An interesting case record of a patient with glomus tympanicum

Clinical details:

54 years old female patient came with complaints of:

1. Pulsating noise in her right ear - 5 years
2. Hard of hearing right ear - 5 years

Past history:

No history of trauma to the ear
No history of bleeding from the ear
Pt is not a known diabetic / hypertensive

Imaging:

These CT scan images show contrast enhancing soft tissrue lesion occupying the whole of the middle ear cavity. The same mass could be seen extending on to fill the attic, aditus and mastoid cavity. Tegmen plate appears to be eroded.


Provisional diagnosis:


Glomus tympanicum

Partial maxillectomy picture slideshow

This is a slide show showing partial maxillectomy procedure.

Importance of debrider in endoscopic management of fungal sinusitis

In this blog I wish to stress the importance of debrider in the endoscopic management of fungal sinusitis. Since debrider cuts only on one side the other normal areas of nasal cavity like the nasal septum are not traumatized. The other advantages include:

1. The debrider blade since it is attached to a suction apparatus sucks and holds the nasal polypi to the cutting surface.
2. The rotating blade cuts the tissue which is held by suction
3. The irrigation portal is connected to saline. This dripping saline prevents clogging of the debrider blade with debris.


This video clipping below amply demonstrates the role of debrider:


Thanks to drtbaluent videos.

An interesting otoscopic finding

Introduction:

Erosion of outer attic wall has always been associated with cholesteatoma. Theoretically eustachean tube is found to be not functioning in these patients predisposing to the formation of attic retraction pocket.

Case report:

This case report would make us rethink the pathophysiology of outer attic wall (scutum) erosion.

40 years old female patient presented with hard of hearing right ear of 3 years duration.
She did not give any history of ear discharge / foul smell emitting from the affected ear. Even on prolonged questioning she denied history of ear discharge.
No history of previous ear surgery for any other ailment.

Video otoscopy showed:

1. Thinned out ear drum
2. Ear drum bulging on valsalva
3. The ear drum could be seen moving as the patient breaths indicating a patulous eustachean tube
4. Erosion of outer attic wall (scutum) without the presence of cholesteatoma

This video clipping would ensure that we start rethinking about the pathophysiology of scutum erosion.

Granulomatous lesions of nose and sinuses a presentation

Granuloma nose

View more presentations from Balasubramanian Thiagarajan

Nasal cholesteatoma

Nasal cholesteatoma is actually a misnomer. This is another name for Rhinitis caseosa. The term “Rhinitis caseosa” was coined by Duplay in 1868. Eggston and Wolff after a detailed study in 1947 concluded that this condition could occur secondarily following pent up secretions in the sinus cavities. Their studies revealed that this condition is more common in patients with extensive bilateral ethmoidal polyposis. The presence of polypi in the nasal cavities caused obstruction to the normal drainage mechanism of the paranasal sinuses. This led to accumulation of secretions. Whitish to yellow cheesy material were found within the nasal cavities of these patients behind the nasal polypi. This cheesy material also caused expansion of sinus cavities, erosion of bone and extension into orbit.

Could this actually be fungal infection? Now the consensus seems to be pointing towards this direction.

Case details:

30 years old male patient came with complaints of:

1. Foul smelling discharge left nasal cavity - 2 years

2. Head ache on and off - 2 years

3. Watering from left eye - 1 year

Patient gave no history of nasal bleed.
He was not a diabetic

Imaging:

CT scan plain of paranasal sinuses showed:

This coronal CT of nose and paranasal sinuses show opacification of
left maxillary sinus with expansion of its walls. The lesion appears to be
heterodense ? fungal sinusitis. Air shadow could be seen within the
maxillary sinus cavity on the affected side ? entrapment ? abscess.
Patient was taken up for surgery. Endoscopic sinus surgery was performed on this patient.
After middle meatal antrostomy the maxillary sinus L was found to be filled with cheesy material
which was removed. The walls of the maxillary sinus was found to be intact.
Probable diagnosis:
Fungal sinusitis
Nasal cholesteatoma

Video clipping of the surgical procedure:

Thymic Stromal Lymphopoietin in nasal polyposis

Introduction:

Nasal polyposis is considered to be the end stage of mucosal inflammation. Nasal polyposis doesnt contribute siginficantly to the mortality, but causes a significant reduction in the quality of life of the patient. The development of nasal polyposis is associated with:

1. Chronic inflammation
2. Allergic responses
3. Autonomic nervous system dysfunction
4. Genetic predisposition

This article discusses the role played by Thymic stromal lymphopoietin in the pathogenesis of nasal polyposis.

