Endoscopic Endonasal Trans-Sphenoidal Minimally Invasive Pituitary Surgery with Image Guided Navigation System (Igns): Learning Experience of Ent Surgeon: First Author

Introduction- Endoscopic minimally invasive pituitary surgery (MIPS) is advantageous over microscopic technique, as it provides superior close up, wide angle view of surgical target area. Image guided navigation system (IGNS) guides the surgeon to localize the lesion. In the present study we analyzed the Image Guided Surgical procedure and outcome of Endoscopic minimally invasive pituitary surgery and shared our experiences regarding disease clearance.

MATERIALS AND METHODS

During the period of April 2015 to August 2022 a total 104 patients, diagnosed with pituitary adenoma underwent surgery and further followed up in a multidisciplinary team approach in a tertiary care hospital of Kolkata, India. The data obtained were reviewed statistically to satisfy the study objectives.

RESULTS

Total 104 operations were done on 98 patients and total cases taken for calculation and analysis was 98, which consist of 11 microadenomas, 81 macroadenomas. Among 35 patients with normal preoperative hormonal assay, one patient developed postoperative hypopituitarism. Among 6 patients with preoperative hypopituitarism 4 patients (66.6%) recovered after surgery. Overall, 85 cases had total disease clearance as detected on post-operative MRI. In functioning pituitary adenoma (FPA) clinical and endocrinological improvement occurred after primary surgery in 85.36% (n = 35) and after revision surgery it was 84.44% (n = 38). Macroadenomas, giant adenomas were found to have statistically significant higher risk of incomplete disease clearance but large adenomas do not have statistically higher risk of incomplete clearance.

CONCLUSION

IGNS requires extra time for setup, but with proper registration of tracker instruments it adds precision to the surgery. IGNS supplements endoscopic visualization with localization of target lesion by real time stereotactic feedback using preset preoperative imaging data, thus increasing accuracy, safety and effectiveness of minimally invasive surgery.

Audio-Vestibular Manifestations in COVID-19; A Systematic Review and Meta-analysis

Introduction Audio-Vestibular (AV) presentation as a consequence of COVID-19 is a less ventured zone. The aim of the study was systematically review the literature (both studies and case reports) published up to August 2021, in order to provide evidence on audio-vestibular symptoms in SARS-CoV-2, COVID-19 patients. Systematic review and meta-analysis was performed for assessment of prevalence of AV symptoms among COVID-19 patients. Materials and Methods A search of existing literature using key words and MeSH (Medical Subject Headings) terms was done. The methods were developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. 36 qualitative studies were narratively synthesized. Meta-analysis was performed on 18 quantitative studies Results Hearing loss was most commonly reported AV manifestation among case series / case reports. In the quantitative studies, the pooled estimate of Hearing loss, Dizziness and Tinnitus was 4.558%, 4.226% and 5.513% respectively. Other reported AV symptoms included ear ache, aural fullness and facial paresis. Conclusion Prevalence of AV symptoms in COVID-19 differs from that of the published literature. This prevalence of hearing loss is less than that reported amongst the world population. Structured community-based studies with homogeneous working definitions have to be conducted to assess the true prevalence.

An Epidemiological Study of Hearing Loss in a Peripheral Tertiary Care Hospital

The estimated prevalence of adult onset hearing deafness in India is 7.6% and childhood onset hearing loss is 2%. But there are very few studies which highlight the prevalence of various types of hearing loss. So a retrospective, cross-sectional study in a peripheral tertiary care hospital was designed to analyze the different types of hearing loss among patients with complaints of hearing disabilities attending and assess the more prevalent type of hearing loss according to severity. Out of total study population of 14,365 patients, Male patients with Mild hearing loss have the maximum correlation coefficient followed by Moderate, Moderately severe, Profound and Severe hearing loss. In the case of female patients Mild Hearing loss has the maximum correlation coefficient. Result of this study may be helpful in planning and management of different programs related to hearing disability prevention. As most of the hearing loss is mild variety and it slowly progress to other form of severe hearing loss, early intervention is very helpful in reducing the severity thus disability.

A Retrospective Comparative Study on the Outcome of Microscope-Assisted Technique and Supra-Auricular Approach in Preauricular Sinus Surgery in a Tertiary Care Hospital

CONTEXT

Preauricular sinus (PAS) can lead to severe complications such as facial paralysis, and squamous cell carcinoma may develop from this sinus later in life. Asymptomatic sinus needs no intervention, but symptomatic sinus needs surgical interventions.

