VOL-9 Issue-II

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY
(An Internationally & Nationally Indexed Journal)

VOLUME - IX
NUMBER II,
JULY-DEC, 2015
Indexed in Index Copernicus International plc, Poland (http://indexcopernicus.com),

PAN No. : AABAA3929N dt. 08/07/1977
The Official Publication of the Association of Otolaryngologists of India, Orissa State Branch. All rights
owned by the Association of Otolaryngologists of India, Odisha State Branch (O.S.B.)
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EDITORIAL BOARD
Editorial Chairman
Prof Abhoya Kumar Kar
Editorial Advisory Board Member of
International Journal of Phonosurgery & Laryngology,
JIMA, World Articles in ENT,
ORL Clinics International Journal,
Indian Journal of Clinical Medicine,
Elsevier (India)
Publications,IJLO & HNS. PANACEA & OMJ.
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Editor
Prof. R.N. Biswal
Professor of ENT and Head and Neck Surgery,
Kalinga Institute of Medical Sciences
(KIMS), KIIT University ,Bhubaneswar
Address for Correspondence
Cell-09437Ce165625, 09437036411
Email: rudra.biswal7@yahoo.com
Associate Editor
Dr K.C.Mallik
Associate Professor,Dept of ENT and HNS
S.C.B.Medical College,Cuttack,Odisha,
Cell-09437092087
Email:drkrishnachandramallik@gmail.com
Vol.-9, Issue-II, July-Dec. - 2015
NATIONAL EDITORIAL ADVISORY BOARD

Prof. B. K. Dash
HiTech Medical College,Bhubaneswar, Odisha
Prof. G. C. Sahoo, Professor and HOD,
Dept of ENT and Head and Neck Surgery
IQ City Medical College and
Narayana Multispecialty Hospital, Durgapur,
West Bengal
Email.gcsent99@gmail.com
Prof. Dipak Ranjan Nayak
Department of ENT-Head & Neck Surgery,
Kasturba Medical College,
Manipal, KARNATAK
E-mail: drnent@gmail.com
Prof. S. K. Behera
Department of ENT-Head & Neck Surgery,
S.C.B.Medical College, Cuttack, Odisha.
Prof Sanjeev Mohanty
Prof and HOD,ENT. SRMC,PORUR
S33, I-Block, Jains Avantika Apartment
Manapakkam, Chennai-600116,
Contact: 9840131091
E mail: drsanjeevmohanty@gmail.com
2
Prof. Bachi T. Hathiram

Flat No.-2, Ground Floor;
M.N.Banaji Building;
Forjett Street Cross Road; Opp.
Saibaba Temple;
Mumbai- 400 036; Maharashtra, India.
bachi.hathiram@rediffmail.com
Prof. B.Viswanatha;
# 716, 10th Cross, 5th Main; MC Layout,
Vijayanagar; Bangalore 560030; Karnataka,
Mobile: 09845942832.
drbviswanatha@yahoo.co.in
Prof. K. K. Ramalingam
K.K.R ENT Hospital & Research Institute,
274 Poonamalllee High Road, Kilpauk,
Chennai- 600 010,
Tamil Nadu. Phone 044-26411444.
kkramalingam@hotmail.com
Dr Madan Kapre;
Neeti Clinics & Nursing Home (ENT);
NeetiGaurav Complex; 21, Central Bazar Road;
Ramdaspeth; Nagpur 440010; Maharashtra.
madankapre@gmail.com
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Prof R. Jayakumar,
Senior Consultant, Dept of E.N.T.,
Kerala Institute of Medical Sciences(KIMS),
P.B. No. 1, P.O. Anayara,
Trivandrum-695029, Kerala.
jkrmenon@rediffmail.com
Prof Ahin Saha,
FE-99, Sector-3, Salt Lake City, Kolkata-700106,
West Bengal.
ahinsaha@gmail.com
Prof AchalGulati;
Prof ENT,Mualana Azad Medical College
A-72, SwasthyaVihar;
Delhi-110092.
achalgulati@rediffmail.com
Prof T. S. Anand;
4, Hemkunt Colony; Opp. Nehru Place,
New Delhi-110048.
doctoranand50@yahoo.com
Prof P.S.N. Murthy,

Head of Dept of E.N.T.,
P.S.I. Medical College, Chinoutpalli, t/P.O. Gannavaram,
Vijayawada, Andhra Pradesh.
drmurtypsn@gmail.com
Prof Vikash Sinha,
Dean, MP Shah Medical College,
Pt. Nehru Road, Jamnagar-361008, Gujrat.
dr_sinhavikas@yahoo.co.in
Prof Mohan Kameswaran
Madras E.N.T. Research Foundation(P) Ltd; 1,
1st Cross Street;
Off. 2nd Main Road; Raja Annamalaipuram;
Chennai-600028; Tamil Nadu.
merfmk@yahoo.com
Prof T.V. Krishna Rao
Uma Krishna; 5-9-30-1/27 AB, Basheerbagh Palace;
Hyderabad-500053; Andhra Pradesh.
drrao@mmdsofttech.com
INTERNATIONAL EDITORIAL ADVISORY BOARD

Prof. Ullas Raghavan, Department of ENT ,
Doncaster Royal Infirmary, Armthorpe Road,
Doncaster DN2 5LT UK
ullasraghavanent@yahoo.com
Prof. Prepageran Narayanan
Dept of Otolaryngology and
Head & Neck Surgery.
University Malaya Medical Center,
Malaysia.
prepageran@yahoo.com
Prof. Peter Catalano, MD, FACS, FARS
Chief of Otolaryngology
St. Elizabeths Medical Center,
Professor of Otolaryngology
Tufts University School of Medicine,
Medical Director of Research,
Steward Health Care
Peter. Catalano@steward.org
Prof. Sady Selaimen da Costa
Federal University of Rio Grande do Sul,
Faculty of Medicine, Department of
Ophthalmology
and Otorhinolaryngology, Rua Ramiro Barcelos,
2350 Zone 19 Room 1922 Good End, Porto Alegre,
RS .Brazil - CEP 90035-003
selaimen@gmail.com
Prof. Douglas D. Backous,MD,FACS.
Medical Director, Center dor Hearing &
SSkull Base Surgery
Swedish Neurosciences Institute,
Seattle Washing ton, USA
douglas.backous@swedish.org
Prof. Ashutosh Kacker M.D

Professor of Clinical Otorhinolaryngology
Weill Cornell Medical College,
NY, NY 10021USA
Personal address:- 1305 York Avenue,
5th floor, NY, NY 10021
USAT: (646)962-5097 F: 646)962-0100
Ask9001@med.cornell.edu
Prof. Arun K. Gadre, MD, FACS
Heuser Hearing Institute
Professor of Otology and Neurotology,
Division of Otolaryngology
Head and Neck Surgery,
University of Louisville, 401 E Chestnut St
Suite 710, Louisville, KY 40202,USA
arungadre@yahoo.com
Prof. Ludwig Moser
University of Wuerzburg
Department of Oto-Rhino-Laryngology,
Plastic, Aesthetic,
and Reconstructive Head and Neck Surgery
Wuerzburg,Bavaria,Germany
l_u_moser@hotmail.com
Prof. Sylvester Fernandes
22 Kelton St, Cardiff NSW
Australia
sylvesterfernandes@newcastle.edu.au
Dr.Sharat Mohan
ENT & Voice surgeon, National Health Services
Derby, United Kingdom
sharatmohan@hotmail.com
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
STATISTICAL ADVISORY BOARD

Dr. Kaushik Mishra
Associate Professor (RHTC)
Dept. of Community Medicine
SCB Medical College, Cuttack
Mob: 9437228312
Email: kaushikmishra1965@gmail.com
Dr. Sandeep Kumar Panigrahi

Assistant Professor,
Dept. of Community Medicine
IMS & SUM Hospital, Bhubaneswar
Mob: 9439369093
Email: dr.sandeepvss@gmail.com
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)
July-December 2015 Volume-IX Number-II
Contents
Sl.No
Tittle and authors
Pages
INVITED EDITORIAL:
A TAILOR MADE APPROACH TO ENDOSCOPIC SINUS SURGERY FOR CHRONIC RHINOSINUSITIS :
Dipak Ranjan Nayak
:
06
MAIN ARTICLES
1.
2.
3.
4.
EVALUATION OF LONG-TERM QUALITY OF LIFE OUTCOMES IN PATIENTS WITH RECURRENT

