Kerala Journal of ENT and Head & Neck Surgery
Deep Lingual Abscess Involving Extrinsic Tongue Muscles Without Visible Swelling: A Diagnostic and Airway Challenge
Lingual abscesses are rare infections that may present without overt mucosal swelling, particularly when involving deep extrinsic tongue musculature. These atypical cases pose significant diagnostic and airway management challenges. Case report: A 54-year-old male presented with fever, odynophagia, and painful tongue movements without visible swelling. Contrast-enhanced computed tomography (CECT) revealed a deep lingual abscess involving the extrinsic muscles. The patient underwent transoral surgical drainage and was treated with intravenous antibiotics, resulting in rapid clinical improvement. Conclusion: A high index of suspicion, supported by prompt imaging, is critical for diagnosing deep lingual abscesses. Early surgical intervention prevents airway compromise and ensures favorable outcomes.
Giant Submandibular Sialolith (Megalith): A Rare Case Report
Background: Submandibular sialolithiasis is the most common salivary gland disorder. Giant sialoliths, also termed megaliths, are rare and pose diagnostic and surgical challenges, particularly in elderly or medically compromised patients. Case Presentation: A 76-year-old male presented with a massive right submandibular duct sialolith measuring 5.5 × 3 × 2.5 cm and weighing 32 g. The patient had multiple comorbidities including atrial fibrillation, pulmonary hypertension, chronic obstructive pulmonary disease, and dementia. Due to high anaesthetic risk, the stone was successfully removed through an intraoral approach under local anaesthesia. Conclusion: This case highlights that even very large submandibular megaliths can be safely and effectively managed via an intraoral approach under local anaesthesia in carefully selected high-risk patients.
Seromucinous hamartoma (SMH) is a rare benign glandular lesion of the sinonasal tract that can clinically and histologically mimic more aggressive neoplasms. We report a case of SMH in a 32-year-old male presenting with unilateral nasal obstruction and snoring, that was initially misdiagnosed as antrochoanal polyp. The lesion was excised endoscopically, and histopathology confirmed the diagnosis. There has been no recurrence at 3 months. This report highlights the importance of considering seromucinous hamartoma in the differential diagnosis of unilateral nasal masses.
Beyond the Bone: Extramedullary Plasmacytoma as a Rare Otorhinolaryngological Surprise in Multiple Myeloma
Extramedullary plasmacytoma (EMP) is an uncommon manifestation of Multiple Myeloma that may involve the nasal cavity and paranasal sinuses. We report a case of a known Multiple Myeloma patient on chemotherapy presenting with a nasal mass. EMP in the sinonasal region is clinically significant due to its varied presentation and resemblance to common nasal pathologies. Radiological findings were non-specific, highlighting the diagnostic challenge in such cases. Biopsy confirmed Plasmacytoma. EMP may indicate disease progression or relapse of Multiple Myeloma. This case underscores the importance of including EMP in the differential diagnosis of vascular or atypical nasal masses to ensure timely diagnosis, appropriate management, and improved prognostic assessment, particularly from an ENT perspective.
Diagnostic Spectrum of Cervical Lymph Node Biopsy: A Retrospective Study from a Tertiary Cancer Centre in South India
Background: Cervical lymphadenopathy is common, and its causes range from benign infection to malignancy. Fine-needle aspiration cytology (FNAC) is usually the first investigation, but when the yield is poor or nodal architecture is required, tissue biopsy becomes necessary. Objective: To describe the histopathological spectrum of cervical lymph node biopsies at a tertiary cancer centre in South India and to assess the diagnostic yield and safety of the procedure. Methods: We retrospectively reviewed the records of all patients who underwent cervical lymph node biopsy over a 2-year period. Demographic characteristics, preoperative imaging findings, biopsy technique, nodal level, type of anaesthesia, histopathological diagnosis, and postoperative complications were recorded and analysed descriptively. Results: Seventy patients were studied (mean age 55.1 ± 18.5 years; 54.3% male). Excision biopsy was used in 91.4% and wedge biopsy in 8.6%, and malignancy was suspected clinically in 90% before biopsy. PET-CT was performed in 77.1%, and level V was the node most often sampled (35.7%). Malignancy was confirmed in 40 patients (57.1%) and benign disease in 30 (42.9%). Benign disease was led by tuberculosis (n = 11) and reactive hyperplasia (n = 9). Among the malignant diagnoses, lymphoma was the commonest (n = 14), followed by metastatic carcinoma from the lung, head and neck, thyroid, breast, cervix and kidney, with a single follicular dendritic cell sarcoma. Complications were minor and occurred in 10%. Conclusion: Cervical lymph node biopsy is a safe, high-yield procedure when FNAC is inconclusive. Tuberculosis and lymphoma dominated, reflecting the region’s twin burden of infection and malignancy, and immunohistochemistry was central to reaching a diagnosis.
