Cochlear implant in a patient with mondini's deformity of the cochlea: pilot patient in Pakistan.

Autosomal-recessive genes account for about 80% of the patients of non-syndromic deafness, and a major portion of those lead to cochlear pathology. Given the strong cultural practice of consanguineous marriages and the lack of awareness regarding screening modalities, a high prevalence of hereditary pre-lingual deafness is seen in Pakistan. Considering the situation, cochlear implant surgery was introduced by Aga Khan University Hospital (AKUH), Karachi, Pakistan, in 2003. Recently we decided to expand the profile and services available and conducted the first ever cochlear implant on an anatomically-challenged cochlea. The case report relates to the experience of our pilot patient who was suffering from Mondini's deformity.

Toluidine blue: yet another low cost method for screening oral cavity tumour margins in third world countries.

OBJECTIVE: To use toluidine blue intra-operatively to identify tumour involved margins after the removal of oral cavity squamous cell carcinoma, and to compare the findings with those of final histopathology. METHODS: The study was conducted at the Aga Khan University Hospital from December 1, 2009, to March 14, 2010, and comprised 56 consecutive patients with biopsy-proven squamous cell carcinoma of oral cavity regardless of grade and stage of tumour. Intra-operatively toluidine blue was used on the resected tumour margins and the staining patterns were assessed. Results were then compared with the final histopathology report. RESULTS: A total of 11(19.64%) margins were positive with toluidine blue staining out of which 8 (14.28%) were false positive. Sensitivity and specificity was found to be 100% and 84.9% respectively with a positive predictive value of 27.2%; a negative predictive value of 100%; and diagnostic accuracy of 85.71%. CONCLUSION: Toluidine blue costs only Rs25 (USD 0.30) and takes only 5 minutes for application and interpretation. It can be used with significant confidence in smaller lesions (T-l and T-II) as an alternative to frozen sections in developing countries where facilities are unavailable. Its use in larger lesions (T-lll and TIV) remains the topic of controversy and awaits a multi centre trial with a larger cohort.

Quality of Life Among Adults With Hearing Loss Who Were Prescribed Hearing Aids in Aseer Province, Saudi Arabia: A Cross-Sectional Tertiary Center-Based Study.

Introduction Hearing loss affects people of all ages, and it may become a burden for patients as well as for those around them. It leads to social isolation and impacts the quality of life (QOL). Many studies aim to investigate the outcome of hearing aids as an intervention to treat hearing loss. Our study's objective is to assess the QOL in participants and investigate the possible factors that have an impact on the outcomes of hearing aid use. Methods The study adopted a cross-sectional design and was carried out in the Armed Forces Hospital South Region, a tertiary care center in Aseer Province, Saudi Arabia. Participants were patients who presented to the ENT clinic with a complaint of hearing loss from 2017 to 2019 and who were prescribed hearing aids as their treatment. The study uses the World Health Organization Quality of Life BREF (WHOQOL-BREF) questionnaire and the International Outcome Inventory for Hearing Aids (IOI-HA) to measure the QOL and its determinants in patients using hearing aids. Results A total of 210 patients were included in the study. Sensorineural hearing loss (SNHL) was found in 72.2%, and 20% of patients were found to have bilateral hearing loss. Moderate or severe hearing loss was found in 80% of the patients in the worst hearing ear. The overall QOL among the participants was satisfactory, with the highest domain score being the social relationship domain (85.9%). The QOL was significantly higher in participants who were in an intimate relationship (P = 0.02). A positive correlation was found between the IOI-HA scores and the WHOQOL-BREF scores in general health (R = 0.14, P = 0.034), psychological health (R = 0.16, P = 0.018), and the overall QOL score (R = 0.15, P = 0.035). Conclusion Hearing aids are a cost-effective intervention that improves QOL and prevents associated comorbidities. Compliance and adherence to hearing aids improve the QOL for patients, as well as for their spouses. Patients suffering from hearing loss while also in an intimate relationship had better QOL scores. A correlation was found in outcomes between the IOI-HA scores and the WHOQOL-BREF scores in general health, psychological health, and overall health.

A comparative analysis of toluidine blue with frozen section in oral squamous cell carcinoma.

