Missed Maxillary Sinus Ostium Syndrome and its Management.

The inflammatory process involving the maxillary sinus is often exacerbated by a functional obstruction due to laterally displaced uncinate process which obstructs the infundibulum and the natural ostium. Physiologically the drainage pathway may be adequate but during periods of inflammation resulting in nasal oedema, the ostium/infundibulum interface is inadequate, preventing adequate ventilation and drainage of the maxillary sinus. Incomplete removal of the uncinate process without including the natural ostium may result in failure and recurrence. This method of Middle meatal antrostomy that does not include the natural ostium of the maxillary sinus, leads to the missed ostium sequence and continued sinus disease. Here a case of missed maxillary sinus syndrome and its management is presented. A 28-year-old man with complaints of post nasal drip and Left facial pain for 4 months. 3 years prior the patient underwent functional endoscopic sinus surgery (FESS), following surgery patient had recurrent episode of sinusitis. Diagnostic nasal endoscopy revealed presence of mucopurulent discharge in left middle meatus, CT scan Paranasal sinus was suggestive of opacity in left maxillary sinuses and in left middle meatus with wide maxillary antrostomy. Revision FESS surgery was performed, where two ostia were present was converted into single wide middle meatal antrostomy using a back bitting forceps and microdebrider to avoid maxillary sinus mucus recirculation phenomenon. On follow up 1 year later, patient had no symptoms of repeated sinusitis. Missed maxillary sinus ostium syndrome has to be recognized and timely addressed by joining the natural and surgically created ostia as single wide middle meatal antrostomy window. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-04385-x.

Dr Ahila's Endoscopic Ear Surgery Chisel and Mallet.

Endoscopic Ear surgery is evolving day by day and there is need for constant improvement in terms of instrumentation with efficient, quicker, with clear bloodless surgical field and good postoperative outcome and results. The application of Dr Ahila's Endoscopic Ear Surgery Chisel and Mallet are presented. This innovation will provide limited and adequate bone removal in a faster way than drill in endoscopic mastoidectomy and stapedotomy surgeries. Surgical instruments represent a major financial asset to the health care facilities. The use of Dr Ahila's Endoscopic Ear Surgery straight 1 mm or 2 mm Chisel and Mallet is presented. Dr Ahila's Endoscopic Ear Surgery Chisel and Mallet, this innovation will provide faster bone removal than drill or curette without bone dust formation, fogging, irrigation in Endoscopic mastoidectomy and stapedotomy. This instrument is essential to avoid costly replacement, surgeon satisfaction, reduce cost and delays in the operating room and in safe and trained hands enhance patient safety. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03629-0.

How I do it:- Endoscopic Reverse Denker's Approach.

Introduction: Endoscopic Denker's approach involves complete exposure of the anterior, inferior and lateral walls of the maxillary sinus providing access to both infratemporal and pterygopalatine fossa. Open approaches to maxillary sinus may lead to a high chance of cranial nerve dysfunction, trismus and wound healing issues. Surgical methods differ based on pathology, exposure, visualization and extent of clearance of the pathology. Method: The technique and surgical steps of Endoscopic Reverse Denker's approach are presented. Results: Critical steps include inferior turbinectomy, uncinectomy, followed by mega middle meatal antrostomy. For exposure drilling is started from the anterior margin of middle meatal antrostomy up to the pyriform aperture anteriorly till the anterior wall of the maxilla is visualized and the nasolacrimal duct can be visualized and transected. This method preserves the pyriform aperture and anterior wall similar to inside-out mastoidectomy tracing the pathology with less bone removal, faster and less morbidity. Conclusion: Endoscopic Reverse Denker's is a 2-handed or 4-handed endoscopic technique for proper exposure, visualization and clearance of the maxillary pathology of the anterolateral and anterior wall. Olfaction is preserved and crusting is less as there is less bone removal with no atrophic nasal changes. It preserves the pyriform aperture thereby preventing alar collapse.

Local Anaesthetic Nerve Blocks in Endoscopic Nasal and Sinus Surgery.

