The learning curve and safety of continuous intraoperative vagus nerve monitoring in thyroid surgery.

INTRODUCTION: Continuous intraoperative nerve monitoring allows for continuous feedback on the integrity of the recurrent laryngeal nerve (RLN) and the quality of its induced myogenic potential. The aims of this study were to assess the time requirements and risks associated with vagus nerve electrode placement when learning the technique. METHODS: This is a prospective observational study carried out in a single otolaryngology department at the start of a trainee's placement. A total of 40 vagus nerve dissections in 31 consecutive operations (22 hemithyroidectomies, 9 total thyroidectomies) using automatic periodic stimulation (APS, Medtronic) are included. Of the electrode placements, 10 were performed by the trainer and 30 by the trainee. The time required for each surgical step and complications relating to vagus nerve dissection were recorded. RESULTS: The average (median+IQR) total additional time attributable to vagus nerve dissection, electrode placement and baseline electromyogenic assessment was 3.1mins (2.5-3.3) for the trainer and 4.8mins (4.1-5.3) for the trainee (p<0.0001). There was a downward trend in time requirement for the trainee (not statistically significant, p=0.080). Total operative time was 38min (35-45) for hemithyroidectomy and 56min (53-62) for total thyroidectomy. There was a mix of benign (74%) and malignant (26%) histology, no intraoperative complications relating to autonomic dysfunction and one (2.5%) transient nerve palsy. CONCLUSIONS: Operative time attributable to vagus nerve electrode placement is short and the procedure is easy to learn. Appropriate surgical technique and careful anaesthetic considerations allow monitoring to be performed safely, and may reduce the rate of RLN palsy.

Neurocognitive and behavioral abnormalities in Indian children with sleep-disordered breathing before and after adenotonsillectomy.

OBJECTIVES: Children with untreated sleep-disordered breathing (SDB) have impaired intellectual ability and behavioral effects. Timely treatment of SDB by adenotonsillectomy (AT) may prevent this morbidity. This study was designed to assess the prevalence of neurocognitive and behavioral dysfunction in Indian children with SDB and to evaluate the impact of AT. METHODS: Children recruited underwent diagnostic polysomnography (PSG), a detailed neurocognitive and behavioral assessment using a battery of validated instruments - the Malin's Intelligence Scale (MIS) for Indian children, Modified Wisconsin's Card Sorting Test, Parent Conners' Scale, and the Childhood Behavior Checklist (6-18). These children then underwent AT and subsequent reassessment at 3 and 6 months. RESULTS: Neurocognitive impairment was common among the 33 enrolled children (mean age 9 [±2.97] years; 78.8% males). There was a significant correlation between the lowest O2saturation and the "categories completed" (r = -0.379; P = 0.029); and the lowest O2saturation and the "failure to maintain sets" (r = 0.386; P = 0.026) of the Modified Wisconsin's Card Sorting Test. Postsurgery, although apnea-hypopnea index (AHI) significantly decreased after surgery, 15 children still had SDB. Mean scores of most of the tested neurocognitive and behavioral domains showed improvement, although residual deficits were prevalent even after 6 months. Patients with a baseline AHI >5/h and those who had complete resolution of SDB (postoperative AHI <1/h) showed improvement in more subscales than patients with baseline AHI < 5/h and patients with incomplete resolution of SDB. CONCLUSION: The decreased neurocognitive performance related to SDB may be a result of hypoxemia, rather than the frequency of SDB events. Despite AT, residual disease is common and such patients may require further treatment.

Comparison of Steroid and Itraconazole for Prevention of Recurrence in Allergic Fungal Rhinosinusitis: A Randomized Controlled Trial.

INTRODUCTION: Allergic Fungal Rhinosinusitis (AFRS) is due to the continuous exposure of fungal antigens to an atopic individual. Medical treatment following the surgery is the standard protocol often practiced for the treatment of AFRS. Steroid (systemic/topical) has been considered as the standard medical treatment for the control of the disease in AFRS although most of the patients show recurrence with long term follow up. Instead, antifungals (itraconazole) can be tried to decrease the recurrence rate which acts by inhibiting the fungal growth in the postoperative period. AIM: In the current study, we have compared the efficacy between steroid and the itraconazole in preventing the recurrence of the disease in patients with AFRS in postoperative period. MATERIALS AND METHODS: This prospective study was conducted in the Department of Otorhinolaryngology in a tertiary care referral hospital from October 2013 to February 2015. Total 60 patients with AFRS with nasal polyposis, diagnosed by Bent-Kuhn's criteria were included in the study. For patients of Group A (containing 30 patients), systemic steroid (oral prednisolone 30 mg OD) was continued for one month and afterwards topical steroid (nasal spray) was continued till six months after surgery. In Group B (containing 30 patients), oral itraconazole (100 mg BID) was continued for six months. Clinical and haematological parameters were compared at the end of six months. RESULTS: The average pre-treatment and post treatment scores of Absolute Eosinophil Count (AEC) in the patients of Group A was 532 µg/l and 482 µg/l respectively and the corresponding values in Group B were 578 µg/L and 438 µg/L respectively at the end of six months (p=0.912). Similarly, the preoperative and postoperative serum IgE level in Group A was 886.20 IU/ml and 620 IU/ml and the respective values in Group B were 935 IU/ml and 570 IU/ml (p=0.555). Mean preoperative and postoperative mean SNOT score in Group A and Group B were 52.5 in 34.3 and respective values in Group B were 55.7 and 29.5. CONCLUSION: Itraconazole can be considered as an effective treatment alternative to the steroid for postoperative management of AFRS. Although there was no significant difference noted between two groups, patients treated with itraconazole had a better symptomatic relief and endoscopic clearance of disease.