Thymic stromal lymphopoietin is actually a protein belonging to the cytokine family. This protein activates the antigen presenting cells which is of paramount importance in the maturation process of T cell population. This protein is secreted by fibroblasts, epithelial cells, stromal cells. Studies have demonstrated that this protein is secreted by non haemopoeitic cells.

Maturation of Helper T cells Type II is hastened by the presence of Thymic stromal lymphopoietin. These Helper T cells play a vital role in the pathogenesis of nasal polyposis.

How exactly thymic stromal lymphopoietin hastens the maturation process of Helper Type II T cells?

Nasal epithelium secretes thymic stromal lymphopoietin. This protein binds on the special receptor on the surface of dendritic cells. This binding causes release of OX40 ligand. This OX40 ligand causes the helper T cells to mature. These mature helper T cells secrete IL-4 and tumor necrosis factor alpha which are the well documented inflammatory mediators which could lead to the formation of nasal polyposis.

Role of staphylococcus aureus derived super antigens in nasal polyposis

Introduction:

There are two types of staphylococcus aureus derived enterotoxins. In patients with nasal polyposis IgE antibodies to staphylococcus aureus enterotoxins A and B have been demonstrated. Now the definition of nasal polyposis has undergone a subtle change. It is now being referred to as chronic rhinosinusitis with nasal polyposis. This disorder is characterised by an eosinophilic T helper type II inflammation. IL-5 happens to be the driving force of inflammation in these patients. It is important to differentiate this disorder from chronic sinusitis without polyposis in which T1 helper cells mediated inflammation is seen. In this disorder gamma interferon and transforming growth factor beta are considered to tbe driving force of inflammation.

A short note on staphylococcus aureus:

Staphylococcus aureus has recognised as an important pathogen in various human diseases. Infections of this organism ranges from skin infections to enteric infections. This organism has been found inside the nasal cavity. Patients in whom these organisms are found in the nasal cavity can be divided into intermittent and persistent carrier states. Staphyloccous have been known to produce toxins. Staphylococcus aureus are capable of secreting super antigens. These superantigens helps the organims in evading the adaptive immune mechanism of the body. These superantigens can directly activate T cells via its ability to bind to the MHC class II molecule. Hence these super antigens need not be processed by the antigen presenting cells. Only when an antigen is processed by the antigen precenting cell the adaptive immune mechanism of the body can be kick started.

How nasal polyposis is formed due to the presence of staphylococcus superantigens like enterotoxin A and e.

T lymphocytes in response to the superantigens starts to proliferate. This proliferation is confined to the T lymphocytes bearing specific vβ domains. This significant clonal expansion of T cells bearing vβ domains is known as (vβ skewing). These T lymphocytes in turn causes increased production of IL-5. This causes oedema of the mucosal lining of the nasal cavity. Excessive and persistent oedema in turn leads to nasal polyposis. These superantigens also cause aspirin sensitivity due to its ability to upregulate eosinophilic inflammation.

Courtesy otolaryngology e news

Role of mucin expression in the pathology of nasal polyposis

Introduction:

Rhinorrhea due to increased mucous secretion is one of the cardinal symptoms of nasal polyposis. Nasal polypi not only causes an increase in the amount mucin secretion but also changes its physical properties. It makes the mucin secretion thicker than usual hampering the normal mucosal transport mechanism. Changes in the physical properties of mucin involve changes in the relative amounts of sol and gel components. Nasal polypi expresses a wide spectrum of mucin genes. This genetic expression of mucin genes have been thought to play a role in the pathophysiology of nasal polyposis.

Causes of increased mucous secretion in patients with nasal polyposis:

1. Sinus infection coexisting / complicating nasal polyposis can cause increased mucous secretion. Studies have shown that 3 types of mucin have been expressed in these patients. They include MUC2, MUC5AC, and MUC5B. In patients with nasal polyposis there was inverse relationship between the levels of MUC2 and MUC5AC levels in the sinus secretion.

2. Increase in the surface epithelial area due to the presence of polypi could be one of the causes of increased mucous secretion. Even when squamous metaplasia is present due to exposure these squamous cells also express mucin.