AIMS

This study compares the surgical outcome of microscope-assisted sinus tract excision technique with the supra-auricular sinectomy technique.

SETTINGS AND DESIGN

This was a retrospective, observational study conducted at a tertiary care hospital in Purulia District, West Bengal, India.

SUBJECTS AND METHODS

Records of patients operated on for PAS were included following the proper inclusion and exclusion criteria. These patients were categorized and followed up based on disease pathology and the type of intervention received.

STATISTICAL ANALYSIS USED

Data were collected, tabulated, and analyzed using the standard statistical software.

RESULTS

Fifty-two patients were included in our study. About 48.07% of patients were found in the age group of 11-15 years. In the microscope-assisted sinectomy category, recurrence of the disease was seen in 2 out of 15 operated patients compared to 1 patient among 13 in the supra-auricular sinectomy approach for uncomplicated cases. In complicated cases, the supra-auricular sinectomy approach had a nil recurrence rate compared to three patients out of ten operated in microscope-assisted technique (Fisher's exact test - 0.0593). Both the outcomes are not statistically significant.

CONCLUSION

Supra-auricular sinectomy technique has the lowest recurrence rate for preauricular sinus surgery.

Cascading effects of composts and cover crops on soil chemistry, bacterial communities and the survival of foodborne pathogens

AIMS

Recent foodborne disease outbreaks have caused farmers to re-evaluate their practices. In particular, concern that soil amendments could introduce foodborne pathogens onto farms and promote their survival in soils has led farmers to reduce or eliminate the application of animal-based composts. However, organic amendments (such as composts and cover crops) could bolster food safety by increasing soil microbial diversity and activity, which can act as competitors or antagonists and reduce pathogen survival.

METHODS AND RESULTS

Leveraging a study of a 27-year experiment comparing organic and conventional soil management, we evaluate the impacts of composted poultry litter and cover crops on soil chemistry, bacterial communities and survival of Salmonella enterica and Listeria monocytogenes. We found that bacterial community composition strongly affected pathogen survival in soils. Specifically, organic soils managed with cover crops and composts hosted more macronutrients and bacterial communities that were better able to suppress Salmonella and Listeria. For example, after incubating soils for 10 days at 20°C, soils without composts retained fourfold to fivefold more Salmonella compared to compost-amended soils. However, treatment effects dissipated as bacterial communities converged over the growing season.

CONCLUSIONS

Our results suggest that composts and cover crops may be used to build healthy soils without increasing foodborne pathogen survival.

SIGNIFICANCE AND IMPACT OF THE STUDY

Our work suggests that animal-based composts do not promote pathogen survival and may even promote bacterial communities that suppress pathogens. Critically, proper composting techniques are known to reduce pathogen populations in biological soil amendments of animal origin, which can reduce the risks of introducing pathogens to farm fields in soil amendments. Thus, animal-based composts and cover crops may be a safe alternative to conventional fertilizers, both because of the known benefits of composts for soil health and because it may be possible to apply amendments in such a way that food-safety risks are mitigated rather than exacerbated.

Conventional versus Flap Tracheostomy: Operative Simplicity, Stomal Care, Complications

Introduction Tracheostomy is a life saving procedure and its operative principle has withstood the test of time although the operative techniques have evolved. Inferiorly based flap on the anterior tracheal wall (Bjork flap) was demonstrated in 1952. The present study aims to compare conventional tracheostomy with flap tracheostomy. Materials and Methods A Randomized Control Trial was conducted in a tertiary care teaching medical institute comparing conventionally tracheostomised patients (Group A) with the group where flap based method was followed (Group B). Results The study population was comprised of 110 patients with equitable distribution in the groups. Per-operative time to establish an airway was measured and statistically correlated. 9.26% patients of Group A had difficult tube change, with none in Group B. Ease of stomal care by the patient and family members (Visual Analogue Scale), depicted it to be “very easy” in 76.36% of the patients in Group B and 16.36% in Group A. Stomal healing in first week was proper in 61.82% of patients in Group A and 80% of the patients in Group B. Tracheo-cutaneous fistula (TCF) developed in 18.18% of the adult and geriatric patients of Group A undergoing stomal closure. None of the patients in Group B had TCF following stomal closure. Conclusion Establishing Bjork flap tracheostomy is equally quick making the process suited for emergency situations. Flap based tracheostomy has early stomal maturation so, care of the stoma by health assistants and family members is easy.