Bilateral Cricoarytenoid Arthritis: A Cause of Recurrent Upper Airway Obstruction in Rheumatoid Arthritis.

We report a case of bilateral cricoarytenoid joint arthritis with history of rheumatoid arthritis, presented with stridor to the outpatient department. Endolaryngoscopy revealed adducted vocal cords and a nodule over left arytenoid which later confirmed to be rheumatoid nodule on histopathologic examination. Initially, although patient responded well to medical treatment, recurrence was noticed after 6 months follow-up.

Outcome of adenotonsillectomy for children with sleep apnea.

BACKGROUND AND OBJECTIVES: The prevalence of obstructive sleep apnea syndrome is about 1%-4.9% in children aged 2-18 years. This is a prospective study carried out to evaluate the role of adenotonsillectomy (AT) in pediatric sleep apnea. METHODS: Fifty children aged less than 15 years presenting with the chief complaints of snoring, mouth breathing, recurrent upper respiratory infections, and adenotonsillar hypertrophy were included in the study. Physical examination included body mass index (BMI) z-score, orodental and nasal examination, modified Mallampati scoring; whole-night level I polysomnography was conducted and repeated after three to six months of AT. RESULTS: The mean preoperative BMI z-score was -0.76, which improved significantly to -0.15 (p < 0.001) after AT. A negative correlation was seen between respiratory distress index (RDI) and pre surgery BMI z-score. As per pre-operative RDI, OSA was classified mild in 6.7% children (31.1% as per apnea-hypopnea index [AHI]), moderate in 35.6% (31.1% as per AHI), and severe in 57.8% (37.8% as per AHI). The average RDI value reduced significantly from 16.2 ± 10.7 to 6.46 ± 4.8 (p < 0.001) and AHI from 8.5 (SD ± 5.7) to 1.3 (SD ± 1) post-operatively. Only 6.7% children could be cured with surgery, of whom none belonged to moderate or severe category. Multivariate analysis shows that initial severity of disease, modified Mallampati scores III and IV, high-arched palate, and age above eight years were associated with significant residual disease after AT. CONCLUSION: AT was associated with a statistically significant change in RDI and AHI. However, complete resolution of OSA could be seen in a small percentage of patients with a mild degree of disease.

Recurrent laryngeal nerve and voice preservation: routine identification and appropriate assessment - two important steps in thyroid surgery.

INTRODUCTION: The aims of this study were to assess and compare vocal cord functions before and after thyroid surgery after intra-operative identification of recurrent laryngeal nerve. PATIENTS AND METHODS: Recurrent laryngeal nerve (RLN) is seen intra-operatively in all cases undergoing thyroid surgeries. Vocal cord functions including any voice change were evaluated by indirect laryngoscopy (I/L) and direct laryngoscopy (D/L) before and after surgery. RESULTS: Prospective study on 100 patients over 18 months with a total of 146 nerves at risk (NAR). Majority were women (n = 86) with mean age of 37.48 years (range, 13-60 years). RLN was seen in all patients and 19 patients complained of some change in quality of their voice after surgery. Evaluation by I/L and D/L at 6 weeks showed recurrent laryngeal nerve palsy (RLNP) in nine (47.36%) and five (26%) of these 19 patients respectively. Analysed according to total NAR, the incidence of voice change and temporary RLN palsy (I/L and D/L) at 6 weeks was still less at 13.01%, 6.16% and 3.42%, respectively. Voice change improved in all cases at 3 months with no RLNP palsy by I/L or D/L. All these 19 patients had undergone difficult or extensive surgery for malignancy, large gland, extratyhroidal spread or fibrosis. CONCLUSIONS: Despite identification and preservation of RLN, patients can develop postoperative voice change and RLNP although all voice change cannot be attributed to damaged RLN. Proper assessment of vocal cord functions by I/L and D/L laryngoscopy is required to rule out injuries to these nerves. Risk of damage is higher in patients undergoing more difficult surgery.

