Endoscopic Middle Ear Cleft Surgery (EMES): Our Philosophy, Concept and Application.

The functional aspect of preservation of every healthy anatomical structure, particularly the ossicles, non-diseased mastoid cortex and middle ear mucosa, and to achieve this by transacanal endoscopic dual hand approach to middle ear, aditus and mastoid antrum with minimal posterior atticotomy and proximal aditotomy. The prospective study has been conducted over a period of 12 years from 2009 to 2021 in the Jorhat Medical College, Assam Medical College and Niramoy Hospital, Jorhat, Assam. Follow up was for a minimum of 4 years. The current study was a prospective hospital based study, carried out from May 1st, 2009 to April 30th, 2021 involving 157 subjects from 18 to 65 years with mean age of 38 + 2.5. Graft uptake rate of 93.6%. Minimal atticotomy with proximal aditotomy offers a clear view of the antrum with angled scopes of 30 degree and 45 degree and if any disease is located it can be removed through the transcanal approach with angled instruments and aditus patency can be confirmed by visual inspection. Hence, decreasing the need of unnecessary bone drilling as done with cortical mastoidectomy to create a parallel view.The endoscopic ear surgeries done with "dual hand endo-holder" were uneventful and much more comfortable as compared to the single hand technique. Functional approach by minimizing bone drilling, reestablishment of ventilation pathways and preservation of ossicles with disease clearance give better postoperative results in long term follow-up.

A Study on Quality of Life in Post-tracheostomised Patients.

Introduction: Tracheostomy is a complex procedure which includes special care and attention with respect to the stoma and wound. But apart from surgical pitfalls certain qualities of life are also affected which needs due consideration for positive prognostic outcomes. Objective: To assess the quality of life in post tracheostomised patients. Materials and Methods: This study was a hospital based observational study conducted for a period of one year and included 97 patients. All patients underwent tracheostomy in ENT department and Central ICU. Nineteen post tracheostomy quality of life parameters were evaluated in 1st, 4th and 12th week interval. Results: 83.51% were male belonging to 6th and 7th decade. Most of them were tracheostomised on emergency basis (90.72%) for malignant causes (82.47%) and 95.88% of them had it for temporary period of time. Aryepiglottic folds were the most common site of malignant lesion. In the 1st week post tracheostomy, all parameters were affected except taste, smell and aesthetic state whereas in the following weeks it was employment, anxiety and voice production which were the affected quality of life. Conclusion: Most people had upper airway malignant growth and due to late presentation, they had to be put under emergency tracheostomy. Thus, leading to less time in pre-operative counselling that is a must in improving post-operative period quality of life. Awareness is required for timely screening of patients from 5th decade onwards so that adequate and timely treatment can be provided.

Cut Neck, Department of E.N.T in a Tertiary Centre: How We Approach.

Cut neck injury needs prolonged hospitalization, high cost care, reduced quality of life and above all death. Proper exploration is a must in preventing co-morbidities like shock, sepsis, laryngotracheal stenosis or fistula formation. Neck trauma can involve muscles, vessels, nerves, bone and hollow viscera. Though the repair of neck means planning and skill for repair of the structure, the tracheal repair needs special attention to avoid tracheal stenosis. 12 patients were included in the prospective study of 8 months. Management plan was undertaken which were thoroughly studied and discussed with respect to two tracheoplasty cases done in ENT OT, AMCH. Apart from haemodynamic stability all patients were assessed for injury to hollow viscera and planned accordingly as this centre is an important centre for airway reconstruction. Male female ratio was 11:1. Suicidal cut neck injury was the most common cause. Two cases were of tracheal stenosis post tracheostomy. One of the case had associated neurovascular injury but with patent airway. Rest of the cases were repaired under general and/or local anaesthesia. Primary aim should be to maintain airway and to look for the extent of injury to reduce morbidity. Expertise of surgeons' skill is developing every day hence the successfulness of repair will be tested by least of morbidity. From this institute which is skilled in airway reconstruction we could comment that airway reconstruction team should be an integral part of surgeons' team.

Proposal of New Key Step in Lateral Approach Thyroidectomy in Light of Comparison of Surgical Outcomes of Medial versus Lateral Approach Thyroidectomy: A Randomised Controlled Study.

