Management of Laryngotracheal Trauma During the COVID 19 Pandemic: Our Experience.

Objective To study the outcomes in terms of airway, voice and swallowing as well as the economic impact of the trauma on patients' finances and the constrained health infrastructure due to the pandemic. Materials and methods Study design Retrospective study. Setting: Tertiary care teaching hospital. Subjects and methods: A retrospective study was done of the 19 subjects who sustained acute laryngotracheal trauma during the SARS CoV-2 pandemic and was managed at our institution from January 2020 to September 2021. Results Change in voice was the most common presenting symptom and thyroid cartilage fractures were the commonest cartilage injury noted. It was found that 93% (decannulated) of the patients had good functional outcome and 90% of them required financial support to meet the medical expenses. Conclusion During the COVID 19 pandemic, it was not only, early presentation, timely detection and intervention by the treating team, but also the multidisciplinary teamwork and the support system that facilitated the recuperation and restoration of these traumatized individuals back into society with good laryngeal function.

Transnasal Flexible Laryngoscopy Using Different Topical Preparations and Methods of Application-A Randomized Study.

BACKGROUND: The field of laryngology has grown exponentially since the advent of the transnasal flexible laryngoscopy. Flexible laryngoscopy when performed skillfully using the proper technique, facilitates a good view of the hidden areas of the larynx. OBJECTIVE: To compare the effectiveness of the topical agents in providing a more comfortable experience for the patient, allowing the practitioner to advance the endoscope with less friction, pain and discomfort for the patient using 10% lidocaine spray, 2% lidocaine gel, 4% lidocaine with xylometazoline (1:1) soaked pledgets, or aqueous gel. MATERIALS AND METHODS: A prospective randomized single-blinded clinical trial was conducted in a tertiary care teaching hospital in South India where 376 patients were recruited and allocated into four groups based on the topical preparation used. Following endoscopy, each subject filled a questionnaire grading their experience on a visual analogue scale. The clinician also then answered a questionnaire on aspects of the endoscopy performed. RESULTS: The pain score and the ease of performing the procedure among the different groups were comparable. Those in the 10% lidocaine arm experienced significant burning sensation (P = 0.0001). The other variables such as throat pain (P = 0.783), gag reflex (P = 0.318), unpleasant taste (P = 0.092), globus (P = 0.190), swallowing difficulty after the procedure (P = 0.273), difficulty in breathing (P = 0.744) and willingness to have a repeat procedure (P = 0.883) were also comparable. CONCLUSION: Aqueous gel can be used topically during a flexible nasopharyngolaryngoscopy instead of an anesthetic agent alone or one combined with a nasal decongestant.

Isolated Aspergillus Laryngitis: Spectrum, Management, and Review of Literature.

PURPOSE: Isolated aspergillus laryngitis is rare and often diagnosed after surgical excision or biopsy for a suspected premalignant or malignant pathology. Unlike other systemic or localized aspergillosis, there are no specific guidelines for isolated laryngeal aspergillosis. Our experience of dealing with a wide variety of isolated laryngeal aspergillosis showed that this entity is very responsive to medical therapy, making extensive debridement (as often carried out in surgically accessible aspergillosis) unnecessary as it would invariably lead to long-term dysphonia. MATERIALS AND METHODS: A retrospective analysis of all cases of isolated aspergillus laryngitis that presented to our hospital over the past 5 years was carried out. All patients with confirmed histopathological diagnosis of aspergillus infection were included. RESULTS: Twelve patients (five males and seven females) aged 28-54 years, who were diagnosed with aspergillus laryngitis presented with dysphonia. The most common involved site was the true vocal cords. All patients underwent cautious biopsies either in the operating theatre or in-office using a channeled fiber-optic laryngoscope. On histopathological examination, eight had invasive aspergillus infection while others showed variety of noninvasive involvement including colonization of cysts and carcinoma in situ. The most common species isolated was Aspergillus fumigatus. Appropriate antifungal chemotherapy was prescribed after ruling out systemic involvement. None of the patients showed recurrence or residual lesions on follow-up and reported significantly improved voice. CONCLUSIONS: This study highlights the wide spectrum of presentation of isolated aspergillus laryngitis with Aspergillus fumigatus being the most common organism isolated. Even the invasive variant is a medically treatable condition with voriconazole being the drug of choice. The importance of cautious biopsies and resections for voice preservation is also emphasized. To our knowledge, this is the largest report on isolated aspergillus laryngitis.