Tuberculosis of paranasal sinuses.

Nasal tuberculosis is very rare but much rarer is tuberculosis of paranasal sinuses. It involves especially the maxillary sinus and is usually unilateral. We report an unusual case of tuberculosis of frontal and maxillary sinus in a 68 years old male, who presented with a swelling above left medial canthus, with no other eye or nasal complaints. Clinical and radiological findings on our initial evaluation suggested that the patient had left frontal mucocoele with bilateral maxillary haziness. Diagnosis was established on FNAC report and subsequent Ziehl - Neelsen staining of nasal swabs and tuberculin skin test. Later chest x-ray examination was suggestive of pulmonary tuberculosis, which was the primary cause. Patient responded well to antituberculosis drug therapy.

Rhinosporidiosis: Its varied presentations.

Rhinosporidiosis is the fungal infection generally affecting the nasal mucosa. In this article we are presenting two unusual cases of rhinosporidiosis. First case presented with nasopharyngeal mass, without any past history of bathing in stagnant water or epistaxis. Mass was excised using nasal endoscope. Second case presented with recurrence of rhinosporidiosis even after nine times surgical intervention with systemic Amphotericin-B. In this patient, surgical excision of mass was assisted with Amphotericin-B nasal douching and oral Itraconazole. Both patients are doing well with no recurrence till date.

Paranasal mucormycosis: Unusual presentation in otherwise healthy child.

Mucormycosis is the fungal infection usually involving immunocompromized individuals. In this article we present a case of mucomycosis affecting a 12-year-old healthy boy who was treated by endoscopic surgical technique. Postoperatively patient was put on Amphotericin B nasal douching and oral Itraconazole. There was no recurrence till the last follow up at six month postoperatively.

Sinonasal haemangiopericytoma.

Haemangiopericytoma is a rare vascular tumour accounting for about 1% of vascular tumours of the body. We report a case involving left maxillary region, its management along with review of literature.

Comparative evaluation of functional endoscopic sinus surgery and conventional surgery in the management of chronic sinusitis.

Fifty patients with signs and symptoms of chronic sinusitis and refractory to medical treatment constituted this study. They were divided at random into two groups of 25 patients each. Group A (study group) patients were subjected to functional endoscopic sinus surgery (FESS) and group B (control group) patients were treated by conventional surgery. The age of the patients varied from 16-55 years (mean 29.1). Out of 25 patients in the study group, 19(76%) had complete relief of symptoms, 4(16%) had partial relief of symptoms and 2(8%) had no relief of symptoms in the follow-up period of 15-33 months (mean 19.2 months). Out of 25 patients in the control group, 15(60%) had complete relief of symptoms, 4(16%) had partial relief of symptoms and 6(24%) had no relief of symptoms in the follow-up period of 15-33 months (mean 19.2 months). The results of this series revealed that FESS had the combined advantages of precise, atraumatic removal of the disease with minimal morbidity and at the same time retaining the physiological function of the nose and paranasal sinuses.

Nasal endoscopy-evaluation in epistaxis.

Epistaxis is generally of two types : one where a cause is recognised ( Local or Systemic ) and the other where the cause is not known. All cases of nose bleeds with no evident cause is customarily categorised into an Idiopathic type. Anterior rhinoscopy ordinarily gives a very limited view of the nose and the probable cause of epistaxis, and this, we feel could he one of the reasons why a proper diagnosis is not always likely. Another problem is the poor localisation of the site of bleeding point. Such cases pose a problem in implementing treatment, as the cause or the site is not easily located. This study tries to venture the exquisite and wide vision provided by the Nasal endoscope. This study also tries to investigate the possibility of reaching the inaccessible bleeding points, to treat them directly. The study was conducted on 60 patients who attended the Out Patient Department and the Indoor ward with complaints of Epistaxis.

Role of microrhinoscopic sinus surgery in chronic sinusitis: Initial results.

Chronic sinusitis with/ without polyposis account for the majority of nasal pathology. The advent of Functional Sinus Surgery has led to a better understanding of the complex anatomy of the paranasal sinuses and the surrounding vital structures. The application of surgical principle and technique of Functional Endoscopic Sinus Surgery to another approach for regional pathology using operating microscope has enabled us to significantly refute this technique of treatment of sinus pathology namely Microrhinoscopic Sinus Surgery (MRSS). In this paper the technique as well as the initial results of the Microrhinoscopic Sinus Surgery(MRSS) is discussed with its advantages.

Functional endoscopie sinus surgery in children.

