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.

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 .

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.

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.

Columellar Strut in Correcting the Recurrent Vestibular Stenosis.

Management of vestibular stenosis is always a challenge in rhinology, especially for patients with complete vestibular stenosis. Tip plasty (with columella strut) can be supplemented to the primary surgery, can ensure good functional and cosmetic outcomes in patients with complete vestibular stenosis.

Assessment of Hearing Loss in Minor Head Injury: A Prospective Study.

Introduction Hearing loss following a head injury is common and well known. The numbers of road traffic accidents have increased recently, with minor head injuries being very common, and usually go unreported. Hearing loss after a minor head injury is often unnoticed. Available literature is limited in this regard. Objective This study was done to assess hearing loss in patients with minor head injuries and to define its natural history and progression/regression by a serial assessment of hearing. Methods This prospective study was done in the Department of Neurosurgery, AIIMS, Bhubaneshwar, Odisha, India, for a period of 24 months to look at the profile of hearing levels of patients presenting with history suggestive of minor head injury. Results This study has shown that some form of hearing loss is common after a minor head injury and should be evaluated in all patients to detect subclinical hearing loss. A significant number of patients having minimal or a mild degree of hearing loss, if managed properly, improve to preinjury status. Distortion product oto-acoustic emission testing should be used as the screening and follow-up tool. Conclusion This study highlights the importance of hearing assessment in minor-head-injury patients and the prognosis of recovery as per the severity of hearing loss and head injury.

Primary Endoscopic Stapes Surgery: A Comparison of Adipose Tissue and Gelfoam Seal.

To compare the efficacy between the commonly used sealing materials, i.e., adipose tissue and the gelfoam in primary endoscopic stapedotomy. Lobular fat and gelfoam have been used in patients who underwent endoscopic stapedotomy between two groups, each containing 29 patients. The hearing outcomes and postoperative complications were compared at the end of 12 weeks between two groups. The ABG of ≤ 10 dB was achieved in 69% of cases in group A and 76% of cases in group B. There was a significant short-term (1 week) improvement in the Dizziness Handicap Inventory score (p = 00) with patients of adipose tissue seal compared to the gelfoam. Although the audiological outcomes were comparable between the two groups, the use of the adipose tissue can be a better alternative than gelfoam to control vertigo in the early postoperative period without causing any significant morbidity to the patient.

Clinical presentations of nontuberculous mycobacteria as suspected and drug-resistant tuberculosis: Experience from a tertiary care center in Eastern India.

Background: Nontuberculous mycobacteria (NTM) are on the rise worldwide. The diagnosis and treatment of NTM disease create a dilemma for physicians as their clinical features often overlap with that of tuberculosis (TB). The present study aims to report a series of NTM infections presenting as suspected TB. Methods: It was a prospective observational study starting from December 2018 to January 2022. A total of 1850 suspected TB patients (pulmonary = 522 and extrapulmonary = 1328) were included in this study. Clinical features, radiological findings, microbiological diagnosis, treatment, and outcome were recorded. Clinical specimens were processed for Ziehl-Neelsen staining, GeneXpert MTB/Rif assay by cartridge-based nucleic acid amplification test, and culture. The culture-positive isolates were categorized as Mycobacterium tuberculosis complex or NTM depending on the detection of MPT64 antigen by immunochromatographic test. The NTM isolates were speciated by line probe assay using GenoType® Mycobacterium common mycobacteria kit. The criteria of the American Thoracic Society/Infectious Diseases Society of America were applied to confirm NTM disease. Results: Of 1850 suspected TB patients, NTM disease was diagnosed in 20 patients (pulmonary = 9, nonpulmonary = 11). Eight NTM cases presented as suspected drug-resistant-TB with a history of antitubercular therapy. Among pulmonary NTM cases, Mycobacterium scrofulaceum (n = 7) was the most common species followed by Mycobacterium kansasii (n = 1) and Mycobacterium intracellulare (n = 1). In nonpulmonary cases, Mycobacterium abscessus (n = 8) was involved in majority of cases followed by Mycobacterium fortuitum (n = 3). Cavitary lung disease and laparoscopic port site infections were most frequent pulmonary and non-pulmonary manifestations respectively. Conclusion: Hence, there is an urgent need for better diagnostic and drug susceptibility testing facility along with standardized treatment protocol for NTM disease.

