Sinonasal schwannoma masquerading as an IgG4-related nasal mass.

An elderly (8th decade) diabetic patient presented with insidious, painless protrusion of the right eye for 1 month, associated with nasal congestion. Past history included healed serous chorioretinopathy in the right eye (>30 years back) and recently diagnosed (1 year prior) autoimmune IgG4-related pancreatitis for which he was on long-term corticosteroids. On nasal endoscopic examination, a well circumscribed mass was found in the right nasal cavity.Keeping in mind the systemic diagnosis, the sinonasal mass was suspected to be a IgG4-related disease. An endoscopic biopsy was performed and revealed a surprise diagnosis of grade 1 nasal schwannoma.

Comparing Diagnostic Efficacy of Imaging During Muller's Maneuver Versus Drug Induced Sleep Endoscopy in Obstructive Sleep Apnoea.

The aim of the study was to compare the diagnostic efficacy of quantitative computed tomography (CT) based upper airway analysis using the Muller's maneuver (MM) and compare the findings with drug induced sleep endoscopy (DISE). A prospective observational study was conducted on 50 adult patients with symptoms of OSA and having apnoea-hypopnea index more than 5. They further underwent CT during normal breathing and during MM; findings of which were compared with DISE. Collapse at velum had statistically significant correlation with collapse at retropalatal level in CT (in MM) (P value = 0.001; r = 0.536). Base of tongue in DISE correlates significantly with retroglossal collapse on CT (P value = 0.002; r = 0.423). Epiglottic and oropharyngeal collapse had no correlation with any CT parameter. Collapse in CT as measured during MM shows significant correlation with DISE findings at velum and tongue base but cannot solely predict all levels without the aid of DISE.

Infected Haller Cell Misdiagnosed as Invasive Fungal Sinusitis - A Parallax.

We report an unusual case of a 29-year-old female with a short duration of right lower eyelid swelling, painful eye movement and paraesthesia of right cheek. She was subsequently worked up with mucormycosis in mind, but intra-operative findings were suggestive of an infected Haller cell and post-operatively she was symptom free.

Endoscope Assisted Combined Drainage of Sino-Orbital Abscess: Technique Revisited.

Orbital complications of acute rhinosinusitis may present with painful proptosis and ophthalmoplegia. Surgical management, when required comprises of endonasal endoscopic sinus clearance with or without external orbital abscess drainage. External drainage involves blind dissection and carries a risk of iatrogenic injury to periorbital structures. We describe a novel technique of endoscope guided orbital abscess drainage under direct visualisation via the external incision site. Patients with orbital cellulitis secondary to rhinosinusitis and planned for surgical intervention were recruited. After endonasal endoscopic sinus surgery, the orbital abscess cavity was opened and an endoscope was inserted externally. The cavity was examined; loculi were opened under direct visualisation till drainage was complete. This procedure was performed in seven patients with a successful outcome. The mean time to resolution was 1.5 months (36.4 ± 18.2 days). None of the patients had any recurrence or residual disease on follow up. In addition, in two cases with obstructed sinus drainage and "walling off" of frontal sinus, visualisation of the instrument placed in the drained abscess cavity via endo-nasally inserted endoscope confirmed the re-establishment of continuity of sinus opening. This approach may allow the surgeon to drain multiloculated abscess completely under direct visualization while minimising iatrogenic damage to periorbital structures. Real time display using endoscopic camera on the monitor screen also serves as a teaching and training tool during the procedure. Technique utilises the existing endoscopic set-up without the need for additional instrumentation.

As the virus sowed, the fungus reaped! A comparative analysis of the clinico-epidemiological characteristics of rhino-orbital mucormycosis before and during COVID-19 pandemic.