Biomechanical Analysis and Occupational Health Strategies in Otorhinolaryngology: A Systematic Narrative Review
Background: The surgical profession in Otorhinolaryngology (ENT) is currently facing a “silent epidemic” of work-related musculoskeletal disorders (WRMDs), which significantly threatens practitioner longevity and patient safety. Objective: This analysis provides a comprehensive examination of the ergonomic landscape in otorhinolaryngology, focusing on the synthesis of epidemiological data, biomechanical mechanisms of injury (specifically prolonged static postures), and evidence-based interventions required to sustain a surgical career. Results: The cervical spine is the most vulnerable anatomical region for ENT specialists, with some surveys reporting a lifetime prevalence of neck complaints as high as 92.53%. Female surgeons face a disproportionately high risk due to anthropometric challenges, such as instruments designed for the average male hand. Conclusion: A sustainable transition to ergonomic excellence requires a multi-level strategy at the individual level, the educational level and the institutional level.
What the Temporal Bone has Always Known History, Evidence, and the Quiet Correction of Received Wisdom in Otologic Surgery
Much of what has been taught and practised in chronic otitis media surgery over the past century was not evidence-based. It was consensus-based — a set of received positions transmitted from teacher to trainee with the authority of tradition rather than data. The dry ear prerequisite. The mandatory mastoidectomy. The uncritical preference for one canal wall strategy over another. Each has been challenged by evidence, and each has proved more fragile than its proponents believed. This article argues that this pattern is intrinsic to the history of temporal bone surgery, which has always been conducted at the intersection of what surgeons believed and what the bone eventually demonstrated. The figures who built modern otologic surgery were, at their best, willing to follow the evidence wherever it led — including away from their own most influential work. That disposition is what the current generation of otologic surgeons most needs, and what the history of this discipline most clearly models.
Genetics and Gene based Therapies: Emerging Horizons in the Management of Hereditary Hearing Disorders in India
Hearing loss remains a major public health concern in India, with congenital and early onset hearing impairment contributing significantly to long term disability, educational disadvantage and socio-economic burden. A substantial proportion of these cases are hereditary, yet clinical management has traditionally focussed on rehabilitation rather than etiological treatment. Rapid advancement in human genetics and gene based therapies are now poised to transform this landscape, offering Indian otolaryngologists an opportunity to move forward precision driven and potentially curative interventions.
Competency Based Medical Education (CBME) – The ENT Perspective
It was in 1997 that Graduate Medical Education Regulations were last introduced by the Medical Council of India. With more than a decade and a half elapsing since those regulations came into force, there was a need for a relook. With the aim of creating a medical graduate competent to serve the community after successful completion of the undergraduate medical course, the Medical Council of India revamped the medical education system in India to one of Competency Based Medical Education. After about four years of work on it by committed medical teachers from across the country, the curriculum was implemented from the 2019 batch of students. This brought about a paradigm shift in Medical Education in the country.
