Skull Base Osteomyelitis Caused by an Elegant Fungus.

Malignant otitIs externa (skull base osteomyelitis) is predominantly caused by bacteria while fungal etiology is rare. We report a middle aged diabetic gentleman who succumbed to invasive skull base infection due to Apophysomyces elegans a fungus belonging to Zygomycetes which causes only skin and soft tissue infections. Mortality and invasive infections due to this genus is rarely reported, especially in the ear.

Recurrent Meningitis in a Non-user Cochlear Implantee.

Meningitis is a known complication in patients with inner ear malformations. Here we present a case of recurrent meningitis following cochlear implantation, in a patient with cochleovestibular anomaly. Good knowledge in radiology to identify the inner ear malformations, presence of cochlea and cochlear nerve is essential before planning cochlear implantation and meningitis can occur several decades after cochlear implantation.

Cochlear Implant in Klippel-Feil Syndrome: Challenges and Concerns.

Cochlear implantation (CI) can be safely performed in patients with syndromic hearing loss. Here we present a case of CI in a child with Klippel-Feil syndrome with various skeletal, extraskeletal, cochleovestibular and Arnold-Chiari malformations. Multidisciplinary approach and good preoperative imaging play a key role in planning for surgery.

An Effective Home-Based Particle Repositioning Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV).

Patients with benign paroxysmal positional vertigo (BPPV) find it difficult to visit the hospital many times for a standard Epley's maneuver performed only by a specialist. The aim of this study was to compare the efficacy of a home-based particle repositioning procedure (HBPRP) with the standard Epley's maneuver in treating patients with posterior canal BPPV. A prospective non-blinded randomized controlled study was conducted. Patients were randomized into two groups, where one group received the standard treatment and other received a new HBPRP. The vertigo scale, duration of nystagmus during Dix-Hallpike test and frequency of vertigo, were documented on first, second and third visits, with complications noted during the second and third visits. These parameters were compared between both the groups following the treatment, during all visits. The patients were randomized into 2 arms with 15 each. Those belonging to group 1 received Epley's maneuver and group 2 received HBPRP. There was no significant difference in the baseline characteristics of patients in both groups. Both groups of patients had significant improvement of symptoms at the end of the study. A comparison of both groups at 2nd and 3rd visits showed no differences in frequency of vertigo, reduction in vertigo scale and duration of nystagmus following Dix-Hallpike test between both groups. HBPRP is a safe and effective procedure and can be taught as a home-based treatment for patients diagnosed with posterior canal BPPV.

Standard Programming of Retrograde Electrode Insertion via Middle-Turn Cochleostomy in Labyrinthitis Ossificans.

Successful cochlear implantation in the setting of labyrinthitis ossificans is challenging. Various surgical techniques are described to circumvent the region of ossification and retrograde insertion of the electrode array is one such option. While reverse programming is often recommended in the case of retrograde electrode insertion, we present our experience of retrograde electrode insertion for labyrinthitis ossificans, where standard programming was adopted due to patient preference and provided satisfactory outcomes.

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.

Dimensions of the Posterior Tympanotomy and Round Window Visibility Through the Facial Recess: Cadaveric Temporal Bone Study Using a Novel Digital Microscope.

To measure the width of the posterior tympanotomy in cadaveric temporal bones using the digital microscope and classify the round window visibility through it. In 17 cadaveric wet adult temporal bones, cortical mastoidectomy followed by posterior tympanotomy was performed, delineating the facial and chorda tympani nerves. Antero-posterior width of the facial recess was measured at the levels of oval window and round window with the help of a digital microscope and its software. Visibility of the round window through the facial recess was assessed and classified according to the St. Thomas Hospital classification. The mean antero-posterior width of the facial recess measured was 4.7 ± 0.6 mm at the level of oval window and 4.3 ± 0.7 mm at the level of round window. Round window visibility grading in bones studied were as follows-Type 1 (53%), Type 2a (24%), Type 2b (18%) and Type 3 (5%). Interobserver variability of the posterior tympanotomy measurements using the digital microscope was found to be 91.1% with a 95% confidence interval of 79 to 97% at the level of oval window and 94.1% with a 95% confidence interval (CI) of 87 to 98% at the level of round window. The visibility of the round window is not entirely dependent on the facial recess width at the round window level, suggesting that other factors like cochlear rotation may also contribute to its actual location. Measurements of micro distances with the help of digital microscope seems to be convenient, cost effective and accurate with good inter observer reliability.