BACKGROUND: The sudden surge of mucormycosis cases which happened during the second wave of COVID-19 pandemic was a significant public health problem in India. OBJECTIVES: The aim of this study was to analyse the clinico-epidemicological characteristics of the mucormycosis cases to determine the changes that had occurred due to COVID-19 pandemic. METHODOLOGY: A retrospective cross-sectional study was conducted at the Department of Otolaryngology Head and Neck Surgery, PGIMER, Chandigarh, India. Patients diagnosed with rhino-orbital mucormycosis were categorised into the following groups: Pre-pandemic(May 2019 to April 2020), Pandemic Pre-epidemic (May 2020 to April 2021) and Epidemic (1 May 2021 to 12 July 2021). The epidemiological, clinical and surgical data of all the patients were retrieved from the hospital records and analysed. RESULTS: The epidemic period had 370 cases, compared with 65 during pandemic period and 42 in the pre-pandemic period. Diabetes mellitus was seen in 87% of cases during epidemic period, 92.9% in the pre-pandemic period and 90.8% in the pre-pandemic pre-epidemic period. The proportion of patients suffering from vision loss, restricted extra-ocular movements, palatal ulcer and nasal obstruction was higher in the pre-epidemic groups, and the difference was significant (p, <.01). There was no history of oxygen use in 85.9% of patients and no steroid use in 76.5%. The death rates were the lowest during epidemic (10%). CONCLUSION: COVID-19 has caused a statistically significant increase in the number of mucormycosis infections. The mortality and morbidity which showed an increase during the first wave of COVID-19 decreased significantly during the epidemic period.

Laryngeal tuberculosis: a neglected diagnosis.

A 24-year-old woman visited the Ear Nose Throat (ENT) outpatient department with complaints of hoarseness for 2 months not responding to conservative management. Laryngoscopic examination revealed a whitish ulceroproliferative lesion in the anterior commissure and anterior two-thirds of bilateral true vocal cords with surrounding necrosis. In view of the above findings, the patient was planned for biopsy under general anaesthesia. Intraoperative findings showed multiple whitish necrotic friable tissue involving anterior two-thirds of bilateral false vocal cords, ventricle, bilateral true vocal cords, both aryepiglottic folds and laryngeal surface of epiglottis. Postoperative histopathology was consistent with tuberculosis. A pulmonology consultation was taken, and the patient was started on anti-tuberculosis chemotherapy. One month post therapy, the voice was symptomatically better. A flexible fibreoptic laryngoscopic examination was done, which revealed almost complete resolution of the lesion with minimal ulceration at the anterior one-third of right true vocal cord.

Allergic Fungal Otomastoiditis: A Case Report and Review of Literature.

Allergic fungal otomastoiditis, a rare known entity has only been published as case reports in literature. There have been 3 cases of adult and 1 case of pediatric allergic fungal otomastoiditis reported as of now. A young male had unilateral otorrhea and hearing difficulty for four years. The audiogram revealed moderate conductive hearing loss and radiograph showed complete opacification of tympanic cavity. He underwent tympano-mastoidectomy, showing polypoidal granulations and thick mucoid discharge. The histopathology was a surprise diagnosis of Allergic fungal otomastoiditis. The clinical and histopathological appearance of this entity matches allergic fungal rhinosinusitis. After extensive review of literature, we propose a working criterion for early identification of allergic fungal otomastoiditis in otolaryngology setting.

Plasma Ablation-Assisted Endoscopic Endonasal Transpterygoid Approach to Sphenoid Lateral Recess Cerebrospinal Fluid Leaks: Technique and Outcome.