ACUTE RHINOSINUSITIS AND CHRONIC RHINOSINUSITIS WITHOUT NASAL POLYPOSIS
D Carlson DO, B Fennessy MD, PJ Catalano MD, FACS
CLINICOPATHOLOGICAL EVALUATION AND SURVIVAL RATE OF ADVANCED LARYNGEAL
MALIGNANCY (T3, T4) MANAGED WITH WIDEFIELD TOTAL/NEAR TOTAL
LARYNGECTOMY WITH NECK DISSECTION
Dipak Ranjan Nayak, Balakrishnan R, Deichu Mudaiah, Suraj Nair, Hazarika P, Melissa Glenda Lewis
POLYPROPYLENE STENTING IN REVISION DACRYOCYSTORHINOSTOMY:
A PROSPECTIVE STUDY
M.S.Vijayashree, MS, B. Viswanatha, MS, PhD, FACS
AUDIOLOGICAL STUDY OF AGE RELATED HEARING LOSS
Jameel K.M. M. Ravi Kumar Raju, M.A.N. Murthy, Beena. V
09
14
20
24
28
31
34
37
40
43
45
49
52
55
5.
6.
7.
8.
19.
10.
11.
12.
13.
A CASE REPORT: BELLS PALSY IN AN 11 MONTH-OLD INFANT

Lina Ling Chooi, MS, Abu BakarZulkiflee, MS, Narayanan Prepageran, FRCS
TUBERCULOSIS OF COLLAURAL FISTULA PRESENTING AS PAROTID ABSCESS
Manish Chandra, Rajeev Krishna Gupta, Ritika Bhatt
EXTRA MEDULLARY PLASMACYTOMA OF LARYNX- A RARE CASE REPORT
K.C Mallik, S.L Routray, D.Bhue, Ankita Joshi, K.Jena
ANCIENT SCHWANNOMA OF CERVICAL SYMPATHETIC CHAIN - A RARE ENTITY
Tanvi Anoop Lohiya, Kshitij Dhaval Shah, Ashutosh Vishwasrao Patil, Renuka Anil Bradoo
CONGENITAL PAROTID SALIVARY FISTULA FROM STENSONS DUCT
Mayashankar B. Vishwakarmam, Hemantkumar O. Nemade, Subhalakshmi. A. Jaiswal, Shankar Kothule
PLEOMORPHIC ADENOMA LOCATED OVER THE NASAL DORSUM: A RARE PRESENTATION
Ehrlson de Sousa, Sai Spoorthi Naik, Manu Wilfred, Saumyata Neeraj
A RARE CASE OF NASAL B CELL LYMPHOMA:A CASE REPORT
LokanathK.V, Srijoy Gupta
UNUSUAL FOREIGN BODY IN AIRWAY - TWO CASE REPORT
Khageswar Rout, K. K. Samantaray, R. N. Biswal
A RARE CASE REPORT OF PLEXIFORM NEUROFIBROMA OF THE SUBLINGUAL GLAND
Satyajit Mishra, Smrutirekha Sahu
INSTRUCTIONS TO AUTHORS
CASE REPORTS
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
INVITED EDITORIAL
A TAILOR MADE APPROACH TO ENDOSCOPIC SINUS SURGERY FOR

CHRONIC RHINOSINUSITIS
*Dipak Ranjan Nayak
ABSTRACT
Chronic sinusitis is a major health hazard that affects the quality of life of an individual significantly. A comprehensive
medical and surgical management is required to treat such cases. Various surgical options are now available to manage such
cases that include FESS, FENS, MIST, MISS and balloon assisted sinuplasty etc. The author proposes a tailor made approach
to tackle such problems based on the extent of disease, past surgical treatment, associated local and systemic factors. The tailor
made surgery ranges from a minimally invasive approach to a complete fronto-maxillo-spheno-ethmoidectomy with uncinate
preservation as required.
Key words: Ultra conservative Endoscopic sinus surgery, Chronic sinusitis, Tailor made approach.
INTRODUCTION
Hirschmann 1901 had performed endoscopic
examination using a cystoscope to examine maxillary sinus
for visualization of oro-antral fistula.1 Reichert used a 7mm
endoscope to perform first transnasal endoscopic surgery for
closure of oro-antral fistula. Speilberg (1922) described the
antroscopy of maxillary sinus via an inferior meatal
approach.3 Maltz(1925) used the term sinuscopy. Evolution
of functional endoscopic sinus surgery started with
Messerklinger in 1978 and took a concrete shape around mid
1980s with the pioneering work of Stamberger and Kennedy46
. Kennedy(1985) is the first sinus surgeon to coin the term
Functional endoscopic sinus surgery.5 It is now the gold
standard in the management of chronic and reccurent sinus
disease. It facilitates ventilation and drainage of the paranasal
sinuses involved and allows the return of adequate functioning
of the mucociliary movements of the nasal mucosa while
providing several benefits when compared to traditional open
procedures.7, 8 Introduction of coronal CT played a pivotal
role in preoperative evaluation, diagnosis, planning and
management of inflammatory paranasal sinus diseases.9
Kennedy found a strong relationship between the surgical
outcome and extent of disease and proposed a staging system
for all inflammatory sinus disease. Several factors including
aspirin intolerance, asthma, allergic fungal sinusitis, systemic
factors can affect the outcome of surgical treatment. In spite
of aggressive treatment modality, many patients can have
residual disease.10 Combined input of CT evaluation, clinical
features and diagnostic endoscopic finding can determine the
accurate extent of the disease and the functional outcome
after treatment and may help in preventing complications11.
Classical functional endoscopic sinus surgery in its early days
still raises some issues and inherent limitations, mainly ending
up in removing the nasal mucosa and osseous tissue, that can
cause pain, bleeding, and physiological changes of the nasosinus mucosa, especially of the mucociliary movements and
local cicatricial fibrosis7, 8. Mucosal preservation during
surgery, precise and safe removal of tissues forms the
cornerstone for a successful surgical outcome[Fig-1]. It has lead
6
to the technological advances in the form of thru cut forceps,

Microdebridor and navigation system etc.12,13
A small sinus ostium is often found at the time of surgery
Fig1. Image guided endoscopic sinus surgery
with healthy sinus clinically and CT suggesting small size

ostium is sufficient to maintain functional sinus. A technique
for opening the transition space of maxillary sinus with no
instrumentation of its ostium obviates the necessity for more
traumatic large hole procedure.14 Uncinate process probably
has a protective role in preventing deposition of bacteriae
and allergens in the sinuses during the inspiratory phase.
Inoculation of new pathogenic bacteriae in the open
ethmoid cavities can probably be prevented by concealing it
from the inspired air. This can be achieved by preserving the
uncinate process and the anterior end of the middle turbinate15.
Nayak et al (2001) coined the term Functional endoscopic
naso-sinus surgery (FENS) where in, a comprehensive sinonasal surgery was performed with preservation of uncinate
process and selective ethmoidal clearance through a
transbullar approach. In case of isolated maxillary sinus
Affiliations:
Professor, Department of ENT-HNS, Kasturba Medical College,Manipal
University,Manipal
Address of Correspondence:
Prof. Deepak Ranjan Nayak
Professor, Department of ENT-HNS,
Manipal University,Manipal, Karnatak.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Isolated sinusitis: Often we find isolated sinusitis

involving major sinuses with no involvement of ethmoids after
maximizing the medical treatment. The best option to manage
such cases is to adopt a balloon assisted endoscopic sinuplasty.
Balloon sinuplasty is a surgical technique where dilation of
the ostium of a major sinus is performed by using a balloon
catheter. The technique involves passing of a balloon dilation
catheter over a fiberoptic luma guide wire that has been
positioned within the involved paranasal sinus under the
endoscopic supervision. The positioned balloon in the
targeted sinus ostium is inflated by an inflation device to dilate
the ostium[Fig2].
Fig2. Showing
balloon assisted
sinuplasty of
frontal sinus (a)
passage of ballon
cathter through
Luma guide wire
(b)
Ballon
dilatation
of
lower segmnt of
frontal recess (c)
Further passage
and dilatation of
upper segment
and
frontal
ostium (c) After
dilatation.
Since balloon device is quite expensive in developing