BACKGROUND: Surgical excision of the primary tumor with safe margins remains the mainstay of treatment for oral cavity squamous cell carcinoma (OSCC). The standard of care for assessment of intraoperative margins is frozen section histopathology. Unfortunately the facility is not available at most centers in limited resource countries. Toluidine blue, a metachromatic dye, has been well described in clinical identification of malignant and premalignant lesion in the oral cavity. Considering this we decided to explore intraoperative use of toluidine blue staining, in comparison with frozen sections, for the assessment of tumor-free margins. METHODS: After obtaining clearance from the in-house ethical review committee, a prospective study was conducted at Aga Khan University Hospital, Karachi, from August 15, 2009 to March 14, 2010. A sample of 56 consenting patients with biopsy-proven OSCC were included in the study, giving us 280 tumor margins. Margins were analyzed using toluidine blue staining and frozen section histopathology. A receiver operator curve (ROC) was then applied to compare assessment of margin status by toluidine blue and frozen section. RESULTS: Of the 280 examined margins 11 stained positive with toluidine blue, three were positive on frozen section biopsy, and three were positive on final histopathology. Toluidine blue staining had sensitivity and specificity of 100% and 97%, respectively. The diagnostic accuracy of toluidine blue was found to be 97.1% with a positive predictive value (PPV) of 27.2% and a negative predictive value (NPV) of 100%. CONCLUSIONS: Toluidine blue can be used as an effective screening modality for the assessment of intraoperative margins in resource limited environments and reducing the number of frozen section biopsies performed. Further by providing real-time clinical information within minutes it can reduce indirect costs such as operating room time. It may also be used as an ad hoc for frozen section biopsies where frozen section facilities are available.

Sinonasal teratocarcinosarcoma.

Teratocarcinosarcoma is a rare, morphologically heterogeneous and highly malignant neoplasm. It is characterized by the presence of benign and malignant epithelial, mesenchymal and neural components. The carcinoma may be either squamous or adenocarcinoma and the mesenchymal component may manifest spindle, smooth, skeletal muscle, cartilage and bone features. Because of their infrequency, these lesions are often misdiagnosed, leading to management difficulties. In this case report we have shared our experience with sinonasal teratocarcinosarcoma in a 23 year old female and performed a brief review of literature.

Minimally invasive endoscopic selective parathyroidectomy.

Primary hyperparathyroidism is a common condition with surgery being the definitive treatment modality. Controversy exists over the extent of optimal neck exploration, whether unilateral or bilateral exploration should be performed, particularly since 85-90% of primary hyperparathyroidism results from single gland disease. Unilateral neck exploration is now considered to be adequate unless a definitive adenoma is not identified on ipsilateral exploration and where the serum intact Parathyroid Hormone (iPTH) level does not show a decline greater than 60% after removal of a suspected adenoma. It also avoids the potential risk of hypocalcaemia, recurrent laryngeal nerve injury along with extended anaesthesia and operative time and in-patient stay. With the advent of advanced imaging modalities and peri-operative localization techniques the hyper-functioning gland can be identified and minimally invasive procedures can be performed, limiting the neck exploration to only the abnormal gland. Here we would like to describe our procedure for a minimally invasive endoscopic selective parathyroidectomy, performed on five patients. We describe our standard setup, procedure and the outcomes.

Nasal encephaloceles presenting at later ages: experience of otorhinolaryngology department at a tertiary care center in Karachi, Pakistan.

Encephaloceles are anomalous herniations of the meninges, with or without brain matter. Globally the incidence of encephalocele is about 1 per 35,000 births, but it is more frequently reported in Southeast Asia. As the defect is more pertinent to embryological development, an encephalocele is a more common entity in an infant with a mean age of presentation ranging between 15.5 and 21 months; making an encephalocele presenting for the first time in a relatively, older individual a rare occurrence. Consequently a surgeon might not consider an encephalocele among his differentials. Here we present a series of encephaloceles that presented at a later than usual age as nasal masses to the otorhinolaryngology department of our hospital, and recommend that the differential of encephalocele be entertained for nasal masses as proceeding with routine procedures may result in potentially lethal complications.

Association of Ultrasonography With Final Histopathology in Diagnosing Thyroid Malignancy: A Single-Institute Retrospective Study.

