Cog - A Radiological Indicator in Identifying Dysventilation Syndrome.

Background: Anterior epitympanic recess (AER) is a small anatomical space in the epitympanum anterior to level of the head of malleus. This space has received lot of attention because of its role in cholesteatoma. Dysventilation of AER can lead to retraction pockets and cholesteatomas. Due to the advent of endoscopic middle ear surgeries the visualization of the mucosal folds and spaces have been possible for the past 2 decades. Mucosal folds and spaces play an important role in middle ear ventilation and pathologies obstructing these ventilation pathways can lead to dysventilation resulting in retraction pockets / cholesteatoma. In our study we have analysed the importance of cog with respect to dysventilation syndrome. Materials and methods: This prospective radiological study was conducted at Apollo Hospitals, BG road, Bangalore for a study period of 1 year (January 2021-January 2022). All patients who underwent high resolution CT scan (HRCT) of temporal bone were included in this study. They were divided into 2 groups (Group I & II). For group I HRCT temporal bone of 200 normal scans were included and scans with chronic otitis media, congenital anomaly, temporal bone fractures and tumors were excluded from the study. 50 HRCT temporal bone scans of chronic otitis media with squamous disease were included in group II. Results: 200 HRCT scans were included in the normative data analysis of the temporal bone. Out of 200, 133 had complete cog, 54 had incomplete cog and 13 had absent cog (Table 2). We also calculated the mean diameters of the AER, AP diameter- 4.24 ± 1.3, TD - 3.36 ± 1.05 and VD - 5.3 ± 1.94 (Table 3). Similarly, we analyzed 50 HRCT temporal bone with squamous disease 32 out of 50 had absent cog (Table 4). We also calculated the dimension of AER in diseased temporal bones (Table 5). A paired T test was conducted in order to analyze these values. Conclusion: In our study we performed a radiological evaluation of AER and cog and found that incidence of absent cog is more among individuals with squamous disease than normal individuals. Hence we advocate that absent cog can lead to horizontally oriented tensor tympani that in turn results in dysventilation. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03507-9.

Endoscopic Ear Surgery: Our Experience.

Endoscopes are presently used as an adjunct to microscopic surgery for better visualization of hidden areas of middle ear or they are used as a primary modality replacing the microscopes. We performed primary endoscopic ear surgery at a tertiary care center to evaluate the scope of endoscopic ear surgeries and to evaluate the anatomical, functional and quality of life outcomes. We evaluated 103 cases of which included patients with chronic otitis media mucosal disease (64), chronic otitis media squamous disease (29), otosclerosis (6), and benign ear tumors (4). In our study, the structural and functional outcomes of endoscopic ear surgeries were comparable to microscopic techniques however it conferred superior patient related outcomes of cosmesis, post-operative pain and early return to daily routine. Thus endoscopic ear surgery is a minimally invasive alternative option to microscopic techniques in the field of otology.

Mini-Incision Parotidectomy-Our Technique.

Traditional parotidectomy incision was devised by Blair (1912) which was modified by Bailey (1941). Over the years various approaches and techniques have evolved to improve the aesthetic outcome and at the same time for complete disease clearance with reduced complications. In this study, we evaluated the feasibility of our mini-incision parotidectomy technique along with the surgical and quality of life (QOL) outcomes. This prospective case series was conducted at Apollo Hospitals, Bangalore over a period of 2 years (June 2018-August 2020) and includes 20 patients. The surgical outcomes were assessed in terms of feasibility of mini-incision technique with respect to levels of parotid involved and functional outcomes in terms of presence or absence of complications like facial palsy (temporary or permanent), seroma and Frey's syndrome. Patient related quality of life (QOL) outcomes were assessed in terms of post-operative pain score, patient comfort score and cosmetic score by using numerical rating scale-11 (NRS-11). The mini-incision parotidectomy technique is feasible for lesions in all the parotid levels and conversion or lengthening of incision was not needed in any of the cases. 2(10%) patients had temporary facial palsy (House-Brackman grade III) which was recovered within 3 weeks after surgery. One patient (5%) with adenoid cystic carcinoma had permanent facial palsy. Out of 20 patients 2(10%) had seroma and 1(5%) patient presented with Frey's syndrome. Mean post-operative pain score at 0, 6 and 24 h were 4.8, 3.4 and 1.8 out of 10 respectively. Mean comfort score was 9 out of 10 and mean cosmetic score was 9.5 out of 10. Mini-incision parotidectomy technique can render improved functional as well as aesthetic outcomes after parotidectomy without compromising the surgical clearance of the disease process.

