Round Window Visibility in Cochlear Implantation : Pre-operative Prediction Using Various Radiological Parameters.

Purpose: The round window approach has become the most preferred route for electrode insertion in cochlear implant surgery; however, it is not possible at times due to difficult round window membrane (RWM) visibility. Our study aims to investigate the relationship between preoperative radiological parameters and the surgical visibility of the RWM in Cochlear implant patients. Methodology: A prospective cross-sectional study of 31 patients, age < 6 years, with bilateral severe to profound sensorineural hearing loss was conducted at a tertiary care hospital. The preoperative HRCT temporal bone scan was studied, and the parameters evaluated were facial nerve location, facial recess width, and RWM visibility prediction. All patients were operated on via the posterior tympanotomy. The surgical RWM visibility was done after optimal drilling of the posterior tympanotomy recess. The relationship between the radiological parameters and surgical visibility of RWM was evaluated. Results: The difference in the facial nerve location as per the type of RWM was found to be significant (p value < 0.05). However, the facial recess width was not significantly associated with RWM visibility. The radiological prediction of RWM visibility by tracing the prediction line over RWM was significantly associated with intraoperative RWM visibility. Conclusion: The goal to look for preoperative scans is to predict the ease or difficulty of RWM visibility during surgery. The difficult visualization of the RWM, can result in dire intraoperative consequences. A comprehensive understanding of preoperative radiological parameters, coupled with meticulous surgical planning, is crucial to address these challenges effectively by focusing on enhancing RWM visualization.

A Study of Round Window and its Adjacent Anatomy to Guide the Cochlear Implant Electrode Insertion.

Introduction: Residual hearing preservation has gained attention now which has brought round window membrane into the light, as a port for cochlear implantation. Atraumatic insertion of electrodes can be achieved by study of anatomical variations of round window and its forms which can guide the surgeon. Objective: This study was undertaken to examine the anatomical variations of round window and its adjacent structures and their impact on surgical approach during cochlear implantation. Methods: A series of 40 adult human temporal bones underwent high-resolution CT scanning and were further dissected for microscopic study of the round window. Results: The antero posterior dimensions of RW ranged from 1.22 to 2.51 mm on radiology and on dissection 1.76 mm +/- 0.3 mm. Shape of round window in 72.5% of bones was oval, and in 27.5% bones it was round shaped. As per Saint Thomas hospital classification for Round window visualization we found 82.5% bones had type I RW visualization and 17.5% had type IIa RW visualization. Area of crista fenestra on dissection was ranging from 0.41 to 0.69 mm2. Conclusion: Residual hearing preservation has become a new motto for surgeons. Therefore thorough anatomic knowledge of round window is must for careful insertion, as round window is closely related to the sensitive inner ear structures.

COVID Associated Invasive Aspergillosis.

To study the possible association between invasive fungal sinusitis (aspergillosis) and coronavirus disease. An observational study was conducted at a tertiary care centre over 6 months, involving all patients with aspergillosis of the paranasal sinuses suffering from or having a history of COVID-19 infection. 92 patients presented with aspergillosis, all had an association with COVID-19 disease. Maxillary sinus (100%) was the most common sinus affected. Intraorbital extension was seen in 34 cases, while intracranial extension was seen in 5 cases. Diabetes mellitus was present in 75 of 92 cases. All had a history of steroid use during their coronavirus treatment. New manifestations of COVID-19 are appearing over time. The association between coronavirus and aspergillosis of the paranasal sinuses must be given serious consideration. Uncontrolled diabetes and overzealous use of steroids are two main factors aggravating the illness, and both of these must be properly checked.

Efficacy of Topical High Volume Budesonide Nasal Irrigation in Post FESS Patients of Chronic Rhinosinusitis With or Without Nasal Polyposis.