Combined Use of Pectoralis Major Myocutaneous Flap and Deltopectoral Flap for the Reconstruction of Advanced Oral Cancers: Our Experience in 29 Cases.

Purpose: To assess the utility of the combined use of pectoralis major myocutaneous (PMMC) flap and deltopectoral flap (DP) in advanced oral cavity cancers in the Indian population. Materials and Methods: It is a retrospective study, considering 29 patients with stage IV carcinoma of the oral cavity, from July 2015 to February 2019. Both pectoralis major Myocutaneous flaps and deltopectoral flaps were used for stage IV oral cancers involving the full-thickness cheek and the mandibular cortex. The reliability of the flaps and clinical outcomes were evaluated in the postoperative period. Results: Of the 29 patients, partial necrosis of the skin island was detected in 6 patients, 2 patients presented with wound dehiscence, and one patient had an orocutaneous fistula. Recurrence was detected in 3(10.34%) patients, in one patient, it was at the primary site and in 2 patients, it was in the neck. When different parameters were compared between the patients with complications and without complications, the comorbidities like smoking and alcohol intake adversely affected the flap survival in the postoperative period. Conclusions: The combined use of PMMC and DP flap can be a reliable option for advanced oral malignancies, especially in patients with poor performance status with the coexisting chronic illness. Due to the presence of a definite vascular pedicle, ease of harvesting the flap, quick surgical procedure, and the minimal postoperative morbidities, these pedicle flaps can be successfully used alternative to the free flaps in advanced oral cancers, especially patients with a low socioeconomic corridor like India.

Tracheostomy in the COVID19 Patients: Our Experience in 12 Cases.

The incidence of tracheostomy has been significantly increased with the increase of patients admitted to the intensive care units. Looking into the literature, there have been various protocols proposed in the past for tracheostomy in COVID 19 patients. In the present case series, we have presented our experience of surgical tracheostomy in COVID 19 patients. It is a retrospective case series consisting of 12 COVID 19 patients who underwent tracheostomy from April 2020 to October 2020. We have discussed the tracheostomy in COVID 19 patients with references to their respective indication, location, the procedure, postoperative care and clinical outcomes. Of 12 patients, 6 were operated in the COVID ICU and 6 were operated in the COVID OT. The average duration of the intubation was 4 days (range 3-7 days). The average period of weaning was found to be 65 h (range 48 h 80 h). Of 4 patients associated with comorbidities, two had died 48 h after the surgery. The Primary indication of the tracheostomy can be made flexible based on the infrastructure of the hospital to accommodate increased patient load in a developing country like India. The location and surgical approach does not significantly affect the clinical outcomes of tracheostomy, and it can be safely performed in ICU/OT with adequate ventilation. Irrespective of the COVID status of the patients, Personal Protective Equipment (PPE) can ensure adequate protection to the health care personals preventing the spread of infection.

Management of Covid Associated Mucormycosis of Mandible: A Mountain Beneath a Molehill-A Lesson Learnt.

The opportunistic infection of post-Covid associated mucormycosis has been reported globally; however, it has reached alarming proportions in India. Mucormycosis of the mandibular region is rare, and only a few cases have been reported to date. Covid associated mucormycosis has not been reported in the literature before, and we are the first to report them. We report two patients who presented with tooth loosening with pus discharge a few weeks following recovery from Covid infection. After tooth extraction adjacent necrotic bony specimen was sent for calcofluor potassium hydroxide mount, which was found positive for broad pauciseptate hyphae. Although CT scan imaging demonstrated the involvement of a mandible segment, we found a much more extensive involvement in both cases during resection. There was intramedullary spread of the mucormycosis throughout the inferior alveolar canal, with pus discharge and foul odor. The management of covid associated mandibular mucormycosis consists of surgical debridement with antifungal therapy and control of the underlying disease. It became challenging because the radiological extent of the disease was different from the definite clinical extension of the lesion found during surgery. The authors recommend surgeons adopt a flexible approach during surgery to plan resection depending on the clinical judgment and not rely entirely on CT scans. And the reconstruction of the mandible will follow as per the extent of excision.

Outcome of Temporalis Fascia Myringoplasty With and Without use of Platelet Rich Plasma: A Randomized Control Trial.