countries like India, the author adopted an ultraconservative
approach where in the maxillary and frontal ostia are enlarged
without disturbing the drainage pathway[Fig-3]. In case of
isolated disease in frontal sinus with limited disease in frontal
recess, an intact uncinate and bulla technique is adopted with
Fig-3. Showing enlargement of maxillary ostium with intact drainage pathway
Fig-4.
Showing
frontal disease with
very
limited
e t h m o i d a l
invovement
on
C T ( a , b & c ) ,
undergone a draff-I
procedure
with
preservation
of
uncinate and bulla via
trans
Axillary
suprabullar approach.
Fig-5. Showing
foleys catheter
assisted balloon
sinuplasty in a
revision case of
frontal
sinus
disease.
Fig-6. Showing
Modified
endoscopic
Lothrop(DraffIII)
with
u n c i n a t e
preservation.
resection of the posterior wall of the agar nasi along with
exenteration of frontal cell through trans-axillary suprabullar
approach[Fig-4]. Considering the poor economic status, a infant
foleys catheter[Fig.5] assisted balloon sinuplasty was carried
out with good results. In case of extensive disease involving
frontal sinus like allergic fungal sinusitis and polyposis, a
Draf-II procedure is done for unilateral disease and Draf-III
surgery for bilateral disease[Fig 6].
If ethmoidal disease is present, the maxillary sinus is
dealt with as described under isolated maxillary sinusitis and
for the ethmoids, a trans-bullar approach is adopted with
uncinate process preservation. The bulla is opened inferomedially as described by Stammberger. The upper anterior
part of the bulla is preserved till frontal sinus is identified.
The anterior ethmoidal artery is identified and confirmed as
per the imaging study. A ball probe is passed between the
remnant of the bulla and posterior wall of the agger nasi gently
without applying pressure to localize the frontal sinus
drainage pathway. The agger nasi is opened inferiorly after
doing an axillotomy with the help of a back biting forceps.
The posterior wall of the agger nasi is removed with an up
turned tru-cut forceps/ microdebrider. The frontal cell type
as per imaging study is identified and removed. The ground
7
disease, a maxillary sinusostomy was carried out while

preserving the uncinate process and bulla ethmoidalis.7 The
author proposes a tailor made approach from minimal
invasive to complete fronto-maxilla-spheno-ethmoidectomy
with uncinate preservation to tackle chronic sinus disease
based on extent of disease and other associated local and
systemic factors that can hamper the outcome of surgery.
Surgical indication & Technique for a tailor made approach:
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
lamella is again opened infero-medially. The remnant of the

upper anterior attachment of the bulla is removed carefully
from its attachment. The author preserves the upper
attachment of the bulla if the frontal recess is not cleared.
The posterior ethmoidectomy is done in the
conventional way with the help of a microdebrider or
mushroom punch forceps based on the imaging finding.
Sphenoid ostium is identified medial to superior turbinate
and lateral to septum. Ostium is enlarged infero-medially
using a sphenoidal mushroom punch forceps of different sizes
if required.
In invasive fungal sinusitis, one needs to be aggressive in
approach with an endoscopic medial maxillectomy and skull
base clearance.
1.
J. Woodham: History of the development of surgery for

sinusitis P.J. Donald, J.L. Gluckman, D.H. Rice (Eds.),
The sinuses, Raven, New York (1995), pp. 314
2.
M. Reichert: ber eine neue Unterscuhungsmethode

der Oberkieferhhle mittels des Antroskops Berl klin
Wochenschr, 401 (1902), p. 478 [in German]
3.
W. Spielberg: Antroscopy of the maxillary sinus;

Laryngoscope, 32 (1922), pp. 441444
4.
Messerklinger W: Endoscopy of the Nose. Baltimore,

MD, Urban and Schwarzenberg, 1978
5.
Kennedy DW (Oct 1985). Functional endoscopic sinus

surgery. Technique. Arch Otolaryngol 111 (10): 6439
6.
Stammberger H: Endoscopic endonasal surgery

Concepts in treatment of recurring rhinosinusitis. Part
II. Surgical technique. Otolaryngol Head Neck Surg
94:147-156, 1986.
7.
Nayak etal : Endoscopic physiological approach to

allergy associated chronic rhinosinusitis; Ear Nose
Throat J. 2001, 80:390-403.
8.
Friedman & Schalch; Op Tech Otolaryngol Head Neck

Surg. 2006, 17:126-34.
9.
Zinreich SJ, Kennedy DW, Rosenbaum AE. Paranasal

sinuses: CT imaging requirements for endoscopic
surgery. Radiology 1987; 163:769-775.
10.
Kennedy DW: Prognostic factors, outcomes and staging

in ethmoid sinus surgery; Laryngoscope,1992 Dec;102(12
Pt 2 Suppl 57):1-18.
11.
Lund VJ, Kennedy DW: Staging for Rhinosinusitis; 1997

Sep; Otolaryngol Head Neck Surg;117(3 Pt 2):S35-40.
12.
Setliff RC, Parsons DS:The Hummer: new

instrumentation for functional endoscopic sinus surgery.
Am J Rhinol 1994; 8:275278.
13.
Kennedy DW: Technical innovations and the evolution

of endoscopic sinus surgery; Ann Otol Rhinol Laryngol
Suppl. 2006 Sep;196:3-12.
14.
Setliff Reuben: Minimally invasive sinus surgery: the

rationale and the technique1996; OCNA vol-29(1). P115-129
CONCLUSION:
15.
A Tailor made ultraconservative sinus surgery with

mucosal preservation is the gold standard for treating
Sinonasal infections. It facilitates early mucociliary recovery
with minimal hospitalization/day care procedure thus
reducing the cost and postoperative morbidity. However
extensive diseases like allergic fungal sinusitis, polyposis, and
invasive fungal sinusitis require more aggressive approach.
Nayak D R & Balakrishnan R : De novo bacterial

reinfections after endoscopic sinus surgery: can uncinate
process preservation surgeries prevent it? Laryngoscope
115(5), p 928; May 2005.
16.
Yogesh M. Seth W, Peter C: Management of early nasal

Polyposis using a steroid impregnated nasal dressing;
international forum of allergy & rhinology, Vol.I, No.5,
P-401-404,, Sept.-Oct. 2011.
A Resorbable nasal dressing available as Nasopore can

be used as a nasal dressing to prevent synechia. The Nasopore
piece was cut into appropriate size and was soaked with
triamcinolone and antibiotic. Each Nasopore piece was then
placed at the maxillary ostium, frontal ostium and frontal
recess and ethmoidal cavity. The author uses this for his recent
cases. Use of Nasopore soaked steroids can be used effectively as
a nasal dressing and can reduced the need for systemic steroid
in the presence of polyposis.16
RESULTS:
REFERRENCES:
The author has followed the above described surgical

protocol in a series of 1211 cases over a period of six years
from 2007 to 2012. The cases were ranging from isolated sinus
disease to extensive pan sinusitis. These cases were advised
regular follow up for a minimum period of one year. The
subjective analysis was carried out using visual analogue scale
for four common symptoms encountered among patients, i.e.
nasal obstruction, headache, anterior/ posterior nasal
discharge and anosmia/ hyposmia. It was observed that 64.9%
of subjects had complete relief from nasal obstruction, 68.4%
from headache, 61.35% from anterior/ posterior nasal
discharge and 51.8% from anosmia/ hyposmia at 6 months
after surgery. Nasal endoscopy at 6 months post operatively
was carried out for 639 cases and revealed persistent nasal
discharge in 36.7%, nasal synechia in 24.9% and recurrence of
polyps in 27.8% (These patients are also a part of an ongoing
study for assessment of long term benefits of surgery).
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
EVALUATION OF LONG-TERM QUALITY OF LIFE OUTCOMES IN