A Novel Account of the 'Forgotten Disease'

Introduction Septic thrombophlebitis of Internal Jugular Vein (IJV) secondary to head neck infection, demonstrated by Lemierre in 1936,  is a rare although known entity. Case Report A 35 year old known diabetic female patient presented in the ENT OPDwith complaints of excruciating pain and swelling on the left side of theneck for past three weeks. A tender neck mass of around 8cm x 5cm inthe left side of neck along the anterior border of sternocleidomastoid waspalpable. A computed tomographic (CT) scan of neck revealed a thrombosed left internal jugular vein along with adjoining left sided level 2 and 3 suppurative cervical lymphadenopathy. She was treated conservatively with broad spectrum antibiotics and the patient improved after prolonged treatment.  Discussion Lemierre syndrome has been appropriately termed as a forgotten disease. This has been an important cause of missed cases. High suspicion of IJV thrombosis in head neck infections, more so in the oropharyngeal infection is the key to diagnosis.

A Comparative Study of Orbital Blow Out Fracture Repair, Using Autogenous Bone Graft and Alloplastic Materials

Maxillofacial trauma, a common injury in urban population following road traffic accident or act of interpersonal violence of which orbital floor fractures is common. It impairs the integrity of the extraocular muscles and may be accompanied by enophthalmos, orbital deformity and diplopia. Orbital reconstruction is essential to improve anatomical and visual deformity. Repair of orbital floor is done by autologous bone graft or synthetic implants. Compare outcome of orbital floor reconstruction in blow out orbital fracture using autogenous bone graft from iliac crest, outer table of mandible, alloplastic implant- silastic block and titanium mesh. 30 patients having orbital fractures were considered in study population. All the patients were treated by ORIF and repair of floor by subcilliary incision. Out of 30 patients, repair of orbital floor was done by autologous bone graft from iliac crest in 7 patients (Group A), bone graft from outer table of mandible in 5 patients (Group B), implant using silastic block in 8 patients (Group C) and titanium mesh in 10 patients (Group D). Factors analyzed were age, sex, cause of fracture and treatment outcome in terms of correction of pre operative diplopia and enophthalmos, rate of development of post operative infection, wound dehiscence and implant exposure. All patents were reviewed at 4 weeks and 12 weeks following operation. 71.42% of patients in Group A had early correction of diplopia and enophthalmos. This was 100% in rest of the groups. All patients had complete correction when assessed at 12 weeks post operatively. Post operative complication rate was 20% and 12.5% in Group B and C respectively. There were no complications in the rest of the groups within the follow up period. No statistically significant difference as to the chance of occurrence of complication could be found amongst the groups. Autologous bone graft has no immunological reaction but donor site morbidity. Silastic block may case immunological reaction, infection, poor drainage of orbital floor. But titanium mesh for orbital floor repair has excellent outcome and superior to other modality of treatment.

A Comparative Study of Pharyngeal Repair in Two Layers Versus Three Layers, Following Total Laryngectomy in Carcinoma of Larynx

Larynx is the second most common site for cancer in the upper aerodigestive tract. One of the dreaded complications following total laryngectomy has been pharyngo cutaneous fistula (PCF). PCF merits special attention due to its significant negative impact on the recovery process. Total laryngectomy profoundly alters speech. Effective voice restoration is essential for the rehabilitation of these patients. Inadequate consensus exists as to the best technique of pharyngeal repair to decrease incidence of PCF and ensure good quality voice following total laryngectomy. 21 patients were included in the study for total laryngectomy with trachea oesophageal voice prosthesis placement. Patients were randomised into 2 groups. Group A had their pharynx repaired in two layers and Group B had it done in three layers. Post operatively the patients were followed up for a period of 12 months to look for incidence of PCF. Subjective and objective evaluation of voice was done. 9.52% of patients developed PCF. All of the cases of PCF were in the group repaired in three layers. In cases with repair by two layers the mean Voice Handicap Index 10 (VHI 10) score was 19.27 and those with three layers pharyngeal repair was 23.20. Average maximum phonation time amongst the study population was 13.09. In three layers and two layers pharyngeal repair the average maximum phonation time was 12.56 and 13.58 respectively. Surgical repair of pharynx in two layers excluding the third layer of pharyngeal musculature reduces the chance of PCF. Two layers pharyngeal repair supplemented by cricopharyngeal myotomy led to significantly better voice outcome.