Background Thyroid nodules are well-defined regions of aberrant echogenicity within the thyroid parenchyma that are radiologically distinct from the normal thyroid gland. The most common incidental finding in imaging scans that include the neck is a thyroid nodule. Rarely are thyroid nodules cancerous, as the majority are benign. Aim The current study aims to assess the concordance between ultrasound (US) of thyroid nodules and final histopathology results to identify the different types of detected thyroid lesions. Methodology A retrospective study reviewed the medical files of all patients presenting to the Armed Forces Hospital, Southern Region, with suspected thyroid nodules from April 2018 to January 2020. Data were extracted using pre-structured proforma to avoid inconsistency. Data extracted included patient demographic, swelling laterality, size, and US and histopathological findings. Results In the present study, 47 samples had a mean age of 44.27 (SD = ±13.5) years, 85.1% were of the female gender, the majority (85.1%) had multiple nodules, 38.3% were with Thyroid Imaging Reporting and Data System (TI-RADS) TR4 US score, and the median size of the nodule on US was 3 cm with a range of 0.6 to 14 cm. The study showed that 10% of TR1 samples were lymphocytic in histopathology, 66.7% of TR3 samples were benign multinodular goiter in histopathology, and 55.6% of samples of TR4 were malignant in histopathology. Conclusions The current study showed that the malignancy rate of the examined nodules was not uncommon both by US and histopathology, where papillary carcinoma was the most detected malignancy. The study showed a satisfactory agreement rate between TI-RADS classification by US sonography and histopathological reporting, where TR4 and TR5 by the US were mainly categorized as pre-malignant/malignant lesions by histopathology.

Association of Fine-Needle Aspiration of Thyroid Nodules With Final Histopathology in Diagnosing Thyroid Malignancy: A Single Institute Retrospective Study.

Background Fine needle aspiration cytology (FNAC) is the gold standard for detecting thyroid nodules. It is a cost-efficient approach that affords prompt and accurate evaluation. It is crucial in deciding to treat patients with suspected malignancy of thyroid nodules that might have thyroid surgery. According to findings in cytology, patients may be observed when the cytology is benign, and surgery can be performed if the cytology is malignant, which leads to a reduction in the incidence of unneeded surgery. Aim The current study aims to assess the concordance between FNAC of thyroid nodules with final histopathology and identify the different types of detected thyroid lesions. Methodology A retrospective record-based study reviewed the medical files of all patients presenting to the Armed Forces Hospital, Southern region, with suspected thyroid nodules from April 2018 to January 2020. Data were extracted using pre-structured data extraction sheet to avoid inconsistency. Data extracted included patients' demographic data, swelling laterality, size, ultrasound, and histopathological findings.  Results The baseline characteristics of studied samples in the present study: Forty-seven samples had a mean age of 44.27 (SD=±13.5) years, and 85.1% were female gender. The study showed that 12.5% of benign samples were lymphocytic in histopathology, 25% suspicious for follicular neoplasm samples were benign multi-nodular goiter in histopathology, and all 100% of samples suspicious for malignancy were malignant in final histopathology. Conclusions The current study showed that the malignancy rate of the examined nodules was not uncommon in FNAC and histopathology. Where papillary carcinoma was the most detected malignancy, the diagnosis of malignancy using FNAC is a cost-efficient approach that affords prompt and accurate evaluation. Once diagnosed, these cases should be subjected to surgery.

Mucoepidermoid carcinoma of the base of tongue.

Mucoepidermoid carcinomas are thought to arise from the reserve cells of salivary gland ducts. Minor salivary glands are located all around the oral cavity and base of the tongue; however few cases of MEC of the base of the tongue have been reported in literature and no guidelines are available for its management. Here we would like to present the case of a 71 year old male with mucoepidermoid carcinoma of the base of the tongue successfully treated with surgical excision and neck dissection. Regular clinical follow up showed no signs of recurrence at 9 months post excision.

Neuronavigation assisted endoscopic sinus surgery.

In the past two decades, endoscopic sinus surgeries (ESS) have been widely advocated as a safe and effective treatment for disorders of paranasal sinuses that are refractory to medical therapy. ESS caters surgeons with two-dimensional visualization of the anatomical structures; however in scenarios where there is a close anatomical relation between the disease and delicate intracranial or intraorbital structures drastic complications can occur. Hence, endoscopic procedures had to be converted into open surgical procedures if the extent of the disease could not be visualized or cleared thoroughly. Recently however; neuronavigation systems have been combined with ESS to yield better results and facilitate this procedure. The implementation of these systems with ESS has aided surgeons in difficult approaches. We recently decided to use the neuronavigation system of our Neurosurgical department to help aid eradicate various nasal and sinus pathologies in a series of patients.