In the present era, Hemostasis in Endoscopic nasal and sinus surgeries are challenging even with appropriate use of instrumentation and surgical skills. This can be addressed with appropriate local anaesthesia and nerve blocks. Expertise in performing surgery under local anaesthesia can be acquired over years of surgical training. The objective  of this article is to define complete nerve blocks which can be used in endoscopic nasal surgeries.

Supra Maxillary Cell (SMC): An Anatomical variant of Ethmoid Sinus.

65 year old female presented with complaints of Right sided nasal obstruction of 1 year duration, intermittent nasal discharge for the past 6 months, without much significant improvement in medical management. Computerized tomography of paranasal sinuses revealed presence of supra maxillary cell (SMC) which was infected, along with sphenoid sinus (Heterodense lesion-suggestive of probable Fungal sinusitis). Patient underwent Functional Endoscopic Sinus Surgery with Septoplasty under local anesthesia. Among the paranasal sinuses, the ethmoid sinus has the largest number of anatomical variations. Important structures near the ethmoid sinus are usually in danger during the endoscopic sinus surgery due to its extreme anatomical variations. Posterior ethmoid cells can also expand towards and into the Maxillary sinus, which drains into the superior nasal meatus, referred to as the Ethmo maxillary sinus. This clinical report highlights about similar  anatomical variation in the paranasal sinuses. We report a case of similar type of cell, only difference is it drains into middle meatus, situated mostly over the maxillary sinus alone along its entire width and the senior author has coined a term for it as supra maxillary cell (SMC).

Will Vestibular Migraine Pathology Lead to Ischemic Changes in Brain Tissue in Later Age?

Migraine has been considered to be an episodic, multifactorial, neurovascular disorder without long-term consequences to the brain, although numerous studies have shown a possible association between vestibular migraine and ischemic changes in the brain. 3 Case based scenarios of previously diagnosed patients with vestibular migraine on treatment, associated  with clinical changes of ischemia, infarction and white matter lesions are reviewed and integrated with the results based on MRI study. There is a need for proper diagnosis to address the complaints and manage symptoms during acute attacks of vestibular migraine and prophylaxis. In addition these cases highlight the ongoing need for proper systemic evaluation, therapeutic management, regular follow up, compliance of medication and life style modification. Pathological sequelae of long standing vestibular migraine are ischemic changes of the brain tissue, which requires further evaluation and extensive study of these symptom complexes.

"Fizz Sign" in Acute Sinusitis-A CT Scan Finding.

To study the Computerized Tomography (CT) Paranasal Sinus findings in patients with acute bacterial sinusitis and the clinical symptom associated with it. 120 patients were examined over 2 years with coronal CT images of paranasal sinus with clinical symptoms of acute sinusitis of 2 weeks duration from the onset. Patients with symptoms of more than 2 weeks and patients with chronic sinusitis, immunocompromised status were excluded. Air mixed with fluid is seen like a Fizz of cola drink within the maxillary, frontal or sphenoid sinus, mucosal thickening of more than 5 mm, fluid level and presence of opacifications were used as evidence of acute sinusitis. 28 patients (23.3%) had Fizz sign (Air mixed with fluid seen as bubbles) coronal CT images of the paranasal sinus. The study demonstrated great variation in the CT paranasal findings amongst patients with suspected acute sinusitis. More than one sinus subsite was affected amongst patients in whom acute sinusitis was confirmed by CT Paranasal sinus imaging. We hereby highlight a new sign of air mixed with fluid which the senior author had named as Fizz Sign because of its resemblance to the fizz of dark cola drink.

Transoral Laryngeal Surgery in Low-grade Myofibroblastic Sarcoma of Larynx: A Plausible Treatment Option.

The laryngeal tumor type, location and disease extent are essential determinants in deciding the type of surgery and the potential voice and swallowing outcomes. The surgical options available are conservative laryngeal surgeries like transoral laser microsurgery (TLM) or open conservative laryngeal surgery and Total laryngectomy. We report an unusual case of low-grade Myofibroblastic sarcoma of vocal cord which was managed by TLM.