Chronic rhinosinusitis (CRS) is a chronic inflammatory process of nasal mucosa and paranasal sinuses, lasting more than 12 weeks, without complete resolution of symptoms. CRS is treated medically, followed by Endoscopic sinus surgery (ESS) if necessary, and supplemented by post-operative topical treatment with highly variable clinical outcomes. However, till date there is no consensus on the composition and duration of maximal medical treatment. Despite proven role of topical steroids, the mode of delivery, dose and duration of topical intranasal corticosteroids still remains debatable. Studies found that high volume sinonasal irrigation (> 50 ml) using budesonide is most efficient method but still there is not sufficient data to prove this and results are variable with multiple modifiable factors therefore, this study has been conducted. (1) To determine the difference in mean decrease in Lund-Kennedy endoscopic scores and SNOT-22 scores among post ESS patients with high volume budesonide nasal irrigation nasal cavity and control nasal cavity of chronic rhinosinusitis patients. (2) To determine safety by measuring serum cortisol levels and intra ocular pressure. This is hospital based interventional, randomised, double blind, control trial study. A total of 66 patients of CRS with previous failed medical therapy were included. Same patients nasal cavities were divided into control and case nasal cavities, to avoid demographic bias. All subjects had a baseline SNOT-22 scores (Sino Nasal Outcome Test scores), Lund Kennedy endoscopy score, NCCT PNS score. All patients were undergone ESS procedure. After nasal pack removal, nasal cavities were randomly assigned 1:1 to receive normal saline irrigation (control group) or 1 mg of budesonide irrigation (case group) for transnasal irrigation twice daily for 12 weeks. A total of 66 patients with 132 nasal cavities were included in the study. Out of which 16 were female and 50 were male with mean age 33 year and mean duration of symptoms was 38.19 months. Mean duration of follow up was for 3 months. Mean decrement in SNOT-22 score in control nasal cavity from 52.54(16.309) to 30.06 (18.16) and in endoscopic score from 6.53 (1.33) to 3.93 (1.6) which is statically significant (p value < 0.05) in both scores. Mean decrement in SNOT-22 score in case nasal cavity from 53.73 (15.75) to 21.15 (13.52) and in endoscopic score from 6.74 (1.8) to 2.77 (1.4) which is statically significant (p value < 0.05) in both scores. Decrement in SNOT-22 scores and endoscopy scores in case nasal cavity in comparision to control nasal cavity were compared by student 't' test and found to be statically significant (p value equals to 0.0001). In subjective outcomes 57.57% shows total improvement in control nasal cavities while 72.73% case nasal cavities shows total improvement. Our study shows high volume budesonide irrigation is safe and superior over normal saline irrigation and results were statistically comparable. Still further studies with larger sample size and longer duration of irrigation needed.Based on available evidence, high volume budesonide irrigation is statically safe and superior over normal saline irrigation.

Invasive Fungal Infections in Dengue Recovered Patients: A New Phenomenon in the Covid-19 Era.

Invasive fungal rhinosinusitis was seen to rise to epidemic levels after the 2nd wave of ongoing Covid pandemic, especially in tropical countries, maximally in India. A similar trend is being observed for cases who have recently recovered from dengue virus infection. Post dengue invasive fungal infection is a new presentation and any associations between it and Covid pandemic need to be studied in detail to help prepare for any complications. 3 patients presented to the out-patient department of E.N.T at a tertiary level teaching hospital in East India with complains similar to rhinosinusitis. These patients were then evaluated and diagnosed to be infected from Mucormycosis and Aspergillosis fungal sinusitis after which they were managed with surgical debridement and systemic antifungal therapy. All had a recent history of recovery from Dengue virus infection and a possible association could be suspected. 3 patients presented with complains of pain over upper jaw with orbital swelling and loss of vision developing over a period of 24 days. Two of them had ulceration of hard palate. They were then subjected to Contrast MRI along with CT scan of the Paranasal sinuses which depicted pansinus involvement with intracranial extension in two patients. These were then planned for diagnostic nasal endoscopies along with biopsies which turned out to be Invasive fungal sinusitis in the form of Aspergillosis and Mucormycosis. All the 3 patients had recent history of recovery from Dengue virus infection and did not have any other co-morbidities. Covid Associated Mucormycosis (CAM) is a well-known entity now but no reports of Dengue associated Invasive fungal sinusitis are yet reported. Whether this new phenomenon has anything to do with the interactions between dengue virus and coronavirus is not known at present and needs to be studied in detail so appropriate management protocols can be formulated.