Evaluation of Portable Tablet-Based Audiometry in a South Indian Population.

While a comprehensive booth audiogram is the gold standard for diagnosis of hearing loss, access to this may not be available in remote and low resource settings. The aims of this study were to validate a tablet-based audiometer in a tertiary medical center in India and explore its capacity in improving access to hearing healthcare. Subjects presenting to Ear-Nose-Throat clinics for conventional booth audiometry testing were recruited for subsequent tablet-based audiometric testing. Testing with the tablet was conducted in a non-sound-treated hospital clinic room. Bilateral air and bone conduction hearing threshold data from 250 through 4000 Hz were validated against conventional booth audiometry. In addition, a small feasibility study was conducted in rural clinics. 70 participants (37 adults and 33 children between the ages 5-18) were assessed. 69% were male, with a mean age of 29.7 years. Sensitivity and specificity for the tablet were 89% (95% CI 80-94%) and 70% (95% CI 56-82%), respectively. While median differences in air conduction thresholds between conventional and tablet audiograms showed statistical significance at 250, 500, and 1000 Hz (p < 0.001), the threshold results of the tablet audiometer were within 5 dB of the conventional audiogram and not clinically significant. Ten patients were successfully screened in rural clinics with tablet audiometry. Tablet portable audiometry is a valid tool for air and bone conduction threshold assessment outside of conventional sound booths. It can accurately identify hearing impairment and offers a screening tool for hearing loss in low resource settings.

Laryngeal Dysplasia: To Biopsy or Not?

A renal transplant recipient with chronic hepatitis B underwent multiple laser excisions over 4 years for laryngeal keratosis. From the initial histopathology reports of mild to moderate dysplasia, a progression to squamous carcinoma was noted over 4 years. This case report highlights the possible role of immunosuppressants and hepatitis virus in the aetiopathogenesis of laryngeal carcinoma.

Early Initiation of Voice Therapy After Microlaryngeal Surgery - A Randomized Control Study.

A prospective single blinded randomized control trial was conducted to study if early initiation of voice therapy after microlaryngeal produces a better voice outcome in patients with benign vocal fold lesions. METHODS: In this Patients undergoing microlaryngeal surgery for benign vocal fold lesions were recruited for the study and underwent voice evaluation and videostroboscopy preoperatively. Participants were randomised into two groups depending on the duration of voice rest-A (2 days voice rest) and B (5 days voice rest). Following the period of voice rest, voice therapy (tube phonation) was carried out for a month. Postoperative evaluation was done at 6 weeks (over telephone) and 3 months (in person visit) follow up. Outcome measures included the VHI-10, auditory-perceptual voice ratings, acoustic analysis and videostroboscopic vibratory ratings. RESULTS: Of the 50 subjects, 35 completed the follow up evaluation. The overall compliance to absolute voice rest was 43%. Among the various parameters used for voice evaluation, there was no statistically significant difference between the two groups except for jitter, where the improvement in 5 day voice rest group compared to the 2 day voice rest group was statistically significant. CONCLUSION: Prolonged voice rest after microlaryngeal surgery is difficult to comply with. As there was no significant difference between the two study groups, clinicians may prescribe a shorter duration of voice rest followed by early initiation of voice therapy after microlaryngeal surgery.

Role of Narrow Band Imaging in Laryngeal Lesions: A Prospective Study from Southern India.