To Give or Not to Give? Prescribing Antibiotics to the Tonsillectomy Patients in a Tertiary Care Setting.

Introduction Adeno-tonsillectomy is one of the most common procedures performed worldwide in pediatric age group. Antibiotics use after tonsillectomy is like any other surgical procedure; and it is thought that the antibiotic use may help to reduce post-operative morbidity. Giving antibiotics in tonsillectomy patients is a common practice for decades but recently there has been a paradigm shift towards not using the antibiotics, especially in the pediatric population. Methods A prospective study was done on a cohort of 123 patients and they were divided into two groups on the basis of choice to receive or not to receive antibiotics after tonsillectomy, and these patients were followed in post-operative period to see any differences in the rate of complications. Results No significant statistical correlation was found between age, gender or post-operative visits and post-operative complications in between the two groups. Half of the patients received antibiotics; however, the use of antibiotics did not show a significant decrease in post-operative complications. Conclusion Regular use of antibiotics in post-tonsillectomy patients should not be advised as the use of antibiotics do not prevent or reduce post-operative complications in tonsillectomy patients.

Laryngopharyngeal Reflux Disease: Outcome of Patients After Treatment in Otolaryngology Clinics.

Introduction Laryngopharyngeal reflux (LPR) is a different entity from gastroesophageal reflux disease (GERD). Patients with LPR usually present with a variety of symptoms such as hoarseness, voice fatigue, burning sensation in the throat, persistent cough, sore throat, dysphagia, a sensation of a lump in the throat, and chronic throat clearing. The management of LPR is based on medications (proton pump inhibitors) along with lifestyle and dietary modifications. It has been suggested that the Reflux Symptom Index (RSI) and Reflux Finding Score (RFS) are useful parameters to assess patients with LPR. The aim of this study is to assess the subjective and objective benefits of RFS and RSI for diagnosing and management of LPR in the tertiary care center and to find the difference in RSI and RSI scoring with respect to gender. Methods A prospective study was performed and 102 patients were included according to inclusion criteria. RFS and RSI questionnaires were filled on the first visit of patients and then treatment with proton pump inhibitors was started along with lifestyle modification instructions. Questionnaires were filled after four weeks and then 12weeks post-treatment. Repeated measure analysis of variance (ANOVA) was performed to compare the mean RFS and RSI from baseline to the end of treatment. The post hoc analysis was done using the Bonferroni test of multiple comparisons. An independent sample t-test was also used to compare the mean RFS and RSI between genders. P-values less than 0.05 were considered statistically significant Results RFS and RSI were found to be significantly decreased post-treatment after four weeks and 12 weeks post-treatment (p-value- <0.01). Eight point eight percent (8.8%) side effects were observed in the study, the change in quality of life after a three-month treatment was significantly improved among 62.7% patients, and 75.5% did lifestyle modifications. In the mean comparison of RFS and RSI with respect to gender, it was observed that the mean RFS of females samples after one month and three months of treatment were significantly less as compared to male samples, p<0.01. There was no significant mean difference observed for RSI after one month and three months of treatment with respect to gender (p>0.05). Conclusion RFS and RSI are convenient and helpful for diagnosing LPR, and they can be easily implemented in ear, nose, throat (ENT) clinics for the subjective and objective assessment of LPR. Females showed greater improvement on laryngoscopy findings (RFS scores) post-treatment as compared to males.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial.

Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo ( p < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Frequency of Cervical Nodal Metastasis in Early-Stage Squamous Cell Carcinoma of the Tongue.

Introduction Oral cavity carcinoma is an aggressive tumor, with the tongue being one of the most common subsites of involvement. Surgery is a gold standard method of dealing with advanced-stage tumors. However, for early-stage carcinomas of the tongue, the management remains controversial. Several studies have indicated that early-stage cancers have a high chance of occult cervical node metastasis, which, if left untreated, can greatly affect the prognosis. Certain parameters can help identify patients with occult cervical node metastases, and can avoid unnecessary neck dissection in node negative patients. Tumor thickness is one such objective parameter. Objective To estimate the frequency of cervical lymph node metastasis in patients with early-stage, node-negative (N 0 ) squamous cell carcinoma of the tongue. Methods In-patient hospital data was reviewed from January 2013 until March 2014, and 78 patients who underwent primary resection of the tumor and neck dissection for biopsy-proven, early stage squamous cell carcinoma of the tongue were included. Data such as tumor thickness, tumor differentiation and presence of occult nodal metastasis in the surgical specimen were gathered from the histopathology reports. The frequency of subclinical cervical lymph node metastasis in patients with early-stage squamous cell carcinoma of the tongue was estimated. Results A total of 69% of the patients with tumor thicknesses > 5 mm had tumor metastases in the neck nodes, while 100% of the patients with tumor thicknesses < 5 mm had no neck nodal metastasis. Conclusion A tumor thickness > 5 mm is significantly associated with subclinical metastasis, and prophylactic neck dissection is warranted in such cases.