Analysis of chemical compositions and larvicidal activity of nut extracts from Areca catechu Linn against Aedes (Diptera: Culicidae).

BACKGROUND: There is a growing need to use green alternative larvicidal control for Aedes larvae compared to chemical insecticides. Substantial reliance on chemical insecticides caused insecticide resistance in mosquito populations. Thus, research for alternate chemical compounds from natural products is necessary to control Aedes larvae. This study explores the analysis of chemical compositions from Areca catechu nut as a potential larvicide for Aedes (Diptera: Culicidae). METHODS: The Areca catechu nut collected from Ipoh, Perak, Malaysia was grounded into powder and used for Soxhlet extraction. The chemical analysis of the extracts and their structures were identified using the GCMS-QP2010 Ultra (Shimadzu) system. National Institute of Standards and Technology (NIST) Chemistry WebBook, Standard Reference Database 69 (https://webbook.nist.gov/chemistry/) and PubChem (https://pubchem.ncbi.nlm.nih.gov/), the two databases used to retrieve the synonyms, molecular formula, molecular weight, and 2-dimensional (2D) structure of chemical compounds. Next, following WHO procedures for larval bioassays, the extracts were used to asses larvicidal activity against early 4th instar larvae of Aedes aegypti and Aedes albopictus. RESULTS: The larvicidal activities were observed against early 4th stage larvae with different concentrations in the range from 200 mg/L to 1600 mg/L. The LC50 and LC95 of Aedes aegypti were 621 mg/L and 2264 mg/L respectively; whereas the LC50 and LC95 of Aedes albopictus were 636 mg/L and 2268 mg/L respectively. Mortality was not observed in the non-target organism test. The analysis using gas chromatography and mass spectrometer recovered several chemical compounds such as Arecaidine, Dodecanoic acid, Methyl tetradecanoate, Tetradecanoic acid , and n-Hexadecanoic acid bioactive components. These chemical constituents were used as additive formulations in pesticides, pest control, insect repellent, and insecticidal agents. CONCLUSIONS: Our study showed significant outcomes from the extract of Areca catechu nut and it deserves further investigation in relation to chemical components and larvicidal actions between different species of Aedes mosquitoes. Even though all these findings are fundamental, it may have some interesting potentials to be developed as natural bio-larvicidal products.

Cribriform CSF Leak: Endoscopic Surgical Repair Using Free Septal Mucosal Graft Without Postoperative Nasal Packs.

Cribriform plate is the commonest site of Cerebrospinal fluid (CSF) leak, its fragility and juxtaposition of arachnoid's investment to the bone, where the olfactory nerve pierces the skull, is a vulnerable site for CSF leak. Endoscopic transnasal approach has been the main stay for CSF leak repair over the past 2 decades. The technique and surgical steps of Endoscopic Surgical Repair of Cribriform CSF Leak using Free Septal Mucosal Graft without Postoperative Nasal packs are presented. Transnasal endoscopic CSF leak repair under General anesthesia with free mucosal graft, the critical steps include visualize the site of leak, lateralisation of middle turbinate, defect site cauterised with bipolar cautery. Free mucosal from contralateral side of the septum was placed as overlay technique. Graft stabilised with surgicel after ensuring adequate contact between the graft and the defect site. If the defect site is large then fat harvested from thigh is used as bath plug the defect, then free mucosal graft is kept supported by surgicel. Finally the middle turbinate was medialized and sutured with 3 0' Vicryl with nasal septum to support the graft and also to stabilize the middle turbinate as a quilting stich. No fibrin glue was used in our case series. No nasal packing was done. Patients discharged on 2nd or 3rd postoperative day. This technique provides consistent good results reduced operating time of 40 min, no post-operative morbidity, early mobilisation, with 100% success rate and with added advantage of no nasal packing, patient can easily breathing through the nose postoperatively & no recurrence on long follow up.

Exploring the growth of COVID-19 cases using exponential modelling across 42 countries and predicting signs of early containment using machine learning.

