Assessment of Preoperative Predictors for Difficult Laryngeal Exposure in Endolaryngeal Surgery.

Introduction: The proper visualisation of the larynx is required for the diagnostic assessment and therapeutic intervention. The most significant challenges for surgeon is to visualise the anterior commissure of the glottis region. The aim of this study is to record the preoperative laryngoscore in patients posted for endolaryngeal surgery and to assess preoperative predictors for intraoperative difficult laryngeal exposure by correlating with preoperative laryngoscore. Design: Prospective, Cross-sectional, Observational study. Setting: Department of Otorhinolaryngology in a tertiary care teaching facility. Subjects: 150 patients were included with an endolaryngeal disease who were planned for surgery with age > 18yrs. Methodology: In 150 subjects preoperative laryngoscore was calculated, which comprised 11 parameters including thyromental distance, mandibular prognathism, macroglossia, micrognathia, trismus, inter incisor gap, degree of neck flexion-extension, history of prior open-neck surgery or radiotherapy, upper jaw dental status, modified Mallampati score and body mass index in order to produce a total score out of a possible maximum score of 17. According to the anterior commissure visualisation all patients were categorised into five classes, ranging from class 0 to class IV during surgery. The laryngoscore parameters were assessed and compared statistically with five classes of intraoperative anterior commissure visualisation. Result: Out of 150 patients 70 (46.6%) were having 3-4 laryngoscore, followed by 45 (30%) patients with 5-6 laryngoscore. Total 123 (82%) patient had class 0,1 and 2 intraoperative anterior commissure visualisation while 27 (18%) had class 3 and 4 visualisation. If laryngoscore was either less or equal to 5, 90% of the patients had excellent laryngeal exposure whereas only 10% of the patients had challenging laryngeal exposure. At univariate analysis, thyromental distance, degree of neck flexion/extension, and modified Mallampati classification were found statistically significant for difficulty of anterior commissure visualisation independently. Conclusion: A sound, easy and valid preoperative laryngoscore may be significantly helpful in identifying intraoperative difficult laryngeal exposure. This may prevent inadequacy of surgery, abandon of surgery, intra operative complication, and medico-legal cases for laryngologist.

Clinico-Etiological Evaluation of Epistaxis.

Epistaxis or bleeding from nose, a commonly confronted condition in the department of otorhinolaryngology can be a disquietening experience and sometimes a life threatening emergency for the patient. The aim of this study is to study the clinical profile and aetiology in epistaxis patients. An observational prospective study carried out over a period of 12 months in the Department of Otorhinolaryngology, Head and Neck Surgery, Swami Rama Himalayan University, Swami Ram Nagar, Dehradun, Uttarakhand. A total of 104 patients of all age groups and gender presenting with epistaxis were included in the study. Males formed majority of the patients (68.27%) as compared to female patients (31.73%). Most of the patients were in the age group of 51-70 years with majority being farmers (30.77%). The finding of variation with age was statistically significant (p < 0.05) with most patients in the age group of 51-60 years presenting in winter season. Local causes were observed to be more common (50.96%) among which trauma was the predominant cause (23.08%). Systemic causes formed 37.58% of cases, out of which hypertension was the commonest cause. In our study, non-surgical measures were most commonly employed treatment modality (85.58%) among which medical management was done in most patients. Trauma and hypertension contributed to the majority of patients presenting with epistaxis in our study with cold, dry winter months associated with increased incidence of epistaxis.

Evaluation of Association of Allergic Rhinitis with Bronchial Asthma.

Allergic rhinitis represents a global health problem. It is a common disease worldwide affecting about 10-50 % of the population and its prevalence is increasing. Although allergic rhinitis is not a fatal disease, it alters the social life of patients, affecting learning performance and work productivity. Moreover, the costs incurred by allergic rhinitis are substantial. In recent years allergic rhinitis has been recognized to be an important risk factor for asthma. The concept of "One Airway, One Disease" was highlighted in the 'Allergic rhinitis and its Impact on Asthma 'guidelines and has arisen as a result of the now well-established link between the upper and lower airways. The aim of this study was to evaluate the association between allergic rhinitis and bronchial asthma by determining the incidence of bronchial asthma in patients of allergic rhinitis and the incidence of allergic rhinitis in patients of bronchial asthma. 83 diagnosed cases each of allergic rhinitis and bronchial asthma were recruited from patients attending Otorhinolaryngology and pulmonary department of the institute. All patients were subjected to detail ENT and pulmonary examination and investigated for nasal and bronchial allergy. In the allergic group, which consisted of 83 diagnosed patients of allergic rhinitis, 49 (59.03 %) were diagnosed to have bronchial asthma, whereas in the bronchial asthma group, which consisted of 83 diagnosed patients of bronchial asthma 61 (78.20 %) were diagnosed to have comorbid allergic rhinitis. It was observed that patients with allergic rhinitis were likely to develop bronchial asthma, and patients of allergic rhinitis should be evaluated for bronchial asthma, for early detection and treatment of the co morbid condition.