3. Due to inflammation there is an increase in the number of mucous secretory elements like goblet cells / submucosal glandular cells. This could be due to the presence of increased levels of inflammatory mediators like IL-9, IL-13. These mediators increase the amount of secretion of mucin by goblet and submucosal glandular elements.

Mucin genes:

MUC1:

This gene has been demonstrated in normal inferior turbinate epithelium and nasal polypoidal tissue. Infact studies have not demonstrated any appreciable changes in this gene expression between these two tissue. One important issue that deserves mention is that this gene is found to be downregulated in the inferior turbinate of patients with vasomotor rhinitis when compared to normal individuals. This has led authors to postulate that decreased amounts of MUC1 expression in the mucosa over inferior turbinate some how trigger off neurogenic stimuli leading on to production of copious watery secretion from the nasal cavity. This feature is classically seen in patients with vasomotor rhinitis.

MUC2:

This gene is responsible for the production of large secretoy mucin. This mucin is commonly seen in intestinal epithelium serving to protect it from the luminal contents. MUC2 upregulation is seen in the mucosa of maxillary sinus in patients with nasal polyposis.

MUC 3 & MUC 6:

MUC3 gene encodes membrane bound mucin. This type of membrane bound mucin is seen in intestinal secretions. MUC6 gene encodes for secretory mucin which is commonly present in gastric secretions. It is this mucin which prevents self digestion of gastric mucosa by the HCL present in the stomach. Patients with nasal polyposis demonstrated MUC 3 upregulation with no increase in the amount of MUC6.

MUC4:

Studies have shown that this gene is the most predominantly expressed one in nasal polyposis. This gene is responsible for encoding membrane bound mucin which is commonly present in patients with nasal polyposis. This gene is also postulated to be involved in the process of epithelial hyperplasia and metaplasia.

A lot of work needs to be done in this direction to throw more light on this issue.

Courtesy news.otolaryngology.co.in

Pregnancy rhinitis

Introduction:

Nasal congestion is common in pregnancy. It goes by the name pregnancy rhinitis. This condition is so common that it is seen in one in five pregnancies.

Clinical features:

Nasal congestion
Rhinorrhoea
These symptoms are aggravated by using nasal decongestant nasal sprays.

Definition:
Ellegard defined pregnancy rhinitis as nasal congestion which occurs during the last 6 weeks of pregnancy without other signs of upper respiratory infections / allergy. This disappears completely within 2 weeks after delivery.

Etiology:
1. Could be due to hormone effects
2. Elevated placental growth hormones have been implicated
3. Smoking is considered to be a risk factor
4. Autonomic nervous system imbalance as it occurs in vasomotor rhinitis
Diagnosis:

1. Watery rhinorrhoea
2. Nasal congestion
3. Secondary infections of paranasal sinuses

Management:

1. Reassurance
2. Elevation of head end during sleep
3. Ensuring normal humidity in the inspired air
4. Adequate hydration
5. Instillation of saline nasal drops
6. Mild to moderate exercise will reduce nasal congestion
7. Pseudoephidrine is the preferred decongestant used during prenancy if situation warrants
8. Minimally invasive surgical procedures like cauterizing the enlarged inferior turbinates can help in some cases.

MBBS Prefinal Otolaryngology Feb 2011 question paper of The Tamilnadu Dr MGR Medical University with solution

mbbs_feb11

 

Medialization thyroplasty using Gor-Tex

Introduction:
Vocal cord paralysis is a rather common problem causing speech problems to the patient. If the other cord doesn’t compensate adequately these patients may have troublesome aspiration also. Aspiration happens to be the most dreaded complication of vocal fold paralysis. Management of these patients is possible only by performing Medialization thyroplasty (Ishiki type I thyroplasty). Various graft materials have been used in this procedure. Presently lot of interest has been generated in Gor-Tex medicalization thyroplasty.
Advantages of Gor-Tex:
Gor-Tex is expanded polytetrafluroethylene has obvious advantages as an implant material in Medialization thyroplasty procedures.
1. It is malleable
2. Its position can easily be adjusted within the thyroid cartilage window
3. Only a small fenestration is necessary in the lamina of thyroid cartilage to introduce this material
4. This procedure is reversible and has very few complications
5. Creates less oedema when compared to that of silastic and hence over correction is not possible
6. Resultant quality of voice is really good
History:
Hoffman and McCullouch reported the first case of medialization thyroplasty using Gor-Tex in May 1996.