Functional Endoscopie Sinus Surgery Which has been introduced in Europe by Messerklinger and Stammberger and later on in United States by Kennedy, has now become a standard modality of treatment for sinus diseases in our country. However, most of the work reported from our country pertain to adult population. In this paper, we present our experience in 30 children who underwent Functional Endoscopie Sinus Surgery over the past four years. The age of the patients varied from 7-14 years. All the patients tolerated the procedure well and there was no major complication. Follow-up period varied from 9-39 months with a mean follow-up of 18.3 months. Out of 30 patients, 27 patients were available for long term assessment of results. 18 patients (66.67%) reported complete improvement of symptoms, while 6 patients (22.22%) had partial improvement. 3 patients (11.11%) showed no improvement. The results of this small series reveal that Functional Endoscopie Sinus Suregery has a definite role in the treatment of sinus disease in children.

Functional endoscopic sinus surgery- a newer surgical concept in the management of chronic sinusitis.

Two hundred and ten patients suffering from chronic hyperplastic rhinosinusitis refractory to medical treatment were subjected to Functional Endoscopic Sinus Surgery using the classical Messerklinger technique ( MT FESS). Of these, 147 (70%) had complete relief of symptoms, 39 (18.5%) had partial relief of symptoms and 15(7.17%) had no/poor relief of symptoms in the follow-up period varying from 6-33 months (Mean 18.3 months). Sine (4.2%) patients were lost to follow-up. The merits and demerits of Functional Endoscopic Sinus Surgery are discussed.

Preliminary analysis of the transcriptional regulation of the human beta 1-adrenergic receptor gene.

One open reading frame of a 13 kb genomic clone of the human beta 1-adrenergic receptor, which lacks introns, encodes the previously isolated cDNA. Transcript(s) between 4.7 and 5.1 kb are detected in total RNA, whereas a approximately 3 kb transcript is detected only in polyadenylated RNA. The poly (A+) transcript is most highly expressed in the pancreas, liver, heart, kidney, thalamus, adrenal, and salivary glands. Primer extension and ribonuclease protection analyses suggest that the major transcriptional start site is located at -263. Transient expression of luciferase reporter gene constructs indicates that the region from -444 to -360 possesses the primary promoter, consistent with the transcriptional start site at -263. Negative transcriptional regulatory elements are located from -3118 to -2730 and -2730 to -2241, while a positive element is located between -2241 and -1790. The present study suggests that, despite similarities, the expression and transcriptional regulation of the human gene are distinct from those of the genes of other species.

Antrochoanal polyp-a cause of obstructive sleep apnoea in children.

Obstructive sleep apnoea syndrome is a well established entity which has received much attention in the recent past. In children the commonest cause of sleep apnoea is adenotonsillar hypertrophy. We report two cases of antrochoanal polyp in children who presented with symptoms consistent with sleep apnoea. Preoperative polysomnography was performed in these cases which confirmed the diagnosis of sleep apnoea. Under general anaesthesia both children underwent polypectomy with middle meatal antrostomy Post operatively the patients were put on steroid nasal spray for 2 weeks. Repeat polysomnograpy performed four weeks following surgery revealed reversal ot disturbed sleep patterns.

Comparative evaluation of chemoimmunoradiotherapy and chemoradiotherapy in the management of advanced head and neck cancer.

50 patients of advanced squamous cell carcinoma of the head and neck were randomised cither to receive chemotherapy followed by radiation therapy or chemoimmunotherapy followed by radiotherapy. In the chemoimmunotherapy arm, the patients received recombinant interferon alpha 2b 3 M.U. subcutaneously, thrice a week on alterante days for 5 weeks from Day 1, Cisplatinum 70 mg/ m(2) on Day 1 and 21, and 5 - flurouracil 1000mg/m(2) on Day 1, 2, 3 and Day 21, 22, 23, followed by from Dav 36, radiotherapy'by Co bait 60 to a tumour dose of 65 Gy in 30 # over 6 weeks. In the control arm, patiens received Cisplatitnum 70 mg/ m(2) on Day 1 and Day 21, 5 flurouracil 1000 mg/ m(2) on Dav 1, 2, 3 and Day 21, 22, 23 followed by radiotherapy by Cobalt 60 to a tumour dose of 65 Gy in 30 # over 6 weeks from Day 36. Only Grade II and III toxicity was observed in the two arms which were manageable Patients treated with chemoimmunotherapy followed by radiotherapy showed 60% complete response, 20% partial response and 12% no change/ progressive disease; while the patients on the control arm treated with chemotherapy and radiotherapy showed 12% complete response 44% Partial response and 32% no change" progressive disease. This trial concludes that chemoimmunotherapy followed by radiotherapy is an excellent alternative therapeutic strategy for the management of advanced head and neck cancers with manageable toxicity.