PATIENTS WITH RECURRENT ACUTE RHINOSINUSITIS AND
CHRONIC RHINOSINUSITIS WITHOUT NASAL POLYPOSIS
ABSTRACT
Objective: The aim of this study is to evaluate and compare the changes in Quality of Life (QoL ) before and one
year after surgical intervention between patients with Recurrent Acute Rhinosinusitis(RARS) and Chronic
Rhinosinusitis without Nasal Polyposis (CRSsNP).
Introduction
Improvements in quality of life (QoL) after surgical management of chronic sinusitis without nasal polyps
(CRSsNP) is well defined and universally accepted as a rationale for surgical intervention, whereas the similar
management of recurrent acute rhinosinusitis (RARS) remains controversial. The aim of this study is to evaluate
and compare the changes in QoL before and one year after surgical intervention between patients with RARS
and CRSsNP.
Methods
A prospective cohort of 32 patients with RARS and 25 patients with CRSsNP (as defined by the Rhinosinusitis
Task force) were enrolled in the study upon failing medical management. CT scan findings were reported using
the Lund Mackay (LMS) scoring system. A SNOT-20 QoL assessment was completed both preoperatively and
one year postoperatively. Patient data was collected, scored and transferred for analysis using Prism6 Graph Pad
software.
Results
Fifty-seven patients enrolled in this prospective study exhibited a mean age of 39 years. The mean pre-operative
LM scores were similar between subgroups: RARS=7.5; CRSsNP=6.3 (p>.05). Pre-operative SNOT-20 scores
were slightly higher for the CRSsNP vs RARS group: 44.3 vs 32.3, respectively (p=.0092).Figure 1 However, the
magnitude of QoL improvement between pre-operative and post-operative SNOT-20 scores were identical (delta=21) and statistically significant in both RARS and CRSsNP groups.
Conclusions
These results show statistically significant, similar and durable improvements in QoL outcomes following
endoscopic sinus surgery in patients with RARS and CRSsNP, providing further evidence that targeted surgical
intervention is appropriate for medically refractory patients with either RARS or CRSsNP.
Key Words: recurrent acute rhinosinusitis, rhinosinusitis, minimally invasive sinus surgery, quality of life, sinusitis,
endoscopic sinus surgery.
INTRODUCTION
Chronic rhinosinusitis (CRS) is an exceptionally
common clinical condition that has been extensively
studied and reported in the literature.1-5 The substantial
effect of CRS on quality of life measures has also been
clearly shown.5 Differing surgical techniques, including
FESS, MIST and balloon sinuplasty, have shown
Affiliations:
*,**,***. Division of Rhinology/Skull Base Surgery, St. Elizabeths Medical
Center, Boston, MA,USA
Peter Catalano, MD,
St. Elizabeths Medical Center,
Department of Otolaryngology,
736 Cambridge Street, Brighton, MA 02135, U.S.A.
Email: Peter.Catalano@steward.org
*D Carlson DO,**B Fennessy MD,***PJ Catalano MD, FACS
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
substantial benefit in quality of life measures when

treating medically refractory CRS.2,4,6-8 In 2007 The
American Academy of Otolaryngology-Head and Neck
Surgery established the Adult Sinusitis Guideline
defining rhinosinusitis while also identifying several
subtypes including recurrent acute rhinosinusitis
(RARS).3 RARS has been strictly defined as four or
more episodes of acute bacterial rhinosinusitis (ABRS)
a year without signs of symptoms of rhinosinusitis
between episodes.3 Each episode must meet criteria for
acute bacterial rhinosinusitis. Relatively little has been
published in regards to quality of life measures or
surgical management in patients exhibiting RARS.6,9-10
Improvements in quality of life (QoL) after
surgical management of chronic sinusitis without nasal
polyps (CRSsNP) is well reported and universally
accepted as a rationale for surgical intervention, whereas
the similar management of recurrent acute rhinosinusitis
(RARS) remains controversial. The aim of this study
is to evaluate and compare the changes in QoL before
and one year after surgical intervention between patients
with RARS and CRSsNP.
PATIENTS AND METHODS
This study was approved by our IRB. Informed

consent for study participation was obtained from all
patients. A prospective cohort of 32 patients with RARS
and 25 patients with CRSsNP (as defined by the
Rhinosinusitis Task force) were enrolled in the study
upon failing maximal medical management.
Failed maximal medical therapy for RARS patients
was defined as the frequent recurrence of acute
rhinosinusitis (>4 episodes/year) over a minimum of
2 consecutive years despite complete clearance of each
episode with effective medical therapy, or patients who
had significant side effects from maximal medical
therapy. Long-term antibiotics were not considered
part of maximal medical therapy in the RARS subset
of patients. However, RARS classification required that
at least one episode of acute bacterial rhinosinusitis
(ABRS) be clinically and endoscopically confirmed
during office evaluation. Enrolled patients underwent
a full history, ENT/head and neck examination and
endoscopic assessment of the nasal cavity. Initial CT
10
sinus scans were completed and graded using the

validated Lund Mackay (LMS) scoring system. Each
patient then completed a validated Sinonasal Outcome
Test (SNOT-20) QoL assessment. The SNOT-20 was
completed at the time of the first office visit and one
year postoperatively. After thorough examination and
maximal medical therapy, all patients deemed as surgical
candidates subsequently underwent a targeted
endoscopic surgical procedure.7-8 Following surgery
patients were initially seen at 3 weeks and 3 months
post operatively for evaluation, and subsequently at 3month intervals. At approximately one-year post
operatively a repeat SNOT-20 assessment was completed
and scored. Patient data was collected, scored and
transferred for analysis using Prism6 Graph Pad
software.
RESULTS
Strict inclusion criteria were required for inclusion
into this study as detailed in the Adult Sinusitis
Guideline.3 A total of 57 patients were enrolled in this
study: 32 patients classified with RARS and 25 patients
classified with CRSsNP. The mean age of the 57 patients
enrolled in the study was 39.98 (range 18-67). Mean
length of follow up of the RARS arm was 10.52 months
while mean follow up of the CRSsNP arm was 13.03
months. The gender breakdown was 24 males and 33
females. Regardless of the study arm, all patients
received a similar surgical procedure consisting of
uncinectomy with subsequent identification of the
maxillary os, anterior ethmoidectomy, and submucosal
turbinate reduction. In certain cases in which a concha
bullosa was noted, the lateral wall of the concha was
resected. Septoplasty was also performed on a majority
of patients to either improve nasal airflow and/or allow
for surgical access. Those patients requiring deviation
from this surgical protocol were excluded from the
study.
Pre-operative mean Lund Mackay (LMK) CT
scores were calculated by an independent blinded
reviewer using published recommendations for scoring.
LMK scores in the RARS arm ranged from 0 to 16
while the CRSsNP LMK scores ranged from 2 to 14.
ANOVA and T-test pairing analysis revealed no
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Initial SNOT-20 assessment values ranged from

