Carotid Anomalies and Their Implication in ENT Surgery

Carotid Anomalies are with significant surgical implication to an Otorhinolaryngologist. The authors discuss the evaluation and management of a child with Pierre Robin Syndrome who presented with severe OSA, secondary to bilateral midline carotids that compromised the airway, and an adult with cervical bolus and dysphagia who presented similar to chronic tonsillitis but found to have Retropharyngeal Carotids. This case study emphasizes the need for awareness and a high index of suspicion to identify the variation of the carotid artery in nasopharyngeal and oropharyngeal surgery that has a propensity to result in catastrophic consequences if operated upon.

A Rare Case Report Of Benign Airway Stenosis and Challenges in its Management

Laryngeal stenosis following surgical intervention of larynx is a difficult condition to manage. The extensive adhesions formed between the vocal cords can obstruct the glottis and subglottis region and make decannulation unfeasible. In this report, we describe the challenges faced in the management of Glottosubglotic stenosis formed post Coblation assisted surgery for bilateral abductor cord palsy. The authors emphasize on the prevention techniques and management of laryngeal stenosis with a successful decannulation in such patients.

An Unusual Lesion of Epignathus with Duplicate Tongue and Ranula in a Neonate

We report a rare case of epignathus (oropharyngeal teratoma) in a neonate, who presented with a midline mass covered with skin and multiple hairs protruding from the Palate and associated with bifid tongue and ranula. With the characteristic presentation, diagnosis of oro/oropharyngeal teratoma was made and a massive internet search revealed very few reported cases of "epignathus". It is unfortunate that the survival of such neonates is only moderate. Prenatal scans and follow up in an institution can prepare the multidisciplinary team to save the child. EXIT procedure to excise the mass or secure the airway, with future repair of the palate is the treatment option available. This case report emphasizes the rare clinical presentation of the disease and the prenatal diagnosis of such a condition can help in prompt decision making and management.

Clinical Outcomes of Endonasal Sphenopalatine Artery Cauterization in Endoscopic Sinus Surgery

Endoscopic sinus surgery (ESS) is one of the common ENT surgeries performed. Various techniques are available for reducing the blood loss during ESS. The efficacy of cauterization of the SPA in reducing the per-operative blood loss has not been explored in the literature. This study evaluates the efficacy of SPA cauterization prior to sinus surgery and its per-operative and post-operative outcomes. To study the outcomes of endonasal SPA cauterization in patients undergoing ESS. This is a prospective observational study conducted in a tertiary care centre from October 2018 to October 2020. 30 patients underwent ESS where SPA was cauterized by bipolar diathermy in one side of the nasal cavity and in the contralateral side, SPA was not cauterized. The results were tabulated and compared between the cauterized and non cauterized side. p value < 0.05 was considered as statistically significant. Mean blood loss (p value = 0.20), operating time (p value = 0.19), surgical field grade, post operative Lund Kennedy Score at 1st, 4th and 12th week were compared and the difference between cauterized and non cauterized was found to be statistically insignificant. In this study, endonasal SPA cauterization did not significantly reduce the intra operative bleeding and surgical field grade in patients undergoing ESS. SPA cauterization did not adversely affect the per operative and post operative outcome and hence authors highlight the fact that it can be safely performed in cases where severe intra operative bleeding is expected and its effectiveness can be studied better in such cases.

Endoscopic Transnasal Management of Giant Paediatric Sinonasal Ossifying Fibroma

The ossifying fibroma is a rare fibro-osseous benign lesion of bone in the head and neck region. The mandible is the most common site reported followed by maxilla and other bones of the skull. A paediatric male presented with protrusion of the right eyeball for one-month duration. Further evaluation by diagnostic nasal endoscopy revealed a smooth mass confined to the superior and middle meatus on the right side. Computed tomography of paranasal sinus showed a large heterogenous bony lesion involving the ethmoid and sphenoid sinus and extending laterally into the orbit and superiorly into anterior skull base. Endoscopic biopsy was suggestive of ossifying fibroma. Transnasal endoscopic excision of the lesion was done and the patient is currently on follow-up. This case is reported for the rarity of presentation and the difficulties in management.

Cholesteatoma extending into the sternocleidomastoid muscle presenting as a Bezold abscess

Cholesteatoma is a non-neoplastic cystic lesion arising in the middle ear cleft with the propensity to spread and recur after surgery, but it is unusual to find cholesteatoma invading sternocleidomastoid muscle after 15 years of modified radical mastoidectomy and presenting as Bezold abscess. In this report, the authors highlight the fact that cholesteatoma recurrence if neglected can present as a Bezold abscess with the invasion of cholesteatoma from the mastoid tip into the sternocleidomastoid muscle. This requires complete excision of the cholesteatoma sac along with the surrounding soft tissue.

