Parapharyngeal Nodal Metastasis in Papillary Thyroid Carcinoma: Catching Early.

Background: Metastasis to parapharyngeal space in papillary carcinoma of the thyroid is rare and often missed in routine clinical and radiological investigations. Although contrast CT /MRI can be done to locate the parapharyngeal lesion, the diagnosis of metastasis mostly deepened upon aspiration cytology, which is a challenge in difficult anatomical locations. Here, we have emphasized the management dilemma of parapharyngeal metastasis in papillary carcinoma of the thyroid. Case Report: A 30-year-old female presented with multiple right-side neck swelling for two months. Ultrasonography of right thyroid showed TIRAD V and left thyroid showed TIRAD II. Aspiration cytology of the right thyroid showed Bethesda III and aspiration cytology revealed thyroid follicles. Due to the diagnostic ambiguity, contrast-enhanced CT scan was advised. It revealed a hypervascular lymph node in the parapharyngeal space besides multiple right cervical lymph nodes and later changed the treatment plan. Conclusion: - Metastasis to parapharyngeal space in Papillary carcinoma of the thyroid is rare and often missed on routine evaluation. Contrast-enhanced CT/MRI can be added as a primary investigation in challenging cases of suspicious malignancy of the thyroid.

Bilateral Karapandzic Flap, a Saviour for Subtotal Lower Lip Reconstruction.

Lip plays an essential role in facial esthetic, food intake, and speech. Lip defect due to trauma or surgical excision needs proper reconstruction to preserve their function. Carcinoma lip is one of the common malignant lesions in the head and neck, which needs wide local excision with proper margin with neck clearance. When the size is more than two-thirds, it becomes a challenge to reconstruct and preserve its functionality and aesthetic issues. Bilateral karapandzic flap plays an important role in this case scenario. We have two cases of subtotal lower lip defect following squamous cell carcinoma of the lower lip excision, which was reconstructed with a bilateral karapandzic flap with reasonable functional outcome and cosmesis. Thus, bilateral karapandzic flap can be an alternative option to free flap in resource-constrained scenarios with acceptable functional outcomes.

Use of Intraoperative Template for the Reconstruction of Septal Replacement Graft.

Anterior and caudal deviation of the septum can severely affect a patient's functional and cosmetic outcomes, especially seen in crooked noses. Hence, extracorporeal septoplasty is often performed where an L-shaped septal replacement graft replaces the septum to restore the functionality and aesthetics of the nose. Although an L-shaped graft can be reconstructed with the help of a caliper, the exact length and angulation between the two cartilages cannot be accurately assessed intraoperatively and preoperatively and the graft needs repeated modification. In contrast, an L-shaped template can be easily made from a wrapper of suture material and can be customized to make the neoseptum. The cartilage graft can be exactly matched to the template, which can later be successfully used as a neoseptum. We have documented using the intraoperative template to make an accurate neoseptum in a crooked nose.Level of Evidence IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Endoscopic Tympanoplasty as an Alternative to Microscopic Tympanoplasty: A Comparative Study on Surgical Outcomes and patient satisfaction.

Background: Chronic otitis media treatment has evolved, with microscopic surgeries as the gold standard and endoscopic surgeries as a newer addition. Materials and Methods: This retrospective study includes 209 patients who underwent type 1 tympanoplasty, utilizing both endoscopic and microscopic techniques, between January 2019 and December 2022 at a tertiary care institute in India. The study aims to compare hearing outcomes, graft uptake, hospital stay, postoperative pain, and cosmesis between the two groups. Results: Mean AB gap closure was 17.09 + 5.98 dB in the endoscopic group and 16.74 + 5.05 dB in the microscopic group (P = 0.687). The duration of surgery was 79.26 ± 17.37 min in the Endoscopic group and 91.92 ± 15.35 min in the Microscopic group. (P = < 0.00001). The Endoscopic group experienced less post-operative pain, shorter hospital stay (P = < 0.00001, P = 0.0008), and exhibited better cosmetic outcomes (P = 0.00001) compared to the microscopic group. Conclusion: Endoscopic tympanoplasty is a better alternative to microscopic tympanoplasty, delivering comparable hearing outcomes, shorter surgical duration, improved pain scores, and better cosmesis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04184-4.

Endoscopic stapedotomy: A comparison between the conventional approach versus CO2 laser-assisted surgery.