OBJECTIVE: Thyroid surgery has travelled a long path, from a surgery which once was considered deemed to fail and even led to death, to the current time when newer techniques are being tested to make the incision smaller and smaller. The aim of our study is to give a precise detailed stepwise description of medial and lateral surgical approach with the anatomical basis and to compare their feasibility and safety. METHODS: 104 cases presenting with thyroid swelling in the Department of Otorhinolaryngology, Assam Medical College Dibrugarh from January 1, 2019, to December 31, 2019, were selected and randomisation was done based on day of admission from OPD. Basic demographic data, preoperative diagnosis, operative time, blood loss, need for transection of strap muscles, and complications were recorded. RESULT: The distribution of thyroid cases according to age ranged from 17 to 81 years. The prevalence of thyroid disorders was the highest (37.5%) in the age group of 31-40 yrs. Of a total of 104 thyroid cases, 49 were colloid goitre, 24 were multinodular goitre, 9 were follicular neoplasm category 4, 4 were papillary thyroid carcinoma, 2 were follicular neoplasm category 3, and 3 were follicular neoplasm category 5. CONCLUSION: Out of the two approaches, lateral approach thyroidectomy showed better results with fewer complications. A single structure (superior belly of omohyoid) can be used as a guide to preserving all vital structures related to the thyroid gland.

Negative regulation of natural killer cell in tumor tissue and peripheral blood of oral squamous cell carcinoma.

Natural killer (NK) cells are the key lymphocytes in solid tumors. Its activity is regulated by both germline encoded receptors and cytokine microenvironment. We conducted a case-control study to investigate the activation status of NK cell in oral squamous cell carcinoma (OSCC). NK cell activation was assessed in context of NK cell cytotoxicity and transcript expression of NK cell receptors (NKp46 and KIRs) and NK cell associated cytokines (IL-1ß, IL-2, IL-10, IL-12ß, IL-15, IL-18, IL-21, IFN-γ, TNF-α and TGF-ß). The results revealed possible mechanisms involved in reduced NK cell activation in peripheral circulation: quantitative deficiency of NK cell number and lowered cytotoxicity together with qualitative NK impairments caused by--(1) decreased expression of NK activating receptor NKp46, (2) increased expression of NK suppressive cytokines--IL-10 and TGF-ß and (3) induction of FOXP3(+)CTLA4(+) suppressor cells. On the other hand, in the tumor tissue, escape of NK immune surveillance appeared to be modulated by upregulation of TGF-ß and IL-10 together with downregulation of NK cell activating cytokines (IL-2, IL-12ß, IL-15, IL-18, IL-21 and IFN-γ) and NK receptors (NKp46 and KIRs). In addition, our study supported the earlier contention that TNF-α and IL-1ß expression levels may be used as markers of malignant transformation in oral leukoplakia. In conclusion, the study provided an insight into the negative regulation of NK cell in tumor tissue and peripheral blood of OSCC patients, which can be exploited to boost the current NK cell and cytokine based immunotherapy for the treatment of oral cancer.

Association of killer cell immunoglobulin-like receptor gene 2DL1 and its HLA-C2 ligand with family history of cancer in oral squamous cell carcinoma.

Killer cell immunoglobulin-like receptors (KIR) are involved in regulating natural killer cell activation through recognition of their human leukocyte antigen (HLA) class I ligands. We conducted a case-control study with 169 oral squamous cell carcinoma (OSCC) patients and 177 healthy participants to study the genomic diversity of KIR and HLA loci and KIR gene expression in context of family history of cancer (FHC) in OSCC. Polymerase chain reaction (PCR) sequence-specific priming approach was used to type 16 KIR genes in individuals. SSP-real-time PCR was used for HLA class I ligand genotyping and real-time quantitative reverse transcriptase PCR was used to determine the expression of KIR gene. KIR2DL1(+)-HLA-C2(+) genotype was higher and positively associated with OSCC. Notably, all KIR2DL1(+)-HLA-C2(+) genotypes occurred exclusively in patients with FHC, showing a strong positive association of KIR2DL1(+)-HLA-C2(+) genotype with FHC. In addition, all younger age group patients (<55 years) with FHC were positive for KIR2DL1(+)-HLA-C2(+) genotype suggesting association of the genotype with early onset of disease. RNA transcript abundance of inhibitory KIR2DL1 in FHC patients, particularly of lower age groups (<45 and 45-54 years), supports the contention. Further, KIR2DL3(+)-HLA-C(+) genotype was negatively associated with OSCC. Our findings suggest KIR2DL1(+)-HLA-C2(+) genotype as heritable risk factor in OSCC predisposing to OSCC at younger age. Interestingly, KIR2DL3(+)-HLA-C(+) genotype was seen to be protective in OSCC. This study may be useful towards cancer surveillance and early detection of oral cancer in patients with FHC.