Relationship of Tumor Thickness with Neck Node Metastasis in Buccal Squamous Cell Carcinoma: An Experience at a Tertiary Care Hospital.

Introduction Squamous cell carcinoma is the most common malignancy of the head and neck, with the buccal mucosa being the most common site involved. Early locoregional metastasis is a hallmark of this disease, and early stage tumors may harbor metastatic nodes that are occult. Certain parameters can help identify high-risk patients for whom the pattern of occult nodal metastasis can be predicted. Tumor thickness is one such objective parameter. Objective To determine the relationship of tumor thickness with neck node metastasis in squamous cell carcinoma of the buccal mucosa. Methods A retrospective chart review of 102 patients with biopsy-proven squamous cell carcinoma of the buccal mucosa with N 0 Necks was performed. All patients underwent tumor resection with neck dissection, and the tumor thickness was measured. Univariate and multivariate analyses were performed. Results A total of 102 patients, of which 73.53% were males and 26.47% were females. The mean age of the patients was 49.3 ± 11.1 years. It was found that the risk of neck node metastasis in buccal squamous cell carcinoma increases 35.5 times for a tumor thickness ≥ 2 mm, and the risk of neck node metastasis in buccal squamous cell carcinoma decreases by 0.58 times for each centimeter decrease in tumor size, while the rate of occult neck lymph node metastasis was found to be 37%. Conclusion We conclude that tumor thickness is significantly related with neck nodal metastasis in buccal squamous cell carcinoma, considering the age of the patient and the size of the tumor.

Using Elasticated Retractors in Head and Neck Surgeries.

Elasticated retractors, a recent advancement in surgical techniques, provide an enhanced and effective way of retraction during head and neck surgeries. These have been used for a number of procedures and are known for their effective retraction and minimizing surgical time span. This article highlights the authors' experience and the pros and cons of this technique.

Venous Thromboembolism-Incidence of Deep Venous Thrombosis and Pulmonary Embolism in Patients with Head and Neck Cancer: A Tertiary Care Experience in Pakistan.

Introduction Although venous thromboembolism (VTE) is seen with morbidity and mortality in various surgical specialties, scarce data are available in the head and neck surgery domain. Objective We aim to determine the incidence of VTE in patients receiving surgery for head and neck cancer. Methods Four hundred thirteen patients who underwent head and neck surgery procedures between 2005 and 2013 were reviewed retrospectively. All patients with head and neck surgery had received thromboprophylaxis (i.e., compression stockings and subcutaneous heparin). Patient demographics, operating time, and length of hospital stay were analyzed. The incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) during the initial postoperative hospitalization was assessed. Results Twelve patients were identified who developed VTE. Three patients developed DVT, and nine developed PE. The incidence of DVT and PE was 0.72 and 2.17%, respectively. Interestingly, all of these patients had undergone excision of extensive head and neck cancers accompanied by a reconstructive procedure. Patients who developed PE had a longer hospital stay compared with those who only had DVT. There were overall three mortalities in the nine patients who developed PE. Conclusion Although VTE has a low incidence, it is a known complication of extensive head and neck surgeries with life-threatening outcomes. We recommend early mobilization and physiotherapy with the possible aid from appropriate mechanical and pharmacologic thromboprophylaxis.

Pilonidal sinus involving the nasal bridge: a rare manifestation.

Pilonidal sinus is very commonly associated with the sacrococcygeal area, but its presence within the head and neck is still unknown to many. Once diagnosed, it is easy to treat and should, therefore, be kept in mind as a possibility when coming across a discharging sinus swelling. We share our experience of two cases of pilonidal sinus presenting over the nasal bridge and their management.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Abstract Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo (p < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.