Background: Although the utility of laser fiber in microscopic stapes surgery has been documented in the past, their role can be highly emphasized in endoscopic stapes surgery, especially in difficult anatomical situations. Methods: This is a retrospective analysis of cases where a total of 46 patients (22 in conventional stapedotomy and 24 in CO2 laser-assisted stapedotomy) were included in the study. The clinical parameters were assessed both in the preoperative and postoperative periods in the respective groups and later compared 12 weeks after stapedotomy. Results: A total of 90.90% (20/22) of the patients in the conventional stapedotomy and 95.83% (23/24) of patients in laser-assisted stapedotomy had <20 dB of AB gap in the postoperative period (P = 0.71). Canaloplasty was required in six patients in the conventional stapedotomy and none of the patients in the laser group needed the same (P = 0.01). Chorda tympani nerve was manipulated in 59.09% (13/22) and 25.00% (6/24) of cases in the conventional group and in the CO2 laser group, respectively (P = 0.01). Conclusion: Although the audiological outcomes with fiber-enabled CO2 laser in endoscopic stapedotomy are comparable to conventional surgery, it is a better tool in a narrow auditory canal, requiring minimal manipulation of the chorda tympani nerve.

Comparing accuracy of cochlear measurements on magnetic resonance imaging and computed tomography: A step towards radiation-free cochlear implantation.

Objective: Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) are commonly employed in pre-operative evaluation for cochlear implant surgery. However, with a decrease in the age of implantation, even minor radiation exposure can cause detrimental effects on children over their lifetime. The current study compares different cochlear measurements from CT and MRI scans and evaluates the feasibility of using only an MRI scan for radiological evaluation before cochlear implantation. Methods: A longitudinal observational study was conducted on 94 ears/47 children, employing CT and MRI scans. The CT and MRI scan measurements include, A value, B value, Cochlear duct length (CDL), two-turn cochlear length, alpha and beta angles to look for cochlear orientation. Cochlear nerve diameter was measured using MRI. The values were compared. Results: The mean difference between measurements from CT and MRI scans for A value, B value, CDL, and two-turn cochlear length values was 0.567 ± 0.413 mm, 0.406 ± 0.368 mm, 2.365 ± 1.675 mm, and 2.063 ± 1.477 mm respectively without any significant difference. The alpha and beta angle measures were comparable, with no statistically significant difference. Conclusion: The study suggests that MRI scans can be the only radiological investigation needed with no radiation risk and reduces the cost of cochlear implant program in the paediatric population. There is no significant difference between the measurements obtained from CT and MRI scans. However, observed discrepancies in cochlear measurements across different populations require regionally or race-specific standardized values to ensure accurate diagnosis and precision in cochlear implant surgery. This aspect must be addressed to ensure positive outcomes for patients.

Newborn Hearing Screening with Two-Step Protocol and Risk Factor Identification: Our Experience at a Tertiary Care Centre in Eastern India.

Objective: To estimate the prevalence of hearing loss and identify the high-risk factors among neonates with hearing loss. Methods: Retrospective study done on 1054 infants in a tertiary care centre in Eastern India from 2020 to 2021 and approved by the Institutional Ethics Committee. A two-step protocol is used for screening. In the well-nursed group, OAE and BOA were performed. In the case of REFER results for automated ABR following OAE evaluation in well-nursed babies, a detailed audiological evaluation was scheduled to be carried out using diagnostic ABR within one month of age. In the high-risk group, hearing screening includes OAE, BOA, and AABR evaluations. AABR evaluation was performed as a part of the screening protocol irrespective of the results of OAE screening as PASS or REFER. Results: In our study among 1053 neonates screened, 375 were in the risk category, and 679 were without risk factors. The overall prevalence of hearing loss in neonates was 22.78 per 1000 screened neonates and 56 per 1000 among high-risk neonates. In the high-risk group, we were able to identify 4 cases of Auditory spectrum neuropathy disorder with the use of AABR during 1st step of screening. In multivariate regression analysis, the risk factors for hearing loss identified were NICU stay (OR = 3.6, 95% CI = 1.1-12.03) and Craniofacial anomalies (OR = 55.37, 95% CI = 16.48- 186.01). Conclusion: Early neonatal screening helps in the detection, intervention, and rehabilitation of hearing loss. The use of AABR in risk infant screening enhanced the chance of detection of auditory spectrum neuropathy disorder (ASND) cases. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03723-3.

Partial Extracorporeal Septoplasty in Crooked Noses.