To assess the utility of Narrow Band Imaging (NBI) as a diagnostic tool in evaluating laryngeal pathology in patients presenting with hoarseness. Study design: Prospective cross sectional diagnostic study. Methods: 200 patients with voice change were recruited and laryngeal findings documented with high definition flexible endoscopy with both white light and narrow band light and the representative still images recorded for analysis. The NBI intraepithelial papillary capillary loop (IPCL) patterns was compared with the histopathology report. Of the 200 patients evaluated, 84 lesions were biopsied which included both benign and malignant lesions. The sensitivity obtained was 73.3% [54.1-87.7% with 95% CI] and the specificity was 87% [75.1-94.6% with 95% CI] for detecting malignant lesions. NBI can be considered as a useful diagnostic tool in evaluating laryngeal pathology and can be used to detect early premalignant and malignant lesions.

Outcome of bacterial culture from mastoid granulations: is it relevant in chronic ear disease?

OBJECTIVE: To detect the presence of bacteria in mastoid granulations and compare its prevalence in both types of chronic suppurative otitis media (CSOM). To find out if stage of disease activity, age, duration of disease, and aditus patency relate to obtaining positive cultures. STUDY DESIGN AND SETTING: A prospective, parallel group study done at a tertiary care referral centre. Mastoid granulations from 79 patients with CSOM undergoing mastoidectomy were processed for anaerobic and aerobic bacteria. RESULTS: Aerobes were isolated from 57.55 per cent of the tubotympanic and 74.4 per cent of atticoantral disease (p=0.18). Anaerobic cultures were positive in one case from each group. Monomicrobial growth was detected in 37.5 per cent of tubotympanic and 48.5 per cent of atticoantral disease. Polymicrobial growth occurred in 20 per cent and 25.6 per cent in the tubotympanic and atticoantral groups, respectively. The predominant aerobic isolate was coagulase negative Staphylococcus, followed by Pseudomonas aeruginosa, Staphylococcus aureus, non-fermenting Gram-negative bacteria, Enterobacter and Enterococcus, Proteus species, Citrobacter, non-pathogenic Neisseria, aerobic spore formers were grown only in atticoantral disease. A single isolate of Aspergillus was grown. Correlating the state of disease activity of the ears with positive mastoid granulation cultures, six out of the eight inactive ears were culture positive along with seven out of the nine active and 10 out of the 23 quiescent ears. Positive mastoid granulation cultures were obtained in 60 per cent of those with blocked aditus and 42.9 per cent with patent aditus. CONCLUSION AND SIGNIFICANCE: In this study, we found that mastoid granulations are not sterile but harbour polymicrobial pathogens. Positive cultures were obtained irrespective of stage of disease activity, age, duration of disease and aditus patency. The pattern of organisms cultured from safe and unsafe CSOM and also from ears in active, quiescent and inactive stages, were similar. These findings suggest that these organisms may be responsible for mastoid granulations. We also noted that positive cultures had no statistical correlation with aditus patency and duration of disease. We suggest further studies to evaluate the significance of asymptomatic mastoid granulations harbouring organisms and whether opening the mastoid antrum and achieving aditus patency, irrespective of the stage of disease activity, will help improve the long-term surgical outcome and also prevent recurrence of ear discharge.

Effectiveness of 7.5 percent povidone iodine in comparison to 1 percent clotrimazole with lignocaine in the treatment of otomycosis.

Objectives. Otomycosis is a common ENT disease frequenting the tropics. Its recurrent nature poses a great challenge to the treating physician. In spite of a number of antifungals in the market, the frequent nature of this disease warrants repeated use of these drugs, contributing to drug resistance and financial burden on the rural population. Our primary aims were to evaluate the effectiveness of povidone iodine in the treatment of otomycosis and to identify the most common fungal isolate in our population. Study Design and Setting. A single blinded prospective longitudinal study was done over a period of 12 months in a tertiary referral center. 34 patients in the age group 15-70 years clinically diagnosed with otomycosis were included in this study. These individuals were divided into two groups selected randomly. One arm received 7.5% povidone iodine otic drops and the other 1% Clotrimazole and lignocaine drops. Evaluation was based on resolution of symptoms and signs after treatment. Result. Both arms showed improvements which were comparable thus suggesting the role of povidone iodine in the management of otomycosis. Conclusion. Povidone iodine is an effective antifungal in the treatment of otomycosis.

