Unusual presentations of primary head and neck tuberculosis and review of literature.

BACKGROUND/PURPOSE: The diagnosis of TB in the head & neck region is challenging due to diverse presentations and due to changing clinical pictures. The aim of this article is to report three unusual primary cases of head and neck tuberculosis in immunocompetent patients presenting to our hospital with description of their clinical presentation, appropriate diagnostic methods used and treatment response of these patients. METHODS: Three clinical cases were of primary tuberculosis of the lacrimal system, the thyroid gland and of the temporal space were clinically worked up. The aspirate from the swellings were sent for Cytology and Gene Xpert tests. RESULTS: The Gene Xpert tests were positive in these unusual cases and aided the Cytology in promptly confirming the diagnosis which otherwise would be missed if staining for AFB is negative. ATT was started and responded well to the treatment. CONCLUSION: These cases demonstrate the importance of having a high index of suspicion for tuberculosis as a cause of head and neck swellings, especially in developing countries. It also illustrates the value of needle aspiration in such swellings and sending it for cytology and Gene Xpert for early diagnosis of tuberculosis.

Palisade Cartilage Tympanoplasty, an Alternative Surgical Approach for CSOM.

Introduction: The hearing outcome and graft take in patients of CSOM with sclerotic mastoids were studied using the novel technique of palisade cartilage tympanoplasty. Besides, it was compared with tympanoplasty type-1 above and over the cortical mastoidectomy in both groups. Materials and Methods: Out of 313 patients of CSOM, 125 had sclerotic mastoid and were included in the study. Palisade cartilage group patients were subjected to palisade cartilage tympanoplasty type-1. While as in the Temporalis fascia group patients, type-1 tympanoplasty was done using temporalis fascia as graft material. These procedures were performed in addition to cortical mastoidectomy done in all cases. Results: Statistically significant (P<0.001) mean postoperative hearing gain was achieved (> 20 dB) in both the groups with a reduction of AB gap to 13.3 & 11.79 dB, respectively. However, the post-surgery hearing outcomes achieved were similar in both groups (P=0.09). The overall graft take rate of 86% was seen in the Palisade cartilage group. The remaining 14% had graft take failure. The primary graft failure rate was 10% (5/50), and the secondary failure rate within six months of follow-up was 4% (2/50). The Temporalis fascia group graft take rate was higher (92%) than the Palisade cartilage group, with only 4 % (3/75) of cases having a primary graft failure rate. However, these findings (92% vs. 86%) were not statistically significant (P=0.2830). Conclusions: As the hearing outcomes and graft take rates were comparable in the two groups, the present study highlighted the use of palisade cartilage tympanoplasty in patients of CSOM with sclerotic mastoids as an alternative method to tympanoplasty.

Management of Fungal Rhinosinusitis: Experience From a Tertiary Care Centre in North India.

Introduction Fungal rhinosinusitis (FRS) has increased over the past few decades due to the rampant use of antibiotics, steroids, immunosuppressive drugs, increased incidence of HIV and uncontrolled diabetes. The current study reviews the types, clinical presentation, microbiology, histopathology and outcomes related to FRS in a tertiary care center in North India. Methods We retrospectively reviewed the clinical and follow-up records of patients diagnosed with FRS over three years. The data reviewed included clinical workup, ophthalmological profile, comorbidities, immunological status, radiological investigations, intraoperative and histopathological findings, treatment and follow-up records. In addition, we performed a descriptive analysis of the reviewed data. Results The study consisted of 30 FRS patients (16 male, 14 female). In that, 77% of cases were of allergic FRS, while fungal ball, chronic invasive, chronic granulomatous and acute invasive FRS represented 3%, 10%, 3% and 7% cases, respectively. The most common presentation in non-invasive forms was nasal obstruction, nasal discharge, hyposmia and polyposis, while it was facial pain and headache in the invasive varieties. After appropriate medical and surgical management through endoscopic sinus surgery, the recurrence rate in non-invasive and invasive fungal sinusitis was 16.6% and 20.8%, respectively. There was nil mortality at a minimum of one year of follow-up. Conclusion The non-invasive forms of FRS are common and have a relatively mild course. Early medical and surgical intervention and management of the underlying comorbidities are the key factors in managing invasive FRS. Close follow-up after surgery is also necessary for the timely detection and management of recurrences.

Stylalgia Revisited: Clinical Profile and Management.