Waldenstrom macroglobulinemia presenting as isolated persistent epistaxis: a very rare presentation.

Nose bleed is the most common rhinological emergency. There are multiple risk factors for the development of epistaxis and it can affect any age group, but it is the elderly population with their associated morbidity who often require more intensive treatment and subsequent admission. Most cases of epistaxis occur in the Little's area, a location readily accessible and treatable by cautery or anterior nasal packing. However, posterior epistaxis often requires more aggressive measures including posterior nasal packing and endoscopic cauterization. After posterior nasal packing, the two most common therapies for intractable epistaxis are transantral ligation of the internal maxillary artery and percutaneous embolization of the distal internal maxillary artery. However, optimal management of intractable posterior epistaxis remains controversial. We hereby report fourth case of Waldenstrom Macroglobulinemia in English literature, which presented as isolated persistent epistaxis and was treated by therapeutic plasmapheresis.

Correlation study between nasal septal deviation and rhinosinusitis.

Chronic rhinosinusitis (CRS) is a major cause of concern worldwide. Nasal septal deviation (NSD) may either cause osteomeatal obstruction or may interfere with proper airflow and potentially predispose to sinusitis. Due to the lack of a universally accepted classification on NSD it has not been established whether NSD influences the development of sinusitis or not. Mladina in 1987 proposed a classification in which he classified NSD into seven different categories. The aims and objectives of this study are to observe the correlation between NSD and CRS and to study the relation of different grades of NSD with sinusitis as per Mladina's classification. Patients above 18 years of age presenting to ENT OPD with complaint of nasal obstruction, nasal discharge and headache were subjected to CT scan (nose and paranasal sinuses) coronal section with contiguous 5 mm thickness slice perpendicular to the hard palate in prone position. Presence of NSD and sinusitis was observed. 120 cases were studied. The mean age was 28.7 ± 9.37 years with age range 18-58 years. There were 92 (76.6 %) males and 28 (23.3 %) females with a M:F ratio of 3:1. Out of 120 cases, 114 (95 %) cases had NSD. Sinusitis was present in 63 (52.5 %) cases on CT scan. Out of 57 (50.0 %) cases with NSD and sinusitis, 13 (11.4 %) cases had sinusitis on the same side of NSD, 14 (12.28 %) cases had sinusitis on the side opposite to NSD and 30 (26.31 %) cases had sinusitis on both sides of NSD. There was no statistically significant relationship between NSD and sinusitis. As per Mladina's classification vertical deviations accounted for majority of patient's septal deviations with 31 (27.1 %) cases of type II NSD and 24 (21.1 %) cases of type I NSD. The maximum number of cases with sinusitis had vertical deviations with type I NSD in 17 (27.0 %) cases and type II NSD in 18 (28.5 %) cases. The present study reveals that there is no correlation between NSD and sinusitis. Vertical deviations type I and type II are more prone to sinusitis as they involve the nasal valve area.

Clinical profile of pharyngeal malignancy in a tertiary care centre, state of uttarakhand.

Pharynx is a common site of malignancy in the head and neck region. This study presents a series of 94 cases of pharyngeal malignancy conducted at Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand in the Department of Otorhinolaryngology for a period of one year (2009-2010). Mean age at presentation was 56.8 years (age range 18-100 years). Male:Female ratio was 8.4:1.0. Maximum patients belonged to lower socio-economic status as per Kuppuswamy's classification (2003). Majority of them were farmer (38.2%) by occupation and belonged to rural areas. 90.4% patients had history of tobacco smoking. Dysphagia was the commonest chief complaint. The most common subsite was oropharynx (51.0%) followed by hypopharynx (45.7%). Ulceroproliferative growth was the most common clinical finding. Histopathologically, squamous cell carcinoma (94.6%) was the commonest. CECT was the commonest and most useful radiological investigation done to see the extent of the disease.