22 to 89 among the CRSsNP patients (avg = 44.25),
and from 10 to 61 (avg = 32.45) in the RARS group;
the difference between the average pre-op scores is
statistically significant (p=0.0092).Figure 1 Post-operative
SNOT-20 scores in the CRSsNP group were reduced
from 44.25 to 23.00 (p=0.0004), and from 32.25 to 11.06
(p=0.0001) in the RARS group.Figure 2 Thus, both
groups showed an equal reduction of 21 points between
pre and post-op SNOT-20 assessments, and the
reduction within each group was also statistically
significant.Figure 3-4 There were no surgical revisions
required in any study patient.
DISCUSSION
Much has been discussed and published with
respect to CRS, however there remains a subset of
patients properly diagnosed as RARS that have received
far less attention. Despite the term RARS appearing in
the literature for roughly 13 years, there is relatively
little published on this subgroup of rhinosinusitis.6,9-11
It has been noted previously that RARS patients have
a significant impact on health-care resources comparable
to CRS patients.10 This was identified in the need for
more frequent courses of antibiotics, more frequent
visits to their doctor, and the increased probability of
missed workdays beyond that of persistent CRS.10
Previous evidence suggests this may be due in part to
increased antimicrobial resistance exhibited by RARS
patients.11 Considering these factors as well as the
increase in RARS subgroup amongst our patient
population, the need to identify whether surgery was
an effective management tool in this subgroup became
relevant.
Our study data identified certain patient
characteristics within the subgroups. Interestingly,
LMK scores in the RARS group were on average higher
than the CRSsNP group, however, no statistical
difference was found between groups. This can be
attributed to the intermittency of disease in the RARS
subgroup, and the likelihood of these acute patients
having a higher (but short-lived) LMK score, versus

the possibility of sinus imaging during disease-free states
where there is no mucosal disease at all. These findings
strongly suggest that absence of mucosal disease on CT
is not a reliable indicator of RARS and should not be
used to exclude the diagnosis of RARS.10 The CRSsNP
subgroup had more consistent LMK scores and no
patient was without mucosal disease on imaging.
One must also consider that many patients with
RARS have been on numerous different antibiotics
throughout their lives, and have subsequently
developed allergies to a number of these medications.
Others report significant side effects from OTC sinus
medications, and most are extremely frustrated with
their primary care physicians for offering them the same
medical treatment option time and again. We must keep
in mind that medical management is not without risks,
side effects or complications, and what may appear as
the conservative option, may be quite problematic
for some patients.
In our study, RARS patients as a group were
slightly less symptomatic as compared to the CRSsNP
group as reported on their SNOT-20 evaluation. This
stands in contrast to a previous study that noted equal
QoL scores between RARS and CRS.9 Again, this can
likely be attributed to the variability of disease free
states noted in the RARS subset of patients. Of
considerable note, RARS patients showed significant
improvement on QoL domains similar to the CRSsNP
cohort after similar surgery. Interestingly, the
magnitude of change between pre-operative and postoperative QoL scores among the RARS and CRSsNP
groups was the same (a 21 point reduction). It has
previously been suggested by Battacharyya to consider
disease directed or targeted surgery in RARS patients,
which would include sphenoidotomy and frontal
sinusotomy when indicated.6 Further opinion suggests
surgery centered around the osteomeatal complex for
RARS patients.9 Our data support limited targeted
sinus surgery focusing on transitional spaces
encompassing the ethmoidal infundibulum, hiatus
semilunaris superior, and retro-agar space/ nasofrontal
recess rather than focusing on each site of mucosal
11
significant statistical difference between both the RARS

and CRSsNP groups with respect to pre-operative
LMK scores (7.47 and 6.25; p=0.2096).
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
disease. This technique not only showed a statistically

significant reduction in QoL scores post-operatively
comparable to CRSsNP patients, but also prevented
more invasive and unnecessary surgery.
We have noted, as have others, that the diagnosis
of RARS may be complicated as many of these patients
may be clinically and radiographically normal at the
time of evaluation due to infection free periods.6,9-10
However, one episode of acute bacterial rhinosinusitis
(ABRS) confirmed clinically and endoscopically was
required during office evaluation to be considered for
the RARS arm of this study. We found that confirming
4+ episodes of ABRS in the office was unsustainable
due to patient follow up factors. Consistent follow up
remains challenging in this group as many patients can
neglect future evaluations, especially if they are
scheduled during disease free periods. Thus, the
diagnosis of RARS usually requires heavy reliance on
patient history, which may over or understate their
condition, and thus affect the reliability of the diagnosis,
treatment results, and conclusions. We perceive this as
Fig. 3.
Fig. 4.
a limitation in our study and these factors have

consequently limited our RARS patient population size
as we strived to be very selective during study
enrollment.
CONCLUSION
Fig. 1. Showing preoperative SNOT-20 in both groups
In this prospective cohort study we report

statistically significant and comparable improvement
in QoL instrument scores in patients with RARS and
CRSsNP who underwent targeted endoscopic sinus
surgery. We propose targeted endoscopic sinus surgery
as a valid treatment option for patients accurately
diagnosed with RARS who have a high frequency of
infection and/or complications despite medical
management and wish to explore surgical options.
DISCLOSURES
(a)
Competing interests/Interests of Conflict- None
(b) Sponsorships - None

(c)
Fig.2. Showing Pre and post operative comparative analysis of both group
12
Funding - None
(d) No financial disclosures
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
1.
2.
3.
4.
5.
Beninger MS, et al. Adult chronic rhinosinusitis:

definitions , diagnosis, epidemiology and
pathophysiology. Otolaryngol Head and Neck
Surg 129S:S1-S32, 2003.
Metson RB, Gliklich RE. Clinical outcomes in
patients with chronic sinusitis. Laryngoscope
110:24-28, 2000.
Rosenfeld, RM, Andes D, Bhattacharyya N, et
al. Clinical practice guideline: Adult Sinusitis.
Otolaryngol Head and Neck Surg 137(suppl 3):S1S31, 2007.
Smith TL, Batra PS, Selden AM, et al. Evidence
supporting endoscopic sinus surgery in the
management of adult chronic rhinosinusitis: A
systematic review. Am J Rhinol 19:537-543, 2005.
Bhattacharyya N. The economic burden and
symptom manifestations of chronic rhinosinusitis.
Am J Rhinol 17:27-32, 2003.
6.
Bhattacharyya N. Surgical treatment of chronic

recurrent rhinosinusitis: A preliminary report.
Laryngoscope 116:1805-1808, 2006.
7.
Catalano PJ. The minimally invasive sinus

technique: Concepts and controversies. Oper Tech
in Otolaryngol 17:189-196, 2006.
8.
Catalano PJ, Strouch M. The minimally invasive

sinus technique: theory and practice.Otolaryngol
Clin North Am 37:401-409, 2004.
9.
Poetker DM, Litvack JR, Mace JC, et al.

Recurrent acute rhinosinusitis: Presentation and
outcomes of sinus surgery. Am J Rhinol 22:329333, 2008.
10. Bhattacharyya N, Lee KH. Chronic recurrent

rhinosinusitis: Disease severity and clinical
characterization. Laryngoscope 115:306-310, 2005.
11. Brook I, Frazier EH. Microbiology of Recurrent
Acute Rhinosinusitis. Laryngoscope 114:129-131,
2004.
REFERENCES
13
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
CLINICOPATHOLOGICAL EVALUATION AND SURVIVAL RATE OF

ADVANCED LARYNGEAL MALIGNANCY (T3, T4) MANAGED WITH
WIDEFIELD TOTAL/NEAR TOTAL LARYNGECTOMY WITH NECK DISSECTION
DipakRanjanNayak*,Balakrishnan R*,Deichu Mudaiah**,Suraj Nair**,Hazarika P***,Melissa Glenda Lewis****
ABSTRACT:
Objective: : This is a study of clincopathological features and outcome of surgical management with 3 years
survival pattern following total/near total laryngectomy in advanced III,IV squamous cell carcinoma larynx.
Methods: Retrospective observational study conducted between January 2000 to December 2013. with 87 patients
of biopsy proved squamous cell carcinoma of larynx in advanced stage T3&T4. Radio residual cases were also
included in the study. 79 patients were treated surgically with Wide field total laryngectomy and 8 with near
total laryngectomy along with bilateral neck dissection. Average follow up period was 15 months postoperative.
All cases received post op radiotherapy except the radio-residual cases which were managed with salvage surgery
alone. Chemotherapy was added in 7 cases due to extra-capsular metastasis. . Data was analyzed using Kaplan
Meier method of estimation to estimate the median survival time wherever applicable. Statistical analysis was
carried out using STATA 13.
Results: The age range was 40 years to 85 years .The maximum incidence was found in 6th and 7th decade. 84% of
the total patients were male. About 69/87 (79.31%) were smokers. 51/87 (58.6%) were T3, 36/87(41.4%) were T4
lesions. 42/87(48.27%) were N0 , 30/87(34.48%) were N1 and 15/87(17.2%) were N2 lesions . Overall incidence
of nodal metastasis was 51.7%. 71% of the supraglottic carcinomas had nodal metastasis at time of presentation
and 44% of glottis tumors had nodal metastasis. There were no cases of distant metastasis. Topographical
Distribution showed 46% were glottic lesions, 35.6% were supraglottic lesions and 18.4% were transglottic
lesions. 22/87(25.28%) were cases of post RT recurrence and the mean duration of recurrence was 21 months.
65/87 cases who underwent the surgical intervention received radiotherapy3 to 4 weeks following surgery. 22/
87 radio residual cases underwent salvage surgery. This study showed overall survival rate of 87.3% and disease
specific survival rate at 3 years to be 86.7 % for all stage III, IV laryngeal carcinoma who underwent wide field
total laryngectomy/near total laryngectomy.
Conclusions: This study demonstrates the overall survival and 3 year specific disease free survival rates with
Wide field total laryngectomy/ Near total laryngectomy in patients with stage III, IV laryngeal carcinoma.
Keywords: Supraglottis, glottis, Wide field laryngectomy, Near total laryngectomy.
INTRODUCTION
Laryngeal cancer is one of the most commonly
encountered head & neck malignancy under a broader
terminology that comprises of carcinoma of the
supraglottis, glottis, and subglottis1. Indian patients
comprise 18 % of the global laryngeal cancer burden2.
Most of the cases with advanced disease require Total/
Near total laryngectomy as a surgical treatment option
depending on the extent. Patients with advanced T3,
T4 laryngeal cancer includes tumors with extra14
laryngeal spread, bilateral arytenoid joint involvement,