Indications of Gor-Tex Medialization thyroplasty:


1. Unilateral vocal fold immobility due to paralysis, paresis, atrophy
2. Unilateral vocal fold scarring / soft tissue loss
3. In select cases of Parkinson’s disease with vocal fold atrophy


Contraindications of Gor-Tex thyroplasty:
1. Previous history of irradiation
2. Malignant lesions involving larynx
3. Poor abduction of contralateral vocal fold as this would cause impairment of airway
Procedure:
This procedure is ideally performed under local infiltration anesthesia using 2% xylocaine mixed with 1 in 100,000 units’ adrenaline.
Incision:
Horizontal skin crease incision beginning at the mid portion of the thyroid cartilage extending to the paralyzed side.
The strap muscles are separated away from midline and held apart from the operating field using umbilical tape.
A tracheal hook is used at the level of laryngeal prominence and pulled medially. This helps in mobilizing the cartilage better.
The thyroid cartilage perichondrium is incised in the midline and extended laterally towards the paralyzed side. The thyroid lamina on the paralyzed side is skeletonized up to the level of cricothyroid membrane. Strips of cricothyoid muscle that come in the way are excised.


Dimensions of cartilage cuts:
Appropriate size of cartilage window is about 5mm x 10mm. The lower border of the window should be about 3mm above cricothyroid membrane. This ensures that the lower strut of thyroid lamina doesn’t fracture when window is being created. Anterior border of the window is about 8mm posterior to midline. If thyroid cartilage is calcified then fissure burr can be used to create the window.
The inner perichondrium is elevated from the under surface of thyroid lamina using scissors. The inner perichondrium incised posteriorly and inferiorly. It is not incised anteriorly. Now the cricothyroid membrane is incised in order to separate it from the lower border of thyroid cartilage. A septal elevator is introduced through the inferior margin of thyroid lamina and the paraglottic space is compressed medially while the voice of the patient is assessed. If the result is acceptable then 1 cm wide Gor-Tex strips dipped in bacitracin solution is introduced via the inferior margin of thyroid lamina and delivered via the window. The amount of Gor-Tex insertion is dependent on the improvement of quality of voice.
If necessary use prolene sutures passing via the inferior strut of thyroid lamina to stabilize Gor-Tex. Wound is closed in layers after keeping a penrose drain.


It is very important to perform pre operative and post operative video laryngeal examination.

Modified septoplasty

Introduction:


Septoplasty is the commonly performed surgical procedure these days. It has been evolving for more than a century. It was in the early part of 20th century Freer and Killian first reported this procedure. The technique developed by them involved removal of the complete nasal septum (SMR). It was left to Cottle to fine tune their procedure of submucosal resection of nasal septum. During initial stages due to fear of complications and constraints of illumination septal deviations involving the anterior and middle portions alone were corrected adequately. Posterior deviations were left unattended. With the advent of excellent equipments like the nasal endoscope the whole of the nasal septum can be visualised and this led to removal of excess septal cartilage leading to complications like septal perforation, flappy nasal mucosa and nasal deformities like saddle nose etc. Inspite of being nearly a century old procedure the concepts governing septal surgery has undergone very few modifications. Metzenbaum recognized the importance of caudal portion of nasal septum and was instrumental in devising the first principles of septoplasty. His swinging door technique is still being followed with minor modifications in the septoplasty procedure performed even now.


Modified septoplasty procedure:
Wang etal suggested certain modifications in the currently performed septoplasty procedures. These modifications were aimed at:


1. Ability to deal with all types of septal deviations
2. Preservation of cartilagenous support framework
3. Avoidance of complications


Before suggesting these modifications they conducted extensive studies on the biomechanics of septal deviation. In their study they identified three key stress lines in the nasal septum. These stress lines are:


1. At the junction between the caudal septal cartilage and the medial crus of the alar cartilage. This often causes anterior deviation.
2. Between the quadrangular cartilage and the perpendicular plate of ethmoid. This often leads to superior deviation.
3. Between the quadrangular cartilage and vomer bone, palatine process of maxilla and nasal crest of palatine bone. Deviations in this area leads to inferior deviation.


The reasons for these stress lines can be accounted if the theory of differential septal ossification is considered to be the cause for septal deviation.

