Canal wall down tympanomastoidectomy: the 'on-disease' approach for retraction pockets and cholesteatoma.

It is well known that cholesteatoma is three-dimensional; hence, we feel that its surgical management requires a three-dimensional approach in order to achieve the best curative and functional results. Retraction pockets are undeniably caused by chronic and recurrent eustachian tube obstruction. However, we found that the presence of a large mastoid antrum was an important, additional aetiological factor in the formation of a retraction pocket and its progression to cholesteatoma formation, with bone destruction and subsequent complications. Canal wall down tympanomastoidectomy--the 'on-disease' approach--is an innovative, three-dimensional technique based on universally accepted surgical principles. We modified the technique to ensure complete exposure and thereby eradication of the disease, with a resultant small cavity. Working in a three-dimensional field, we began drilling at the posterior meatal wall, lowering it while simultaneously widening the cavity as the mastoid was drilled to reach the antrum and the aditus. The bridge was lowered and the incus removed to completely expose the entire disease. The facial ridge was debulked and the temporalis fascia graft placed so as to simplify the middle-ear cleft. We present a comprehensive report of this technique, based upon 600 patients studied retrospectively over a five-year period. After one-year follow up, 546 patients had a dry, healed cavity. Canal wall down tympanomastoidectomy performed by the on-disease approach ensures complete eradication of the disease, with excellent curative as well as functional results.

Nasopharyngeal angiofibroma-an unusual origin & presentation.

Case report presenting an unusual site of angiofibroma is described. An adult male presented with a mass hanging out from the right nostril with epistaxis. A C.T. scan performed in this cast described it to be an infected polyp. The patient was operated upon. The mass arose from the septum and bled on removal. The histopathological diagnosis of the mass showed characteristic features of an angiofibroma.

The melkersson - rosenthal syndrome as a rare cause of facial nerve palsy - a case report.

The Melkenson Rosenthal syndrome is the rarely encountered triad of intermittent facial paralysis, recurrent facial oedema and lingua plicata. The intervals between the recurrence of symptoms may vary in duration. The cause of this syndrome is yet unknown. This paper discuses the pathology, clinical features and management as well as reports a case of this unusual disorder.

Otitic hydrocephalus of tubercular origin: a rare cause.

Otitic hydrocephalus is characterized by increased intra-cranial pressure without focal signs of neurological dysfunction. It usually occurs secondary to lateral sinus thrombosis more commonly on the right side, but it can also occur without lateral sinus thrombosis. With the advent of new antibiotics there has been a spectacular decrease in the complications of otitis media. Otogenic intra-cranial hypertension, always an uncommon condition, is seen only very rarely nowadays. Tubercular otitis media still occurs in India, and due to delays in its diagnosis it usually presents with complications. We present three patients with otitic hydrocephalus of tubercular origin.

Inverted Papilloma - An Unusual Presentation (Foreign-Body like).

Inverted papilloma of the nose is an uncommon, but, well document ed lesion of the mucosal lining of the nose and paranasal sinuses. The manifestation of this disease are usually unilateral nasal obstruction, mucopurulent nasal discharge, anosinia and occasional headache. It is very rare to she this condition presenting with dyspnoea and dysphagia due to its extension in the laryngopharynx. In this paper, we report a patient who presented to us with dyspnoea and dysphagia due to a huge papillomatous mass extending from right nasal cabity to the maxillary antrum laterally, posteriorly into the nasopharynx, interiorly into the oropharynx and the laryngopharynx.

Unusual cases of foreign bodies in air passage in children.

Tracheobronchial foreign bodies when not treated promptly continue to be a source of morbidity and mortality specially in the paediatric population. Chevaliar Jackson, through meticulous analysis of mechanical problems related to foreign bodies in the air and food passages and their solution, created a science of rehearsed and tested instrumental techniques for their extraction (Jackson and Jackson, 1936). They developed instruments to achieve remarkable results with an almost unbelievably low morbidity and mortality.Aspiration of foreign bodies is seen more commonly in the paediatric age group and nearly 94% of them occur in infants and children (Holinger and Holinger, 1978). According to Jackson, nearly 90% of these foreign body accidents are due to carelessness, and are therefore avoidable. We present two unusual cases of inorganic foreign bodies in the air passages in children with special reference to the problems encountered in their diagnosis and management.

Endoscopic endonasal emergency management of bilateral choanal atresia in new borns.

The advent of the rigid paediatric nasal endoscope has revolutionized the management of congenital choanal atresia. This endoscopic endonasal approach is considered as a simple, safe and reliable procedure. Also, definitive surgery for choanal atresia has been quite a challenge especially regarding the fulfillment of two important objectives- complete removal of the atretic plate and assurance of wide long-term patency of the posterior nares. Several approaches to the posterior nares have been described in the past. These include: the transpalatal (English, 1981 and Owens,196S), transnasal (Singhl990 and Singh 1991), transseptal and transantral (Hall et al 1982 and Osquthorpe et al 1982) approaches. However, endoscopie endonasal surgery for choanal atresia is found to be better due to the simplicity of the surgery, better access and lesser morbidity. The objective of this presentation is to encourage the use of the rigid nasoendoscope in the management of cases of bilateral choanal atresia of the newborn.

Tuberculoma of the cheek: a case report.

Tuberculoma of the cheek in the absence of tuberculosis elsewhere in the body is rarely seen and hence rarely thought of as a differential diagnosis when such a patient presents. In the following case, the patient was provisionally diagnosed as carcinoma of the cheek because of the exophytic nature of the growth and its presentation. However, histopathology of a biopsy revealed tuberculoma and the response to antituberculous therapy was rapid and curative.

Retraction pockets in the tympanic membrane - aetiology and management - our view point.

Retraction pockets of the tympanic membrane are believed to be due to eustachian tube obstruction or malfunction. Our observations based on intraoperative findings suggest that the presence of a large sized mastoid antrum along with chronic eustachian tube obstruction plays an important role in the causation of retraction pockets. Granular myringitis may also occur in these circumstances when there is a recurrent eustachian tube blockage due to infection especially if the patient has received frequent and inadequate courses of antibiotics. The use of chromic catgut to create a healed air-filled middle ear space along with a canal wall down tympanomastoidectomy is discussed for their effective treatment.