Blunt Cerebrovascular Injury with Delayed Ischemic Stroke - A Case Report with Discussion on Diagnosis and Management
Blunt cerebrovascular injury(BCVI) can cause devastating morbidity and mortality. The problem with BCVI is that most physicians and health workers are not aware of this condition. It can present with periods of a varying time frame of about 12 to 36 hours or as late as 1 week after trauma. This may result in the complacent attitude of health workers that all is well given the initial normal finding in CT. This article aims at highlighting the importance of early diagnosis and treatment, to prevent and halt the progression of the injury into stroke and its resultant morbid consequences. This case report is that of a young male patient who came to the casualty with a history of assault and neck injury. He was hemodynamically stable and was managed with suturing of the wound. Initial imaging did not reveal any vessel injury, but he developed a stroke 36 hours later. A brief commentary on causes, presentation, early diagnosis, and management is described.
Nervus Intermedius Neuralgia With Vestibular Paroxysmia -A Rare Combination of Nerve Compression Syndromes
Introduction: Posterior cranial fossa nerve compressions in a rare combination are discussed here. Case Reports: 51 year old male with intractable vertigo, vomiting and left ear ache, had left spontaneous nystagmus. Another 25 year old female had recurrent ear ache and vertigo. Both MRI Brain showed compression of VII/VIII nerve complex in the cistern. They were given Ox carbamazepine with supportive therapy tapered with no recurrence in past 1 year. Discussion: The combination of the 7th and 8th cranial neuralgias presents with common symptomatology. The investigation of choice is HR T2 weighted MRI brain (CISS/FIESTA SPACE sequence), treated medically. Surgically, decompression or nerve sectioning are done. Conclusion: Though rare due to different positions of the nerve entry/exit zones of these nerves, this combination of posterior cranial fossa nerve compression syndromes can coexist. Diagnosis can help in the proper management of such patients and even open the horizon for surgical options in recalcitrant cases.
Mucocele Beyond Frontal Sinus: A Case Report
Unilateral maxillary sinusitis with a dental origin is a commonly seen condition both in the otorhinolaryngology and dental outpatient settings. Failure to recognize Odontogenic Maxillary Sinusitis (OMS) can cause intractable sinusitis leading to grave complications.
“THE BROKEN TOOTH” – Case Series on Unilateral Maxillary Sinusitis
Unilateral maxillary sinusitis of dental origin is a common condition encountered in both otorhinolaryngology and dental practice. Failure to recognize odontogenic maxillary sinusitis (OMS) may result in persistent or intractable sinusitis with potentially serious complications. This article presents a case series of four patients with unilateral maxillary sinusitis of odontogenic origin. The cases involved retained or broken teeth acting as foreign bodies within the maxillary sinus or untreated dental pathology. Patients were managed with functional endoscopic sinus surgery (FESS), removal of the offending dental pathology, and appropriate antibiotic therapy, leading to symptomatic improvement. The authors emphasize the importance of considering odontogenic causes in patients presenting with unilateral sinonasal symptoms and highlight the need for combined ENT and dental management to prevent recurrence.
Case Series on Covid Associated Mucormycosis
Mucormycosis is a rare fungal infection. The rapid increase in the number of cases of mucormycosis during the second wave of COVID-19 led to the recognition of a new entity called COVID-Associated Mucormycosis (CAM). This case series discusses seven cases of CAM that presented during the second wave of COVID-19, describing their clinical features, investigations, treatment, complications, and follow-up. The male-to-female ratio was 4:3, with a mean age of 57.85 years. The average interval between COVID-19 infection and the onset of mucormycosis symptoms was 2 weeks. All patients had diabetes mellitus, and three had cerebral involvement. All underwent surgical debridement followed by antifungal therapy. The mortality rate was 42.86%, comparable with rates reported in the literature. This is reported as the first case series on COVID-associated mucormycosis from a government hospital in Kerala.
A Beginners Guide to Approaching a Patient with a Perforated Tympanic Membrane
Perforations of the tympanic membrane are among the most everyday presentations to an otolaryngologist. Whilst many heal without treatment, there are some which need surgical closure. There have been so many ways to do this, and overall can be bewildering to a young Otologist. The article summarizes the most pertinent do’s and don’t’s to achieve a good result and how to maintain that over the years. The article is the result of many years work of by the author, a busy practising otologist for the last three decades.