Diagram illustrating the three stress lines of nasal septum

During the development of nasal septum uneven ossification of the various parts of the septum can occur. The developing nasal septum is supposed to contain a membranous component anteriorly and cartilagenous and osseous component posteriorly. The posterior portion of nasal septum ossifies and forms perpendicular plate of ethmoid, nasal crests of palatine and maxillary bones and the vomer. Studies have shown that the septal cartilage is still in the process of continuous growth even after full maturation of maxilla and palatine bones. Due to the space constraint the growing cartilagenous portion of the nasal septum buckles.

In the modified procedure of septoplasty suggested by Wang etal the septum is surgically accessed via the standard Hemitransfixation incision. The septal cartilage is freed from its anterior, posterior and inferior attachements. Only the superior attachment is intact ensuring that the septal cartilage does'nt fall off. The cartilage can be shortened in order to fit in to the space. The shortening of the cartilage causes the septum to straighten. Since cartilage is fractured in order to correct the deviation healing takes a little longer. Splinting of the nasal septum is a must atleast for 10 days for optimal wound healing to occur.

Advantages of this modified procedure:

1. It maintains the thickness and rigidity of the nasal septum
2. Avoids synechiae formation
3. Prevents depression of nasal tip and pyramid
4. It reduces the incidence of septal perforation.
5. This procedure can safely be performed in adolescents also.

Drugs used in otology and their formulations

Introduction: Various drugs and formulations are used in otological practice. Some of them may be of questionable value from the therapeutic stand point, still it is worthwhile knowing about these formulations. Topical otological preparations are so unique they need to be studied in detail.

Advantages of topical drug use in otology:

1. The drug can be administered right where it is needed
2. First pass metabolism doesnt come into play
3. Drug is delivered in a targetted manner, in adequate doses. Toxicity is not common
4. Chronic inflammatory diseases of middle ear cavity causes a certain amount of fibrosis preventing adequate concentrations of systemically administered drug reaching it.

Ear drops are solutions / suspensions of medicines in solvents like water, glycerol, diluted alcohol, or propylene glycol. These solutions can be instilled into the ear. For these ear drops to be effective sufficient contact time should be provided.

Indications for use of topical ear drops:

1. Bacterial / fungal infections of external auditory canal
2. Chronic suppurative otitis media with a large drum perforation
3. To liquefy accumulated wax in the external auditory canal
4. Myringitis granulosa

If drops are to reach the middle ear in adequate concentration the ear drum perforation should be fairly large. The method of administration of ear drops to reach the middle ear cavity is known as the displacement method. In this method the external ear is made dependent by turning the head to the opposite side, with the chin touching the shoulder. The external auditory canal is filled with ear drops. Pressure is applied to the external ear by alternate pressing of the tragus. This maneuver displaces the air from the middle ear cavity which is duly filled up by the ear drops.

Difference between solution and solvent ear drops:

Solution usually consists of a drug which is dissolved in a solvent where as suspension consists of an insoluble drug distributed in a liquid medium. Some of the ear drops can be used as eye drops also. To facilitate such multi usage certain adjuvant drugs are added to the drops in addition to the active drug. Commonly used adjuvants in such drops which can be used as eye and ear drops include:

1. 0.01% Benzalkonium chloride – This acts as an antifungal agent
2. Sodium metabisulphite – This agent acts as a buffer maintaining the pH of the solution. This strict maintenance of pH prevents easy degradation of the active drug molecule present in the drops. It also minimizes the irritation caused due to application of the drops. It also retards the oxidation of the active drug there by prolonging the effect of the active drug.
3. Disodium edetate – This is another adjuvant commonly used. It also acts as an excellent buffering agent. This adjuvant drug increases the bactericidal and antifungal activity of Benzalkonium chloride.
4. Steroids – Beclamethazone is the commonly used steroid adjuvant drug in the ear drops for its antiinflammatory effect.

Some of the local drug preparations to be used in the external auditory canal may be in the form of creams / ointments. These ointments usually contain antibiotics and antiinflammatory agents in a suitable base like liquid paraffin, wool fat, yellow soft paraffin. Ointments usually have paraffin base. Ointaments are very useful in managing dry scaly skin conditions of external auditory canal. Ointment preparations with Lanolin as the base (wool fat) should be marked clearly on the tube because some patients may develop hypersensitivity reaction to this component of the medicine.