Surgical Landmarks for Parapharyngeal Internal Carotid Artery During Extended Endoscopic Surgery of Nasopharynx: A Cadaveric and Radiological Study.

Nasopharynx is a complex region situated at the center of skull surrounded by various vital neurovascular structures. Surgical access to the nasopharyngeal space poses significant challenges due to the position of the internal carotid artery (ICA). Open approaches to nasopharynx utilize the lateral to medial anatomy but the endoscopic endo-nasal approach warrants knowledge about the medial to lateral anatomy. In this study we attempted to find the consistent surgical landmarks for parapharyngeal portion of internal carotid artery at the level of nasopharynx by means of cadaveric and radiological study. Eight fresh frozen cadavers (16 sides) and 30 CT angiography (60 sides) were included in the anatomical and radiological study respectively. Superior aspect of the torus tubarius was taken as the reference point in cadaveric study and C1-C2 interspace was used as the reference point for the radiological study. The distance between the ICA to the landmarks such as fossa of Rosenmullaer, torus tubarius, medial and lateral pterygoid plates were recorded. The mean distance of ICA to the fossa of Rosenmuller was 8.5 ± 1.4 mm and 9.1 ± 1.1 mm in the cadaveric and radiological study respectively. The mean distance between ICA to torus tubarius was 19.8 ± 1.3 mm in cadaveric and 20.6 ± 1.0 mm in radiological study. The mean distance of ICA to medial and lateral pterygoid plates were 25.3 ± 1.4 mm and 18.2 ± 1.4 mm in the cadaveric study and 25.9 ± 1.2 mm and 18.8 ± 1.3 mm in the radiological study respectively. On correlating the measurements between cadaveric and radiological study, the p values were not statistically significant (p > 0.05). The closest landmark to the ICA was the fossa of Rosenmuller. ICA was located at the same sagittal plane as that of the lateral pterygoid plate. The nasopharynx is a complex anatomical region closely related to ICA. Inadvertent injury to ICA is one of the dreaded complications of nasopharyngeal surgery. Fossa of Rosenmuller is only few millimeters away from the ICA and must be treated very cautiously. During the endoscopic approach, the ICA is at the sagittal plane as of the lateral pterygoid plate. This must be kept in mind when advancing toward the ICA by keeping intact the lateral pterygoid plate when possible and one should stay in the plane of medial pterygoid plate as the ICA lies posterolateral to it. Cadaveric dissections supported by radiological data would definitely aid surgeons to successfully perform surgeries in nasopharynx.

Modified CT Scan Scoring System for Evaluating Symptom Severity of Chronic Rhinosinusitis.

There are various subjective as well as objective tools to evaluate the severity of chronic rhinosinusitis (CRS). SNOT-22 is the most commonly used subjective scoring system to determine the severity of CRS. Lund-Mackay (LM) CT scan scoring is widely used as an objective tool in CRS. However LM scores does not correlate well with the subjective tools. We evaluated the modified CT scan scoring system (SN score) for its efficacy in determining the severity of CRS in both subjective as well as objective manner. To correlate the severity of symptoms and CT scan findings in adult patients with chronic rhinosinusitis by estimating the strength of correlation of severity of symptoms of CRS assessed by SNOT-22 scorings with CT scan findings by Lund Mackay scoring system and SN CT scan scoring system. A prospective, observational study was conducted in the tertiary care center from June 2019 to August 2020. The study included 150 adult patients diagnosed with Chronic Rhino Sinusitis resistant to primary medical therapy, who were subjected to CT scan imaging. The symptom severity of CRS was assessed by the SNOT 22 scores. CT scan was done and Lund Mackay scores and SN CT scan scores by the senior author were calculated. The correlation of SNOT 22 score with LM score and Modified CT score were assessed. The correlation of LM score with SNOT 22 score was assessed by plotting Scattered plot diagram, which showed a moderate positive, statistically significant correlation (Person correlation co-efficient: 0.466; p value: 0.032). The correlation of SN CT score with SNOT 22 was assessed by Chi Square test which showed a highly significant, positive correlation (p value of 0.000793). Our study shows a positive correlation of symptoms assessed by SNOT 22 system with radiological findings analyzed by both LM system as well as SN CT scan scoring system. However, SN CT scan scoring system showed a highly significant positive correlation over LM system as it correlates well with symptoms and also provides a grading of disease severity. SN CT scan scoring system can be considered as a tool for assessing the disease severity both in subjective and objective manner. It can be used in place of subjective tools like SNOT 22 for assessing the severity of symptoms in CRS where subjective analysis of the disease is difficult.

