Novel Grading System Based on Nasal Endoscopy: Our Experience with 650 Mucormycosis Cases.

Rhinocerebralmucormycosis, is a progressive fungal invasion of a hard palate, paranasal sinuses, orbit, and brain. Post covid the huge number of mucor cases reported in our institute. To combat them a uniform assessment scale was needed as multiple healthcare workers were involved. Thus, a novel linear grading system on nasal endoscopy was developed for the early management of patients to prevent morbidity and mortality. A Prospective study of 650 patients in Epidemic duration from April to June 2021 in a tertiary health center, Central India. Patients subjected to Nasal Endoscopy with 0degree 4 mm Telescope and classified into 5 categories according to the severity of the disease. In a novel grading system, minimum patients were of grade 0, maximum was in Grade I. Maxillary sinus was most commonly involved. This novel grading system on nasal endoscopy makes the management of patients much easier in an epidemic, reducing human errors, morbidity, and mortality of the fulminant disease.

Role of Imaging in Evaluating Patients for Cochlear Implantation.

Role of Imaging in evaluating patients for Cochlear Implantation. To assess the role of imaging using High resolution computed tomography (HRCT) and Magnetic resonance imaging (MRI) temporal bone for evaluating candidates for cochlear implantation (CI). It was a prospective study conducted in the department of Otorhinolaryngology at a tertiary care centre, 30 children up to 5 years of age with severe to profound sensorineural hearing loss(SNHL) were included in the study, radiological evaluation was done in all children. 20(66.67%) children were in 2-4 years age group with female preponderance. Radiological abnormalities were reported in 13(43.33%) children. Abnormalities of inner ear were seen in 8(26.67%) cases, which included bilateral cochlear nerve aplasia, unilateral cochlear aplasia with bilateral cochlear nerve aplasia, bilateral severe cochlear hypoplasia, mondini's dysplasia. Cochlear nerve deficiency was found in 3(10%) children and narrow Internal auditory canal in 4(13.33%) children. 2(6.67%) patients out of 30 were not the candidates for CI, they had bilateral absent cochlear nerve which is an absolute contraindication for CI. 28(93.33%) patients were evaluated as candidates for CI. Imaging is a fundamental part of the preoperative workup for cochlear implantation, HRCT and MRI temporal bone are complementary to each other in evaluating children for cochlear implantation as HRCT is excellent for demonstrating bony details but, lack in providing details of inner ear neural structures and MRI is better than CT in demonstrating vestibulocochlear nerves.

Mucormycosis Epidemic in Covid Era: A Sinister Superinfection.

In this study, we attempt to look at the various presentations, comorbidities and association of the recent epidemic of rhino-orbital cerebral mucormycosis with Covid-19 in central India. A prospective study of 612 patients diagnosed with mucormycosis from April to July 2021. Detailed history was taken and thorough clinical examination was done. The relation of mucormycosis with Covid-19 and other morbidities was studied. Nasal endoscopy, imaging and management findings were tabulated and analyzed. Male predominance of the disease was noted. The most common age group affected was found to be 41-50 years group having 33.1% of all patients. 83.2% patients had history of Covid-19 infection. Majority of the patients (41.6%) had mucormycosis symptoms within 1 month of Covid-19 symptom onset. Nasal symptoms predominated with 61.1% patients having one or more of the several nasal symptoms. Most common comorbidity was diabetes mellitus (75.8% cases). Nasal and sinus debridement was performed in 584 patients (95.4%). Mucormycosis turned into a widespread epidemic during the second wave of Covid-19 in India. Diabetes mellitus was the most common associated comorbidity that increased the risk of mucormycosis in patients with history of Covid-19 infection. A high index of suspicion in patients presenting with early symptoms in the context of Covid-19, along with prompt diagnosis using radiological, endoscopic and microbiological tools will help reduce mortality to a great extent. Mainstay of treatment is aggressive surgical and medical management, controlling comorbidities and adequate post-operative care.