Acetic acid ear drops – Acetic acid in concentration of 2% is an excellent antibacterial and antifungal agent. Acetic acid ear drops can be used to treat mild otitis externa. This is commonly used in paediatric age group.

Aluminium acetate ear drops: This is an astringent drug which can be administered as ear drops or by dipping a cotton wick in the drug and inserting the same into the external auditory canal. Astringent belongs to a group of medicine that causes shrinkage of tissue on local application. Shrinkage of tissue is caused due to the hydroscopic effect of the drug. Hence it can be used to reduce oedema involving the external auditory canal. If this drug needs to be used for its astringent effect then it should be administered using a cotton wick. This drug is known to cause deposition of aluminium acetate crystals in the external auditory canal. Hence periodic cleansing of the ear is a must when this drug is used. This drug can be safely used even in pregnant mothers. In fact this is safest drug that can be administered during pergnancy.

Boric acid ear drops: Formerly this drug was used for their bacteriostatic and antifungal efects. It can be used in varying concentrations. Maxium concentration that can be safely used is 5%. This drug gets absorbed via the inflammed skin leading on to systemic toxicity due to the drug.

Antibiotic & steroid ear drops:

Betnesol / prednisolone sodium phosphate can be administered along with antibiotics like gentamycin / neomycin / quinolenes. When used in combination with these antibiotics they faciliate better effects due to their antiinflammatory effects.

Clotrimazole ear drops:

Clotrimazole is a broad spectrum antifungal agent. This drug inhibits ergosterol synthesis by the fungal cell wall. This destroys the fungus. Fungal infections involving the external auditory canal can also be caused due to inappropriate use of steroid ear drops. Administration of clotrimazole can cause burning sensation in the external auditory canal. Patient should be advised to tolerate it.

Ceruminolytic ear drops:

These are the most commonly used ear drops. Drugs belonging to this group include oil / aqueous preparations. These drugs are known to soften the wax facilitating its removal by aural syringing. 0.9% sodium choloride solution can be used as ceruminolytic agent. 5% sodabicarb solution can also be used as ceruminolytic agent.

Olive oil / coconut oil / liquid paraffin can also be used as ceruminolytic agents.

Organic solvents like chlorbutanol / paradichlorobenzene can also be used as solvents, but may cause irritation to meatal skin.

Indications for administration for systemic antibiotics:

1. Acute otitis media
2. Furunculosis of external auditory canal
3. Perichondritis of pinna
4. Acute mastoiditis
5. Malignant otitis externa

Drugs administered systemically include:

1. Amoxycillin
2. Flucloxacillin
3. Ciprofloxacillin
4. Penicillins

Drugs used in the management of vertigo:

Betahistine can be used in the management vertigo associated with meniere's disease. This drug reduces the endolymph pressure by improving microvascular circulation in the striavascularis of the cochlea. It also reduces the vertigenous sensation by inhibiting the firing rate of vestibular nuclei. Betahistine is known to reduce vertigo / tinnitus but does little to improve hearing. It is usually prescribed in doses of 16 mg thrice a day.

This drug should be used with caution in patients with bronchial asthma / peptic ulcer.

Dopamine antagonists: Prochlorperazine belongs to this group. Goes by the popular name Stemetil. It is a dopamine antagonist acting by blocking the chemoreceptor trigger zone. It is less sedating with fewer antimuscarinic effects.

Antihistamines: Drugs belonging to this group acts on H1 receptor at the level of chemoreceptor trigger zone thereby blocking the vomiting centre. Examples of drugs belonging to this group are cinnarizine and cyclizine. Cinnarizine can be used as prophylaxis for migraine in doses of 30 mg three times a day. Cyclizine is useful only during acute attacks and is given in doses of 50 mg thrice a day.

Diuretics in the management of meniere's disease: Thiazides and acetazolamide can be used in the management of acute symptoms of Meniere's disease. The cause decompression of the endolymphatic sac due to their diuretic effects.

Steroids in the treatment of sudden sensorineural hearing loss: Steroids have been used in the management of sudden sensorineural hearing loss with varying degress of success. Dosage regimen is as follows:

Prednisalone

60 mg on day I

50 mg on day II

40 mg for following three days

30 mg for subsequent three days

Use of antiviral drugs in otology:

Acyclovir is the classic example of drug belonging to this group. It can be administered in patients with Herpes Zoster oticus. It acts by inhibiting nucleic acid synthesis. It is administered orally in doses of 800 mg five times a day for 5 days. If administered within 72 hours after development of rash it reduces post herpetic neuralgia.