The coronavirus disease 2019 (COVID-19) pandemic spread by the single-stranded RNA severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) belongs to the seventh generation of the coronavirus family. Following an unusual replication mechanism, its extreme ease of transmissivity has put many countries under lockdown. With the uncertainty of developing a cure/vaccine for the infection in the near future, the onus currently lies on healthcare infrastructure, policies, government activities, and behaviour of the people to contain the virus. This research uses exponential growth modelling studies to understand the spreading patterns of SARS-CoV-2 and identifies countries that showed early signs of containment until March 26, 2020. Predictive supervised machine learning models are built using infrastructure, environment, policies, and infection-related independent variables to predict early containment. COVID-19 infection data across 42 countries are used. Logistic regression results show a positive significant relationship between healthcare infrastructure and lockdown policies, and signs of early containment. Machine learning models based on logistic regression, decision tree, random forest, and support vector machines are developed and show accuracies between 76.2% and 92.9% to predict early signs of infection containment. Other policies and the decisions taken by countries to contain the infection are also discussed.

The potential use of Azolla pinnata as an alternative bio-insecticide.

Four different tests showed the effectiveness of Azolla pinnata plant extracts against Aedes aegypti and Aedes albopictus mosquitoes. In the adulticidal test, there was a significant increase in mortality as test concentration increases and A. pinnata extracts showed LC50 and LC95 values of 2572.45 and 6100.74 ppm, respectively, against Ae. aegypti and LC50 and LC95 values of 2329.34 and 5315.86 ppm, respectively, against Ae. albopictus. The ovicidal test showed 100% eggs mortality for both species tested for all the concentrations tested at 1500 ppm, 1000 ppm, 500 ppm, 250 ppm and 125 ppm. Both tested samples of Ae. aegypti and Ae. albopictus did not lay any eggs in the plastic cups filled with the A. pinnata extract but instead opted to lay eggs in the plastic cups filled with water during the oviposition deterrence test. Similarly, the non-choice test of Ae. aegypti mosquitoes laid eggs on the sucrose solution meant for the nutrient source of the mosquitoes instead of in the plastic cup that was designed to facilitate oviposition filled with the extract. This clearly indicates the presence of bioactive compounds which are responsible in adulticidal and ovicidal activity in Aedes mosquitoes and at the same time inducing repellence towards the mosquitoes. The LC-MS results showed mainly three important chemical compounds from A. pinnata extracts such as 1-(O-alpha-D-glucopyranosyl)-(1,3R,25R)-hexacosanetriol, Pyridate and Nicotinamide N-oxide. All these chemicals have been used for various applications such as both emulsion and non-emulsion type of cosmetics, against mosquito vector such as Culex pipens and Anopheles spp. Finally, the overall view of these chemical components from A. pinnata extracts has shown the potential for developing natural product against dengue vectors.

Systematic literature review on novel corona virus SARS-CoV-2: a threat to human era.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the seventh-generation coronavirus family causing viral pandemic coronavirus disease (COVID-19) across globe affecting millions of people. The objectives of this study are to (1) identify the major research themes in COVID-19 literature, (2) determine the origin, symptoms and modes of transmission of COVID, (3) recommend the intervention and mitigation strategies adopted by the Governments globally against the spread of COVID-19 and the traumatization among the public? and (4) study the possible drugs/treatment plans against COVID-19. A systematic literature review and comprehensive analysis of 38 research articles on COVID-19 are conducted. An integrated Research focus parallel-ship network and keyword co-occurrence analysis are carried out to visualize the three research concepts in COVID-19 literature. Some of our observations include: (1) as SARS-CoV-2's RNA matches ~ 96% to SARS-CoV, it is assumed to be transmitted from the bats. (2) The common symptoms are high fever, dry cough, fatigue, sputum production, shortness of breath, diarrhoea etc. (3) A lockdown across 180 affected counties for more than a month with social-distancing and the precautions taken in SARS and MERS are recommended by the Governments. (4) Researchers' claim that nutrition and immunity enhancers and treatment plans such as arbidol, lopinavir/ritonavir, convalescent plasma and mesenchymal stem cells and drugs including remdesivir, hydroxychloroquine, azithromycin and favipiravir are effective against COVID-19. This complied report serves as guide to help the administrators, researchers and the medical officers to adopt recommended intervention strategies and the optimal treatment/drug against COVID-19.