BACKGROUND: Management of sphenoid lateral recess (SLR) cerebrospinal fluid (CSF) leaks present a challenge because of the location and requiring complete visualization of the defect for a successful repair. The endoscopic endonasal transpterygoid approach (EETPA) is considered the gold standard in addressing these defects. We lay out our experience in implementing this approach with plasma ablation. METHODS: This is a case series of 11 diagnosed patients of SLR CSF leaks who underwent plasma ablation-assisted EETPA repair by a single surgeon between 2011 and 2020 at our institution. Outcomes in terms of surgical field grade on the Wormald 11-point grading scale, postoperative complications, healing on nasal endoscopy and imaging, and surgical success rate were assessed. RESULTS: The etiology was spontaneous leak in 10 (90.9%) patients and secondary to temporal lobe abscess and/or meningitis in one (9.09%). Three (27%) patients were previously operated elsewhere by the transsphenoidal route, which we reoperated by this technique. As per Wormald grading, grade 1 field in 3 (27.27%), grade 2 in 6 (54.5%), and grade 3 in 2 cases (18.18%) were noted. Complications occurred in 3 patients (27%) in the form of dry eye (9%), meningitis (9%), and transient CSF rhinorrhea in the immediate postoperative period (9%). Repair sites were well healed on follow-up nasal endoscopy and imaging. The surgical success rate was 100%. CONCLUSIONS: Plasma ablation-assisted EETPA allows for a uninostril approach to the SLR, easy accessibility, and better visualization with a bloodless field, which allows appropriate repair, thus minimizing complications and preventing recurrence.

Laryngeal lymphangioma as a cause of respiratory distress in an adult with Down's syndrome: an extremely rare presentation.

A 32-year-old man with Down's syndrome was referred to the ear, nose and throat (ENT) department in view of failed attempts at extubation, and subsequently, at decannulation of tracheotomy tube. He had previously required ventilatory support and had history of intubation for 1 week. A flexible fibre-optic laryngoscopy showed a smooth mass covering the laryngeal inlet which moved with respiration. Direct laryngoscopy under general anaesthesia revealed a smooth mucosa covered fleshy mass arising from the left aryepiglottic fold and arytenoid, obstructing the laryngeal inlet. The mass was removed using controlled plasma ablation, and histopathological examination of the same was consistent with lymphangioma. Endoscopic examinations during the regular follow-up visits revealed well-healed supraglottic area with adequate glottic chink and the patient could be successfully decannulated.

Endonasal endoscopic versus microscopic transsphenoidal surgery in pituitary tumors among the young: A comparative study & meta-analysis.

PURPOSE: The transsphenoidal approach presents unique challenges in young, with scanty literature. This study compares the outcome of pituitary tumors among young in our center between endoscopic(EES) and microscopic(MTS) transsphenoidal surgery, with a meta-analysis. METHODS: Patients within 20 years were studied for their surgical approach to a favorable outcome of endocrine remission (ER) (functioning) or Gross/Near-Total resection (nonfunctioning), besides the need for retreatment. Relevant studies were pooled and analyzed according to PRISMA guidelines. RESULTS: Out of 64 young patients with pituitary tumors, 48 underwent transsphenoidal surgery using MTS(33) or EES(15). Of these, 21, 14, 5, and 8 had Cushing's, somatotropinomas, prolactinomas, and non-secreting tumors, respectively. Mean symptom duration was 28months, with weight gain(50 %) and visual complaints(29 %) most prevalent. Hypogonadism(21 %) was the most frequent endocrinopathy. The mean tumor volume was 3.8 cm3. Over mean follow-up of 4.4years, favorable outcome was significantly higher after EES than MTS(78.6 % vs. 46.7 %)(odds ratio 4.18, p = 0.05). EES's better outcome was homogeneous across subgroups of age and tumor type, with no significant subgroup difference. Symptom duration was significantly higher among those who required retreatment(p = 0.05), while ER had a non-significant association with tumor volume(p = 0.07). Overall, 40 %, 27 %, 17 %, and 8% were on hydrocortisone, thyroxine, sex hormone, and desmopressin, respectively, at follow-up with no significant difference between EES and MTS. In pooled analysis of literature, both favorable outcome(74 % vs. 48 %,p = 0.02) and retreatment rate(8% vs. 37 %,p = 0.004) were significantly better with EES than MTS. CONCLUSION: Among young patients with pituitary tumors, the favorable outcome and retreatment rates are better with endonasal endoscopy and associated with symptom duration and tumor volume.