Cochlear Implantation in Goldenhar Syndrome.

Goldenhar syndrome is a rare genetic condition characterized by hemifacial microsomia, mandibular hypoplasia, auricular malformations, and epibulbar dermoids. The syndrome has both sporadic and familial occurrence. Incidence of congenital hearing loss in these patients is 1:1000 in children with a male to female ratio of 3:2. In our case study we report a case of Goldenhar Syndrome who underwent cochlear implantation. The patient had right side microtia, right hemifacial microsomia and right side torticollis, pterygium in her right eye, right hypoplastic thumb and unilateral right side kidney. Radiologically, there was narrow duplicated internal auditory canal on right side with absent right cochlear nerve with normal anatomy on left side and the left side showed malformed facial nerve at tympani segment and second genu. Therefore, the patient was planned for left side cochlear implantation. Intraoperatively, there were malformed ossicles with anomalous facial nerve covering whole of oval window and partially the round window. Thus, a separate cochleostomy was done. Impedance was < 5 Hertz in all electrodes and electrically evoked action potential (ECAP) thresholds were obtained on all electrodes.

A Comparative Study of Cold Dissection Tonsillectomy and Harmonic Scalpel Tonsillectomy Under Microscope- Our Experience.

Tonsillectomy is one of the most common proceduresin routine otolaryngology.Given that the pediatric demographic is usually in question, ENT surgeons are resorting to newer modalities that minimize the dreaded complication of intra-operative and post-operative hemorrhage and have shorter operative time. The present study was conducted on patients admitted in ward in the Department of Otorhinolaryngology at SMS Medical College and Hospital, JaipurFrom July 2019 to June 2020 on a sample size of 40 patient diagnosed as adeno-tonsillar hypertrophy of grade 3-4. Each patient underwent tonsillectomy by cold dissection method on one side and by ultrasonic scalpel on other. The present study was conducted on patients admitted in ward in the Department of Otorhinolaryngology at SMS Medical College and Hospital, JaipurFrom July 2019 to June 2020 on a sample size of 40 patient diagnosed as adeno-tonsillar hypertrophy of grade 3-4. Each patient underwent tonsillectomy by cold dissection method on one side and by ultrasonic scalpel on other. In our study Mean operation time, mean blood loss, Analogue score for post-operative pain at 24hrs and 7th postoperative day respectively and Healing of wound on 14th post-operative day were significantly lower in cases of tonsillectomy with harmonic scalpel than cold dissection method tonsillectomy. The novel technique of tonsillectomy harmonic scalpel is proven to be better with regard to lesser operative time, blood loss and lesser post-operative morbidity.

CSF Otorhinorrhea Due to Inner Ear Malformation-A Case Report.

Inner ear malformations are an important cause of sensorineural hearing loss ranging from severe to profound and they also contribute to Cerebrospinal fluid leakage and recurrent meningitis. The most severe is the complete labyrinthine aplasia (Michel Deformity), then there is cochlear aplasia, cochlear hypoplasia, incomplete partition of the cochlea, enlarged vestibular acqueduct and cochlear aperture abnormality.

SMS classification of inner ear malformations: our experience with implantation in type II anomalies.