Recurrent Acute Tonsillitis, The 'Core' Issue

Introduction: Today bacteriological and patho-anatomical considerations too are taken into account while treating a case of tonsillitis. Past decade has seen the rise of resistance amongst the common pathogens, as well as rise in the number of unusual offenders. Determination of the true offending organism and prescribing an antibiotic as per the sensitivity pattern is of utmost importance.  Materials and Method: A prospective longitudinal study was conducted in a tertiary care hospital in Kolkata. The study population consisted of patients presenting with recurrent attacks of acute tonsillitis. Determination of throat swab micro flora, ASO titre and core tissue microflora was done and correlated statistically. Result: There was poor correlation between throat swab and core tissue microflora. Positive predictive value of throat swab was 10%. Pseudomonas is the predominant flora harbouring tonsillar core in our study population. Amoxicillin the most commonly prescribed antibiotic stands out to be the most resistant one. No statistical significance could be reached comparing streptococcal tonsillitis with ASO titre. Discussion: The real pathology within the tonsil core is not always reflected in routine throat swab and bacteriology of recurrent tonsillitis may differ in different regions. ASO titre estimation adds up to the economic burden if rheumatic fever is not suspected. Judicious use of antibiotics based on true sensitivity pattern is encouraged. In the era of antibiotics Tonsillectomy still holds an important position in the management of recurrent attacks. Conclusion: Pseudomonas was found to be the most common pathogen in recurrent acute tonsillitis. Core tissue study remains the Gold standard in identifying the pathogenic organism. Oral third generation Cephalosporin was the most efficacious antibiotic for recurrent tonsillitis in our study population.

An Arrow Penetrating the Globe and the Sinonasal Complex

Introduction: Foreign bodies represent on average 11% of all ENT emergencies. Associated eye trauma represents 5% of all cases of blindness in developing countries. Accidental and homicidal arrow injuries presenting to an otorhinolaryngologist are still a stark reality in this modern era. Case report: A 22 year-old female presented with an accidental arrow injury in her left eye; extending into the nose. On examination, she had no light perception in left eye and a penetrating injury of the sclera. CT scan showed extensive injury to ipsilateral nasal cavity, floor of left orbit and the maxillary sinus and anterior ethmoid cells. Multidisciplinary approach ensured removal of the unusual foreign body from the orbit, nose and paranasal sinuses. Discussion: Accidental injury in ear, nose or throat with sharp projectiles presents a challenge. Arrowhead may be poisoned and thus exploration is delayed until the systemic effect of the poisoned is reduced. An injury such as this involves a multidisciplinary approach. As ENT surgeons we must be aware such challenges and equip ourselves with the knowledge to tackle them.

Charge Puddles in Graphene near the Dirac Point

The charge carrier density in graphene on a dielectric substrate such as SiO_{2} displays inhomogeneities, the so-called charge puddles. Because of the linear dispersion relation in monolayer graphene, the puddles are predicted to grow near charge neutrality, a markedly distinct property from conventional two-dimensional electron gases. By performing scanning tunneling microscopy and spectroscopy on a mesoscopic graphene device, we directly observe the puddles' growth, both in spatial extent and in amplitude, as the Fermi level approaches the Dirac point. Self-consistent screening theory provides a unified description of both the macroscopic transport properties and the microscopically observed charge disorder.

Cyclization and unsaturation rather than isomerisation of side chains govern the selective antibacterial activity of cationic-amphiphilic polymers

The influence of cyclization and unsaturation on the hydrophobic side chains of cationic-amphiphilic polymers towards antibacterial activity and mammalian cell toxicity is reported.

Isosteric substitution in cationic-amphiphilic polymers reveals an important role for hydrogen bonding in bacterial membrane interactions

The important role of hydrogen bonding in the interactions of cationic-amphiphilic polymers with bacterial membranes has been reported.