Use of sodium fluroide in otosclerosis:

sodium fluroide is used tto slow down the development of sensorineural hearing loss in a patient with otospongiosis. It acts due to its enzyme inhibiting activity there by preventing osteoclastic bone resorption. Usually it is administered in doses of 40 mg per day for a period of 3-6 weeks. This drug is really useful in patients with cochlear otosclerosis. It has propensity to cause gastric irritation and renal damage.

Endoscopic vidian neurectomy a video clipping

This is a video clipping showing Endoscopic vidian neurectomy being performed.

Canine fossa trephination

Introduction:


The key to any successful Endoscopic sinus surgery lies in clearing the residual disease from the maxillary sinus cavity. The diseased mucosa of the maxillary sinus cavity could cause formation of pus, eosinophilic fungal debris, polyps etc. These disorders dont reverse after performing a wide middle meatal antrostomy. They need to be cleaned out physically which can be rather difficult via the middle meatus as the anterior wall of the maxillary sinus and the high lateral walls are virtually not reacheable via the natural ostium. It is hence advisable to remove as much as diseased mucosa from the maxillary sinus in order to facilitate the rapid return of the sinus mucosa to normal. This is where maxillary sinus trephination has a role to play.


Optimal location for Canine fossa traphination:


Anatomical studies have shown that the best place to insert the trocar in the canine fossa is at the junction of the mid pupillary line and a horizontal line drawn through the floor of the nasal vestibule. At this site a 5mm hole can very easily be drilled thorough which a 4 mm nasal endoscope can easily be passed.

Illustration showing the exact location for placing the trocar in the canine fossa

Indications for canine fossa trephining:

1. Grade III maxillary sinus disease that cannot be addressed adequately via the enlarged natural ostium
2. Presence of excessive polypoidal mucosa within the maxillary sinus
3. Presence of mucopyoceles
4. Presence of a large antrochoanal polyp

Before proceeding with canine fossa trephining a large middle meatal antrostomy should be performed. A 70 degree endoscope can be used to inspect the interiors of the maxillary sinus cavity. This inspection will also help in grading the maxillary sinus disease.

Grade I – Normal or slightly oedematous mucosa

Grade II – Oedematous mucosa with small polypi without eosinophilic mucous

Grade III – Presence of extensive polypi and thick tenacious mucin

Anatomy of the canine fossa:

The canine fossa is the thinnest portion of the anterior wall of the maxillary sinus. Hence it is easy to breach this area and enter into the sinus. Boundaries of the canine fossa include:

1. Canine eminence formed by the canine tooth – medial
2. Root of the zygoma – laterally
3. Alveolar process of maxilla - inferiorly
4. Infraorbital foramen with the infraorbital nerve superiorly

The trephining of the canine fossa can be performed sublabially. After successful trephination using the trocar has been performed the opening can be widened using a burr. The opening should be wide enough to permit insertion of a 4 mm nasal endoscope. The maxillary sinus can be visualized from both angles i.e via the natural ostium using a 70 degree endoscope and via the opening in the anterior wall of maxilla. One port can also be used to introduce instruments to remove the diseased mucosa and pent up secretions.

Complications: Are very few if anatomy is respected.

1. Facial numbness
2. Numbness of upper dentition
3. Pain over the cheek
4. Hematoma over cheek

Most of these complications are self limiting and resolve within the first week after surgery.

Middle turbinate Implant

Middle turbinate lateralization has been reported as the most common factor associated with the failure of primary endoscopic sinus surgery.  Currently various techniques have been used to prevent lateralisation of middle turbinate like packing the middle meatal area with merocel or resorting to Bolgerisation.  This middle turbinate implant helps in preventing lateralization of middle turbinate following endoscopic sinus surgery.