Effect of Neonatal Hearing Screening on Early Diagnosis of Sensorineural Hearing Loss.

The aim of the study to screen the neonates for earlier diagnosis of sensorineural hearing loss and to assess the relationship between the hearing loss in newborns along with the high risk factors. A prospective, cohort, observational analytical study done at department of ENT,MGMMC & MYH INDORE (M.P.) carried out during 2018-2019 over 200 neonates who were randomly selected screened by OAE & BERA before their discharge from the hospital and after stabilizing high risk neonates. Out of 200 neonates, sensorineural hearing loss found to be in 4 neonates (2%) and hearing impairment seen 13.8 times more in high risk neonates as compare to the low risk neonates. The core goal of the study was to emphasize the importance of universal newborn hearing screening for early diagnosis & intervention in newborns & Neonates in terms of auditory rehabilitation as every child is precious and hearing is their fundamental right.

Our Experience with Two Handed Endoscopic Tympanoplasty.

Endoscopic tympanoplasty is a minimally invasive procedure and may be an alternative to conventional microscopic tympanoplasty with less operative time, producing similar graft uptake. Endoscopic tympanoplasty has a major disadvantage of single handedness which is overcome by a novel concept of "Two-handed technique" using Khan's Justtach (endoholder). The aim was to study the outcomes of two handed endoscopic tympanoplasty in terms of graft uptake and hearing outcome. Two handed endoscopic tympanoplasty was performed in 20 patients with chronic suppurative otitis media between April 2018-April 2019, in the Department of Otorhinolaryngology, M.G.M. Medical college and MYH hospital, Indore. Tragal cartilage graft via palisading supported with perichondrium was used. Postoperative follow up was done at 3rd month's period, graft status and hearing evaluation was done using Pure tone audiometry. Graft uptake was intact in 19 (95%) out of 20 patients and infection and failure in 1 (5%) case, average preoperative A-B gap was 15-25 dB loss (minimal) in 1 (5%) patient, 3 (15%) patients had 25-40 dB loss (mild) and 16 (80%) patients had 40-55 dB loss (moderate) hearing loss. The post-operative improvement was evaluated in which 6 (30%) patient had 15-25 dB loss (minimal), 12 (60%) patients had 25-40 dB loss (mild), and 2 (10%) patients had 40-55 dB (moderate) conductive hearing loss. We used Wilcoxon Signed Ranks Test for audiological evaluation with a 'p value' of 0.000 making the hearing improvement significant. "Two handed endoscopic tympanoplasty" is an emerging technique which can overcome almost all the major issues related with single handed technique with high degree graft uptake and good hearing outcomes. Endoscope holder is a valuable adjunct to conventional endoscopic surgery.

VEMP: An Objective Test for Diagnosing the Cases of BPPV.

Vertigo is a medical condition where a person feels as if they or the objects around them are moving when they are not. Any disturbance in the functioning of vestibular organ may cause vertigo. This study aims to find the role of cervical Vestibular evoked myogenic potential in diagnosing BPPV. The study performed was a prospective study of 50 patients with the age distribution from 20 to 60 years of age, attending the OPD in ENT department of MY Hospital, Indore with complaints of Vertigo. c-VEMP test was performed. The results were evaluated to diagnose BPPV. Of all the patients with the complaints of vertigo maximum belonged to the 5th decade of life. Of all the patients, females were found to be affected more than males making the male female ratio to be 1:1.28. In our study Dix-Hallpike test was found to be positive in 38 (74%) patients. On performing cervical VEMP, 15 (30%) patients of 50 patients showed abnormal latencies and amplitudes suggesting abnormal saccular functioning on affected side. Of these 15 abnormal VEMPs, 13 patients were positive on performing Dix-Hallpike test i.e. were diagnosed to have BPPV. VEMP showed a positive correlation with Dix-Hallpike test in diagnosis of vertigo of postural origin and thus can be used as a diagnostic tool for BPPV as VEMP is found to have high specificity.