Acute Fulminant Mucormycosis Triggered by Covid 19 Infection in a Young Patient

Covid 19 infection can result in various opportunistic infections. Altered immune response, associated comorbid conditions like diabetes, prolonged steroid and broad spectrum antibiotics usage with ICU interventions lead to increased chance of such superadded infections in covid 19 patients. Here we report a case of 31 year old male with covid 19 infection who had new onset Diabetes Mellitus, developed severe acute fulminant Mucormycosis during the treatment for covid 19 infection. He presented with severe headache, nasal obstruction and discharge, bilateral ophthalmoplegia and blindness with Cavernous Sinus Thrombosis. Patient underwent aggressive surgical debridement with frontal craniectomy, maxillectomy and right orbital evisceration and left endoscopic orbital decompression and judicious efforts to revert back the immunocompromised status with high dose of Liposomal amphotericin. Post operatively patient developed right temporal lobe abscess which was drained through Endonasal Endoscopic Trans Cavernous drainage of Temporal Lobe Abscess. Patient is in 2 months follow up, with bilateral blindness and tolerating oral feeds with improved left eye ophthalmoplegia. It is imperative to note that the rising trend of mucormycosis is there in Covid 19 infections and it should be dealt with high index of suspicion in high risk patients and early aggressive treatment can save the patient as the survival rate is not high in such infections.

Exploring the role of macular thickness as a potential early biomarker of neurodegeneration in acute schizophrenia

OBJECTIVE

The retina has been investigated as a gateway to assess the neurodegenerative changes in the brain. Schizophrenia is also conceptualized as a neurodegenerative disorder like Alzheimer's and Parkinson's disease. The current literature suggests reduced retinal nerve fibre layer (RNFL) thickness and macular thickness (MT), as a marker of neurodegeneration, in patient suffering from chronic schizophrenia. This study aims to compare RNFL thickness and MT in acute schizophrenic patients with age and sex matched healthy controls.

METHODS

Twenty acutely ill schizophrenic patients and 20 normal controls were included in the study after proper informed consent. RNFL thickness and MT was measured using spectral domain Optical Coherence Tomography after clinical psychological assessment and ocular examination.

RESULTS

The two groups were comparable in terms of socio-demographic variables. The average RNFL thickness of patients and healthy controls was 102.11 ± 29.18 µm and 105.14 ± 27.35 µm, respectively. Central macular thickness was 181.12 ± 13.63 µm in patients and 234.58 ± 10.71 µm in controls. There was a statistically significant reduction in thickness of macula (p < 0.05) but not for RNFL (p = 0.339).

CONCLUSION

The study concludes that macular thinning rather than reduced RNFL is an early manifestation in acute schizophrenia patients and can be considered as a potential early biomarker of neurodegeneration in schizophrenia.

Necrotising fasciitis following accidental injection of intraoral xylene: a preventable medication error

The most common cause of preventable mortality and morbidity to the patient in a healthcare system is medication error. Medication errors have got a significant impact on the patient health and healthcare system. These errors are multidisciplinary and can occur at various stages of drug therapy. Physicians, nursing staff, pharmacists, hospital administration all have an important role in preventing medication errors from recurring. The most common causes include wrong patient, wrong drug prescription, look-alike sound-alike drugs, faulty drug administration, wrong dosage, drug storage, delivery problem, lack of staff, patient and physician education and failure to monitor closely. This case illustrates the importance of incorporating protocol and cross-checking before administering a drug during the procedure. Here, we discuss a case of accidental intraoral injection of xylene instead of xylocaine (local anaesthetic agent), which was a sound-alike drug that resulted in significant morbidity to the patient.

A Rare Case of Primary Tuberculous Otitis Media with Bezold's Abscess

Tuberculous Otitis Media is a rare clinical presentation. The signs and symptoms are variable that leads to delayed diagnosis and treatment. Persistent ear discharge not responding to topical and systemic antibiotics should be considered for investigation of tuberculosis. We report a case of Primary Tuberculous Otitis Media who presented with Bezold's Abscess. Patient underwent Mastoidectomy. Diagnosis was made with the Histopathological examination of the suspicious extensive pale granulation tissue. Patient was started on ATT immediately. Greater awareness regarding the disease is needed to make an early diagnosis. Late diagnosis increases the risk of complications. Anti Tubercular Therapy is the treatment of choice. Surgical intervention may be added to drug therapy. In cases with complications, radical surgery will be needed. Bezold's abscess is a rare complication of Otitis Media. CT imaging should be considered in suspected neck abscess patients with history of ear discharge to rule out aural cause of abscess.

