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.

ACE grading-A proposed endoscopic grading system for adenoids and its clinical correlation.

OBJECTIVES: To propose a novel endoscopic adenoid grading system using a rigid nasal endoscope and to study its correlation with the clinical diagnosis. METHODOLOGY: Prerecorded video clips of rigid nasal endoscopy taken during endoscopic adenoidectomy were retrieved. Otolaryngology consultants blinded to the clinical diagnosis of the child were presented these videos and asked to grade the adenoid hypertrophy as per the proposed endoscopic ACE (Airway/Choana/Eustachian tube) grading system. The clinical diagnosis was correlated with the different aspects of the descriptive endoscopic grading system. RESULTS: 152 video clips were presented to the otolaryngology consultants for grading. The average age was 8.6 years (SD-3.48), while the male female ratio was 3:2. The A subcomponent of the ACE grading showed significant correlation with the diagnosis of sleep disordered breathing and chronic adenotonsillitis, C subcomponent with sleep disordered breathing and the E subcomponent with the diagnosis of otitis media. CONCLUSION: The proposed endoscopic grading is easily applicable and at the same time clearly describes the relation of the adenoids to the nasopharynx, choana and Eustachian tube. Different aspects of the grading system correlated differently with the clinical diagnosis emphasizing that a descriptive scoring rather than a comprehensive scoring is a more relevant clinical tool.

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.