a surgical challenge. The objective of this study is to analyse and compare the results of composite cartilage perichondrium island (CCPI) graft and temporalis fascia graft by endoscopic technique in anterior quadrant perforations. METHODS: A prospective study was conducted in a tertiary care centre from 2012-16. A total of 187 ear drums(n) in 168 patients with perforations involving anterior quadrant were included in the study. All the patients were operated completely by endoscopic technique. Tragal Composite cartilage perichondrium island (CCPI) graft was used in 87 ears and temporalis fascia in 100. Each group was categorised into A and B depending on perforation size. The outcome parameters assessed include graft success with regard to perforation size, pre- and postoperative ABG, mean improvement in ABG, ABG closure ratio and graft medialisation/lateralisation status. RESULTS: Cartilage group had 91.95% (80/87) success rate overall, while fascia had 79% (79/100). In category 1, the success rate for cartilage and temporalis fascia were 89.6% (26/29) and 68.9% (20/29) respectively (p=0.51788). In category 2, the success rates were 93.1% (54/58) and 83.1% (59/71) respectively (p=0.86356). The mean improvement in ABG for both groups were 17.52±3.84dB and 15.26±5.56dB respectively (p=0.04). ABG closure ratio for both the groups were 62.84±11.87 % and 53.6±19.6 % respectively (p=0.0008). CONCLUSION: Endoscopic composite cartilage perichondrium island graft is an effective technique in managing perforations of anterior quadrant barring the expertise required for endoscopic ear surgeries.

Flexible Laryngoscopy in Management of Congenital Stridor.

The incidence of congenital stridor is on rise due to improved neonate and infant survival rate. The gold standard investigation for evaluation of stridor is rigid laryngotracheobronchoscopy, but this is invasive and requires general anesthesia. Flexible fibreoptic laryngoscopy, a relatively simple and less invasive procedure can be done under topical anaesthesia for evaluation of stridor. In this study, we have presented our experience of flexible laryngoscopy in children with congenital stridor, their results and management. Laryngomalacia was the commonest cause of stridor accounting for 80% of cases. 15% (6) patients required tracheostomy for relieving airway obstruction and 22.5% (9) patients required a definitive surgical procedure for correcting the cause. Flexible laryngoscopy is safe and gives a comprehensive analysis of airway including its dynamic functions. We also recommend flexible laryngoscopy as a frontline investigation for evaluation of stridor.

An unusual position of retromandibular vein: a surgical challenge in parotid surgeries.

A 44-year-old man presented with swelling in the left parotid region. The swelling was firm and Fine Needle Aspiration Cytology report proved pleomorphic adenoma. In the CT scan, the tumour was confined to the superficial lobe of parotid. So, left superficial parotidectomy was planned. Modified Wilson Blair's incision was used. On course of identifying the facial nerve, a large calibre vein was identified running vertically through the parotid substance. Assuming it as retromandibular vein, further dissection was carried out more meticulously. Marginal mandibularbranch of facial nerve was identified near the angle of mandible and retrograde dissection showed the cervicofacial division running medial to retromandibular vein with the main facial nerve trunk lying unusually medial and posterior to it. Adding to it, the temporofacial division was found 'forked' between the branches of retromandibular vein. These variations in head and neck venous channels are not that rare as we believe. All these variations have an embryological basis. Therefore, knowledge and understanding of this complex anatomy will help us preventing devastating complications like bleeding and facial nerve injury in such cases.