Virtual Bronchoscopy: Highly Sensitive Time and Life Saving Investigation in the Diagnosis of Foreign Body Aspiration-Our Experience.

Foreign body airway is a common cause of morbidity and mortality in children. Virtual bronchoscopy is a new investigative technique useful in locating non radiopaque FB missed on plain radiography. The aim of the study was to study the clinical profile of patients with suspected foreign body aspiration and to evaluate the changing trends in the diagnosis and quicker management of foreign body aspiration as a way of virtual bronchoscopy. This was a retrospective and prospective cross sectional study conducted in the Department of Otorhinolaryngology M.G.M.M.C. and M.Y. Hospital Indore for a period of 10 years. The medical records of patients with foreign body aspiration, from August 2006 to September 2016 were reviewed. Data was collected regarding their clinical presentation, examination and chest X-ray, virtual bronchoscopy, rigid bronchoscopy findings. Patients with suspected foreign body aspiration were subjected to virtual bronchoscopy and rigid bronchoscopy was performed. The techniques and methods to extract different types of foreign bodies has been elaborated in this study. In the 150 subjects, we observed mean age group of presentation was 2.1 years, male is to female ratio was 4.1, 70% of the cases came from the rural areas, 86% were vegetative foreign bodies, and remaining non vegetative were aspirated mostly during the winter season. Betel nut was the most common aspirated foreign body 0.63% had a positive history of foreign body aspiration, where as 37% had a negative history. Right main bronchus was the most common site of lodgement. Breathlessness and reduced air entry were the most common symptoms and signs. We also observed, that chest radiograph were normal in as many as 40% cases. Hence negative chest radiographs does not rule out FB. In 150 patients with foreign body aspiration, which was detected by virtual bronchoscopy, 148 patients were diagnosed to have foreign body on rigid bronchoscopy. This amounts to a positive predictive value of 97.3% which was similar to the positive predictive value of rigid bronchoscopy which was 99%. Virtual bronchoscopy is the only imaging modality which gives 99.9% reassurance about the presence or absence of a foreign body, because of its high sensitivity and specificity, hence proves to be a life saving tool.

A Comprehensive Analysis of Benign Vocal Fold Lesions Causing Hoarseness of Voice and Our Experience with Cold Knife Endolaryngeal Surgery in a Tertiary Healthcare Centre.

Benign vocal fold lesions (BVFL) frequently affect the general population and cause significant hoarseness by interfering with daily communication. Healthcare for low income groups in India is all about affordability and availability without giving up on quality and providing maximum satisfaction. (1) To analyse over a period of 4 years, the demographics, clinical profile, diagnostics and management options of BVFL. (2) To assess the diagnostic potential of rigid laryngoscopy in diagnosing these lesions. (3) Cold knife endolaryngeal surgery as a cost effective, satisfactory and efficient treatment modality to tackle majority of these BVFL. A prospective cross sectional study over a period of 4 years from 2013 to 2017. 114 patients presenting with hoarseness of voice were evaluated by indirect laryngoscopy followed by video laryngoscopy and stroboscopy in the department of ENT, MYH Hospital Indore (M.P.). Male:female ratio of 1.59:1 with male predominance (61.4%) and maximum incidence in the third decade (32%). All cases presented with hoarseness (100%) while vocal fatigue (63%) was the most common associated complaint followed by foreign body sensation (60%). Housewives (32%) were most commonly involved non professional group while teachers (13%) constituted the most common group of professionals. Laryngitis (26%) involving bilateral vocal folds diffusely was the most common finding followed by vocal fold sulcus (18%) and vocal fold cysts (14%). The duration of symptom was 6 months to 1 year in 52% patients. The positive predictive value for rigid laryngoscopy was 100% for vocal nodules, arytenoid granulomas and anterior glottis web. Out of 114 patients, 66 patients improved on conservative management while 48 patients underwent cold knife endolaryngeal surgery. As per the GRBAS scale to assess the post therapeutic prognosis, all had good outcome of voice with only two recurrences due to patient non compliance. In this rapidly evolving era of sophisticated lasers which is a costly affair that requires skilled personnel and safety precautions, the prime goal in a government run setup has always been to provide affordable and quality healthcare to the common man. Cold knife endolaryngeal surgery is a simple, cost effective and efficient way to tackle most of these lesions and hence helps in achieving this goal.