PURPOSE: To study and analyse the radiological and surgical findings of 24 cochlear implantees with SMS type II cochleovestibular malformation and to compare their outcomes in terms of hearing and speech gains pre- and postoperatively. METHODS: Retrospective analysis of cochlear implanted candidates over a period of 8 year 6 months from 3 institutions was undertaken and 24 patients suffering from prelingual profound congenital sensori-neural hearing loss along with the presence of SMS type II cochleovestibular malformation were studied. Preoperative radiology, surgical difficulties and complication, and postoperative hearing and speech outcomes up to a period of 2 years, using IT-MAIS and SIR scores were noted. Statistical comparison pre- and postimplantation was done using Wilcoxon signed rank test and a p value of < 0.05 was considered statistically significant. RESULTS: In 24 cases, we encountered four cases of SMS type IIa malformation with a smaller modiolus, while the rest 20 were type SMS type IIb with partially defective modiolus. Intraoperatively, CSF leak was observed in 11 patients. Complete electrode insertion and good electrical response (NRT) was detected in all. No facial nerve anomaly was encountered. IT-MAIS and SIR scores increased from a preoperative mean of 5.6 and 1.16-34.56 and 3.88 after 2 years postsurgery, respectively and this difference was found to be statistically significant. CONCLUSION: Our experience with SMS Type II malformations show promising and motivating results with less chances of complications. Proper evaluation and surgical planning preoperatively can lead to an uneventful surgery with good outcomes. A simple and uniform classification system of these anomalies is a must for appropriate prognostication and right decision making.

New SMS Classification of Cochleovestibular Anomalies: Our Experience with 25 Cases of Type I Anomaly.

PURPOSE: To study and analyse the radiological and surgical findings of 25 cochlear implantees with SMS type-I cochleovestibular malformation and to compare their outcomes in terms of hearing and speech gains pre- and post-operatively. METHODS: Retrospective analysis of cochlear implanted candidates over a period of 8 year from 3 institutions was undertaken and 25 patients suffering from pre-lingual profound congenital sensori-neural hearing loss along with presence of SMS type I cochleovestibular malformation were studied. Pre-operative radiology, surgical difficulties and complication, and post-operative hearing and speech outcomes upto a period of 2 years, using IT-MAIS scores were noted. Statistical comparison pre- and post-implantation was done using Wilcoxon signed rank test and a p-value of < 0.05 was considered significant. RESULTS: In 25 cases, we encountered 2 posterior SCC dysplasia, 15 enlarged vestibular aqueducts (LVA), 2 dilated vestibules, 4 superior SCC dysplasia, 2 cases with both posterior and superior SCC dysplasia and of those 1 had a dilated vestibule also. Intra-operatively, CSF leak was observed in 10 patients. Complete electrode insertion and good electrical response (NRT) was detected in all. No facial nerve anomaly was encountered. IT-MAIS scores increased from a pre-operative mean of 4.32 to 34.56 two years post-operatively and this difference was found to be statistically significant. CONCLUSION: Our experience with SMS Type I malformations show promising and motivating results with less chances of complications, similar to implant candidates with normal anatomy. The outcomes in this group of patients are definitely not affected by any malformations in semicircular canals, vestibule or vestibular aqueduct.

Cochlear Implantation in Pierre Robin Syndrome.

Hereditary hearing loss accounts for nearly 60% of deafness in developed countries and about 30% of them are syndromic. Pierre Robin Syndrome is one such condition. The patient with this syndrome usually presnts with triad of micrognathia, glossoptosis and cleft palate. Hearing loss is mostly conductive but there can be sensorineural hearing loss also. Here we present a case of Pierre Robin Syndrome who presented with congenital hearing loss. He also had bilateral serous otitis media. He underwent cochlear implant surgery and was prescribed antihistaminics and steroid spray for middle ear effusion. Therefore, proper clinical evaluation is required.

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.

To Study the Association of the Size and Site of Tympanic Membrane Perforation with the Degree of Hearing Loss.