Endoscopic Trans-Nasal Trans-Sphenoidal (TNTS) Approach For Pituitary Adenomas: Our Experience.

Advances in optics, miniaturization, and endoscopic instrumentation have revolutionized surgery in the past decade. Current progress in the field of endoscopy promises to further this evolution: endoscopic telescopes and instruments have improved upon the optical and technical limitations of the microscope, and require an even less invasive approach to the sella. Pituitary surgery is traditionally within the realm of the neurosurgeon. However, since the reintroduction of the transseptal transsphenoidal approach and endoscopic transnasal transsphenoidal approach to the sella turcica for resection of pituitary adenoma, otolaryngologists have been active partners in the surgical management of these patients. Otolaryngologists have lent their expertise in nasal and sinus surgery, assisting the neurosurgeon with the operation. The otolaryngologist has the advantage of familiarity with the techniques and instruments used to gain exposure of the sella turcica by transnasal approach. Hence, the otolaryngologist provides the exposure, and the neurosurgeon resects the tumour. Such collaboration has resulted in decreased rates of complication and morbidity. We hereby discuss our experience of treating 54 cases of pituitary tumour by endoscopic transnasal approach at our hospital.

Clinico-etiolological study of vocal cord paralysis.

The purpose of this study was to identify patients of vocal cord paralysis and to establish an etiological diagnosis. Patients with vocal cord paralysis have been followed prospectively at a tertiary referral center. 120 patients identified with vocal cord paralysis by laryngeal endoscopy were evaluated clinically, radiologically and pathologically to make an etiological diagnosis. Those patients in whom no cause was found, a CT scan from base of skull to thorax was done before labeling them as idiopathic. Most of the patients presented in 5th (26.67 %) and 6th (21.67 %) decade. Males out numbered females in the ratio 2.3:1.0. The most common symptom of vocal cord paralysis was change in voice (98.21 %). Bilateral vocal cord palsy was found in 6.67 % patients and unilateral vocal cord palsy was found in 93.33 % patients. Among patients of unilateral vocal cord paralysis left vocal cord was paralyzed in 69.64 % and right cord in 30.36 %. Malignant (34.16 %) causes accounted for largest number of patients followed by central (15.00 %) and idiopathic causes (14.16 %). VCP has got a variable etiology which varies with the laterality of the vocal cord involvement. Malignant causes predominated in our series, occurring in 34.16 %, followed by central and idiopathic causes.

Fungus cerebri (brain fungus): a rare complication of mastoidectomy.

Fungus cerebri is a relatively rare disease. The various reasons attributed to such pathology are, long standing mastoiditis, previous temporal lobe fracture, spontaneous herniation and most important common cause is post operative to mastoidectomy. The diagnosis is mainly clinical and supplemented by imaging studies. The commonly herniated part is the temporal lobe, but cerebellar herniation are also reported Different surgical modalities are used in managing this condition. Surgical approaches in the treatment of brain herniation into the mastoid or middle ear are, neurosurgical, otosurgical and combined. A case of fungus cerebri complicating mastoidectomy is presented and the pathogenesis is discussed.

Clinico-pathological profile of sinonasal masses: An experience in tertiary care hospital of Uttarakhand.

BACKGROUND: The purpose of this study was to classify various types of non-neoplastic and neoplastic lesions presenting as sinonasal mass and characterize their clinico-pathological profile in a tertiary care center in the state of Uttarakhand. MATERIALS AND METHODS: This was a prospective study where 110 cases of sinonasal masses were included over a period of 12 months. Clinico-pathological study was carried out in these cases. A provisional diagnosis was made after clinical assessment and radiologic investigations, but final diagnosis was made after histopathologic examination. OBSERVATIONS: The number of non-neoplastic lesions were more than the neoplastic lesion, 60% versus 40% respectively. In the neoplastic group, 19.8% and 23.76% patients presented with benign and malignant lesion, respectively. The incidence was more predominant in the age group of 11-20 years (22.72%) with male to female ratio of 1.08:1. In our study, among non-neoplastic lesions the occurrence of sinonasal polyps was highest seen in 80.30% cases. In neoplastic lesions, angiofibroma was most common benign lesion seen in 35% cases. Carcinoma nasal cavity was the commonest malignant lesion seen in 45.83% cases. In 3.63% patients, clinical and radiologic diagnosis was not correlated with histopathologic diagnosis. Only two cases required immuno-histocytochemistry to confirm the final diagnosis. CONCLUSION: We concluded that for proper evaluation of a sinonasal mass, clinical, radiologic, and histopathologic evaluation should be carried out conjointly in all the cases. Histopathology always gives a confirmatory diagnosis but in few cases immuno-histocytochemistry becomes the ultimate diagnostic technique for correct and timely intervention.