To compare efficacy of temporalis fascia myringoplasty using platelet-rich plasma(PRP) {MP-PRP} and conventional emporalis fascia myringoplasty (MP-C) in treatment of moderate to large central tympanic-membrane(TM) perforation. Randomized-Control-Trial. We randomly assigned eighty-patients with COMmucosal-type with medium to large central TM-perforation and conductive hearing loss planned for primary myringoplasty to receive either MP-PRP orMP-C. Myringoplasty was performed through postauricular approach underlay graft using temporalis fascia. Primary-outcome was graft uptake (an intact TM) at 6 months postoperatively. Secondary-outcome was the postoperative hearing improvement measured by pure-tone-audiometry (PTA). Eighty-myringoplasties (MP-PRP group-40, MP-C group-40) done for 80 patients (male = 41; female = 39, age-group = 18-45-years) were included in analysis. At 6 months postoperatively graft uptake rate was 94.4% in MP-PRP and 92.1%% in MP-C group. There was no statistically significant difference in graft-uptake between the two groups (p = 0.358). Success in terms of hearing gain (≥ 10 dB) was achieved in 34 patients (89.5%) in MP-C and 37 patients (94.9%) in MP-PRP group. At 6 months follow-up; mean-PTA-average improved from 35.10 ± 5.401 dB to 27.74 ± 5.660 dB and mean ABG improved from 24.00 ± 5.204 dB to17.42 ± 5.559 dB in MP-C group. At 6 months followup; mean-PTA-average improved from 37.00 ± 6.144 dB to 26.65 dB and mean air bone gap (ABG) improved from 25.98 ± 5.736 dB to 16.21 ± 4.318 dB in MP-PRP group. No statistically significant differences in improvement in PTA-values were observed between both groups (p = 0.336).Postoperative complications were similar in both groups. Graft-uptake, hearing outcomes and complications of MP-PRP were similar to MP-C. MP-PRP offers no advantages over MP-C for treatment of TM perforation.

Cunninghamella arunalokei a New Species of Cunninghamella from India Causing Disease in an Immunocompetent Individual.

Mucormycosis due to Cunninghamella spp. is a rare disease, especially in immunocompetent individuals. Here, we describe the isolation and characterization of a new species of Cunninghamella, causing chronic rhino-orbital-cerebral disease, and review cases of mucormycosis due to Cunninghamella spp. in immunocompetent individuals. The Basic Local Alignment Search Tool (BLAST) analysis of the internal transcribed spacer region (ITS) sequence of isolate NCCPF 890012 showed 90% similarity with Cunninghamella bigelovii, while the large ribosomal subunit (28S) and translation elongation factor-1 alpha (EF-1 alpha) gene sequences showed 98% identity. Further, the phylogenetic analysis with concatenated sequences clustered isolate (NCCPF 890012) closely with C. bigelovii. The ITS sequence showed the maximum variation among three genes analyzed and helped in the new species' delineation. Comparison of the assembled whole genome of NCCPF 890012 with other Mucorales using 123 single-copy orthologous genes showed clustering within the genus Cunninghamella. Based on these findings, the isolate is considered to be a new species of Cunninghamella and designated as Cunninghamella arunalokei sp. nov. Despite repeated debridement and antifungal treatment, the patient had multiple recurrences with intracranial extension and succumbed to the illness.

Peripheral Cardiopulmonary Bypass in Two Patients With Symptomatic Tracheal Masses: Perioperative Challenges.

Tracheal tumors or masses causing critical airway obstruction require resection for symptom relief. However, the location and extent of these tumors or masses often preclude conventional general anesthesia and tracheal intubation. Peripheral cardiopulmonary bypass often is required before anesthetizing these patients. Herein, two cases of patients with tracheal masses, in whom awake peripheral cardiopulmonary bypass was instituted, are reported. The first case was that of an obese male child weighing 102 kg, with tracheal rhinoscleroma, who developed Harlequin, or north-south, syndrome after institution of femorofemoral venoarterial partial cardiopulmonary bypass. The second case was that of a female patient with adenoid cystic carcinoma of the trachea causing near-total central airway occlusion. She had severe pulmonary artery hypertension, which prevented the use of venovenous bypass. Instead, femoral vein-axillary artery venoarterial bypass was established to avoid Harlequin syndrome. Some of the challenges encountered were the development of Harlequin syndrome with risk of myocardial and cerebral ischemia, type and conduct of extracorporeal bypass, choice of monitoring sites, and provision of regional anesthesia for peripheral extracorporeal cannulations. Management of such patients needs frequent troubleshooting and multidisciplinary coordination for a successful surgical outcome.

