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.

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.

A Comparative Study of Outcomes and Quality of Life in Canal Wall up Mastoidectomies and Canal Wall down Mastoidectomies.

Abstract: Chronic Otitis Media (COM) of the squamosal type was primarily managed by performing a canal wall down mastoidectomy; however, the latter era otolaryngologist envisioned benefits in preserving the posterior canal wall. Our primary objective was to assess the disease specific quality of life following canal wall up (CWU) mastoidectomy and canal wall down (CWD) mastoidectomy surgery after a 6 month post-operative period. A prospective observational study was done from September 2017 to August 2018 where the charts of 380 patients from Christian Medical College, Vellore were reviewed. Details of patients above 18 years who had undergone the above surgeries for COM active squamosal disease from the period of January 2014 to December 2016; and had their post-operative follow up (average of 16 months) during the period of study were looked at. The CWU group had a significantly better disease-specific quality of life in the symptoms subscale than the CWD group (p value < 0.01). The CWU group showed a significant air-bone gap closure to 23.3 dB as compared to 27.7 dB in CWD (p value = 0.005). The recurrence rates were 4.5% (9 cases) in the CWU group and 3.9% (7 cases) in the CWD group, which was not statistically significant. Both CWU and CWD methods of mastoidectomy for COM squamosal type give comparable outcomes in terms of recurrence with the CWU group having a better disease-specific quality of life after surgery. Level of Evidence: 2a.

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.

Time to Revisit a Low-Cost Alternative? Palpation Assessment Nerve Monitoring (PANM) for Recurrent Laryngeal Nerve to Predict Postoperative Vocal Cord Function-a Validation Study Using an In-House Neuromonitoring Device.

Neuromonitoring has proved to be a useful technique in reducing nerve injury during thyroid surgery; however, costs continue to limit its use in resource-constrained settings. This study was done to assess the functional integrity of the recurrent laryngeal nerve (RLN) during thyroid surgery using palpation assessment of posterior cricoarytenoid muscle twitch in response to RLN stimulation. Between August 2016 and July 2017, 24 patients with 47 nerves at risk (NARs) underwent thyroid surgery with visual identification and testing of 44 RLNs. The functional integrity of the RLN was checked by stimulation of the RLN. Intraoperative assessment showed 100% sensitivity and positive predictive value in predicting postoperative vocal cord function. The postoperative vocal cord assessment confirmed all 44 nerves tested to be normally functioning. The mean (standard deviation) peak-to-peak amplitude and latency of the CMAP were 0.889 (0.740)/1.336 (1.660) mV and 2.295 (0.319)/2.217 (0.393) ms for left/right side NARs, respectively, with no statistically significant difference (P > 0.05). Palpation assessment of the posterior cricoarytenoid muscle provides a simple and reliable technique for confirming integrity of the RLN. Combining palpation assessment with CMAP from the inferior constrictor muscle may help reduce potential false negative results. With the use of our in-house built device which is significantly cheaper than the commercial ones, this could be considered a low-cost alternative to current established techniques.

Voice Change Following Adenotonsillectomy in Pediatric Population: Myth or Reality?-A Pilot Study.

Modifications in the structure of pharynx following adenotonsillectomy are presumed to cause changes in the voice characteristics of patients. Data on effect of tonsillectomy/adenotonsillectomy on changes in voice among Indian children are sparse. This study was thus conducted to study the effect of adenotonsillectomy/tonsillectomy on childrens' voice. It was a prospective observational study of children aged 4-15 years undergoing tonsillectomy with or without adenoidectomy. Measures of voice were noted preoperatively, 1 and 3 months post-operatively. Subjective evaluation was done using Paediatric Voice Outcome Survey (PVOS) questionnaire administered to participants' parents. Objective evaluation was done by recording and analyzing using PRAAT voice analysis software which is an open-software tool. Statistical analysis was done using the statistical software SPSS 17.0 version. There were 31 children between 4 and 14 years of age 65% being male. Adenotonsillectomy was done in 83.5%. There was statistically significant difference in the subjective scores (PVOS) pre-operatively and 3 month postoperative score (p value = 0.001). However, there was no statistically significant difference between any other pre op and post op parameters. Though the only significant post tonsillectomy voice changes noted was subjective by parents 3 months later, it does raise concern whether this could be a reality and not a myth. Further studies with larger number of patients, including involving the subjective evaluation (PVOS) by another person in addition to patients' parent need to be undertaken to address this issue.