Role of imaging in the diagnosis of parapharyngeal and adjacent neck space lesions

Introduction:

Parapharyngeal space is a suprahyoid neck space. It is surrounded by other important facial spaces. Old text books divided this space into prestyloid and post stymoid compartments. The prestyloid compartment lying infront of the styloid process and the post styloid one lying behind it. Current literature designates post styloid compartment as carotid space and the prestyloid compartment is considered to be the true parapharyngeal space. The parapharyngeal space contains fat. This is clearly visible in imaging and displacement of fat indirectly helps the radiologist to identify and quantify the extent of lesions involving parapharyngeal space. Parapharyngeal space is a hidden area that cannot be easily examined. Lesions of this space present rather late and in advanced stage. A surgeon will have to resort to imaging in order to visualize this area. 

Paraph Imaging

Labyrinthitis ossificans

Introduction:

The human bony labyrinth is composed of endosteal, enchondral and perisoteal layers. The endosteal layer consists of bone lined with a single layer of cells that have numerous gaps separating them. This layer is significantly thin. The enchondral layer is rather unique in that it reaches the adult size by 23 weeks of gestatation and undergoes minimal remodelling after the age of 2. The periosteal layer is composed of lamellar bone and is capable of bone remodelling and repair.

Labyrinthitis ossificans is the pathologic new bone formation within the lumen of otic capsule. This condition is always associated with profound deafness and loss of vestibular function. Cochlear ossification in this condition doesnot cross the endosteal layer or alter the architecture of the enchondral bone.

Causes of labyrinthitis ossificans:

1. Bacterial meningitis
2. Vascular obstruction to labyrinthine artery
3. Temporal bone trauma
4. Autoimmune inner ear disease
5. Leukemia
6. Tumors of temporal bone
7. Suppurative labyrinthitis following CSOM

Commonly involved portion of cochlea in this condition is scala tympani portion of the basal turn of the cochlea. This is more severe in patients with bacterial meningitis. Infections from inflammed meninges reach the inner ear via the cochlear aqueduct. Usually the cochlear aqueduct drains into the scala tympani close to the round window region. This is the reason why predominant ossification of the inner ear occurs in this area following bacterial meningitis. This creates lot of problem during cochlear implant electrode introduction via the round window. This ossified area should be drilled out with a microdrill inorder to insert the electrode in these patients.

According to Paperella labyrinthitis ossificans can be divided into three stages:

Acute stage – This stage is characterised by pus which fills up the perilymphatic spaces, sparing the endolymphatic space. This is followed by the formation of serofibrinous exudate.

Stage of fibrosis – This stage is characterised by fibroblastic proliferation within the perilymphatic spaces which usually begins two weeks after the onset of infection. This stage is also associated with new bone formation (angiogenesis).

Stage of ossification – This stage is characterised by bone formation and is first observed at the basal turn of the cochlea.

Theories proposed to explain the pathogenesis of labyrinthitis ossificans:

1. Paperella's theory: This theory was proposed by Paperella and Sigiura in 1967. They hypothesized that bone lining cells of the cochlea are plueripotent stem cells that remain uncomitted till they are stimulated to differentiate into osteoblasts.
2. Linthicum theory: Linthicum in 1985 said that bone originates from osteoblasts within the otic capsule. He also suggested that ectopic bone forms on the endosteal layer after an inflammatory insult.
3. Pericyte theory: This theory suggests that pericytes associated with blood vessels that supply the modiolus and spiral ligament have been hypothesized as cells of origin.
   
   
   
   
   
   
   

Effects of sectioning chorda tympani nerve during middle ear surgery

Introduction:


The chorda tympani nerve is a branch of facial nerve. It derives all its fibers from the nervous intermedius of wrisberg. The chorda tympani nerve contains gustatory fibers from the anterior two thirds of the tongue and parasympathetic fibers to all the salivary glands excepting the parotid. Sectioning the chorda tympani nerve not only affects the taste but also reduces the basal secretion of salivary glands causing xerostomia.


Discussion:


The sublingual and submandibular salivary glands are responsible for about two thirds of the basal saliva production. The parotid gland contributes to just a third of the basal salivary production. Destruction / trauma to chorda tympani nerve on both sides can definitly cause dryness of mouth due to a reduction in the amount of saliva secreted by sublingual and submandibular salivary glands. Usually sectioning of one chorda tympani nerve will go unnoticed. When middle ear surgery is contemplated on both ears then the patient should be warned of the realistic risks of xerostomia. Caution should be exercised in operating on the opposite ear of patients who have already undergone middle ear surgery in the ipsilateral ear.


Hence all otologists should take extra care to preserve this nerve during middle ear surgical procedures.