An Exposition on Surgical Experiences in Identification, Exposure, and Injuries of Recurrent Laryngeal Nerve (RLN) During Thyroid Operations: Gleanings, Narrative, and the Reflections.

BACKGROUND: Identifying and preserving the recurrent laryngeal nerve (RLN) is of paramount importance during thyroid surgeries. Iatrogenic injuries to RLN (RLNI) are considered one of the most serious and feared complications of thyroidectomies. Surgically, there are four routes/approaches (lateral, inferior, superior, and medial) for localizing and identifying the RLN. This study aims to estimate the incidence of RLNI in the context of various approaches taken intra-operatively for nerve localization and identification. MATERIALS AND METHODS: This retrospective analytical study included 54 cases of thyroidectomies operated for various benign and malignant thyroid disorders in a tertiary care center from January 2018 to December 2020. Intraoperative search, identification, and dissection of the nerve were done with superior, inferior, medial, and lateral approaches. The chi-square test and exact test were used to analyze the data and p-value < 0.05 was considered significant. Pre- and post-operative recurrent laryngeal nerve evaluation was done with 90 degrees Hopkins laryngoscope. RESULTS: Overall in this series, the incidence of post-thyroidectomy RLNI was 3.7% and 3.7% for permanent and temporary nerve insults, respectively. Non-recurrent RLN on the right side was identified in one case and extra-laryngeal branching of RLN was identified in two cases. There was no statistically significant difference (p = 0.929) between the different approaches taken and the incidence of RLNI. The type of surgery and pathology also expressed no statistically significant relevance with the incidence of RLNI (p = 0.463 and p = 0.277, respectively). CONCLUSION: Adoption of a particular surgical approach to localize and identify RLN during thyroid surgery carries no statistically significant difference between RLNI and approaches taken. Meticulous handling and dissection of the tissue in the correct surgical plane are crucial determinants in preventing RLNIs.

Considerations on Ossicular Reconstruction Using Lenticular Prosthesis for the Necrosed Lenticular Process During Endoscopic Tympanoplasty in Chronic Otitis Media (Mucosal) Cases.

Purpose: To evaluate hearing outcome and fate of LPIRP (lenticular process of incus replacement prosthesis) prosthesis in the reconstruction of erosion of long process of the incus. Methods: In this retrospective descriptive study 17 patients with erosion of long process of incus who were operated (reconstructed with LPIRP prosthesis) between January 2015 to December 2017 in a tertiary care center were included. The hearing outcome was evaluated by comparing mean PTA and mean ABG preoperatively and postoperatively at the end of 3 months and 18 months. The graft uptake rate, reperforation, and extrusion of the prosthesis were assessed using otoendoscopy. Results: Preoperative mean PTA was 53.8 dB while mean postoperative PTA was 36.6 dB and 33.4 dB at the end of 3 and 18 months respectively (p-value ˂ 0.05). The mean preoperative ABG was 30.2 dB while the postoperative mean was 13.4 dB and 11.2 dB at the end of 3 months and 18 months respectively (p < 0.05). Extrusion with re-perforation was seen only in one case 1/17 (5.8%). Conclusion: LPIRP has all the characteristics for an ideal middle ear implant which is a cost-effective alternative in the reconstruction of an eroded long process of the incus. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03317-5.

Contemporary Plural Deliberations and Perspectives in Revision Middle Ear Surgery. Causes, Outcomes and Lessons Learned.

The indications for revision middle ear surgery are inter-linked to the objectives of surgery and needs of the patient. Revision middle ear surgery is often challengingly arduous not only for the patient but for the surgeon as well. This study concentrates on the causes of failures of primary ear surgery, indications, techniques, outcomes and lessons learned in revision ear surgery. This retrospectivedescriptive study included 22 cases (12.29%) of revision surgery,with a follow up of at least one year, out of total 179 cases of middle ear surgeries performed over a period of 5 years.These revision cases included tympanoplasty, cortical mastoidectomy and modified radical mastoidectomy alongwith ossiculoplasty and scutumplasty, wherever required. Hearing improvement, closure of perforation, and prevention of recrudescence were the main outcome parameters. The overall morphologic success of revision surgery in our series was 90.90%.There was one graft failure, one attic retraction and the main complication observed was post-operative worsening of hearing.Mean postoperative pure-tone average air -bone gap (ABG) was 20.86 ± 11.29 dB compared with preoperative ABG of 29.64 ± 10.63 dB and the difference was statistically significant ( p < 0.05) with p value 0.0112 on paired t-test. Detailed knowledge and anticipation of the cause of failure is a must in preventing another failure in revision ear surgeries. Hearing preservation must be considered in a pragmatic perspective and accordingly surgical indications must complement the realistic and reasonable expectations of the patients.