Newer Surgical Options for Nasal Allergy.

Allergic rhinitis is a common disorder that affects several patients annually and the hallmark symptoms are nasal obstruction, rhinorrhea and sneezing which significantly impacts the quality of life. Many surgical options exist for the treatment of allergic rhinitis which is directed primarily addressing the nasal obstructive component. The purpose of this review article  is to highlight newer surgical options in the management of patients with nasal allergy. Surgical modalities such as endoscopic resection of the posterior nasal nerve and senior author's own mini inferior turbinoplasty tunnelling technique for patients with nasal allergy is described here. Most of the literature has focused on medical management for patients with allergic rhinitis. Endoscopic Posterior Nasal neurectomy combined with mini inferior turbinoplasty has good overall significant improvement in nasal allergy symptom scores by 60-80%. Although no single modality has evolved as the gold standard for the surgical management of allergic rhinitis. The main stay of surgical intervention targets the inferior turbinate and posterior nasal nerve which is the parasympathetic supply to the nose causing rhinorrhea. This combined technique provides consistent, robust results with long-term relief of nasal symptoms due to allergic and vasomotor rhinitis without additional risk of complication.

Application of Platelet Rich Fibrin Matrix to Repair Traumatic Tympanic Membrane Perforations: A Pilot Study.

Trauma in the form of instrumentation, slap, blast, accident, and sporting injury can result in tympanic membrane (TM) perforations which spontaneously recover in 53-94%. The closure rates of TM perforation due to above causes do not vary greatly; however, some otolaryngologists prefer to perform immediate microsurgical procedures to accelerate the recovery process. Our aim is to study the efficacy of Trichloroacetic acid (TCA) Chemical Cauterization (50%) and Platelet rich fibrin (PRF) Plug Myringoplasty technique in healing traumatic tympanic membrane perforations. To evaluate the preoperative and postoperative hearing outcome from the procedure and compare them. Study design is prospective study. A pilot study was carried out amongst selected 25 patients with central perforations in the Department of ENT, for duration of 2 years from July 13 to July 15. All 25 patients underwent PTA assessment & TCA (50%) and Autologous PRF Plug Myringoplasty technique done and follow up to 6 months postoperatively. The success rate traumatic tympanic membrane closure was found to be 92%. Pre- and post-operative hearing assessments of each patient were done & showed statistically significant air-bone gap closure with success rate of 88% (p < 0.05). From this study, the closure rate in traumatic tympanic membrane perforation by TCA (50%) and PRF Plug Myringoplasty technique was 92% with statistically significant hearing improvement (88%). This technique can be recommended as a time and cost effective office based procedure for treatment of traumatic tympanic membrane perforations.

Infra-auricular Sinus: A Very Rare Case Presentation.

A 22-year-old male patient presented with right infra-auricular sinus since birth with preauricular swelling and discharge on and off since age of 3 years. He had no history of previous surgery. Patient noted frequent swelling and foul smelling discharge inferior to right tragus through a small puncta every 3-6 monthly, resulting in abscess formation and scaring around 1-1.5 cms below and anterior to puncta site. The infra tragal sinus tract and the cyst were completely removed surgically by infra-auricular approach. The histopathology report was suggestive of an infra-auricular preauricular sinus. No recurrence was noted on follow up to 2 years. We report this case for its rarity since less than 5 cases have been reported in literature.

[Endoscopic posterior nasal neurectomy].