Application of the new SMS system of cochleovestibular anomalies: our experience with nine cases of type III anomaly.

OBJECTIVE: To present and analyse the radiological findings, surgical findings, pre-implantation and post-implantation speech and hearing outcomes of nine children with SMS Type III cochleovestibular malformation. STUDY DESIGN: Retrospective case series of nine children with pre-lingual profound sensorineural hearing loss who underwent cochlear implantation (Jan 2012 to July 2019). These children had been classified as Type III malformation according to the SMS Classification of cochleovestibular anomalies. Facial nerve anomalies, CSF leaks and any other significant surgical finding were noted. Meaningful Auditory Integration Scale (MAIS) was used to report the child's pre-operative and two-year post-implantation auditory and speech abilities. Any significant improvement was assessed using the Wilcoxon signed rank test. P value < 0.05 was considered significant. RESULTS: Out of nine patients, five patients sustained CSF gushers, while three patients had mild CSF leak, which were plugged adequately. No facial nerve anomalies were encountered. Post-op course was uneventful for all nine patients. MAIS scores at a two-year follow-up showed significant statistical improvement (P < 0.05) when compared to pre-operative scores. CONCLUSION: Cochlear implant is the treatment of choice for children with type III cochleovestibular malformation. There are significant auditory and speech improvements expected. However, the surgeon should bear in mind the risk of CSF leak and subsequent meningitis.

SMARCB1/INI1 Deficient Sino-Nasal Carcinoma: Extending the Histomorphological Features.

SMARCB1/INI1 deficient sinonasal carcinoma is a variant of sinonasal undifferentiated carcinoma (SNUC). There is a paucity of literature describing the histomorphological features of this relatively new entity. Herein we describe the histomorphological features of three such cases and review the literature. We retrospectively reviewed the cases of SNUC diagnosed in our institute in the last 6 years. Immunohistochemistry for INI1, NUT & p16 were performed on these cases. Three cases showed loss of INI1. The histomorphology and clinicopathological features of these cases were studied and compared with non INI1 deficient SNUC. A total of 9 cases of SNUC were identified. Three of these cases showed loss of INI1. These three cases had presented with large sinonasal mass and with intracranial extension. Histopathology of these cases showed a diffuse infiltrative pattern, nest, and islands of predominantly basaloid cells with focal rhabdoid morphology. Additional features like small cell carcinoma like pattern, pseudoalveolar and pseudoglandular patterns, clear vacuoles and pseudopapillary appearance were also noted. We conclude that in presence of a mixed pattern of cells with a predominance of basaloid morphology, the possibility of SMARCB1/INI1 deficient sinonasal carcinoma must be strongly suspected and immunohistochemistry for INI1 must be performed.

Primary endoscopic stapedotomy using 3 mm nasal endoscope: Audiologic and clinical outcomes.

OBJECTIVE: To report the use of a 3 mm rigid nasal endoscope in primary endoscopic stapedotomy and clinical and audiological outcomes. MATERIALS AND METHODS: Thirty patients diagnosed with primary otosclerosis underwent endoscopic stapedotomy that was performed using a 3 mm nasal endoscope (Karl Storz). At 6 months follow-up, the patients were evaluated for intraoperative findings, postoperative hearing outcomes and complications. RESULTS: Canaloplasty was performed in 2 (6.66%) patients, and no curettage of the canal wall was required in 12 (40%) patients. Transposition of the chorda tympani nerve was conducted in 11 (36.66%) patients. The average duration of surgery was 36 min (range 31-65 min). The air-bone gap (ABG) was 35 dB (range 24-50 dB) preoperatively and 14.63 dB (range 9-20 dB) postoperatively (p = 0.00). At 6 months follow-up, <20 dB ABG was achieved in 93.33% of the patients. No major intraoperative/postoperative complications were detected. CONCLUSION: A 3 mm rigid nasal endoscope can be effectively used in stapedotomy to obtain adequate audiological outcomes. It can be considered as a better alternative to the standard microscope or 4 mm endoscope in preserving the posterior canal wall and chorda tympani nerve while minimizing operative time without causing significant complications.