Audio-vestibular function in human immunodeficiency virus infected patients in India.

OBJECTIVE: As the acquired immunodeficiency syndrome (AIDS) epidemic shows no signs of abating, the impact of AIDS is felt more in the developing countries due to socioeconomic reasons. The possibility of drug-induced ototoxicity also adds to the risk of audio vestibular dysfunction. We sought to determine if there was a difference between the audio-vestibular function in the asymptomatic human immunodeficiency virus (HIV) infected patients and patients with AIDS. STUDY DESIGN: A prospective, cross-sectional study SETTING: A tertiary care center in South India MATERIALS AND METHODS: The audio-vestibular system of 30 asymptomatic HIV positive subjects (group 1) and 30 subjects with AIDS (group 2), and age-matched 30 healthy controls (group 3) were assessed using pure tone audiometry and cold caloric test. RESULTS: Sixteen patients each, in group 1 and group 2 and four subjects in the control group were detected to have a hearing loss indicating significantly more HIV infected individuals (group 1 and 2) were having hearing loss (P=0.001). Kobrak's (modified) test showed 27% of patients in group 1 and 33% of patients in group 2 and none in the group 3 had a hypofunctioning labyrinth (P=0.001). CONCLUSION: It seems that the human immunodeficiency virus does affect the audio-vestibular pathway. There was a significant incidence of audio-vestibular dysfunction among the HIV infected patients, as compared to the control population (P=0.001) and no significant difference between the asymptomatic HIV seropositive patients and AIDS patients. Majority of the patients had no otological symptoms.

Chronic pharyngitis: role of atypical organisms: a case control study from South India.

BACKGROUND: Bacteria including Chlamydophila pneumoniae, Mycoplasma pneumoniae, and anaerobic bacteria such as Fusobacterium necrophorum have been implicated as etiological agents of chronic pharyngitis in Western literature. Because there are no data regarding this from India, the authors undertook this study. STUDY DESIGN: Prospective case-control study. SETTING: Tertiary-level medical college and hospital. METHOD: In total, 343 consecutive adults with persistent throat pain and/or irritation (duration ≥3 months) were screened for known causes of pharyngitis by a thorough clinical and endoscopic examination. In 71 patients, the evaluation performed was unable to determine any cause, and these were considered cases. An enzyme-linked immunosorbent assay test to detect IgA and IgG antibodies to C pneumoniae and M pneumoniae was performed on 66 of these cases and 62 controls. The posterior pharyngeal swabs taken from both the cases and controls were subjected to aerobic and anaerobic culture. RESULTS: Individuals with chronic pharyngitis had a 3.43 times odds of being seropositive for C pneumoniae as compared with controls (P = .001; odds ratio = 3.43). Aerobic organisms and M pneumoniae did not seem to be significant etiological agents for chronic pharyngitis. On the contrary, isolation of Fusobacterium spp was found to be significantly more in controls as compared with cases. CONCLUSION: This study suggests an association between IgA antibodies to C pneumoniae and chronic pharyngitis. Further studies using more specific tests combined with long-term follow-up are needed to confirm these findings.

Pneumocephalus: a rare complication of nasal myiasis.

Infestation of ear, nose, and throat by maggots, the larvae of the fly (genus Chrysomyia) [J Laryngol Otol 1976:393-399], is termed "myiasis." Prevalent in tropical countries, atrophic rhinitis is the most common predisposing factor for this condition. The maggots burrow into delicate membranes and feed on underlying structures, causing considerable destruction of tissues, resulting in complications such as extensive erosion of the nose, face, and orbit, with rarely meningitis and death as a result of intracranial involvement [J Laryngol Otol 1989;103:489-491]. We report a rare complication of pneumocephalus after atrophic rhinitis with nasal myiasis.