An Exposition on Endoscopic Broad Palisade Cartilage Tympanoplasty: Procedural Illustrations and Connotations in Context of Audiological and Morphological Outcomes.

The objective of this study was to evaluate graft take up rate and hearing improvement in type I and type III endoscopic tympanoplasty using broad palisade cartilage graft and to compare the results with other studies who have used single piece cartilage as graft. This retrospective observational descriptive study was done in a tertiary care hospital. This study included 64 cases, who met the inclusion criteria, which were operated over 2 years and were followed for 3 years. The results were evaluated using graft uptake rates and hearing improvement comparing the preoperative and postoperative air conduction threshold (ACT) and air bone gap closure (ABG). The graft take rate was 92.1% and 87.5% at the end of 1 year and 3 years respectively. The preoperative and post-operative air conduction threshold were 35 ± 6.0 dB HL and 17.5 ± 2.7 dB HL in type I tympanoplasty respectively (p value <0.0001) while in type III tympanoplasty, preoperative and post-operative air conduction threshold (ACT) were 43.3 ± 8.6 dB HL and 23.1 ± 4.2 dB HL respectively (p value <0.0001). The preoperative and postoperative air bone gap (ABG) were 29.0 ± 5.6 dB HL and 14.4 ± 4.20 dB HL in type I tympanoplasty respectively (p value <0.0001). In type III preoperative and post-operative air bone gap were 36. 1 ± 7.5 dB HL and 16.4 ± 3.3 dB HL respectively (p value < 0.0001). Endoscopic broad palisade cartilage tympanoplasty has similar outcomes in morphological and audio logical perspectives as single piece cartilage tympanoplasty. Further studies with long term follow up period are required to corroborate the result of this study.

The Emerging Surgical Concepts and Principles of Attic and Postero-Superior Wall Reconstruction by Auricular Cartilage and Free Fibro-Periosteal Tissue in Middle Ear Surgery. An Exposition on Surgical Experiences, Observations and Mistakes.

In middle ear surgeries, addressing the pathologies (cholesteatoma, retractions or tympanosclerosis) in attic or postero-superior area, are associated with difficulties like reconstruction of attic and postero-superior canal wall after clearing the disease. There are various graft materials available for such attic reconstruction in intact canal -wall surgeries. We describe our experience of attic and postero-superior canal wall reconstruction in combined approach tympanoplasty (CAT) using free auricular cartilage and free fibro-periosteal tissue and to present our results in anatomical and functional perspectives. This retrospective observational study was conducted in a tertiary care center which comprised 25 cases of combined approach tympanoplasty (with attic wall reconstruction) which were operated for attic cholesteatoma, tympanosclerosis or adhesive otitis media from January 2017 to December 2019 in our otolaryngology department. Outcomes were evaluated in audiological and morphological dimensions and paired "t" test (significant p value < 0.05) was used to analyse the audiological data. A total of 25 cases (22 primary and 3 revision cases) were included in the study. Defect in attic and posterosuperior canal wall was caused by pathology (disease itself) in 2 cases, surgically created (intraoperatively to clear the disease) in 11 cases and both by pathology and surgically in 12 cases. 22 cases had successful graft uptake, with a morphological success rate of 88%, whereas graft failure was encountered in 3 cases. Complications observed were post-operative otorrhea (2 cases), recurrence (3 cases), no hearing improvement despite intact graft (1 case) and worsening of hearing post operatively in 1 case. Pre-operative ACT (Air conduction threshold) was 45.96 ± 12.47 dB and the post-operative ACT was 38.61 ± 9.76 dB (p value = 0.0246). Pre-operative ABG (Air-bone gap) was reduced from 30.58 ± 11.06 dB to the post-operative ABG of 21.89 ± 6.24 dB (p value = 0.0013). Reconstruction of postero-superior canal wall and attic defects in CAT using auricular cartilage and fibro-periosteal tissue (over mastoid cortex) is a novel method and associated with satisfactory morphological and audiological results. It is also effective in preventing postoperative retractions.

Analysis of Different Techniques of Tonsillectomy: An Insight.

