Management of Recurrent Aphthous Stomatitis: An Indian Expert Consensus.

Recurrent aphthous stomatitis (RAS) is characterized by painful, oral mucosal ulcers with wide range of prevalence ranging from 2 to 78%. Etiology of RAS is idiopathic and multifactorial. There are numerous gaps in assessment and management of RAS and the absence of guidelines or a consensus document makes the treatment further difficult. The aim of this document is to provide an Indian expert consensus for management of RAS. Experts from different specialties such as Otorhinolaryngology, Oral Medicine/Dentistry and Internal Medicine from India were invited for face to face and online meetings. After a deliberate discussion of current literature, evidence and clinical practice during advisory meetings, experts developed a consensus for management of RAS. We identify that the prevalence of RAS may lie between 2 and 5%. In defining RAS, we advocate three or more recurrences of aphthous ulcers per year as criterion for RAS. Investigation should include basic hematological (complete blood count) and nutritional (serum vitamin B12, and iron studies) parameters. Primary aim of treatment is to reduce the pain, accelerate ulcer healing, reduce the recurrences and improve the quality of life. In treating RAS, initial choice of medications is determined by pain intensity, number and size of ulcers and previous number of recurrences. Topical and systemic agents can be used in combination for effective relief. In conclusion, this consensus will help physicians and may harmonize effective diagnosis and treatment of RAS.

Transoral release to realign postoperative loss of reduction following occipitocervical fixation for congenital basilar invagination.

PURPOSE: Revision surgery in an irreducible atlantoaxial dislocation (IAAD) previously operated with a posterior approach is challenging. Multiple modalities using anterior, posterior, and dual approaches have been described. We report a so far unreported technique of revision surgery by posterior implant removal and decompression with anterior transoral release followed by posterior instrumentation. METHODS: 14-year male with basilar invagination (BI) with IAAD, previously operated with posterior decompression and instrumented occipitocervical fusion presented three months later with post-traumatic recurrence of myelopathy with quadriparesis with Di Lorenzo grade 4 and loss of reduction. He was operated with a posterior implant and early fusion mass removal with extended foramen magnum decompression (FMD), followed by anterior transoral release with a satisfactory reduction on traction, and finally, a posterior revision instrumented occipitocervical fusion. RESULTS: At 2-year follow-up, the patient was symptom-free with Di Lorenzo grade 1 and cervicomedullary angle improvement from 97.4° to 141.2°; achieving bony fusion. CONCLUSION: Single-stage posterior-anterior transoral-posterior approach can be used to achieve satisfactory reduction for a revision BI with IAAD with prior posterior instrumentation.

An unusual presentation of impacted foreign-body in the adult larynx.

Foreign-bodies in the aero-digestive tract are a frequent occurrence in ENT practice. The diagnosis and management are based on clinico-radiological findings. We report a case of a 50 paise coin impacted in the adult larynx where the patient came to us 3 days later with the symptom of change of voice and pain in the throat but, surprisingly no dyspnoea or stridor.

Traumatic optic neuropathy - our experience.

A great deal of controversy surrounds the physiology and management of traumatic optic neuropathy. Needless to say, it has formed the topic of much debate in the past, especially with regard to its surgical management. With the advances in sinus endoscopic procedures, and their extended applications to the orbit and optic nerve, endoscopic optic nerve decompression offers a very good chance for salvaging vision in patients with traumatic optic neuropathy. However, there is no definite protocol laid down in the world literature for this condition, owing partially to the fact that a majority of such cases are not amenable to surgery within the critical period, due to the coexisting morbidities of head injury. There is also much controversy regarding medical versus surgical management of traumatic optic neuropathy. We present here our experience with this condition, and outline the management protocol followed.

Labyrinthine fistula: a complication of chronic suppurative otitis media.

A labyrinthine fistula is a frequent complication of long-standing unsafe chronic suppurative otitis media. It is characterized by a slowly progressive erosion of the bony labyrinth. In this paper we present our observations regarding the diagnosis and management in 50 patients with unsafe chronic suppurative otitis media with labyrinthine fistula.

Retraction pockets in chronic suppurative otitis media- our experience.

Retractions of the tympanic membrane constitute a large proportion of ear diseases causing concern to the otologist. The clinical features in a case of retraction pocket are varied and cholesteatoma. Also, that a retraction pocket in the posterosuperior region and pars ftaccida is a precursor of cholesteatoma is now well recognized. We have studied 60 cases of retraction pockets during a period of 5 years and have attempted to find out the etiology as well as the most effective treatment in such cases. Though over the years along with a dysfunctional eustachian tube, a sclerotic mastoid has been implicated as one of the causes of Retraction Pockets, we in our study have seen a large sized mastoid antrum (beyond 2 mm vf Lateral Semicircular Canal) as a consistent feature in most of our cases. This was subjectively assessed as a surgical finding in tympanomastoidectomy and objectively assessed by a high Resolution Computed Tomography of the temporal bone. We have found that a canal wall down mastoidectomy was the most effective in preventing the recurrence of retraction pockets. In a coutry like India, canal wall down mastoidectomy offers an acceptable solution to the problem of retraction pocket as not only is the follow up of patients poor but also the "Second- Look" procedure is not always possible. The use of 1- 0 chromic catgut in the middle ear instead of the more conventionally used silastic in preventing recurrent retractions can be considered as an effective single-staged procedure.

Nasopharyngeal angiofibroma with cavernous sinus involvement - An unusual presentation.

Juvenile nasopharyngeal angiofibrama (JNA) is a benign vascular tumour which is locally aggressive and occasionally extends intracranially. It occurs mainly in adolescent males. We report an interesting case of a targe JNA with intracranial extention encroaching on the cavernous sinus which we treated surgically by the conventional lateral rhinotomy and transpalatal approach.

Surgical decompression in bell's palsy - our viewpoint.

Bell's palsv or acute idiopathic lower motor neuron facial palsy is a common cause of facial palsy seen in clinical practice. The cause of this disease is not exactly known though there arc many theories regarding Ils etiology. In this article, we present the theory of "Tertiary is chacmia " in eases of pertinent Bell's palsy. Our concept of Tertiary ischaemia is further supported by histological findings of the nerve sheath biopsy taken during surgical decompression In eases of Bell' s palsy. The procedure, of performing posterior tympanotomy and improving the exposure of the middle ear structures therein is also explained.

An unusual case of impacted oesophageal foreign body.

Impacted sharp foreign bodies in the oesophagus can be very difficult to manage. When attempts are made to remove such objects inappropriately, life-threatening complications such as oesophageal perforation can occur. We hare reported a rare case of impacted denture in the oesophagus where endoscopic removal was not possible due to the perforation already caused by the denture, sinee this would have caused an oesophageal laceration, which could have proved fatal. Hence surgical removal had to be performed with repair of the oesophageal perforation.