A Comprehensive Voice Analysis in Benign Vocal Fold Lesions Treated by Cold Knife Endolaryngeal Surgery Using Subjective, Objective and Video-Stroboscopic Parameters.

In the era of globalisation, numerous technical methods have emerged in the management of benign laryngeal lesions. Still cold knife endolaryngeal surgery holds the basic and effective position in providing excellent voice outcome. The aim of this study is to assess the cold knife as a tool for excision of benign laryngeal lesions by protocol of voice assessment. Fifty-five patients with benign vocal fold lesions were included (26 women and 29 men), with age ranging from 22 to 56 years. Each patient was subjected to endoscopic microlaryngeal surgery with cold instruments. Voice assessment was done preoperatively and 3 weeks postoperatively and 3 month post-operatively. The patients were assessed subjectively by Voice Problem Self-Assessment Scale and objectively by laryngoscopy, stroboscopy, and acoustic analysis. Outcome was measured by comparing preoperative and postoperative groups. Significant improvement (< 0.05) was observed in the voice handicap index, acoustic parameters and video stroboscopy parameters between the preoperative and the postoperative groups. The cold knife endo-laryngoscopic surgery still stands out to be a simple, cost effective yet efficient way in treating majority of benign vocal fold lesions causing hoarseness of voice.

Narrow Band Imaging: An Effective and Early Diagnostic Tool in Diagnosis of Oral Malignant Lesions.

The management of oral carcinoma leads to both cosmetic and functional deficit to the patient and the confirmatory histopathology is a time consuming process which may be a reason for a reduced follow up and compliance of the patient. We hereby use this study as an opportunity to tell that narrow band imaging (NBI) serves both the above purposes in an earlier period and in a non-invasive manner and thereby improving the lifestyle of the patients. To find out a better non-invasive and time saving diagnostic tool in the management of premalignant and malignant oral lesions in its earlier period. A prospective cross sectional study of 38 patients presenting to the department of ENT, MGMMC, MYH, Indore was taken with suspicious lesions and subjected to endoscopic examination by both white light and NBI and samples were sent to histopathological examination for confirmation. The Intrapapillary Capillary Loop were identified through NBI with Type I (50%) and Type II (31%) to be the most common pattern both correlating with the histopathological squamous cell carcinoma. The sensitivity and specificity of White Light Endoscopy is to be 75.75% and 76.43% respectively and of NBI to be 93.93% and 80% respectively. Narrow band imaging is found to be an optical diagnostic tool in the diagnosis of the lesions at an earlier stage and preventing from further functional and structural deterioration by the disease progression.

Role of Electronystagmography in Diagnosis of Secondary BPPV in Elderly Patients with Vertigo: A Retrospective Study.

