Kerala Journal of ENT and Head & Neck Surgery
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.
Vocal Fold Cysts: An Analysis of Flexible Fibreoptic Laryngoscopic Findings
Vocal fold cysts are benign laryngeal lesions that affect both children and adults. Diagnosis is established using flexible laryngoscopy and videostroboscopy. This retrospective study analysed videos of flexible laryngoscopic findings from 84 cases of vocal fold cysts. Most patients were adults, and almost all cysts were unilateral. The most common site of origin was the medial margin of the vocal folds. Thin-walled and thick-walled cysts occurred with nearly equal frequency. On videostroboscopy, mucosal waves were absent over the cysts in all cases, with hourglass-shaped phonatory gaps being the most common finding. Ventricular band hyperadduction (Type 2 muscle tension dysphonia) was the most frequent compensatory maneuver. Interarytenoid pachydermia was present in approximately 70% of patients, indicating a strong association between vocal fold cysts and laryngopharyngeal reflux.
Effectiveness of Pulse Steroid Therapy in Idiopathic Sudden Sensorineural Hearing Loss – A Prospective Study
Objective: To study the role of an initial high dose of intravenous steroids in patients with idiopathic sudden sensorineural hearing loss. Study Design: A prospective case series of 20 patients presenting to the Department of Otorhinolaryngology, Jubilee Mission Medical College, with idiopathic sudden sensorineural hearing loss. All patients were treated using the same protocol of initial high-dose intravenous steroids. Results: Of the 20 patients, 5 showed complete recovery, 10 showed slight improvement, and 4 showed no improvement according to Siegel’s criteria. One patient was lost to follow-up. The mean improvement in hearing was 19.663 dB. No differences in outcome were observed with respect to age, sex, tinnitus, or vertigo. Conclusion: Initial steroid therapy is the recommended treatment for idiopathic sudden sensorineural hearing loss according to the 2019 AAO-HNS guidelines, although the optimal dose and route are not specified. The study protocol of initial pulse steroid therapy achieved a recovery rate exceeding the expected spontaneous recovery rate. The presence of vertigo or tinnitus did not indicate a poorer prognosis. Significance: Initial high-dose intravenous steroid therapy may contribute to improved hearing recovery rates.
Vertigo Clinic – Our Departmental Experience
Background: Vertigo, dizziness, unsteadiness, and falls are common symptoms encountered in clinical practice. Detailed evaluation is necessary for accurate diagnosis, and vertigo clinics equipped with videonystagmography facilitate appropriate diagnosis and management. Aims and Objectives: To determine the age and gender distribution of patients attending the vertigo clinic; identify the various causes of vertigo and the most common etiology; classify benign paroxysmal positional vertigo (BPPV) subtypes; evaluate the corrective maneuvers used and their success rates; and describe non-BPPV causes of vertigo encountered in the clinic. Materials and Methods: A retrospective study was conducted on patients attending the Rajagiri Vertigo Clinic between 3 May 2021 and 3 May 2022. Patients were evaluated according to the departmental protocol. Statistical analysis was performed using the Chi-square test. Results: Females constituted the majority of patients. BPPV was the commonest cause of vertigo, accounting for 85.425% of cases. Posterior canal BPPV was the most frequent subtype, followed by lateral and anterior canal BPPV. The success rates of corrective maneuvers were 98% for Epley's maneuver, 99% for the Barbeque roll maneuver, and 100% for the Yacovino/Bangalore maneuver. Non-BPPV cases included both peripheral and central causes. Conclusion: Vertigo clinics equipped with videonystagmography significantly improve the diagnosis and management of vertigo and facilitate comprehensive evaluation of patients.
Do I Have Thyroid Cancer: Should Everyone Ask This Question?
“Do I have a thyroid cancer?” If everyone asks this question and starts a screening, we would be detecting more and more thyroid cancers. That is the impact of screening which may not have any survival benefit rather more economic burden, health resource utilization and more complications, as was seen in the Korean population. Thyroid cancer diagnosis is increasing over the decades worldwide as well as in India due to various factors which includes overdiagnosis by imaging. Is there a real increase in thyroid cancers due to some environmental factors, is a question to ponder!
Migration Beyond Imagination – A Case Report
Coins, bones, food bolus, etc. are some of the common foreign bodies that can become impacted in the throat. Occasionally, unusual foreign bodies may become impacted in unusual anatomical sites. The main aim of this report is to highlight foreign body impaction at an uncommon location. The authors present the case of a patient with a fish bone that migrated into the superficial lobe of the parotid gland, emphasizing the importance of appropriate imaging, timely diagnosis, and surgical management to achieve a complication-free recovery
Mastoid Osteoma – A Rare, But Aesthetic Challenge!
Mastoid osteomas are benign, slow-growing tumours arising in the temporal bone. Osteomas of the temporal bone are a rare entity, with an incidence of about 0.1–1% of all benign tumours of the skull, and only a few cases have been reported to date. This report presents a rare case of mastoid osteoma that was managed surgically because of cosmetic concerns.
Trans Nasal Endoscopic Choanoplasty – The Ideal Treatment Option for Choanal Atresia and Stenosis
Background: Choanal atresia (CA) is a congenital narrowing or complete obstruction of the posterior nasal aperture and represents the most common congenital anomaly of the nose. Bilateral CA presents as a neonatal airway emergency requiring prompt diagnosis and treatment. Acquired choanal stenosis may occur following trauma, surgery, or inflammatory disorders. Endoscopic transnasal repair has become the preferred management approach because of its high success rate and lower complication profile. Case Series: The authors describe three different clinical scenarios: congenital bilateral choanal atresia, acquired bilateral choanal stenosis managed with stenting, and acquired bilateral choanal stenosis managed without stenting. All patients underwent endoscopic choanoplasty with resection of the posterior septal plate and medial pterygoid plate. Surgical techniques, postoperative care, and outcomes are discussed along with a review of current literature. Conclusion: Endoscopic transnasal choanoplasty with resection of the posterior septal plate and medial pterygoid plate provides excellent outcomes in congenital and acquired choanal obstruction. The technique offers a high success rate with minimal morbidity and has become the preferred surgical treatment for choanal atresia and stenosis.
Evaluation & Management of Benign Paroxysmal Positional Vertigo (BPPV): Review of Guidelines with Updated Summary
Benign Paroxysmal Positional Vertigo (BPPV), was first described by Barany in 1921; with a life time prevalence of 2.4% it is the most common cause of vertigo constituting about 1/3rd of the total cases.