posterior commissure tumors, circumferential subAffiliations:
*Professor,**Resident,*** Ex Professor,
**** Research fellow medical statistics
Deaprtment of ENT-Head &b Neck Surgery,
Kasturba Medical College, Manipal, Karnataka, India
Dr.Dipak Ranjan Nayak
Professor Head of Unit-I
Manipal
E mail: drnent@rediffmail.com
mucosal disease and subglottic extension with extensive

invasion of the cricoid cartilage.
Various surgical treatment options have been
available depending on the stage and site of laryngeal
cancer. These include vertical or horizontal partial
laryngectomy, near total laryngectomy, widefield total
laryngectomy and also the laser assisted organ
preserving surgeries. Owing to the propensity of
lymphatic metastasis seen in advanced laryngeal cancers
especially supraglottic ones, it is mandatory to perform
bilateral neck dissections in even N0 cases1. Post-op
radiotherapy is advocated in all T3, T4 cases with
chemotherapy being added in cases with extra-capsular
spread, vascular spread, and positive margins3. Surgical
salvage can be considered for patients who fail to
respond to radiation therapy or partial laryngectomy
procedures4. Speech rehabilitation plays an important
role in the overall quality of life of patients. With the
upcoming better voice prosthesis and artificial larynx,
patients have been provided a better social life5.
This study evaluates the clincopathological features
and outcome of surgical management with survival
patterns following definitive treatment of laryngeal
cancers.Various factors were considered in this study
like age, sex distribution, predisposing factors,
locoregional and systemic extent of disease. The efficacy
of total/near total laryngectomy in advanced T3, T4
squamous cell carcinoma was assessed with the overall
and 3 year disease specific survival rate in these set of
patients. The aim of this study was to retrospectively
assess the clinical outcomes of total/near total
laryngectomy and its potential postoperative
complications. This knowledge would help in better
counseling of patients and improving quality of life.
MATERIALS AND METHODS :
This is a retrospective observation study carried
out from January 2000 to December 2013 in a tertiary
care centre. A total of 87 biopsy proven squamous cell
carcinoma of larynx of advanced T3 & T4 stage who
opted for total/ near total laryngectomy as primary
modality of treatment were taken up for study. Twenty
two cases of radio-residual/recurrent laryngeal cancer
treated with total laryngectomy with a curative intent
were also included in the study. Complete clinical
evaluation of patients was done with detailed history,
personal habits, direct Laryngoscopy with preoperative
assessment of extent of the growth and staging. Contrast

enhanced CT neck and thorax was done in all cases to
evaluate the extent of primary and for loco-regional
and distant metastasis. Direct telescopy of larynx carried
out using 70degree endoscope in all patients to evaluate
the larynx. Microlaryngoscopy was preformed to
further access the extent of growth involving larynx
and to perform biopsy.79 patients were managed
surgically with widefield total laryngectomy as there
was involvement of both arytenoid/ gross subglottic
extension/ involvement of interarytenod region while
8 suitable cases underwent near-total laryngectomy
along with bilateral modified neck dissection. In
addition to laryngectomy, ipsilateral thyroidectomy
was performed in 48 individuals. T3 cases involving
paraglotic spread with mobile vocal cords treated with
trans-oral microendoscopic KTP-532 laser surgery were
excluded from this study. Laryngeal cancer extending
to hypopharyngx that required total laryngopharyngectomy / laryngo-pharyngo-esophagectomy
were also excluded from the study. All the cases treated
with surgery as primary modality, received post
operative radiotherapy (65-70 gray in multiple
fractions). The radio-residual/ recurrence cases were
managed with salvage wide field total laryngectomy
alone. Locoregional radiotherapy usually commenced
within 4-6 weeks after definitive surgery except when
wound healing complications occurred. Chemotherapy
with Cisplatin on day 1, 22 and 43 was added in 7 cases
due to extra-capsular metastasis. Minimum follow-up
period of fifteen months was standardized. At each
post-op visit, endoscopy of larynx and other
radiological investigations were carried out to assess for
loco-regional recurrence and distant metastasis.
SURGICAL TECHNIQUE:
Patient is prepared under general anesthesia after
procuring written and informed consent. Arterial and
venous line secured and urinary catheter inserted. An
apron flap incision is planned extending from both
mastoid processes to approximately 2 fingerbreadths
above the level of the sternal notch. A planned U shaped
incision is given in all cases with lateral limit till the
posterior border of sternocleidomastoid muscle. A
superior subplatysmal flap is then elevated till the hyoid
bone. A subplatysmal flap is also raised inferiorly to
the level of the sternum and clavicles on both sides.The
skin flaps are secured using or sutures and rubber bands.
The superficial layer of the deep cervical fascia overlying
15
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
the sternocleidomastoid muscle is incised along its

anterior margin.Dissection of the outer and deep
tunnels is performed1. The sternocleidomastoid muscle
is laterally retracted to identify the contents of the
carotid sheath. Dissection is carried out bluntly
between the laryngotracheal complex and the great
vessels on both sides. This frees the medial contents of
the neck from the surrounding tissues6. Meticulous neck
dissection is carried out in all cases resecting the lymph
nodes and fibro-fatty tissue from levels II, III, IV, and
V on both sides depending on the case. Resection of
sternocleidomastoid and internal jugular vein and
preservation of spinal accessory was done in all the cases
that undergone modified neck dissection. The strap
muscles are then divided at the level of the sternal notch.
Dissection proceeds superiorly until the thyroid gland
is identified. The thyroid lobe ipsilateral to the tumor
is resected along with the specimen while the
contralateral lobes along with parathyroid glands are
preserved with their blood supply in selected cases.
Diathermy is used to skeletonize the hyoid bone. In
total laryngectomy(Fig.1) the lateral aspects of the hyoid
are then dissected and care is taken not to injure either
the lingual artery or hypoglossal nerve. The opposite
thyroid ala is identified and retracted medially. The
inferior constrictor muscles are divided off of the
thyroid ala, and the underlying pyriform mucosa is
bluntly dissected off of the undersurface of the thyroid
cartilage6. A similar procedure is carried on the right
side. The trachea is entered transversely between the
second and third tracheal cartilages. An angled cut is
then carried out superiorly and posteriorly using Mayo
scissors beveling the tracheotomy incision. In case the
patient had a prior tracheostomy, a new stoma is created
by including the old stoma in the patient. The
endotracheal tube is then slowly removed, and an
armored flexo-metallic tube placed in the tracheal
stump. An incision is made directly onto pharynx at
the level of vallecula contralateral to the primary tumor.
The epiglottis is then identified through the pharyngeal
incision and grasped with an Allis forceps. Under direct
visualization, mucosal cuts are given to resect the tumor
with 1cm margin of normal appearing mucosa and also
to preserve enough mucosa for later closure. In near
total laryngectomy (Fig. 2) the middle 1/3rd of contralateral
thyroid cartilage is resected. The larynx is entered
through vallecula on the healthier side and cuts are given
in such a way that one functional cricoarytenoid unit
16
is retained along with superior laryngeal nerve of