BACKGROUND: Surgical techniques for resistant chronic rhinitis (rhinorrhoea) vary, ranging from vidian neurectomy to post-nasal neurectomy. The techniques vary mainly on the basis of instrumentation, and the avoidance of post-operative epistaxis, transient hypoesthesia of the soft palate and dryness of the eye. Endoscopic visualisation, and cauterisation or resection of posterior nasal nerve branches, can prevent such complications. METHOD: The technique and surgical steps of endoscopic posterior nasal neurectomy are presented. RESULTS: The critical steps include: bilateral sphenopalatine nerve blocks, transnasally or transorally via the greater palatine foramen; vertical incisions made behind the posterior fontanelle; and elevation of the mucoperiosteal flap. The sphenopalatine foramen and artery is identified. The posterior nasal nerve is located 4-5 mm inferior to the sphenopalatine artery, and is resected or cauterised. The flaps are repositioned back into place. No post-operative nasal packing is required. The same procedure is performed on the opposite side for effective results. CONCLUSION: This technique provides consistent, robust results, with long-term relief of allergic and vasomotor rhinitis related nasal symptoms, without risk of complication.

Prevalence of Goitre in Raichur District (Karnataka): A Descriptive Study.

This prevalence study was exclusively for the goitre detection in individuals who has no prior awareness of thyroid disorder and also those patients giving history of signs and symptoms of such conditions. Subjects underwent investigations for (T3, T4, TSH and FNAC) to analyze status and type of Goitre. Of the first 30 cases, only 8 cases were investigated and later on personal  interest  for confirmation of goitre disorder prevalence additional 70 cases were assessed of which 51 cases were investigated. On basis of investigation and epidemiology, we concluded that probably soil and water sources contain less iodine. Sample shown are comparatively less, but in our area number of goitre  cases are more and it needs further extensive survey.

The Dimethylnitrosamine Induced Liver Fibrosis Model in the Rat.

Four to six week old, male Wistar rats were used to produce animal models of liver fibrosis. The process requires four weeks of administration of 10 mg/kg dimethylnitrosamine (DMN), given intraperitoneally for three consecutive days per week. Intraperitoneal injections were performed in the fume hood as DMN is a known hepatoxin and carcinogen. The model has several advantages. Firstly, liver changes can be studied sequentially or at particular stages of interest. Secondly, the stage of liver disease can be monitored by measurement of serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) enzymes. Thirdly, the severity of liver damage at different stages can be confirmed by sacrifice of animals at designated time points, followed by histological examination of Masson's Trichome stained liver tissues. After four weeks of DMN dosing, the typical fibrosis score is 5 to 6 on the Ishak scale. The model can be reproduced consistently and has been widely used to assess the efficacy of potential anti-fibrotic agents.

Apoptogenic activity of ethyl acetate extract of leaves of Memecylon edule on human gastric carcinoma cells via mitochondrial dependent pathway.

OBJECTIVE: To evaluate the anti-proliferative and apoptogenic activity of ethyl acetate extract from the leaves of Memecylon edule (EtAc-LME) in MKN-74, NUGC gastric cancer cells and non cancerous gastric mucous cells (GES-1), and to explore the mechanism of EtAc-LME induced apoptosis. METHODS: The mechanism of EtAc-LME induced apoptosis was explored by analysing the activation of pro-caspases, PARP cleavage, expression of cytochrome-c (Cyt-c) was determined by western blotting, mRNA expression of Bcl-2, Bax by RT-PCR, loss of mitochondrial potential using DiOC6 dye, annexin binding assay and its influence on cell cycle arrest by flow cytometry. RESULTS: The results indicated that EtAc-LME inhibited the gastric cancer cell growth in dose-dependent manner and cytotoxicity was more towards the gastric cancer cells (NUGC and MKN-74) compared to normal gastric cells (GES-1), suggesting more specific cytotoxicity to the malignant cells. Over expression of Cyt-c and subsequent activation of caspases-3 and down regulation of Bcl-2 and loss in mitochondrial potential in EtAc-LME treated MKN-74 and NUGC cells suggested that EtAc-LME induced apoptosis by mitochondrial dependent pathway. CONCLUSIONS: The present findings suggest that ethyl acetate extract of Memecylon edule induces apoptosis selectively in gastric cancer cells emphasizing the importance of this traditional medicine for its potential in the treatment of gastric cancer.