Otolaryngology Practice in Covid 19 Era: A Road-Map to Safe Endoscopies.

Covid-19 has changed the way medical services are being delivered all around the world. Otolaryngology as a speciality is anecdotally associated with high risk of infection. Endoscopies can be associated with aerosolization of particles due to cough or sneeze which may be induced. An overhaul of endoscopy and associated procedures is necessary keeping in mind the prevailing situations. This paper aims at a review of the on-going research and development of a road map for safe endoscopies-both for patients and heath care workers.

Cerebrospinal fluid leak from lateral orbit during exenteration for mucormycosis.

We describe an elderly diabetic patient presenting with sudden onset right-sided proptosis and vision loss secondary to rhino-orbital mucormycosis and central retinal vascular occlusion. He underwent orbital exenteration that was complicated by intraoperative cerebrospinal fluid (CSF) leak from lateral orbital wall. The leak was surgically repaired and the patient recovered well. We postulate the cause of the CSF leak to be twofold: necrotic periorbital tissue due to mucormycosis rendering the thin bones susceptible to damage and second, intraoperative manipulation and dissection at the orbital apex with monopolar cautery and instruments. We describe measures taken to successfully repair the CSF leak and the possible precautions that can be taken to avoid it.

Plasma Ablation-Assisted Endoscopic Management of Postintubation Laryngotracheal Stenosis: An Alternate Tool for Management.

The current study was conducted to highlight the use of plasma ablation as a promising method in management of adult laryngotracheal stenosis. We present our institutional experience with a minimum follow-up of 6 months. Seventy adult patients with acquired postintubation laryngotracheal stenosis were included. Efficacy and clinical outcomes of plasma ablation in endoscopic management and eventual decannulation rate were studied. Number of patients with Myer-Cotton stenosis grades 1, 2, 3, and 4 were 20, 25, 18, and 7, respectively. The mean number of surgical interventions required in each grade of stenosis were 1, 2, 3.8, and 4, respectively. Overall, 47 patients (67%) were without tracheotomy by the end of 6 months. Plasma ablation is an effective treatment option for adult laryngotracheal stenosis, with a better success rate for lower-grade stenosis. It has lesser complications and requires fewer surgical interventions.

Miller Laryngoscope Blade: An Aid to Pediatric Laryngeal Surgery.

Pediatric upper airway disorders are a major cause of morbidity and mortality. They can be congenital or acquired and provide diagnostic and therapeutic challenge to the paediatrician and otolaryngologists. Though fibreoptic laryngoscopy or bronchoscopy is the initial mode of assessing the pathology, detailed assessment and therapeutic intervention can only be done combining both direct laryngoscopy and bronchoscopy. Any kind of intervention routinely requires rigid direct laryngoscope with suspension. Identifying the potential use of Miller laryngoscope blade for pediatric airway surgery is the aim of the study. We have included pediatric patients from new born to 12 years of age in our clinical study. We have been using Miller laryngoscope blade for approaching till the level of subglottis for diagnostic laryngoscopy along with Hopkins 0 degree endoscope and performing surgical procedures like supraglottoplasty, vallecular cysts, subglottic stenosis etc. Miller laryngoscope blade can be used as an aid to upper airway surgery for the otolaryngologists with minimal operating time and effort.

Osteoma of the Middle Turbinate Presenting with Frontal Lobe Abscess and Seizure.

Osteomas are the most common benign tumours of the sinonasal tract. Even though their location in the sinuses is well known, turbinate osteomas are quite rare. We report one such case of a 26-year-old female who presented with neurological complaints of a seizure rather than nasal complaints. The cause of the seizure was found to be a small abscess in her frontal lobe, secondary to frontal sinusitis due to a bony hard nasal mass arising from the middle turbinate. She underwent endoscopic excision of the mass which was confirmed on histopathology as an osteoma. The case highlights an unusual presentation of a middle turbinate osteoma.