Low FODMAP in 2017: Lessons learned from clinical trials and mechanistic studies

Given the prevalence of irritable bowel syndrome (IBS) and the suboptimal response to most therapeutic approaches, there has been increasing interest in and adoption of dietary treatment strategies, such as the low Fermentable Oligo-, Di-, & Mono-Saccharides and Polyols (FODMAP) diet. FODMAPs are a diverse group of carbohydrates that exert effects in the gastrointestinal tract not only via fermentation but likely via alterations in the microbiota, metabolome, permeability, and intestinal immunity as well. Clinical evidence for efficacy of this diet is mounting, but there are significant questions regarding short- and long-term safety and effects on the microbiota and nutrition that remain unanswered. This review article interprets the recent findings reported in this issue of Neurogastroenterology and Motility and summarizes the mechanistic and clinical efficacy data of the low FODMAP diet in IBS patients to date.

Limited hepatitis B immunoglobulin with potent nucleos(t)ide analogue is a cost-effective prophylaxis against hepatitis B virus after liver transplantation

BACKGROUND

Prophylaxis against hepatitis B virus (HBV) recurrence after orthotopic liver transplantation (OLT) includes lifelong hepatitis B immunoglobulin (HBIG) and oral antiviral agent(s). In the presence of high-genetic-barrier nucleos(t)ide analogues, the need for lifelong HBIG is questioned. We evaluated the safety and cost-effectiveness of a limited HBIG course.

METHODS

OLT from 2006 to 2013 were reviewed. Patients with pre-OLT hepatitis B virus surface antigen who received HBV prophylaxis with 2 HBIG doses (anhepatic and first post-operative day; 10,000 units/dose) and potent nucleos(t)ide analogues were included. The primary end point was HBV recurrence (HBV-DNA detection).

RESULTS

Thirteen patients (primary transplants) were included, median Model for End-Stage Liver Disease score was 18, and there was no fulminant failure; HBV-DNA was detected in 4 patients at OLT. After OLT, 10 patients received entecavir and/or tenofovir. Median follow-up was 23 months. One recurrence occurred (7.7%) at month 13 (HBV-DNA: 14 IU/mL); the graft maintained excellent function. This minimal viremic expression is related to hepatocellular carcinoma recurrence with neoplastic replication carrying integrated HBV-DNA; thus, there is no defined HBV viral recurrence. No graft loss or patient death was related to HBV recurrence. The 1-year patient and graft survival rate was 84.6%. Cost-savings in the first year was $178,100 per patient when compared with Food and Drug Administration-approved HBIG dosing.

CONCLUSIONS

In the era of potent oral nucleos(t)ide analogues, a limited HBIG course appears to be cost-effective in preventing HBV recurrence.

Development of chitosan conjugated DNA vaccine against nodavirus in Macrobrachium rosenbergii (De Man, 1879)

The protective efficacy of a DNA construct containing extra small virus antisense (XSVAS) gene of nodavirus encapsulated with chitosan nanoparticles (NPs) was investigated in giant freshwater prawn Macrobrachium rosenbergii (De Man, 1879). The delivery was carried out using oral and immersion methods. A plasmid concentration of 100 ng μL(-1) when conjugated with chitosan NPs was found to be more effective in increasing the survivability of the infected prawn. The particle mean size, zeta potential and loading efficiency percentage were 297 nm, 27 mV and 85%, respectively. The ability of the chitosan to form a complex with the plasmid was studied by agarose gel electrophoresis. The NPs were characterized by atomic force microscopy (AFM). Persistence study showed the presence of the DNA construct up to 30th day post-treatment. The oral treatment was found to be better than the immersion treatment for delivery of the chitosan-conjugated DNA construct. This is probably the first report on the delivery of nanoconjugated DNA construct in M. rosenbergii, against nodavirus.

A COMPARATIVE STUDY OF MMPI PROFILES OF PSYCHIATRIC PG's v/s MEDICAL PG's

MMPI profiles of 10 psychiatric PG's have been compared with 10 medical PG's. The findings are discussed statistically and otherwise. Both the groups fall within the range of normal. Some interesting findings are not unexpected, if a larger section of population could be studied preferably over a span of few years.

A turbidimetric method for the screening of amylase-producing mutants of Aspergillus niger

The method is based on the assumption that extracellular amylase, which is produced by strains of Aspergillus niger in liquid culture, hydrolyses the starch in the media and brings about a corresponding decrease in the turbidity of the media. Mutant strains which produced different quantities of amylase exhibited different degrees of decrease in turbidity of the media. The results showed that a greater degree of decrease in turbidity was observed for a higher quantity of amylase produced.