Comparing Intratympanic Gentamicin with Methylprednisolone in Meniere's Disease with Non-Serviceable Hearing.

Abstract: To compare the effectiveness of high dose fixed alternate day intratympanic gentamicin with methylprednisolone in the treatment of patients with unilateral, intractable Meniere's disease with poor hearing. Randomized single blind prospective parallel group trial in a tertiary referral centre. Twenty-two patients with definite unilateral Meniere's disease with average pure tone thresholds worse than 50 dB in the affected ear were enrolled. Eleven patients were treated with intratympanic buffered gentamicin and the other eleven were administered intratympanic methylprednisolone (both 4 injections, 40 mg/ml, on alternate days). Patients were assessed pre-intervention, 3 months post intervention and subsequently followed up for 2-4 years. Both groups of patients had significant control of vertigo, DHI scores and THI scores after treatment while the functional scores in the methylprednisolone group was not better than the pre- treatment scores in the long-term follow-up. 9 of 11(82%) patients in gentamicin group and 3 of 11(27%) patients in the methylprednisolone group achieved Class A vertigo control. The gentamicin group had better post intervention DHI scores (p = 0.016, 3 months and p = 0.046, long term) and Functional score (p = 0.014, 3 months and p = 0.05, long term). The hearing in both groups and THI scores, post intervention was similar between both groups. In patients with unilateral intractable MD with non-serviceable hearing, high fixed doses of both intratympanic gentamicin and methylprednisolone are effective in alleviating disease symptoms in long term follow-up. However, intratympanic gentamicin resulted in better control of vertigo, total DHI score and functional level scores than intratympanic methylprednisolone with no significant difference in hearing levels. Trail Registration Number: Clinical Trials Registry of India (CTRI- REF/2016/10/012363).

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.

Etiopathology and Prevalence of Pulsatile Tinnitus in a Tertiary Care Referral Hospital.

The diverse etiopathogenesis of pulsatile tinnitus (PT) makes it a difficult condition to diagnose and treat. To describe the clinical features, investigations and diagnosis of patients presenting with pulsatile tinnitus (PT). Retrospective chart review in an otology unit of a tertiary care referral centre. All medical records of patients who had a complaint of pulsatile tinnitus during the period 1st January 2014-1st May 2020 were included in the study. Data regarding history, characteristics of tinnitus, examination findings, investigations and diagnosis were collected and analyzed. Sixty-four patients with complaints of PT presented to our clinic during this time period and were included in the study giving a prevalence of 0.09%. Definite diagnosis was made in 62 (96.8%) cases with a detailed history, clinical examination and tailored investigations. Pathologies diagnosed were paraganglioma (25%), superior semicircular canal dehiscence (20.3%), anterior inferior cerebellar artery loop (7.8%), sigmoid sinus wall dehiscence (10.9%), sigmoid sinus diverticulum (6.25%), jugular bulb anomalies (7.8%) and hyperpneumatised petrous apex (3.1%) among others. Rare causes encountered were IgG4 disease, far advanced otosclerosis, vestibular aqueduct dehiscence and idiopathic intracranial hypertension. Pulsatile tinnitus is a rare complaint in the Otology clinic. Almost all cases of PT can be diagnosed correctly and appropriate treatment initiated with a logical approach to investigations.

Skull base osteomyelitis with secondary cavernous sinus thrombosis: a rare presentation of an animate foreign body in the ear.