Elderly population is frequently affected by vertigo which affects their mobility and makes them vulnerable to fall and other morbidities. Often these patient visit neurologist and are often subjected to CT scan, MRI brain etc. to rule out a central cause of vertigo; whereas majority of these patients suffer from vestibular cause of vertigo. A schematic approach by detailed history, simple tests for vestibular functions like Dix Hallpike, supine roll and head impulse test give important clue to diagnosis. Often the diagnosis is benign paroxysmal positional vertigo (BPPV) which is treated by repositioning maneuver. There are often other vestibular causes which may be diagnosed by Electronystagmography (ENG), electrocochleography and other tests. This study was undertaken to study occurrence of secondary BPPV utilizing various parameters of ENG. The study group comprised of 131 patients from the neuro-otology proforma data base at ENT centre and vertigo clinic from January 2015 to December 2017. Inclusion criterion was male and female aged 51 years and above presenting with dizziness, imbalance, rotational vertigo, unsteadiness as the chief complaint. Exclusion criterion was BPPV relieved after Epley's maneuver, Otitis externa, acute Otitis media, Suppurative Otitis media, pre existing neurological condition and history of ear surgery. Neuro-otology Data obtained and the ENG findings were tabulated in the master chart and the observations interpreted and transferred to Claussen's butterfly chart. The study group comprised of 58 male (44.27%) and 73 female (55.73%) with a male female ratio of 1:1.25. ENG exhibited 36 patients (27.49) to have recurrent BPPV, 53 (40.45%) were found to have unilateral/bilateral canal paresis. Meniere's disease was diagnosed in 39 (29.77%) patients and brain stem pathology identified in 3 (2.29%) cases.

Role of virtual bronchoscopy in children with a vegetable foreign body in the tracheobronchial tree.

OBJECTIVES: Multidetector computed tomography virtual bronchoscopy is a non-invasive diagnostic tool which provides a three-dimensional view of the tracheobronchial airway. This study aimed to evaluate the usefulness of virtual bronchoscopy in cases of vegetable foreign body aspiration in children. METHODS: The medical records of patients with a history of foreign body aspiration from August 2006 to August 2010 were reviewed. Data were collected regarding their clinical presentation and chest X-ray, virtual bronchoscopy and rigid bronchoscopy findings. Cases of metallic and other non-vegetable foreign bodies were excluded from the analysis. Patients with multidetector computed tomography virtual bronchoscopy showing features of vegetable foreign body were included in the analysis. For each patient, virtual bronchoscopy findings were reviewed and compared with those of rigid bronchoscopy. RESULTS: A total of 60 patients; all children ranging from 1 month to 8 years of age, were included. The mean age at presentation was 2.01 years. Rigid bronchoscopy confirmed the results of multidetector computed tomography virtual bronchoscopy (i.e. presence of foreign body, site of lodgement, and size and shape) in 59 patients. In the remaining case, a vegetable foreign body identified by virtual bronchoscopy was revealed by rigid bronchoscopy to be a thick mucus plug. Thus, the positive predictive value of virtual bronchoscopy was 98.3 per cent. CONCLUSION: Multidetector computed tomography virtual bronchoscopy is a sensitive and specific diagnostic tool for identifying radiolucent vegetable foreign bodies in the tracheobronchial tree. It can also provide a useful pre-operative road map for rigid bronchoscopy. Patients suspected of having an airway foreign body or chronic unexplained respiratory symptoms should undergo multidetector computed tomography virtual bronchoscopy to rule out a vegetable foreign body in the tracheobronchial tree and avoid general anaesthesia and invasive rigid bronchoscopy.

Unusual Foreign Body Aspiration in Infants Below 6 months of Age.

Foreign body aspiration is one of the leading causes of accidental death in children. In older infants, tendency to explore their environment by putting objects in mouth leads to aspiration, but in younger infants below 6 months of age, as they are non ambulatory, it is the elder sibling who puts the foreign body into younger child's mouth. Diagnosis is often difficult because of no definite history in most cases. The purpose of this study is to diagnose and manage airway foreign bodies in younger infants with unusual presentation and no definite history. All patients referred to our Otorhinolaryngology Department with respiratory symptoms unresponsive to medical treatment and no definite history of foreign body aspiration were prospectively evaluated using virtual bronchoscopy. All patients underwent rigid bronchoscopy and foreign body removal with use of a maneuver in some cases.

CT Scan Study of Influence of Septal Angle Deviation on Lateral Nasal Wall in Patients of Chronic Rhinosinusitis.