Clinical Analysis of Techniques and Complications in 414 Consecutive Cochlear Implantations
Aim: To report the frequency of surgical complications following 414 consecutive cochlear implant surgeries (402 children and 12 adults), compare standard and minimal access incisions, and evaluate the feasibility of using the minimal access approach for all cochlear implant candidates. Methods: A retrospective analysis of patients who underwent cochlear implantation between February 2012 and February 2019 by a single surgeon at a single center. Patients: The study included 414 consecutively implanted patients (323 standard incision and 91 minimal access incision). Demographic characteristics, surgical approaches, incision sizes, and operative details were analyzed. Results: Among 414 patients, there were 30 surgery-related complications (12 major and 18 minor) and 11 device-related complications. Major complications included wound infection, device extrusion, electrode displacement, temporary cerebrospinal fluid (CSF) leak, and magnet displacement. Minor complications included transient facial paresis, vertigo, seroma, hematoma, and tinnitus. The overall complication rate (9.6%) was low compared with published literature. Clinical Significance: Cochlear implantation is a low-risk procedure when performed by an experienced surgeon following standard protocols. The minimal access incision offers reduced morbidity, improved cosmetic outcomes, and adequate surgical exposure without compromising essential operative steps.
Hearing Devices and Ear Care in Children and Young Adults
Use of personal listening devices had tremendously increased in the recent times. The technology for such devices had a quantum leap with the advent of wire-less and blue tooth technology. From cassette players to mobile phone compatible earbuds, the transition has been a drastic one. Health problems posed by these devices are also on the increase. COVID pandemic made us shut inside our room and dependent on these gadgets. The concern for the health hazards caused by these devices need to be addressed.
Identification of the Most Common Odours Recognizable in the South Indian Community: A Preliminary Survey
Background: There is increasing medical evidence regarding olfaction disorders being a key to the diagnosis of diseases. However, there is a lack of a simple kit that can test the sense of smell in local populations, specifically the South Indian population. Method: A questionnaire was created and disseminated to a random cross-section of people domiciled in South India to obtain a list of commonly recognized smells (odourants). The responses were then collated and analysed. Results: Responses were obtained from 135 individuals, yielding a total of 651 odourants after refinement. Jasmine and Coffee emerged as the two most commonly recognized odourants, along with many other locally familiar smells reflecting the South Indian community. Conclusions: There is a need to develop an olfaction testing kit using odourants that are readily identifiable by the target population. This preliminary survey successfully identified a suitable set of odourants for use in the South Indian population.
Necrotising Fasciitis Complicating Rhino Orbito Cerebral Mucormycosis – A Case Report
Introduction: Mucormycosis became a common life-threatening fungal infection during the COVID-19 Delta variant wave in India. These fungi have an intrinsic ability to invade blood vessels. Rhino-orbito-cerebral mucormycosis is the most common and most aggressive form of mucormycosis. Uncontrolled metabolic conditions, especially diabetes mellitus with ketoacidosis, are the principal risk factors, and mortality remains high (30–70%) despite advances in diagnosis and treatment. Clinical Discussion: This report describes the first documented case of monomicrobial necrotising fasciitis caused by Pseudomonas aeruginosa secondary to rhino-orbito-cerebral mucormycosis. The authors detail the patient's management, including extensive surgical debridement, prolonged antifungal and antibiotic therapy, reconstructive procedures, and the challenges posed by multidrug-resistant Pseudomonas infection.
Diffuse Large B Cell Lymphoma Mimicking Ulceroproliferative Lesion
Introduction: The oropharynx contains abundant lymphoid tissue, particularly in the palatine and lingual tonsils, which form the anterolateral components of Waldeyer's ring. Lymphomas arising in the oropharynx are almost exclusively Non-Hodgkin lymphoma and originate from lymphoid tissue. Methods: A case of a 69-year-old male with Non-Hodgkin lymphoma of the oropharynx is presented, discussing the clinical features, radiological findings, histopathological findings, and management. Discussion: Most patients with Non-Hodgkin lymphoma present with neck swellings. Although infections and inflammatory conditions may also cause lymphadenopathy, timely clinical examination and appropriate investigations facilitate early diagnosis and treatment. Results: The patient presented with neck swelling, odynophagia, and dysphagia, clinically mimicking oropharyngeal squamous cell carcinoma. Punch biopsy confirmed Diffuse Large B Cell Lymphoma (DLBCL). Chemotherapy using the R-CHOP regimen was initiated, but the patient succumbed to the disease because of its poor prognosis. Conclusion: Non-Hodgkin lymphoma of the oropharynx can mimic squamous cell carcinoma. Improved patient awareness and earlier detection may reduce mortality. DLBCL carries a poor prognosis.