BACKGROUND: In crooked noses, the standard septoplasty is a challenge because of the complex deviation of the septum, where straightening of the cartilage in situ is impossible. Hence, it is required to remove the partial/total septum and later is replaced back after being straightened; the procedure is called partial/total extracorporeal septoplasty. In the present study, we shared our experience of partial extracorporeal septoplasty in patients with crooked noses. MATERIALS AND METHODS: It is a retrospective analysis of 30 crooked noses who underwent extracorporeal septoplasty due to gross septal deviation from March 2020 to August 2022. The functional and aesthetic outcomes were evaluated at the end of 12 months. RESULTS: Of 30 cases, partial and total extracorporeal septoplasty was performed in 28 cases and two cases respectively. Neoseptum was reconstructed with septal cartilage in 27 (90%) cases, costal cartilage in one case and conchal cartilage was used in two instances. All the patients had good functional and aesthetic outcomes till 12 months of follow-up, and there were no major intraoperative or postoperative complications. CONCLUSION: Extracorporeal septoplasty can be an excellent surgical procedure in the highly deviated nasal septum, in Indian noses with a crooked nasal deformity. It provides adequate exposure to the whole septum, ensuring good functional and aesthetic outcomes with minimal complication rate. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Perioperative stroke in parapharyngeal space schwannoma: an unusual, dreaded complication.

BACKGROUND: Post-styloid parapharyngeal space tumours (PPS) have a notorious course owing to their anatomy and proximity to neurovascular bundles. Nerve injuries are usual outcomes in schwannomas. Our case is the first documented complication of contralateral hemiplegia occurring in the postoperative period in a benign PPS tumour. CASE REPORT: A 24-year-old presented with a swelling on the left lateral aspect of the neck, diagnosed as a PPS schwannoma. He underwent transcervical excision with mandibulotomy with extracapsular dissection of the tumour. Contralateral hemiplegia, as a dreaded complication, was encountered. He was managed conservatively according to ASPECTS stroke guidelines by the critical care team. On a regular follow-up, he noticed an improvement in the lower limb with subsequent upper limb power. CONCLUSION: Perioperative stroke is a dreaded complication involving PPS in large benign tumours. To prevent unforeseen circumstances, necessary preoperative patient counselling and immense intraoperative care should be taken while dissecting the major vessels.

Use of Dormia Basket for Retrieval of Tracheobronchial Foreign body.

Background: It is always challenging to remove a long-standing smooth spherical foreign body through standard optical forceps. These foreign bodies do not negotiate with the traditional optical forceps and the chance of dislodgement during the surgery is high. Instead, a Dormia basket can be effectively used to remove these foreign bodies. Case report: We have reported two cases of smooth spherical bronchial foreign bodies, which were failed with the standard optical forceps and later successfully retrieved with a Dormia basket. Conclusion: Dormia basket can be effectively used to remove smooth spherical bronchial foreign bodies in children not amenable to the standard bronchoscopic forceps and later can be added to the standard tool in the foreign body retrieval kit for the otolaryngologist who deals with rigid bronchoscopy on a routine basis.

Carotid Body Tumors: Institutional Experience of 10 Cases and a Review of Literature.

Carotid body tumors are slow growing neck masses that arise from the neural crest cells at the carotid bifurcation. Majority are asymptomatic and are diagnosed incidentally. Surgical excision is accepted as the treatment of choice to reduce complications. In the present series, we report 10 cases of carotid body tumors and our institutional experience. All patients underwent radiological evaluation with an ultrasonography with Doppler, contrast enhanced computed tomography and MR angiography. 6 cases were operated by a transcervical excision. The tumor was excised in tototranscervically. One of the cases required saphenous vein graft intraoperatively due to vascular injury and also had postoperative vocal cord palsy. The rest had an uneventful recovery. Carotid body tumors although rare and seemingly indolent can cause substantial symptoms if left untreated. A prompt multi modality approach is needed for both diagnosis and treatment to avoid major complications.

Endoscopic Repair of CSF Rhinorrhea: Our Experience at a Tertiary Centre.