Chronic suppurative otitis media is a serious health problem worldwide. It has been a general view that the hearing loss increases with the size of the perforation, more so if it is in the postero- inferior quadrant. The present study is an effort to test the validity of above concepts. With Institutional ethical committee clearance, an observational study was carried at SMS medical college, Jaipur. A total of 90 cases were studied. All cases between the age group 15-50 years with dry tympanic membrane perforations were divided into 3 groups Group I (0-9 mm²), Group II (9-30 mm²), Group III (>30 mm²) with 30 in each group based on size of perforation. Hearing loss was calculated as average of hearing loss at 500, 1000, 2000 Hz. Similarly the site of perforation was grouped as perforation involving anterior quadrant, posterior quadrant and multiple quadrant as Group A, Group B, Group C respectively. At the end of study, data was compiled systematically and analyzed using Post Hoc test. The age group ranges between 15 and 50 years with mean age of 25.6 years. Hearing loss was found to be directly proportional to the size of perforation in our study. (p = 0.000, highly significant). We also observed that hearing loss was more in posterior and multiple perforations than in anterior perforations. (p = 0.000, highly significant). Overall this study has shown significant correlation between the size and the site of the perforation to the degree of hearing loss.

Outcome Analysis of Microlaryngeal Surgery for Benign Lesions of Vocal Cord Using Videostroboscopy and Voice Handicap Index.

Benign vocal cord mass lesions are common causes of dysphonia which are often surgically correctable. They include lesions like vocal polyps, vocal cysts, vocal nodules and Reinke's edema. A prospective study of 30 patients was carried out at SMS medical college and hospital between April 2014 to November 2015 after institutional ethical committee clearance. The purpose of our study was to evaluate outcome of microlaryngeal surgery for benign lesions of vocal cord using videostroboscopy and voice handicap index. All cases between the age group 15-60 years with clinical evidence of benign lesions of vocal cord were included in study. Preoperative amplitude, mucosal wave, glottic closure was seen by videostroboscopy and subjective assessment of severity of handicap in voice was assessed by set of questionnaire using voice handicap index (Jacobson et al. in Am J Speech Lang Pathol 6: 66-70, 1997). Postoperative follow up was done at 3rd week and 10th week, and outcome of microlaryngeal surgery was assessed using videostroboscope and voice handicap index. At the end of study data was compiled systemically and analysed using paired 't' test and Chi square test. Our study observed statistically significant improvement in amplitude and mucosal wave and glottic closure. Subjective improvement in perception of severity of handicap in voice was analysed by voice handicap index which shows statistically significant data. Overall our study conclude microlaryngeal surgery as an effective way for improvement in speech parameters, that can be assessed by use of videostroboscopy and voice handicap index.

Soft tissue reactions following cochlear implantation.

INTRODUCTION: Cochlear implantation is a boon to children with hearing loss. Rarely, it can be associated with complications. Soft tissue reaction can be a particularly distressing complication. MATERIALS AND METHODS: The study was conducted on all patients presenting with soft tissue reaction post-cochlear implant in a tertiary care referral institute from March 2011 to June 2018. We graded the severity of soft tissue reaction as per the severity and then managed these patients accordingly. RESULTS: Thirty-five patients were included in this study. Grade 1 had 12 patients, grade 2 had 9, grade 3 had 4 and grade 4 had 9 patients. Grade 1, 2 and 3 reactions were managed conservatively, while grade 4 required surgery. The incidence of explantations increased with the grade severity. CONCLUSION: Soft tissue reaction post-cochlear implant is a rare, but distressing complication. Grading and analyzing them can help us manage them in a better way.

Cochlear implant in Thalassemia patient - Case report.

