Comparative Study of Endonasal Endoscopic Dacryocystorhinostomy with or without Preservation of Nasal Mucosal Flap.

OBJECTIVE: To analyse the result of endoscopic endonasal dacryocystrhinostomy with or without preservation of nasal mucosal flap. STUDY DESIGN: Randomised prospective cohort design. SETTING: Tertiary academic centre. SUBJECTS AND METHODS:  100 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups. Standard surgical procedure of endoscopic endonasal dacryocystorhinostomy was carried out except for the preservation of flap in group A and without preservation of flap in group B. Additional surgeries were done according to necessity. Postoperatively, patients were followed up on OPD-basis at the end of 1st week, 2nd week, 1st month, and 3rd month. Symptomatic improvement was assessed and patency checked by syringing by the ophthalmologist. RESULTS: Nil intraoperative complications (p < 0.05) and nil postoperative complication noted (p < 0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96% at 3rd month in case group A and 98%, 92% and 82% respectively at the end of 2nd week, 1st month and 3rd month in group B. Nasal endoscopy of all surgical failures showed restenosis in both groups and synechiae in 2 patients in group B. CONCLUSIONS: Preservation of nasal mucosal flap with modification around stoma can be used to cover the bared bone with avoidance of granulation tissue formation reducing the risk of closure of ostium with large rhinostomy and improve success of endoscopic endonasal DCR.

Fine Governance of Difficult Tracheostomy in Difficult Airway with Stridor and Respiratory Distress.

Difficult airway is a commonly encountered problem in the anesthesia practice, might needing otolaryngologist expert in creation of surgical airway. Supraglottic airways, surgical or needle cricothyrotomy, high frequency jet ventilation, cardiopulmonary bypass (Tunstall in Can J Anaesth 36:611-613, 1989) are initial rescue measures in such scenario. But in otolaryngology practice, patient presenting with stridor having difficult airway and difficult tracheostomy concurrently will definitely pose problems resulting in life-threatening consequences. We report cases in which difficult airway and difficult tracheostomy coexisted. (1) upper tracheal stenosis following strangulation and intubation (2) short neck with obesity (3) blunt trauma to neck with surgical emphysema (4) deep neck space infection (5) Paediatric tracheostomy in faucial diphtheria. Though difficult surgical tracheostomy in difficult airway is challenging, the anticipation of complications and planning can minimise the difficulty in the technique.

'Primary Thyroid Tuberculosis'-The Masquerader: A Case Report.

Tuberculosis of thyroid is a rare entity even among highly prevalent regions of tuberculosis. Primary tuberculosis of thyroid is even more rarer. The reason is attributed to the inherent relative immunity of the thyroid gland. Clinical manifestation is unpredictable accounting to both asymptomatic and variable benign and malignant mimicking symptoms. Clinical course may too vary depending on the thyroid dysfunction and complications. Aspiration cytology is diagnostic, though the yield is low. Histological diagnosis, depicting caseating granuloma added with acid fast staining confirms the diagnosis. High clinical suspicion is to be maintained to prevent total thyroidectomy.

Improving the Results of Endonasal Dacryocystorhinostomy with Mitomycin C Application: A Prospective Case-Control Study.

Many surgical advancement paved to surgical success in endonasal endoscopic dacryocystorhinostomy. Mitomycin C is a systemic chemotherapeutic agent derived from Streptomyces caespitosus that inhibits the synthesis of DNA, cellular RNA, and protein by inhibiting the synthesis of collagen by fibroblasts. The objective of the study was to evaluate the advantage of mitomycin C in primary endoscopic endonasal dacryocystorhinostomy without stenting. Randomised case control design. Tertiary academic centre in central India. 112 patients who presented with epiphora and diagnosed as chronic dacryocystitis after syringing by ophthalmologist, were selected and randomised into two groups with or without mitomycin C intraoperative application. 112 eyes underwent endoscopic-dacryocystorhinostomy. Additional surgeries were done according to necessity. Mitomycin C was applied in concentration of 0.4 mg/dl for 5 min. Patients were followed up on OPD-basis at the end of 1st week, 1st month, 3rd month and over phone call at end of 1 year. Symptomatic improvement assessed by verbal enquiry and clinically by syringing by ophthalmologist. 8 patients underwent septal surgery in case group and 4 in control group along with 1 concha bullosa correction in the case group (p < 0.05). Nil intraoperative complications (p < 0.05) and nil postoperative complication noted (p < 0.05). Functional and anatomical patency found to be 100% at the end of 1st week in both groups, 96.5% at 3rd month in case group and 96.4% and 92.9% at 1 month and 3 month respectively in control group. Nasal endoscopy of all surgical failures showed restenosis in both case group and control group except 1 patient with granulation in control group. Eventhough intraoperative mitomycin C application is effective in increasing the success rate of endonasal DCR surgery in standard nasolacrimal duct obstruction, and with no significant complications from its use, the study did not show added benefit in the primary endoscopic endoscopic dacryocystorhinostomy without stenting.

Innovative Use of Insulated Microear Ball Probe Cautery in Creation of Nasal Mucosal Flap in EnDCR.

To study the outcome and complications of endoscopic endonasal dacryocystrhinostomy without stenting. Randomised prospective observational design. Tertiary academic centre. Seventy patients, clinically diagnosed as chronic dacryocystitis with nasolacrimal duct obstruction on the basis of syringing, were enrolled. Endoscopy was done for nasal pathology especially mucosal disease, hypertrophied turbinate, DNS. Seventy-eight eyes were operated with endoscopic-dacryocystorhinostomy along with additional surgeries and periodically followed up on OPD-basis at the end of 1st week, 2nd week, 1st month and 3rd month and evaluated clinically and by syringing (Ophthalmologist) and endoscopy done, wherever required. Insulated microear ball probe cautery was used to create nasal mucosal flap in all cases. Eleven patients underwent septal surgery along with one concha bullosa and one agger nasi removal (p < 0.05). Nil intraoperative complications (p < 0.05) and single postoperative complication noted (p < 0.05). Functional and anatomical patency found to be 100% at the end of 1st week, 98.7% at the end of 2nd week, 93.6% at end of 1st month and 91% at end of 3rd month. Nasal endoscopy showed restenosis in 1 patient at end of 2nd week, 4 patients at end of 1st month, 1 patient at the end of 3rd month along with granulation in 1 patient at the end of 3rd month. Revision surgery was done on 2 patients. Endoscopic dacryocystorhinostomy is safe and successful procedure for chronic dacryocystitis, due to nasolacrimal duct obstruction with less complications without stenting. The associated intranasal pathology, which might be the cause, can be corrected and bilateral dacryocystorhinostomy can be performed in single sitting reducing patient's morbidity and hospital stay. Use of cautery with insulated ball probe for making nasal mucosal flaps gives an precise and excellent blood less field.