A 42-year-old woman presented with fever, left ear pain, restricted mouth opening, difficulty in swallowing and inability to open her left eyelid for a period of 10 days. She was treated with antibiotics for the same at a local medical facility; however, a sudden decrease in her left eye vision prompted her to visit our tertiary centre. Her history was insignificant except for having multiple left ear syringing for an insect removal 10 days before onset of her current symptoms. On examination, she had ptosis of the left eye with chemosis, dilated pupil with only perception of light and restricted ocular mobility. Oral examination revealed trismus and bulge in the left peritonsillar region. Left ear examination revealed a large central perforation with mucopurulent discharge. CT of the neck with contrast demonstrated a collection in the left peritonsillar space with left internal carotid artery thrombosis. MRI of the brain with gadolinium revealed left cavernous sinus thrombosis with acute infarcts in the left frontal lobe. An emergency incision and drainage of the left peritonsillar abscess was performed. Culture grew broad aseptate fungal hyphae. Despite starting on antifungal therapy, she succumbed to her illness.

Prevalence, clinical profile, and diagnosis of pediatric dizziness in a tertiary care hospital.

INTRODUCTION: Pediatric dizziness is an uncommon complaint presenting to the Otolaryngology clinic. While the term dizziness may be used to describe any altered sensation of orientation to the environment which includes presyncope, light-headedness and ataxia, vertigo refers to a false sensation of motion of self or surroundings. Although a variety of etiologies are known to cause dizziness and vertigo, evaluation of this symptom becomes challenging in children who are unable to clearly explain what they experience, the provoking factors, associated symptoms and the duration of attacks. Vestibular tests are also difficult to conduct in the pediatric age group leading to apathy from the clinician. OBJECTIVES: To ascertain the prevalence of pediatric vertigo in children under 18 years of age, presenting to the Otolaryngology Clinic of a tertiary care hospital, and to describe the clinical profile, investigations and diagnosis in these children. METHODS: A prospective cross-sectional, descriptive clinical study was undertaken from January 1, 2018 to April 30, 2019. All children below the age of 18 years presenting to our department with primary complaints of dizziness were included in the study. After a thorough history and physical examination, screening methods and diagnostic tests were conducted to make a diagnosis. Referrals were sought from other specialties when necessary. RESULTS: The number of children visiting the Department for various ENT ailments during the study period was 10,950. Among these 89 children presented with a primary complaint of dizziness. Their ages ranged from 3 to 18 years; mean age was 11.42 years (SD 3.45). A diagnosis was made in all except two children. The most common cause of dizziness in the age group less than 6 years was benign paroxysmal vertigo of childhood (BPVC) and in the older children was migraine associated vertigo, which was also the commonest overall diagnosis made (28.1%). This was followed by circulation related dizziness like orthostatic hypotension and vasovagal syncope (15.7%). CONCLUSIONS: The prevalence of pediatric dizziness in children presenting to the Otolaryngology clinic was 0.8%. The diagnosis of pediatric vertigo may be challenging, but careful history and examination along with guided investigations and referrals results in correct diagnosis in almost all patients.

Posterior semicircular canal dehiscence: a diagnostic and surgical conundrum.

Third window defects have increasingly been identified as a cause of vertigo. These defects are bony dehiscences that occur in the bony labyrinth, resulting in abnormal pressure gradient in the inner ear fluids leading to sound (Tullio's phenomenon) or pressure (Hennebert's sign) induced vertigo. The superior semicircular canal dehiscence syndrome is a well-described entity in this regard, however defects of the posterior semicircular canal are rare and may have overlapping symptomatology. We describe the history, clinical profile and management of a patient who had importunate symptoms despite being on conservative management for a year and had resolution of vestibular symptoms following surgical management.

Tuberculous osteomyelitis of the hyoid bone: a case report.

Skeletal tuberculosis is a well-known disease entity. We report the first case involving hyoid bone and the use of polymerase chain reaction-based test in detection and management. A 62-year-old male presented with neck swelling of a 20-day duration along with change of voice and dysphagia. Examination revealed a cystic, osteolytic lesion of the hyoid bone which histopathologically demonstrated features of granulomatous infection. A polymerase chain reaction test confirmed the diagnosis of tuberculosis.

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.

A reclusive foreign body in the airway: a case report and a literature review.

A foreign body in the larynx is an airway emergency that requires urgent evaluation and treatment. Irregular foreign bodies tend to orient in a sagittal plane and may produce only partial obstruction, allowing adequate air movement, hence making them undetectable for a long period of time. We report a case of a laryngotracheal foreign body that remained reclusive for 9 years.