Tonsillectomy is one of the most commonly performed surgical procedure in otolaryngology especially in children. This is an age old procedure which has seen continuous changes in the surgical technique from guillotine method to snare technique to coblation tonsillectomy, and is still evolving day by day. But there are no consensus as to which technique is the best or most appropriate for tonsillectomy. The objective of this study is to compare three different surgical techniques of tonsillectomy namely the Cold dissection snare technique (CDST), Bipolar electro-dissection technique (BEDT) and Harmonic scalpel technique (HST) and to identify the method which is safe, with less operative time, which offers decreased intra-operative blood loss and with lowest post-operative morbidity and complications. This prospective and comparative study was conducted over a time duration of 1 year 6 months from January 2018 to July 2019 after the approval from ethical committee. Total 150 cases of tonsillectomy were done by dividing into three groups of 50 cases each. The study showed maximum cases of tonsillitis in the age group less than 10 years and the most common indication for tonsillectomy being chronic recurrent tonsillitis. Harmonic scalpel technique (HST) had least operative time, least intra-operative blood loss, took minimum time for resumption of normal diet and normal activity and also had least pain score on post-operative day 1st, 5th, 10th and 15th. STATISTICS: Kruskall-Wallis and the non-parametric Analysis of variance (ANOVA) tests were applied to determine statistically significant variances. All the differences are found to be significant P < 0.05. Harmonic Scalpel Technique (HST) is the latest technique as it is associated with quicker procedure, less intraoperative blood loss and less post-operative pain.

Extra-Rhino Cerebral Manifestations of Mucormycosis in Head and Neck Region: An Insight.

Mucormycosis is a potentially life-threatening fungal infection with a high mortality rate. The difficulty and delay in diagnosis due to its rarity usually results in a poor prognosis. Most common site in head and neck region is the nose and paranasal sinuses. However there are other very unusual areas in head and neck region where mucormycosis is encountered. Knowledge of these unusual areas is must and can save a patient's life. To elaborate and highlight the unusual areas in head and neck region where mucormycosis can mimic other common diseases. This retrospective study was done from May 2010 to May 2019 over a period of 9 years. All histopathologically confirmed cases of Head and Neck mucormycosis were evaluated and data analyzed. Total 35 cases of head neck mucormycosis were encountered from May 2010 to May 2019 over a period of 9 years. Out of which 30 cases (85.72%) were of rhino-orbito-cerebral mucormycosis and 5 cases (14.28%) were EXTRA rhino-orbito-cerebral mucormycosis in head neck region. Mucormycosis at such unusual sites can cause diagnostic dilemma for the treating doctor. Clinical knowledge with anticipation is a must for success in treatment of mucormycosis in unusual places in head neck region especially when normal looking diseases does not respond to usual treatment.

An Overview of Parotidectomy for Benign Parotid Lesions with Special Reference to Perioperative Techniques to Avoid Complications: Our Experience.

The aim of this analytical study was to assess the reduction in intra- and post-operative complications of parotid surgeries for benign lesions following simple surgical steps and to compare the outcome with the literature. A retrospective study of 77 patients requiring parotidectomy surgery for benign parotid lesions was conducted in Department of Otorhinolaryngology, Sri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun from the period of January 2011 to January 2016. Patients were followed up for 1-5 years and serial evaluation was done for all cases who developed any of intra- or post-operative complications in their disease course. The ages of presentation varied from 1.5 to 70 years. There were 51 males and 26 female patients. Majority cases were of pleomorphic adenoma followed by warthins tumor. Superficial parotidectomy was done in 69 patients; 4 cases required near total parotidectomy while total conservative parotidectomy was done in 4 cases. The commonest complication was altered sensations around the ear which was seen in 10 cases followed by temporary facial nerve paresis and sialocele formation which occurred in 3 cases each. This study advocates the importance of detailed anatomical knowledge, behavior of various benign pathologies, experience of surgeon and his fine dissection techniques to ensure minimum risks of injury to important structures in surgical field.

A Perspective of Clinical Behaviour and Management of Deep Neck Space Infections (DNSI): The Clinical Conundrum.

The diagnosis and management of deep neck space infections remain a challenging task for otolaryngologists. A retrospective observational analysis of 137 cases of deep neck infections at a tertiary care centre was reviewed. We present 137 treated cases of DNSIs in a retrospective 5 years clinical study conducted in the department of otolaryngology at a tertiary care center from January 2012 to December 2016. Demographic information, Socio-economic data, etiopathogenesis, clinical presentation, spaces involved, diagnosis, and treatment strategies, associated morbidities, course and complications were analysed and compared with past experiences. Odontogenic and salivary gland infections causes were the most common source of DNIs. Major complication observed was skin defect. In this study, submandibular space infection was found to be the most common space involved in DNSI. Pain (100%) was the most common clinical complaint followed by neck swelling (65.69%). Staphylococcus aureus (38 cases) was the most common micro-organism isolated. Surgical intervention was the main modality of treatment and there was one mortality. DNSIs are fairly common challenging and potentially lethal entities which can lead to severe complications in a very short time, should there be delay in its prompt diagnosis and management. Computerized Tomography Scan (CT scan) with contrast is the investigation of choice in diagnosing DNSIs. Assessment of airway control must take precedence.