Febuxostat: a novel agent for management of hyperuricemia in gout.

Gout is a metabolic disorder characterized by elevated uric acid levels in the body, associated with painful arthritis, tophi and nephropathy. The most frequently used pharmacologic urate lowering strategies involve reducing urate production with a xanthine oxidase inhibitor and enhancing urinary excretion of uric acid with a uricosuric agent. Urate lowering agents are limited in number, availability and effectiveness. The emergence of a new medication, febuxostat, to lower serum urate levels is welcome as no new drug have been approved since the introduction of allopurinol, in 1964, and the drugs that are available have limitations owing to inefficacy or toxicity. Febuxostat is a novel, nonpurine selective inhibitor of xanthine oxidase, is a potential alternative to allopurinol for patients with hyperuricemia and gout.

Effect of Palliative Drug Therapy on Quality of life in Advanced Head and Neck Cancer Patients.

Advanced cancer patients are managed by palliative care and its main aim is to provide best possible quality of life to the patients by symptom management. Pain is the most agonizing symptom experienced by advanced head and neck cancer patients. Control of pain hence requires more attention by the caregiver in order to improve their quality of life. Recently quality of life issues have emerged as a main focus of cancer treatment as compared to conventional increase in survival rate. This study mainly focuses on the effect of palliative drug therapy on quality of life.

Ototoxicity: the hidden menace.

Otolaryngology, although considered a surgical specialty, also covers many diseases that are not cured by surgery. These are treated medically and thus the otolaryngologist should have a good knowledge of drug treatments. It also entails ability to recognize, when an ENT symptom may be caused by one of the patient's medications, particularly as this is easily remedied by changing the drug. Although most of us know the common drugs that can cause otological side effects, there are many others that we may not be aware of. Here we have tried to consolidate a list of some commonly used drugs having otological side effects.

Biological response modifiers: current use and future prospects in cancer therapy.

Over the past few decades, considerable success has been achieved in the field of cancer treatment with biological response modifiers (BRM), which are agents that improve the body's ability to fight cancer by immunostimulation. Biological agents, such as interferons and interleukins, provide nonspecific active immunity, whereas the monoclonal antibodies provide passive immunity. Apart from this, other biological agents, such as antiangiogenic agents, matrix metalloprotease inhibitors, tyrosine kinase inhibitors, and tumor vaccines, are also increasingly being used in cancer treatment. Hematopoietic factors, such as granulocyte colony-stimulating factor, are used to increase the general immunity and prevent opportunistic infection. BRM are basically used alone or as adjuvants to cancer chemotherapeutic agents. This review sheds light on the current use and the future development of cancer immunotherapy. Search strategy included Pubmed, using the terms "Biological response modifiers in cancer" citations relevant to the topic were screened.

Angiogenesis: Future of pharmacological modulation.

Angiogenesis is a fundamental biological process that is regulated by a fine balance between pro- and antiangiogenic molecules, and is deranged in various diseases. Historically, angiogenesis was only implicated in few diseases, such as, cancer, arthritis, and psoriasis. However, in recent years, it has been increasingly evident that excessive, insufficient or abnormal angiogenesis contributes to the pathogenesis of many more disorders. Research in angiogenesis offers a potential to cure a variety of diseases such as Alzheimer's and AIDS. Modulation of angiogenesis may have an impact on diseases in the twenty-first century similar to that which the discovery of antibiotics had in the twentieth century.

Anterior craniofacial resection - for paranasal sinus tumors involving anterior skull base.