Difficult Laryngeal Exposure in Microlaryngoscopy: Can it be Predicted Preoperatively?

The aim of the present study was to identify preoperative clinical predictors for difficult laryngeal exposure (DLE) and to define a simple grading system for laryngeal exposure. This is a prospective descriptive study carried out in a tertiary teaching hospital in South India. Patients above 18 years undergoing microlaryngoscopy had presurgical evaluation of 11 physical parameters. Grading of Modified Cormack-Lehane Score (MCLS) and rigid laryngoscopy were done during procedure. On logistic regression analysis, with a 95 % confidence interval (CI) MCLS was found to be a statistically significant predictor (odds ratio 12). With 90 % CI, neck circumference, atlanto-occipital extension and MCLS were significant (odds ratio of 4, 4, 12 respectively). Neck circumference of more than 34.25 cm and limited atlanto-occipital extension of less than 19.50, predicts difficult laryngeal exposure. A simple grading system for laryngeal exposure during microlaryngoscopy is being proposed. MCLS grade more than 2a done intra operatively correlates well with difficult intubation.

Endoscopic Repair of CSF Rhinorrhea: An Institutional Experience.

INTRODUCTION: Endoscopic repair is considered the treatment of choice in cerebrospinal fluid (CSF) rhinorrhea. The aim of our study was to analyze the etiopathogenesis of CSF rhinorrhea, the outcome of treatment and the causes of failure in a developing-country setting. MATERIALS AND METHODS: A retrospective review of patients treated with endoscopic repair for CSF rhinorrhea at a tertiary care hospital in southern India from January 2002 to December 2009 identified 36 patients, the majority of them being women. The defects were closed in three layers using fat, fascia lata and nasal mucosa along with a fibrin sealant in the majority of the patients. Per-operatively, a subarachnoid drain was placed in all patients. Patients were followed up for 1 year. RESULTS: Spontaneous onset of CSF rhinorrhea was noted in 61% of patients. The most common site of leak was found to be the left cribriform plate area. Hence the most common cause of CSF rhinorrhea in our study was spontaneous and the second most common was post-traumatic. Our success rate on the first attempt at endoscopic repair was 100%, with a recurrence rate of 6%. A large defect, failure of localization of the defect, or other co-morbid conditions such as chronic cough may be the most likely causes of recurrence of leak. CONCLUSION: Accurate localization of the site of lesion using a high-resolution computed tomography (CT) scan with magnetic resonance imaging (MRI) and confirmation of the site of leak by intraoperative Valsalva maneuver along with multilayered closure of the dural defect and post-operative lumbar drain appear to be essential for the successful endoscopic repair of CSF rhinorrhea.

Solitary Fibrous Tumor of Nasal Cavity: A Case Report.

INTRODUCTION: Solitary fibrous tumours (SFTs) of the nose and paranasal sinuses are extremely rare. These were originally described as neoplasms of the pleura originating from spindle cells. It is further sub-classified as a benign type of mesothelial tumour. Its occurrence in many extra pleural sites have been reported earlier, mainly in the liver, parapharyngeal space, sublingual glands, tongue, parotid gland, thyroid, periorbital region, and very occasionally in the nose and paranasal sinus area. CASE REPORT: A 28-year-old man with a 6 month history of persistent progressive left nasal obstruction and watering of the left eye is reported. Further imaging by CT and MRI revealed a large, left-sided, highly vascular, nasal cavity mass (Figs.1-4) pushing laterally on the medial wall of the maxilla. The patient underwent a lateral rhinotomy, which proceeded with the excision of the mass. Histopathological analysis of the specimen was consistent with SFT. CONCLUSION: This case is reported to develop insights regarding diagnosis and management of such rare tumours.