Spontaneous or post-traumatic CSF (cerebrospinal-fluid) rhinorrhea occurs when there is a skull-base defect. In our study, we tried endoscopic approach, exclusively as surgical modality. To study feasibility of trans-nasal endoscopic approach for repair of skull-base defects and success rates at each anatomical subsite, with complications. Patients, who underwent endoscopic repair of CSF rhinorrhea between 2016 and 2019 were recruited into study. Details of investigative work-up, aetiology, surgery done, site of leak, number of surgical procedures done, post-operative complications and their management, success rate for each anatomical sub-site, was retrieved retrospectively and analyzed. All patients were initially managed with conservative measures before taking up for surgery. Eighteen-patients (male-11, female-7, mean age-40.3 years) with CSF rhinorrhea {spontaneous-5(27.7%), traumatic-13(62.3%)} were found. Sites of leak were cribriform-plate (CP), fovea-ethmoidalis (FE) and posterior-table of frontal-sinus (FS) in 8(44.4%), 5(27.7%) and 5(27.7%) respectively. Twelve (66.6%) patients had no postoperative complications. No patients with defects in CP had post-operative complication. Two (11.1%) patients with FS defect had meningitis, one (5.5%) patient with FS defect developed pneumocephalus. One (5.5%) patient developed frontal sinusitis at end of 4-months. Two (11.1%) patients, each with defects in FE and FS needed a revision repair on postoperative day 0 and 90-till date, none of the patients have any delayed procedure related complications or recurrences. Endoscopic repair of CSF leaks is the norm of the current day due to its minimally invasive nature. However, endoscopic repair of leaks through the frontal sinus were challenging and was associated with a high rate of complications.

Exclusive Endoscopic Approach in the Management of Sinonasal Inverted Papilloma.

Background: With the advancement in endoscopic endonasal surgeries, there has been a change in the surgical approach from the traditional open surgeries to the more conservative endoscopic endonasal approach for the management of sinonasal inverted papilloma. In the present study, we have shared our experience of endoscopic excision inverted papilloma involving the paranasal sinuses in a tertiary care hospital. Materials and methods: It is a retrospective case series of 28 patients who underwent endoscopic excision of inverted papilloma of paranasal sinus in a tertiary care hospital from April 2017 to October 2020. The medical records were retrospectively analyzed for the clinical, radiological, pathological, intraoperative and postoperative findings and later compared among the surgical approaches. Results: Of the total of 28 patients with inverted papilloma (3; Krouse 2 and 25; Krouse 3), 11(21.4%) patients were operated through endoscopic modified Denker, 8(39.3%) patients with endoscopic medial maxillectomy and 6(21.4%) patients with endoscopic sinus surgery. Patients who underwent modified endoscopic approach had lesser complications compared to the standard endoscopic procedures. Conclusion: Endoscopic excision of the sinonasal inverted papilloma can be a valid alternative to the open surgical approach, enabling complete clearance of the disease with a minimal complication rate. A large population with a long-term follow-up may be needed for a better understanding of the results. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03332-6.

Outcomes in Managing Vascular Tinnitus: Institutional Experience and Review of 6-Year Literature.

To evaluate the outcomes in patients of vascular tinnitus managed at our institute. The clinical data of all patients diagnosed with pulsatile tinnitus from January 2014 to April 2022 and managed at AIIMS, Bhubaneswar, was retrospectively reviewed. The diagnosis, treatment and outcomes were analyzed. A 6-year literature review was performed from March 2015 to April 2021. Our series discusses managing eleven cases of vascular tinnitus with varied aetiology and their outcomes. Out of the eleven cases, eight patients underwent surgical or radiological intervention, and seven had complete resolution of symptoms. Of the eleven patients, three had partial resolution. The 6-year literature review revealed sigmoid and transverse sinus as the most common causative anatomical sites for pulsatile tinnitus. Amongst those who received an intervention, 83.56% of the patients had complete resolution of symptoms. Vascular tinnitus can be cured if the exact vessel causing it is localized. Clinical suspicion is based on the character of tinnitus and patient history. A careful evaluation of the head and neck sites for any vascular anomaly that can cause pulsatile tinnitus must be done. Radiology demonstrates treatable causes of it. It delineates the aberrant anatomical variations that can lead to this disturbing aetiology. Treatable causes are best addressed, and pathology should be taken care of. A multidisciplinary team comprising ENT surgeons, audiologists and interventional radiologists must identify and treat the pathology.

Posterior nasal nerve neurectomy for the treatment of chronic rhinosinusitis with nasal polyposis: a randomized controlled trial.

BACKGROUND: Managing Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP) is always challenging due to the chronicity of the disease and its intractable course. Posterior nasal neurectomy (PNN) can be effective in alleviating symptoms of CRSwNP. MATERIALS AND METHODS: The study was conducted in a tertiary care referral hospital from August 2019 to April 2022. A total of 46 patients of CRSwNP were included (23 patients in the study and 23 in the control group). Patients in the study group underwent endoscopic sinus surgery (ESS) and PNN and patients in the control group with ESS. The symptoms and quality-of-life improvement were assessed at 1, 4, 12, and 24 weeks after the surgery. RESULTS: On intragroup analysis between the preoperative and postoperative scores (SNOT-22, RSDI and LK Score), we found a significant difference for each (p < 0.05). When the improvement of outcome scores was compared between the two groups, a significant difference was obtained for SNOT-22 and RSDI scores at 1 week and 4 weeks (p < 0.05). There was no significant difference found for the duration of surgery/complications between the two groups (p = 1.00). CONCLUSION: The PNN can be an effective add-on procedure in patients with CRSwNP in alleviating short-term control of the symptoms and the quality of life. A larger sample size with long-term follow-up may be required for a better understanding of the efficacy of the PNN in patients with CRSwNP.