The nasal septum is an important physiological and support structure of the nose. The nasal septal deviation causes alteration in air flow, mucociliary clearance and effects structures of the lateral nasal wall causing various nasal symptoms and other sinonasal disease. A systematic analysis was performed to measure the angle of septal deviation on CT scan PNS coronal section and to evaluate the influence of increasing septal angle deviation on the severity of lateral nasal wall abnormalities. A total of 61 patients with clinical evidence of chronic rhinosinusitis refractory to medical therapy for minimum three months were included in this study. After preliminary anterior & posterior rhinoscopic examination, all patients were evaluated with nasal endoscopy & CT scan PNS coronal view. There was statistically significant increase in hypertrophy of the middle turbinates and prominence of bulla ethmoidalis with OMC impingement on the side opposite to the direction of septal deviation. No apparent statistically significant difference between ipsilateral and contra lateral side OMC disease and anterior sinus mucosal disease in relation to direction of septal deviation in various groups was seen. We concluded that there is a strong association of increasing angles of septal deviation with corresponding patterns of disease in ostiomeatal complex. The result of the present study reemphasized the fact that, obstruction at ostiomeatal complex and anterior ethmoids secondary to septal deviation is the key factor for causation of chronic sinusitis.

Tympanoplasty in subtotal perforation with graft supported by a slice of cartilage: a study with near 100 % results.

The aim of this study is to evaluate the results of closure of subtotal perforation by tympanoplasty using underlay technique with the perichondrium/temporalis fascia graft supported by single cartilage slice anteriorly. Our hypothesis was that the cartilage support, single slice, offers an extremely reliable method for reconstruction of the tympanic membrane in cases of advanced middle ear pathology and Eustachian tube dysfunction. Retrospective and prospective study of patient undergoing tympanoplasty in subtotal perforation with graft supported by a slice of cartilage between March 2000 and October 2005. Intact perichondrium/temporalis fascia was placed as graft in subtotal perforation, supported by a slice of cartilage. Slice was placed anteriorly from hypotympanum to anterior part of attic. It does not obstruct Eustachian tube opening, as it is curved with concavity facing towards medial wall and lined by perichondrium without any raw area, which prevents adhesion formation. Hearing results were reported using four frequency (500, 1,000, 2,000 and 3,000) pure tone average air-bone gap. During the study period, perichondrium/temporalis fascia graft with support of cartilage slice was used for tympanic membrane reconstruction in 94 patients. Overall graft take rate was 98.94 %. In 95.74 % of patients of different types of tympanoplasty achieved hearing level of 30 dB or less. Complications included residual perforation in (1.06 %), infection or gaping of wound in 2 (2.13 %). Cartilage slice support offers an extremely reliable method for reconstruction of tympanic membrane in cases of high-risk perforation (subtotal perforation, retraction pocket, cholesteatoma, anterior perforation of tympanic membrane).

Unusual case of frontoethmoid mucopyocele with intracranial and orbital extension.

A case report of rare occurrence of frontoethmoid mucopyocele with Intracranial and orbital extension with complete recovery after endoscopic surgery.

Mucormycosis of nose and paranasal sinuses with orbital complication in young diabetic.

A case report of mucormycosis of nose and paranasal sinuses with sudden loss of vision in a young diabetic with good recovery after endoscopic debridement, systemic and topical amphotericin B and control of Diabetes mellitus.

Endoscopic removal of malignant melanoma of the nasal cavity.

Mucosal melanoma of the nasal cavity is a rare tumour. With the extended used of nasal endoscopes and advent of CT scan, early diagnosis of nasal melanoma and accurate assessment of its extent is possible. This allows endoscopic excision of tumour, avoiding unnecessary removal of healthy tissue. Here we present a case where endonasal endoscopic excision with postoperative radiotherapy achieved disease free survival till follow up (nearly 2 years).