INTRODUCTION: Eagle's syndrome is a constellation of signs secondary to an elongated styloid process or due to mineralization of the stylohyoid or stylomandibular ligament or the posterior belly of the digastric muscle. The syndrome includes symptoms ranging from stylalgia (i.e. pain in the tonsillar fossa, pharyngeal or hyoid region) to foreign-body sensation in the throat, cervicofacial pain, otalgia, or even increased salivation or giddiness. MATERIALS AND METHODS: We describe a clinical study of 12 patients with Eagle's syndrome, along with their clinical profile and the treatment offered. Patients were diagnosed based on history and clinical examination, as well as the Xylocaine 2% tonsillar fossa injection test. A visual analog scale (VAS) was used for comparison of pain before and up to 3 months after treatment. Radiology (orthopantomogram or three-dimensional computed tomography) was used for further exploration. Nine patients underwent tonsillo-styloidectomy surgery and three underwent medical treatment with pregabalin (75 mg/day). RESULTS: The majority of surgically-managed cases (88%) achieved a definitive benefit by tonsillo-styloidectomy surgery, whereas all medically managed cases achieved only short-term pain relief. CONCLUSIONS: Besides the common throat diseases, the symptoms associated with Eagle's syndrome may be similar to those due to cervicofacial neuralgias, dental, or temporo-mandibular joint diseases. Diagnosis is primarily based on symptomatology, physical examination and radiographic investigations, and should not be missed. Treatment by tonsillo-styloidectomy produces satisfactory results in stylalgia.

Gustatory function in chronic otitis media (mucosal type) before and after tympanoplasty.

Chronic inflammation in the middle ear may result in functional impairment of the chorda tympani nerve, which carries taste from the anterior two-thirds of the tongue. This may lead to impaired taste sensation. Timely intervention and adequate disease clearance may help the chorda tympani nerve to recover. Gustatory function of 107 patients who underwent Tympanoplasty for Chronic otitis media (mucosal type) was evaluated in a cohort of Indian patients. To compare the preoperative and postoperative gustatory function in these patients taste scores were documented preoperatively, and at 6 weeks and 3 months postoperatively, in an effort to document taste function improvement after disease clearance. The taste scores thus obtained were recorded and analyzed. A significant improvement in taste threshold postoperatively in comparison to the preoperative taste scores (p = 0.001) was found. It was observed that age of the patient and duration of illness have a significant impact on the recovery of taste function. Our study suggests that taste perception improves over a period of time after successful tympanoplasty in patients with chronic otitis media (mucosal type).

Nonseptic and septic lateral sinus thrombosis: a review.

Thrombosis of the lateral sinus can be classified into nonseptic lateral sinus thrombosis and septic lateral sinus thrombosis. Nonseptic lateral sinus thrombosis differs from septic lateral sinus thrombosis in that it is not associated with ear or sinus infection. Etiologies of these conditions are different and hence the management of these conditions is different. Nonseptic lateral sinus thrombosis requires medical line of management and anticoagulant therapy, where as septic lateral sinus thrombosis needs surgical treatment along with antibiotics therapy. An otologist should be familiar with the septic lateral sinus thrombosis existence and nonseptic variant lateral sinus thrombosis for early recognition and initiation of appropriate treatment.

Fungal infections of the ear in immunocompromised host: a review.

Otomycosis is a fungal infection of the external ear; middle ear and open mastoid cavity.1 Meyer first described the fungal infection of the external ear canal in 1884. External ear canal has an ideal warm humid environment for the proliferation of fungus.2 Although this disease is rarely life threatening, it can presents a challenging and frustrating situation for the otologist and patients due to long term treatment and high rate of recurrence.3 Otomycosis is seen more frequently in immunocompromised patients as compared to immunocompetent persons. Recurrence rate is high in immunocompromised patients and they need longer duration treatment and complications are more frequent in immunocompromised patients.In the recent years; opportunistic fungal infections are gaining greater importance in human medicine as a result of possibly huge number of immunocompromised patients.4 In immunocompromised patients, it is important that the treatment of otomycosis be vigorous, to minimize complications such as hearing loss, tympanic membrane perforations and invasive temporal bone infection.5 Fungal cultures are essential to confirm the diagnosis.Hematological investigations play a very important role in confirming the diagnosis and immunity status of the patients. In diabetic patients with otomycosis, along with antifungal therapy, blood sugar levels should be controlled with medical therapy to prevent complications.

Lateral sinus thrombosis in otology: a review.