Olfactory Groove Meningioma – A Case Report
Introduction: Olfactory groove meningiomas are rare anterior cranial fossa meningiomas, constituting 8–13% of all intracranial meningiomas. Case Report: A 54-year-old female presented with left-sided sensorineural hearing loss, ipsilateral trigeminal nerve involvement, and impaired cerebellar function tests. She also had absent smell sensation for the previous 2–3 years, although this was not her primary complaint. MRI demonstrated a left cerebellopontine angle lesion and an incidental olfactory groove lesion suggestive of meningioma. The CP angle tumour was excised initially, while the olfactory groove meningioma was followed radiologically. Progressive enlargement of the lesion prompted endoscopic transnasal excision. The postoperative period was uneventful. Conclusion: Complete surgical excision remains the definitive treatment for skull base meningioma. The endoscopic transnasal approach offers lower morbidity than traditional open approaches when appropriate patient selection is ensured. The case also emphasizes the importance of evaluating patients presenting with anosmia, a symptom that may otherwise be overlooked.
The Extent of Thyroidectomy in Differentiated Thyroid Cancers – Revisited with Evidence
Differentiated thyroid carcinoma (DTC) is the most common endocrine malignancy, with papillary thyroid carcinoma accounting for the majority of cases. Although the incidence of DTC has increased worldwide, mortality has remained relatively stable, raising concerns regarding overdiagnosis and overtreatment. The extent of thyroidectomy remains a matter of debate, particularly for low-risk tumors measuring 1–4 cm. This review summarizes the available evidence comparing thyroid lobectomy and total thyroidectomy, discussing recurrence, survival, complications, radioactive iodine therapy, completion thyroidectomy, and the role of molecular testing. The authors conclude that treatment should be individualized using a risk-based approach as recommended by the American Thyroid Association, balancing adequate oncologic treatment with avoidance of unnecessary morbidity.
Background: There is increasing medical evidence regarding olfactory disorders as important indicators of disease. However, there is a lack of a simple olfaction testing kit suitable for the South Indian population. Method: A questionnaire was created and distributed to a random cross-section of individuals domiciled in South India to identify commonly recognized odours. The responses were collated and analyzed. Results: Responses were obtained from 135 individuals, yielding 651 odourants after data refinement. Jasmine and Coffee were the two most frequently recognized odourants, along with several other odours reflecting the local characteristics of the South Indian population. Conclusions: There is a need to develop an olfaction kit using odourants that are readily recognized by the target population. This preliminary survey successfully identified a suitable set of odourants for the South Indian community.
A Descriptive Study of Aetiology of Dysphonia in A Voice Clinic
Background: Dysphonia is an alteration in normal voice quality due to structural and/or functional causes. It may result from benign or malignant organic pathology, functional disorders such as muscle tension dysphonia and puberphonia, or neurological conditions including unilateral vocal cord palsy and spasmodic dysphonia. Method: This retrospective descriptive study included all patients presenting with dysphonia to the voice clinic at PRS Hospital, Thiruvananthapuram, during 2022. All patients underwent flexible fibreoptic laryngoscopic examination, often supplemented with stroboscopy or narrow-band imaging (NBI). Age, sex, and laryngoscopic diagnosis were analysed. Results: Most patients were between the fourth and seventh decades of life, with the highest frequency in the 60–69-year age group, followed by the 40–49-year group. The male-to-female ratio was approximately 1.41:1. As a tertiary referral voice clinic, unilateral vocal cord palsy was the most common cause of dysphonia, followed by Type I muscle tension dysphonia and spasmodic dysphonia. Conclusion: Dysphonia has a wide spectrum of causes ranging from unilateral vocal cord palsy and adductor spasmodic dysphonia to sulcus vocalis and submucous cleft palate. Thorough history-taking, clinical examination, and endoscopic evaluation using chip-on-tip flexible laryngoscopy are essential for accurate diagnosis of the underlying aetiology.