contralateral side if not diseased. It is followed by
creation of a cricotracheal shunt7.The shunt was closed
in a layer over a 14F red rubber catheter. Ryles tube
passed under vision. The pharyngeal mucosa was closed
in layers. The entire specimen is handed off for
histopathological examination. Cricopharyngeal
myotomy is carried out. Pharyngeal closure is done in
L fashion. Stomal suturing is done by creating a
window on the anterior tracheal wall and the incision
site is closed in layers. A secondary TEP was performed
to facilitate speech, minimum three months after
completion of RT. Primary TEP was performed in
five cases only due to financial factors.
OBSERVATION AND RESULTS :
The age range was 40 to 85 years .The maximum
incidence was found in 6th and 7th decade. There was
predominant male preponderance with 84% of the total
patients being male. About 69/87 (79.31%) were
smokers and more than 60% were beedi smokers
consistent with other studies8.
51/87 (58.6%) were T3, 36/87(41.4%) were T4
lesions. 42/87(48.27%) were N0, 30/87(34.48%) were
N1 and 15/87(17.2%) were N2 lesions. Topographical
distribution showed 46% were glottic lesions, 35.6%
were supraglottic lesions and 18.4% transglottic lesions.
Overall incidence of nodal metastasis was 51.7. 71% of
the supraglottic carcinomas and 44% of glottis tumors
had nodal metastasis at time of presentation. Of the T4
cases, 16 had tumor with thyroid cartilage invasion
while 12 had extension to base of tongue and vallecula.
Eight cases had extra laryngeal soft tissue involvement.
Histopathological grading showed that 64/
87(73.56%) of cases were moderately differentiated, 18
/87(20.68%) well differentiated and 5/87(5.68%) poorly
differentiated. 5 radio-residual cases were initially well
differentiated while post surgery histopathology was
suggestive of moderately differentiated squamous cell
carcinoma.
22/87(25.28%) had received primary radiotherapy
and the mean duration of recurrence was 21 months.23/
87(26.43%) of cases underwent preoperative
tracheostomy of which 16/23(69.5%) of these were
transglottic tumors, 3/23(13.04%) were glottic tumors
and 4/23(17.3%) was supraglottic tumors.
79/87 cases underwent widefield total
laryngectomy while 8/87 cases were managed with near
total laryngectomy along with bilateral modified neck
dissection. Post operative adjuvant radiotherapy was

provided 2 to 3 weeks following surgery to all patients
except the (22/87) radio-residual cases that underwent
salvage surgery alone. Chemotherapy was added in 7
cases due to extra-capsular spread of cancer.
We had an overall 11 cases with locoregional
recurrence during the study period with an average
duration of recurrence being 34 months. 4/11 were the
radio residual cases which were treated with salvage
surgery. 53 patients were followed for a period of 3
years or more out of which 7 patients had locoregional
recurrence. 4 cases presented with recurrence after 3
years of surgery. All cases (8/87) of near total
laryngectomy were disease free at their last follow up.
Pattern of Complication-25/87(28.7%) of cases
developed post surgical complications. Most common
early complication noted was wound infection (29%)
and pharyngo-cutaneus fistula 13%, chyle leak (7% )and
pleural effusion (4%). The late complication were 4%
persistent dysphagia, 13% had stomal narrowing and
12 patients developed hypothyroidism requiring oral
thyroxin supplementation. Hypocalcaemia was noted
in 15 cases treated with calcium tablets. Three patients
died during follow up 1 due to carotid blow out and 2
of MI.
All these case of advanced T3, T4 laryngeal cancer
were motivated for speech rehabilitation. 52/87 cases
underwent secondary tracheo-esophageal puncture and
insertion of Blom Singer prosthesis which was done 8
months to 1 year post surgery. 6 patients could afford
an artificial larynx. Rest of cases were trained for
esophageal speech.
This study showed overall survival rate of 87.3%
and that at 3 years to be 86.7% for all T3,T4 laryngeal
carcinoma who underwent widefield total/ Near total
laryngectomy. 53 patients were followed up for a period
of 3 years or more with 46 of them surviving without
disease. The overall median survival time was 58 months
and the 95% Confidence Interval (CI) ranged between
52 to 64 months. Similarly, for the specific 53 patients
the mean survival time was 55 months with 95% CI
(51.61, 57.67).These estimates were calculated based on
the Kaplan Meier method. Figure 3a displays the Kaplan
Meier (KM) curve for all patients who underwent
widefield total/ near total laryngectomy and Figure
3b displays the KM curve for those patients who were
followed up for 3 years or more. Stage specific survival
showed 3year survival rate 27/31(87%) for T3 and (17/

22)77.22% for T4 lesions.
DISCUSSION :
Laryngeal cancer is a common treatable cancer
among all head and neck malignancies presenting with
early symptoms especially glottic cancers2. The peak
incidence is noted in the 5th and 6th decade. There is
predominant male preponderance as noticed in the
study2. Our study also throws light on the affinity
between smoking and laryngeal cancers with 45% of
cases consuming alcohol which is also an additive risk
factor8. The presenting symptoms included hoarseness
(55%), neck swelling (30%),foreign body sensation in
throat(25%),referred otalgia(23%) and dysphagia(20%)
with overlapping features. 10 patients presented with
stridor and underwent emergency tracheostomy in our
study.
The two most important adverse prognostic
factors for laryngeal cancers include increasing tumor
(T) stage and nodal (N) stage and comorbidities of the
patient3. Cases having more than 4 (with 2 being
cardiovascular) comorbidities have a poorer prognosis9.
Other prognostic factors usually include age,
performance status, male sex and features like tumor
grade, extra laryngeal spread and depth of invasion9, 10.
Cases with positive neck nodes have poor survival rated
as compared to their counterparts as seen in our study.
Prognosis for small laryngeal cancers that have not
spread to lymph nodes is very good, with cure rates of
75% to 95% depending on the site, tumor bulk, and
degree of infiltration10.
We have obtained a 3-year specific survival rate of
86.7% which is noticeable and comparable if not better
to other studies of recent times. A similar study by
Young et al11 showed a survival rate of 85% at 25 months
follow-up in 20 salvage cases .Stoekliet al.4 reported that
the 5-year Disease specific survival (DSS) for 39 cases
after salvage total laryngectomy was 0.63, with
mortality rate of 49%. In contrast, the overall mortality
after salvage surgery in this study was 65%. The overall
5-year DSS was poorer in a cohort of 83 Stage IV
laryngeal squamous cell carcinoma studied by Spector
et al 12 with survival rate of about 45%. Leong et
al13notined an overall mean survival period following
total laryngectomy to be 42.4 months. Lilly-Tariah et
al.14 found a recurrence rate of 47.5% within 9 months
of total laryngectomy without a follow-up
radiotherapy, in middle belt of Nigeria; they found
17
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
this operation to be unsatisfactory due to lack of proper