Biomimetic antibacterial polymers, the functional mimics of antimicrobial peptides (AMPs), targeting the bacterial cell membrane have been developed to combat the problem of antibiotic resistance. Amphiphilicity, a balance of cationic charge and hydrophobicity, in these polymers has been shown to be pivotal for their selective interactions with anionic lipid membranes of bacteria instead of zwitterionic mammalian (human erythrocyte) membranes. However, it is unclear if and to what extent hydrogen bonding in amphiphilic antibacterial polymers contributes to this membrane binding specificity. To address this, we employ isosteric substitution of ester with amide moieties that differ in their potency for hydrogen bonding in the side chains of N-alkyl maleimide based amphiphilic polymers. Our studies reveal that amide polymer (AC3P) is a potent antibacterial agent with high membrane-disrupting properties compared to its ester counterpart (EC3P). To understand these differences we performed bio-physical experiments and molecular dynamics (MD) simulations which showed strong interactions of AC3P including hydrogen bonding with lipid head groups of bacterial model lipid bilayers, that are absent in EC3P, make them selective for bacterial membranes. Mechanistic investigations of these polymers in bacteria revealed specific membrane disruptive activity leading to the delocalization of cell division related proteins. This unprecedented and unique concept provides an understanding of bacterial membrane interactions highlighting the role of hydrogen bonding. Thus, these findings will have significant implications in efficient design of potent membrane-active agents.

A Rare Variety of Adenoid Cystic Carcinoma involving Submandibular Salivary Gland

IntroductionAdenoid cystic carcinoma, an uncommon malignant salivary gland neoplasm, is known for its long clinical course, indolent growth, neural invasion, local recurrence and late distant metastasis. Three distinct histological patterns have been identified, amongst which, solid pattern is the rarest one having the worst prognosis. Materials And MethodsA case of sixty year old male patient presented with a swelling in the left side of the neck, below the jaw gradually enlarging during the last three years. FNAC from the neck swelling was suggestive of benign adenoma of the salivary gland, possibly basal cell adenoma or pleomorphic adenoma. Submandibular gland was excised. Histopathological examination confirmed the solid pattern of adenoid cystic carcinoma, which is the rarest among the three distinct histological subtypes of the malignancy. DiscussionAdenoid cystic carcinoma is well known for its perineural spread. In cases of submandibular gland adenoid cystic carcinoma, surgical wide excision is very much possible and in T1 or T2 cases post-operative radiotherapy may not be needed. In our case, post operative radiotherapy was given for best local control, as the tumour showed histopathlogical solid variety, grade III pattern, which is known to have the worst prognosis.

Universal Neonatal Hearing Screening - a Necessity and not a Choice

INTRODUCTION Congenital deafness in a child is often missed. Several distraction tests have evolved over time to diagnose congenital deafness. These are of limited value in the era of Evoked response audiometry. Evoked responses, such as Oto-acoustic emission (OAE) and Brainstem Evoked Response Audiometry (BERA) have played a significant role in early diagnosis of congenital hearing impairment. The study was conducted to compare the result of neonatal hearing screening in high risk and non high risk neonates.   MATERIALS AND METHODS A study was conducted over a time period of three months at a tertiary care institute to screen all live neonates for congenital hearing impairment using OAE and BERA.   RESULT 1182 neonates were screened for hearing impairment. 336 were in High risk group and rest in Non high risk group. Nine neonates turned out to have abnormal BERA result (absence of wave V). Six of them were high risk babies and rest 3 were non high risk.   DISCUSSION 33.33% of congenital deaf population detected by UNHS belong to the Non High Risk group. Studies across the world suggest at least 50% chance of missing out a congenital deaf child if Universal Neonatal Hearing Screening is not practiced.   CONCLUSION In order to ensure that early detection and effective intervention are made on all newborns with hearing impairment, UNHS should be performed. Three stage UNHS protocol using TEOAEs and BERA showed that the implementation of UNHS for congenital childhood hearing loss among all newborns in India feasible and effective.

Niobium-based superconducting nano-device fabrication using all-metal suspended masks

We report a novel method for the fabrication of superconducting nano-devices based on niobium. The well-known difficulties of lithographic patterning of high-quality niobium are overcome by replacing the usual organic resist mask by a metallic one. The quality of the fabrication procedure is demonstrated by the realization and characterization of long and narrow superconducting lines and niobium-gold-niobium proximity SQUIDs.