To evaluate the efficacy of topical anti-fungal therapy in postoperative cases of COVID Associated Mucormycosis (CAM): A single-blinded randomized control trial.

PURPOSE: To compare the efficacy of 0.1 % w/w Liposomal Amphotericin-B gel with 10 % w/w Povidone-Iodine and saline nasal douching in preventing revision surgery in patients with CAM. STUDY DESIGN: Multi-arm, parallel randomized control trial. STUDY SETTING: The trial was conducted in the Department of ENT, All India Institute of Medical Sciences (AIIMS) Bhubaneswar. METHODS: Participants: Microbiologically and histologically proven cases of mucormycosis who underwent surgical debridement were included in the study. INTERVENTIONS: Postoperatively, patients were randomized into three groups based on the type of topical intervention received, in the form of Lipid-based Amphotericin B gel, povidone­iodine ointment or saline nasal douching. OUTCOME: Requirement of revision surgery in postoperative cases of CAM. RANDOMIZATION: Participants were allotted to one of the three arms by block randomization. BLINDING: Single-blinded trial. RESULTS: Numbers randomized: 15 participants were randomized to each group. Recruitment: Completed recruiting. Numbers analyzed: 15 participants were analyzed in each group. OUTCOMES: Control arm's risk of revision surgery was 4.50 (95 % CI: 1.16-17.44) times than Lipid-based Amphotericin B gel arm and 1.50 (95 % CI: 0.71-3.16) times that of the Povidone- Iodine arm. The difference was statistically significant (p = 0.02) for Amphotericin but not for Povidone-Iodine. CONCLUSIONS: Topical Amphotericin-B gel application in the postoperative cavity can decrease the need for revision surgery and help in early recovery. TRIAL REGISTRATION: CTRI/2021/10/037257. Clinical Trials Registry of India.

Infolding of Nasolabial Flap: An Excellent Surgical Technique for Full-Thickness Defect of the Lip.

To find out the usefulness of the infolding technique of nasolabial flap to reconstruct full-thickness defects of the lower lip. It is a retrospective analysis of 5 surgically operated cases. The infolding nasolabial flaps were utilized for the full thickness defect over the lower lip in carcinoma of the oral cavity from January 2018 to July 2019. The patients were followed up for a minimum period of 12 months, and the outcomes were evaluated. The mean age of the patients was 39.72 ± 7.58 years (range 30-52 years). The infolding nasolabial flap has used each case for the reconstruction of the lower lip. The average length and breadth of the flaps were 65 mm (range 60-75 mm) and 35 mm (range 30-40 mm), respectively. One patient presented with partial necrosis of the flap its tip. The functional and cosmetic outcomes were found satisfactory till 12 months of follow-up, and none of the patients had a recurrence of the disease. Infolding of the nasolabial flap can be a good surgical technique for the reconstruction of the full-thickness defect of the lower lip, ensuring satisfactory functional and cosmetic outcomes without causing major intraoperative/postoperative complications in patients with carcinoma of the lower lip.

Efficacy of Balloon Tamponade Versus Merocel Nasal Packs in Endoscopic Sinonasal Surgery: A Randomized Controlled Study.

Although absorbable nasal packings have been abundantly used in the recent time, the conventional packings are still used in different sinonasal surgeries in the various parts of the globe due to their lower cost. To compare the effectiveness of the balloon tamponade (Rapid Rhino) with Merocel nasal pack in sinonasal diseases. This study was conducted from July 2018 to July 2019 in a tertiary care referral hospital. Rapid Rhino and Merocel were put in 30 patients and 31 patients, respectively. Pain, bleeding, and mucosal healing was evaluated and compared between two groups postoperatively. The reduction in the pain and postoperative bleeding was significant with balloon tamponade (Rapid Rhino) compared to the Merocel (p < .05). Although insignificant (p > 0.05), patients with balloon tamponade nasal packs had less crusting and synechia in the postoperative period. Balloon tamponade (Rapid Rhino) nasal pack can be a better alternative to the Merocel nasal pack in reducing postoperative pain, bleeding, and mucosal damage.