INTRODUCTION: Beta-thalassemias are a group of hereditary blood disorders characterized by anomalies in the synthesis of the beta chains of hemoglobin. Iron overload occurs in thalassemia, with blood transfusion therapy being the major cause. Deferoxamine continues to be the mainstay of therapy to remove excess iron in patients requiring long-term transfusions. One of the most important complications of deferoxamine therapy is neurosensory toxicity, including sensorineural hearing loss (SNHL). Labyrinthine hemmorhage (LH) is thought to result from altered capillary hemodynamics or reperfusion injury. It is theorized that LH incites a reparative response that cascades from fibrosis to sclerosis and ultimately ossification of the inner ear structures. CASE PRESENTATION: We present a case of 3-year-old thalassemic child with bilateral profound sensorineural hearing loss. Patient was on regular blood transfusions with chelation therapy. HRCT temporal bone and MRI brain and temporal bone had features of labyrinthitis ossificans (LO). Child underwent uniateral cochlear implantation and postimplantation speech perception and production outcomes were normal. DISCUSSION: This case illustrates the unique feature of labyrinthitis ossificans in a thalassemia patient which has not yet reported in the English literature. Hearing screening of all thalassemia patients and therefore early diagnosis of SNHL prompts early intervention and improved quality of life.

Island cartilage vs temporalis fascia in type 1 tympanoplasty: A prospective study / Cartílago en isla vs. fascia de músculo temporal en timpanoplastia tipo 1: un estudio prospectivo

OBJECTIVE: (1) To compare the results of graft take-up and audiological outcome of temporalis fascia versus island cartilage graft in type 1 tympanoplasty. (2) To compare the rate of postoperative retraction of neotympanum in both. METHODS: A prospective study was conducted on 70 patients of ages ranging from 11 to 50 years with dry subtotal perforation. 35 underwent island cartilage tympanoplasty and 35 underwent type 1 tympanoplasty using temporalis fascia graft. Graft acceptance rates and post-operative audiograms were compared. RESULTS: At one year follow up, the graft take-up rate for temporalis fascia and island cartilage graft were found to be 82.9% and 97.1% respectively, which was found to be statistically significant (p < 0.05). In the temporalis fascia group, two out of 35 patients (5.7%) had retraction of the neo tympanum. There was no incidence of retraction using island cartilage graft. There was no significant difference in the postoperative air-bone gap gain between temporalis fascia graft and island cartilage graft. CONCLUSION: Island cartilage tympanoplasty shows a high degree of reliability in high risk cases. It has a higher graft take-up rate with no incidence of retraction of neotympanum. Moreover, it provided significant hearing improvement in our patients

OBJETIVO: 1) Comparar los resultados del injerto y el resultado audiológico de la fascia del músculo temporal versus injerto de cartílago en isla en la timpanoplastia tipo 1, y 2) Comparar la tasa de retracción postoperatoria del neotímpano en ambos. MÉTODOS: Se realizó un estudio prospectivo en 70 pacientes de edades comprendidas entre los 11 y 50 años con perforación subtotal en seco. En 35 de ellos se realizó timpanoplastia con cartílago en isla y a los 35 restantes timpanoplastia tipo 1 mediante injerto de fascia de músculo temporal. Se compararon las tasas de aceptación del injerto y los audiogramas postoperatorios. RESULTADOS: Al año de seguimiento, la tasa de toma del injerto de fascia de músculo temporal y el injerto de cartílago en isla fue del 82,9 y 97,1%, respectivamente, que resultó estadísticamente significativa (p < 0,05). En el grupo de fascia de músculo temporal, 2 de 35 pacientes (5,7%) tuvieron una retracción del neotímpano. No hubo incidencia de retracción en el injerto de cartílago en isla. No hubo diferencia significativa en cuanto a la ganancia en el umbral diferencial de audición entre los injertos de fascia de músculo temporal y cartílago en isla. CONCLUSIÓN: La timpanoplastia con cartílago en isla muestra un alto grado de fiabilidad en casos de alto riesgo. Tiene una mayor tasa de aceptación del injerto, sin incidencias de retracción del neotímpano. Además, aportó una importante mejora de audición a nuestros pacientes