Neonatal hearing screening--experience from a tertiary care hospital in southern India.

OBJECTIVE: To implement a neonatal hearing screening program using automated auditory brainstem response audiometry in a tertiary care set-up and assess the prevalence of neonatal hearing loss. DESIGN: Descriptive study. SETTING: Tertiary care hospital in Southern India. PARTICIPANTS: 9448 babies born in the hospital over a period of 11 months. INTERVENTION: The neonates were subjected to a two stage sequential screening using the BERAphone. Neonates suspected of hearing loss underwent confirmatory testing using auditory steady state response audiometry. In addition, serological testing for TORCH infections, and connexin 26 gene was done. MAIN OUTCOME MEASURES: Feasibility of the screening program, prevalence of neonatal hearing loss and risk factors found in association with neonatal hearing loss. RESULTS: 164 babies were identified as suspected for hearing loss, but of which, only 58 visited the audiovestibular clinic. Among 45 babies who had confirmatory testing, 39 were confirmed to have hearing loss and were rehabilitated appropriately. 30 babies had one or more risk factors; 6 had evidence of TORCH infection and 1 had connexin 26 gene mutation. CONCLUSION: Neonatal hearing screening using BERAphone is a feasible service. The estimated prevalence of confirmed hearing loss was comparable to that in literature. Overcoming the large numbers of loss to follow-up proves to be a challenge in the implementation of such a program.

Diagnosis of adult chronic rhinosinusitis: can nasal endoscopy predict intrasinus disease?

OBJECTIVES: To define the role of endoscopic evaluation of middle meatus in adult patients clinically diagnosed to have chronic rhino-sinusitis and its ability to predict intra-sinus mucosal involvement as compared to CT scan. METHODS: This prospective analytical study was conducted on consecutive patients with diagnosis of chronic rhino-sinusitis who were symptomatic and fulfilled the American Academy of Otolaryngology - Head and Neck Surgery Task Force criteria. The patients were enrolled prospectively and were subjected to rigid diagnostic nasal endoscopy and classified as defined by the revised Sinus Allergy Health Partnership Task Force criteria. The patients then underwent non contrast CT sinuses on the same day. Results were analyzed as a diagnostic test evaluation using CT as a gold standard. RESULTS: Among the 75 study patients with symptom based chronic rhino-sinusitis, nasal endoscopy was abnormal in 65 patients (87%). Of these patients, 60/65 (92%) showed positive findings on CT scan. Ten patients had normal endoscopy, of these 6/10 (60%) had abnormal CT scan. Sensitivity and specificity of diagnostic nasal endoscopy against CT scan were 91% (95% CI: 81-97) and 44% (95% CI: 14-79), respectively. The likelihood ratio for positive nasal endoscopy to diagnose chronic rhino-sinusitis was 1.6 and the likelihood ratio to rule out chronic rhino-sinusitis when endoscopy was negative was 0.2. CONCLUSION: Nasal endoscopy is a valid and objective diagnostic tool in the work up of patients with symptomatic chronic rhino-sinusitis. When clinical suspicion is low (<50%) and endoscopy is negative, the probability of rhino-sinusitis is very low (<17%) and there is no need to perform a CT scan to reconfirm this finding routinely. Endoscopy alone is able to diagnose chronic rhino-sinusitis in >90% of patients when clinical suspicion is high (88%) as defined in this study by AAO-HNS Task Force criteria. Negative endoscopy, however, does not totally exclude the sinus disease in patients fulfilling task force criteria. CT scan may be needed on follow-up if there is clinical suspicion in 10% of these patients who are negative on endoscopy if symptoms persists. It is thus possible to reduce the number of CT scans if patients are carefully selected based on clinical criteria and endoscopy is done initially as part of their evaluation.