Lateral sinus thrombosis (LST) is usually occurs as a complication of middle ear infection. The involvement of lateral sinus during the course of ear infection was a well known complication in preantibiotic days. The decrease in the incidence of LST is due to the introduction of broad-spectrum antibiotics, early diagnosis and surgical treatment. Now, it is a rare complication of otitis media and poses a serious threat that warrants immediate medical and surgical treatment. The classical clinical picture is often changed by previous antibiotic therapy. An awareness of this rare potentially devastating condition and its varied presentations is necessary for early diagnosis and treatment. LST can also occur after head injury.Anticoagulants are recommended in cases LST, where there is propagation of thrombus after surgery. The use of anticoagulants is not apart of standard care of patients with LST and was more common prior to the advent of antibiotics. Anticoagulants arrests the spread of thrombosis but may increase the risk of venous infarctions and should be used cautiously.

Complications in primary and secondary acquired cholesteatoma: a prospective comparative study of 62 ears.

OBJECTIVES: This study aimed to compare the clinicopathologic behavior of complications in primary and secondary acquired cholesteatoma and figure out the differences between them. DESIGN: This was a prospective cross-sectional study. METHODS: This was a study conducted in a tertiary referral medical college hospital comprising of 62 ears, of which 32 were in the primary acquired cholesteatoma group (PACG) and 30 were in the secondary acquired cholesteatoma group (SACG). We compared the 2 groups with respect to 7 prognostic variables, as follows: age distribution, sex, duration of ear discharge, pathology in the ear, predisposing disease focus in nose and throat, pattern of complications, and microbiology of ear. OBSERVATION AND RESULTS: The presence of cholesteatoma increased the risk for complications by more than 2 times in PACG, but the presence of granulation tissue did not show the same risk. More than half of the ears with complication contained some or the other predisposing disease focus in the nose or throat. The PACG was 3 times more prone to complications than the SACG in the presence of these foci. They showed a similar pattern of complications. Brain abscess and mastoid infections were the commonest complications. CONCLUSIONS: The PACG was more prone to complications than the SACG in the presence of cholesteatoma and focus in the nose and throat. Irrespective of the different pathologic origin of the 2 types, the patterns of complications remained the same with no major differences, indicating a common final pathway in the natural course of the disease.

Sino-orbital chloroma presenting as unilateral proptosis in a boy.

Granulocytic sarcoma or chloroma is an unusual localized tumor composed of cells of myeloid origin. Involvement of the orbit and the ethmoid sinuses and presenting as proptosis is rare. Diagnosis could be difficult and delayed when there are no other systemic manifestations, especially with normal peripheral blood and bone marrow picture. We present one such case with unilateral proptosis as the sole presenting sign that posed a diagnostic challenge to us. Orbital decompression by an otolaryngologist may have a role in managing such a case.

Combined tuning fork tests in hearing loss: explorative clinical study of the patterns.

OBJECTIVE: To combine the tuning fork tests of Rinne, Weber, and absolute bone conduction, explore their clinical patterns, and study their combined specificity, sensitivity, and validity in assessing the hearing status of an individual. DESIGN: A cross-sectional study of the tests of Rinne, Weber, and absolute bone conduction was done on 317 adult patients from the otolaryngology outpatient clinic selected at random. All possible patterns in the combination of three tests were explored, and their interpretations worked out. The findings were compared with those of pure-tone audiometry to check their sensitivity, specificity, and validity. RESULTS AND OBSERVATIONS: Fifty-eight patterns were obtained, which were classified into 10 types (5 tables) according to the type of hearing loss. The type of hearing loss was determined in all cases, and the better ear was identified in many cases. The overall sensitivity was 76.86%, the specificity was 85.48%, and the validity was 78.54%. CONCLUSIONS: The tuning fork tests of Rinne, Weber, and absolute bone conduction, when combined and interpreted, can be reliable initial diagnostic tools. They can be used to decide whether referral to a specialist or further audiometric testing is required. The patterns presented here depict the vast number of logical possibilities wherein the authenticity of these tests can be checked and the source of errors identified.

Sublabial approach to sinonasal juvenile ossifying fibroma.

Juvenile ossifying fibroma is a rare, unusual fibro-osseous benign tumor of the craniofacial region. It is a progressively growing tumor and has to be removed completely to prevent recurrence. A radical surgery is not advisable in a pediatric patient. Here we describe the sublabial approach for excision of this tumor that allows the complete removal of the tumor without compromising with the aesthetic looks of the patient.