Outcomes of Totally Endoscopic Versus Microscopic Techniques in Middle Ear Cholesteatoma: A Systematic Review and Meta-Analysis.

Endoscopes have revolutionized the field of otology for the past two decades due to its minimally invasive technique and improved visualization. The advantage of endoscope during surgery for middle ear cholesteatoma both for diagnosing and aiding in removal of residual disease from the hidden areas and the resulting lower recurrence rates have been proven in the past by many authors. But the feasibility of totally endoscopic ear surgery and its surgical and patient related outcomes are yet to be explored in detail. We conducted this systematic review and meta-analysis to compare the surgical and patient related outcomes between totally endoscopic and microscopic technique in cases of acquired middle ear cholesteatoma. This meta-analysis has been conducted as per Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Search engines used to identify the eligible articles were Pubmed, Web of Science, Cochrane Library, Virtual Health Library databases. The studies that compared the outcomes of microscopic and endoscopic techniques in case of acquired middle ear cholesteatoma and with more than 10 patients were included. Outcomes like recurrence, residual disease, graft uptake rate, audiological outcome, conversion rate, pain score, surgery duration, complications and quality of life outcomes were compared.The quality of the included studies was assessed by Methodological Index for Non-randomized studies criteria in case of non-randomized studies and by means of Cochrane Risk of Bias Tool in case of randomized controlled studies. A random effects model was used to calculate pooled estimates. The ODDS ratio and 95% confidence interval were calculated. The heterogeneity among the studies was represented by the Q statistic and Higgins I2 statistic. The test for overall effect was calculated by Z test and a p value of < 0.05 was considered as statistically significant. 11 studies were included in this meta-analysis. Out of 11 included studies, 4 were prospectively designed and 7 were retrospective studies. The overall effect showed recurrence rate (Z:2.69, P:0.007) was lower among endoscopic technique. Post-operative pain was less among the endoscopic technique and there was no difference between the groups with respect to surgical duration. Although endoscopic technique showed lower residual rate and post-operative vertigo with better graft success rate among the individual studies, the overall analysis showed that the difference was not statistically significant. Endoscope has been an invaluable tool in the cholesteatoma surgery over the past 20 years due to its excellent optics and minimally invasive technique. Evaluation of the present data available in the literature reveals that both the techniques have similar outcomes except for a definite advantage of endoscopic technique in reducing the recurrence and post-operative discomfort.

Giant Facial Nerve Schwannoma with Extra-Temporal Involvement: A Series Of Two Cases.

Facial nerve schwannoma is a rare benign tumor of temporal bone arising from the schwann cells with incidence of 0.8%. They can arise from any segment of facial nerve with geniculate ganglion being the most common and labyrinthine segment the second commonest site. Intra-temporal location is common while only 9% of the cases have extra-temporal or parotid gland involvement. Bony remodeling or scalloping of the facial canal and the surrounding bone is the classic radiological feature of schwannoma. However schwannomas of temporal bone location can show bony erosions. The management option depends on site, extent, facial nerve function and hearing status. Surgery is reserved for large tumors with poor facial functions, hearing loss and giddiness. Giant facial nerve schwannoma with extra-temporal involvement is a rare entity with only handful number of cases reported in the literature. We present a series of two cases of giant facial nerve schwannoma with parotid gland involvement.