Management of anterior skull base tumors is complex due to the anatomic detail of the region and the variety of tumors that occur in this area. Currently, the "gold standard" for surgery is the anterior craniofacial approach. Craniofacial resection represents a major advance in the surgical treatment of tumors of the paranasal sinuses involving anterior skull base. It allows wide exposure of the complex anatomical structures at the base of skull permitting monobloc tumor resection. This study presents a series of 18 patients with anterior skull base tumors, treated by a team of head-neck surgeons and neurosurgeons. The series included 15 malignant tumors of the nose and paranasal sinuses and 3 extensive benign lesions. All tumors were resected by a combined bi-frontal craniotomy and rhinotomy. The skull base was closed with a pediculated pericranial flap and a split-thickness free skin graft underneath. There were no postoperative problems of wound infection, cerebrospinal fluid-leakage or meningitis. Recurrent tumor growth or systemic metastasis occurred in 3 out of 15 patients with malignant tumors, 6 months to 2 years postoperatively. Craniofacial resection was thus found to give excellent results with low morbidity in malignant lesions and can also be adapted for benign tumors of anterior skull base.

Ossicular chain status in chronic suppurative otitis media in adults.

This study was conducted to find out the status of the ossicles in cases of chronic suppurative otitis media (CSOM). One hundred and fifty cases of CSOM, who underwent surgery, were included and their intra-operative ossicular chain findings noted. Ossicular erosion was found to be much more common in unsafe CSOM than in safe CSOM. Malleus was found to be the most resistant ossicle to erosion whereas incus was found to be the most susceptible.

Quality of life as an outcome variable in the management of advanced cancer.

BACKGROUND AND OBJECTIVE: Though well recognized in the West, palliative care and quality of life are relatively newer concepts in a developing country like India. The aim of this study was to assess the effect of palliative care on pain and quality of life and to identify the association between the two. STUDY DESIGN: Observational prospective study. MATERIALS AND METHODS: Patients with advanced cancer, receiving palliative drug therapy, were recruited from a tertiary care hospital. City of Hope Medical Center Quality of Life Survey and visual analog scale (VAS) were used to assess the quality of life and cancer pain severity, respectively. RESULTS: A total of 100 patients were included in the study. Palliative drug therapy produced a significant reduction in pain scores expressed as mean ± SD in VAS [7.13 ± 2.2 vs. 2.62 ± 2.1 (P<0.001) after 1 month in 93 patients; 7.06 ± 2.1 vs. 2.47 ± 2.1 (P<0.001) after 1 month and 2.02 ± 1.9 (P<0.001) after 2 months in 51 patients]. Also, significant improvement in the quality of life scores [919.78 ± 271.3 vs. 1280.65 ± 306.8 (P<0.01) after 1 month in 93 patients; 950.39 ± 238.2 vs. 1336.67 ± 291 (P<0.01) after 1 month and 1405.49 ± 368.3 (P<0.01) after 2 months in 51 patients] was obtained. There was a high correlation between the average change of pain intensity and quality of life scores (r= -0.53, P<0.02). Overall, a reduction in pain resulted in significant improvement in the quality of life (P<0.001). CONCLUSION: This study emphasizes the role of palliative care and, more importantly, pain management in improving the quality of life of advanced cancer patients.

Zenker's diverticulum - a case report.

A Zenker's diverticulum is a blind pouch that branches off the cervical esophagus. Affected individuals may suffer from long-standing swallowing difficulties, regurgitation, bad breath, weight loss, and even aspiration.. Here we report a 80-years-old male presenting with dysphagia and regurgitation. Barium swallow reported the presence of a Zenker's diveticulum. In view of the patient's age, endoscopic diathermy was considered as a therapeutic option for the management.

Orthodontic treatment after adenoidectomy patients: effect on jaw relations in saggital plane.

Adenoid hypertrophy is a normal phenomenon seen in young children. Adenoids may however be of large size or may not reduce in size in adulthood. Large adenoids may cause mouth breathing, overcrowding of teeth or otological symptoms. When adenoids are large and producing these effects, adenoidectomy is necessary. Adenoidectomy immensely benefits such patients but they may still continue to be habitual mouth breathers. This can lead to formation of long narrow face, labially protruded maxillary incisors and class 2 malocclusion. Immediate orthodontic treatment of such patients will improve facial profile and lead to class 1 (Angle) occlusion. We present here a study of 20 patients who were given early orthodontic treatment in postadenoidectomy period as compared to those patients who were not treated by orthodontist.