Long-Term Outcomes in Obstructive Salivary Gland Disease due to Calculus after Sialendoscopy
Background: The introduction of sialendoscopy has brought about a paradigm shift in salivary calculi management. Objectives: To assess the long-term outcomes of sialendoscopy in obstructive salivary gland disease due to calculi. Methods: This prospective observational study included 65 patients with sialolithiasis who underwent interventional sialendoscopy. Subjective assessment of salivary gland function was performed preoperatively and at the first, sixth, and twelfth postoperative months using the Chronic Obstructive Sialadenitis Symptoms (COSS) Questionnaire. Results: Interventional sialendoscopy for sialolithiasis produced statistically significant improvement in COSS scores at all stages of evaluation. Conclusions: Long-term follow-up demonstrated sustained positive outcomes for sialolithiasis up to one year after the procedure. These findings support salivary gland preservation through sialendoscopy and highlight the need for wider availability of this technique.
Mobile phone has become a necessity in our day-to-day lives. More than a luxury, the utility of a mobile phone has increased considerably. There are over 6 billion mobile users in the world with India ranking only second to China. The scope of technology has widened tremendously. The impact of this on the practice of otolaryngology cannot be undermined. Mobile health (mHealth) has been defined as medical and public health practice supported by mobile devices, such as mobile phones, patient monitoring devices and personal digital assistants. Mobile health (mHealth) has a lot of applications in otorhinolarygology, when they are designed scientifically and validated by medical experts.
An Endoscopic Transoral Approach to Parapharyngeal Space
Surgical approaches to the parapharyngeal space are challenging, and selecting the appropriate surgical approach is key to a successful operation. Literature regarding the endoscopic transoral approach to the parapharyngeal space is limited. This article presents two different parapharyngeal space conditions that were successfully managed using an endoscopic transoral approach, demonstrating its feasibility and effectiveness in appropriately selected cases.
Rare Case of Nasal Polyp: Inflammatory Myofibroblastic Tumor
Inflammatory myofibroblastic tumor (IMT) is a rare tumor with a variable natural history and biologic behavior, ranging from completely benign to malignant with a fatal outcome. It is an uncommon, presumably benign (non-cancerous) tumor composed of myofibroblastic spindle cells.
Nasolacrimal Duct Primary B Cell Lymphoma – A Case Report
Non-Hodgkin lymphoma (NHL) is a type of haematological malignancy originating from lymphocytes. NHL involving the nasal cavity and paranasal sinuses is rare. This case report emphasizes the importance of careful clinical history, examination, and appropriate management protocols to avoid missing this uncommon but potentially life-threatening disease. A middle-aged woman presented with left-sided epiphora of one year's duration. Initial imaging suggested a mucocele causing nasolacrimal duct obstruction; however, biopsy with immunohistopathological examination demonstrated diffuse large B-cell lymphoma involving the nasolacrimal duct.
Sarcoidosis Masquerading as Parotid Gland Disorder: A Unique Clinical Scenario
Sarcoidosis is a multifaceted systemic disorder characterized by granulomatous inflammation, often presenting with diverse clinical manifestations. Parotid gland sarcoidosis is a rare manifestation of sarcoidosis. This case study presents a 40-year-old woman with bilateral parotid and lacrimal gland swelling and describes her subsequent diagnostic evaluation, biopsy findings, and treatment, highlighting the complexities involved in diagnosing and managing this uncommon presentation. Through this detailed case, the authors contribute to the understanding of the varied clinical manifestations of sarcoidosis and emphasize the importance of recognizing atypical presentations.