Radiological and cadaveric study of anatomical safe zone for transoral base of tongue surgery.

The aim of this study is to identify a surgical safe zone in base of tongue surgery. Fifteen Fresh frozen cadavers (30 head and neck regions) were included in the anatomical study. Twenty-two CT-angiogram (CTA) scans of neck were included in the radiological study. Surgical safe zone for base of tongue surgery was studied in cadavers and correlated the same in CTA. Depth of the lingual artery (LA) from the tongue surface and distance of origin of lingual artery from tip of greater cornu of hyoid bone was significantly different when comparing anatomical to radiological study (p < 0.005). On protruded position of tongue, lingual artery appeared more close to the tongue surface and was never encountered posterior to foramen caecum. Preoperative CTA evaluation would over-estimate the depth of LA putting the lingual artery at risk during resection. A surgical safe zone exists posterior to foramen caecum and towards the midline.

Anatomical and Surgical Study to Evaluate the Accuracy of "C-M-S" Technique in Facial Nerve Identification During Parotid Surgery.

Facial nerve identification is considered to be a crucial step in parotid surgery as inadvertent injury to the nerve will lead to facial paralysis. Multiple landmarks are described in literature to identify the facial nerve during parotid surgery but controversies remain as the consistency and accuracy of these landmarks vary. Numerous studies exist in literature but they fail to address a single landmark that is most reliable to identify the facial nerve during parotid surgery. The purpose of this study is to find reliable landmarks for identification of the main trunk of facial nerve during parotid surgery by evidence gathered by cadaveric dissection and intraoperative study during parotid surgery and develop a systematic approach to identify the facial nerve trunk. This prospective study included 41 cadavers (82 parotid regions) and 20 patients with parotid pathology who underwent parotidectomy. We evaluated the feasibility of our C-M-S technique to identify the main trunk of facial nerve in both anatomical and surgical study. The relationship of landmarks (tragal pointer, tympanomastoid suture, superior border of posterior belly of digastric muscle) to the facial nerve trunk was assessed and the shortest distance between them from the facial trunk was measured using a slide caliper. The measurements were compared between the anatomical and surgical study. The main trunk of facial nerve was successfully identified in all cases using C-M-S technique in both anatomical and surgical study. Distance of facial nerve trunk to tragal pointer was more in the cadaveric sample (13.04 ± 5.238 mm) compared to live patients (9.95 ± 3.967 mm) with statistically significant difference (p = 0.036). The mean distance of tympanomastoid suture and posterior belly of digastric muscle to the facial nerve trunk was similar in anatomical and surgical study with p value of 0.877 and 0.083 respectively. The tympanomastoid suture, posterior belly of digastric muscle and tragal pointer are the most useful landmarks for facial nerve identification during parotid surgery. In our study we found that the tympanomastoid suture line is the most consistent landmark present in all our cases and being closest to the facial nerve trunk in both anatomical and surgical study. Further we recommend using the "C-M-S technique" in order to locate the main trunk of the facial nerve.

Peripheral T Cell Lymphoma of Parotid Gland: A Diagnostic Challenge.

Peripheral T-cell lymphoma of salivary gland is a rare clinical entity most commonly involving the parotid gland and mimics a salivary gland carcinoma. It has an aggressive clinical course with poor prognosis. Majority of the cases are diagnosed after surgical excision whereas the principal treatment is non-surgical (chemotherapy). Core biopsy is an excellent method of identifying these indeterminate lesions pre-operatively which would avoid unnecessary surgical intervention. We present a case report with diagnostic challenge in identifying peripheral T cell lymphoma of salivary gland with the review of literature.

Selective Neck Dissection Technique in the Treatment of Recurrent Pyriform Sinus Fistula.

The 3rd and 4th branchial arch fistulas are rare conditions which are due to embryological persistence or incomplete developmental anomalies. They have a typical course as described by the embryological development but the presentation of cases with true course as per embryology is rare. These patients usually present with repeated infections, inadequate surgical interventions and recurrences. We present two index cases of 3rd and 4th pyriform sinus fistulas with their varied anatomical course and clinical presentation who were treated by selective neck dissection technique.