follow-up radiotherapy.
The patients who received primary surgery
followed by radiotherapy had better survival and quality
of life as compared to the radio-residual/recurrence
cases that underwent salvage surgery which is consistent
with observations by Yuen et al15. Spector et al 12
described that the chance of distant metastases
developing was higher in the patients presenting with
advanced-stage (T4) primary disease as seen in our study.
Owing to better local and regional control of the
primary malignancy, it is more likely that morbidity
in these patients arise from distant metastases and
radiation related changes.
The incidence of pharyngocutaneous fistula has
also been reported to be dependent on pharyngeal
closure technique and post-op radiotherapy. Sarkeret
al.16 reported a fistula rate of 34.7% of which 65% had
received previous radiotherapy. Johansen et
al.17reported an overall fistula rate of 32%. It was 13%
in our study all of which were managed conservatively.
Early suspicion, adequate radiological evaluation,
Microlaryngoscopy and early tissue biopsy with
prompt treatment are footholds of laryngeal cancer
management. Voice preservation by near total
laryngectomy was carried out in 8 cases in our study
with roaring success. The pre-requisites for selecting a
patient for this surgical procedure7are:
1. Inter-arytenoid area should be disease free
2. No extension to cricoid cartilage
3. One crico-arytenoid unit should be free and
functional.
All patients in our study underwent bilateral
modified neck dissection of various types according to
the clinical case scenario. Management of neck for all
patients improves the prognosis of laryngeal cancer
patients10. Patients who have cancer recurrence after
total laryngectomy for laryngeal cancer have poor
prognosis and absolute lack of treatment options,
particularly when radiotherapy already has been
applied18. The most important aim of regular followup visits after treatment for laryngeal cancer is the early
detection of asymptomatic local or regional failure.
Endoscopy of larynx with metastatic work up along
thyroid and calcium levels were the basic protocols
followed during each follow up. Our study emphasizes
the role of early detection of laryngeal cancers and the
18
Fig-1 Showing specimen of total laryngectomy with Left modified neck dissection.The growth
is involving the left Ventricular band, with extention to left ventricle and paraglottic space, left
arytenoid and Interarytenoid region associated with left vocal cord fixation.
Fig2. (a) Showing near total laryngectomy with neck dissection in progress, (b) operated specimen
of left near total laryngectomy with left modified neck dissction.
Fig 3a&b. Showing Kaplan Meier survival graph
need for stringent selection criteria while choosing the

surgical technique for laryngeal cancer patients.
CONCLUSION :
The present series comprises of 87 cases of which
supraglottic, glottis, transglottic constituted 46%,
35.6% and 18.4% respectively. It puts forward the
better survival rates of patients who have undergone
total/ near total laryngectomy with neck dissection for
laryngeal cancers at our institute. Adequate post op
management with radiotherapy, speech rehabilitation
and counselling and psychological support go a long
way in reducing the morbidity of patients. Further
follow-up of these patients is in progress and long-term
efficacy and complications of this surgical technique
needs to be evaluated.
DISCLOSURES
(a) Competing interests/Interests of Conflict-None
(c) Funding - None
REFERENECES :
1. Birchall M, Pope L. Tumours of the larynx. In
GleesonScott-Browns Otorhinolaryngology:
Head & Neck Surgery; London, Arnold Hodder,
2008; 259899.
2. Head and neck cancer: a global perspective on
epidemiology and prognosis. Sankaranarayanan
R. Unit of Descriptive Epidemiology
International Agency for Research on Cancer 150,
Lyon, France. Anticancer Research 1998; 18(6B):
4779-478.
3. Total Laryngectomy and Postoperative
Radiotherapy for T4 Laryngeal Cancer: A 14-Year
Review. Ampil FL, Am J Otolaryngol. 2004; MarApr; 25(2): 88-93.
4. S.J. Stoeckli, A.B. Pawlik, M. Lipp, et al. Salvage
surgery after failure of nonsurgical therapy for
carcinoma of the larynx and hypopharynx. Arch
Otolaryngol Head Neck Surg.2000; (126) 1473
1477.
5. Frans J. M.: A new low-resistance, self-retaining
prosthesis (Provox) for voice rehabilitation after
total laryngectomy. The Laryngoscope 1990;
100(11), 12021207.
6. Tumor clearance at resection margins in total
laryngectomy. A clinicopathologic study. K. H.
Lam. Cancer 1988; 61(11), 22602272.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
An Easier Technique for Near-Total

Laryngectomy. Alfonso et al. The Laryngoscope
1996; 106(2) 235238.
Kapil U, Singh P, Bahadur S et al. : Assessment
of Risk Factors in Laryngeal Cancer in India: A
Case- Control Study, Asian Pacific J Cancer Prev
2005; 6, 202-207.
F. T. Hall, C.J. OBrien, A.R. Clifford, et al.:
Clinical outcome following total laryngectomy for
cancer; ANZ J Surg 2003; 73(5), 300305.
Luiz P K, Eduardo L. F, Jozias Detal.: Prognostic
factors in laryngeal cancer patients submitted to
surgical treatment; Journal of Surgical Oncology
1991; 48(2), 8795.
Young V.N., Mangus B.D., Bumpous J.M.:
Salvage laryngectomy for failed conservative
treatment of laryngeal cancer Laryngoscope 2008;
118(9), 15611568.
G. J. Spector, D. G. Sessions, J. Lenox, et al.
Management of Stage IV glottic carcinoma:
therapeutic outcomes Laryngoscope 2004; 114(8),
14381446.
Leong S. C, Kartha S. S, Kathan Cetal: Outcomes
following total laryngectomy for squamous cell
carcinoma- One centre experience. European
Annals of Otorhinolaryngology-Head and Neck
diseases: 2012; 129(6), 302307.
Kufre I: Total Laryngectomy for Laryngeal
Cancer in a Nigerian Tertiary Health Center:
Prognosis and Outcome. J Surg Tech Case Rep.
2011; 3(1): 2330.
Wong LY, Wei WI, Lam LK etal. Salvage of
recurrent head and neck squamous cell carcinoma
after primary curative surgery. Head & Neck
2003;Volume 25( 11), 953959.
Sarker S, Mehta SA, Tiwari J, Mehta AR, Mehta
MS. Complications following surgery for cancer
of the larynx and pyriform fossa. J SurgOncol.
1990; 43: 245249.
Johansen L, Overgaard J, Elbrond O.
Pharyngocutaneous fistulae after laryngectomy:
influence of previous radiotherapy and
prophylactic metronidazole. Cancer. 1988; 61:
673678.
Ritoe SC, Bergman H, Krabbe PF et al : Cancer
Recurrence after Total Laryngectomy-Treatment
options, survival and complications; Head & Neck
2006 28(5) 383-388.
19
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
POLYPROPYLENE STENTING IN REVISION

DACRYOCYSTORHINOSTOMY: A PROSPECTIVE STUDY
*M.S.Vijayashree, MS,**B. Viswanatha, MS, PhD, FACS
ABSTRACT
Objective: This study was done to evaluate the clinical efficacy of polypropylene for stenting in endoscopic
revision dacryocystorhinostomy.
Patients and methods: Revision endoscopic dacryocystorhinostomy operation was performed in 10 patients (4
men and 6 women) between 2009 and 2014.After recreating an aperture in the medial wall of the lacrimal sac, 2/
0 polypropylene suture material was inserted through both upper and lower canaliculi into the sac and both the
ends were knotted in the nasal cavity. The polypropylene was left in the lacrimal sac for 3 months. The patients
were followed up for 6 months. Based on the improvement in the complaint of epiphora, they were grouped as
good improvement, partial improvement and no improvement.
Results: In 8 patients (80%) improvement was good, whereas improvement was partial in 1 patient (10%), and
there was no improvement in 1 patient (10%). Granulation tissue formation around the polypropylene was seen
in one patient.
Conclusion: Polypropylene can be used successfully in endoscopic dacryocystorhinostomy as an alternative to
silicone stent. Polypropylene suture material is cheap, effective, and readily available in all operating theaters.
Keywords: Nasolacrimal duct obstruction, dacryocystorhinostomy, stent, polypropyl.
INTRODUCTION
Dacryocystorhinostomy (DCR) is a surgical
procedure performed for the relief of nasolacrimal duct
obstruction of either anatomical or functional cause1.
The first report of DCR (intranasal approach) was by
Caldwell in 18932.DCR is indicated for saccal and postsaccal stenosis and is traditionally performed externally
by Ophthalmologists3. This procedure is based on the
formation of a surgical fistula on the lateral nasal wall
between the nasal cavity and the lacrimal sac. The
operation can be carried out using either an external or
endonasal surgical approach. The external approach is
the surgery of choice for ophthalmologists4. Since its
first description by McDonough and Meiring,
endoscopic DCR gained popularity5.
Advances in endoscopic equipment have led to a
widespread use of the endoscopic transnasal approach
by Otorhinolaryngologists with results comparable to
the external approach and the potential for less
morbidity3.The advantages of endoscopic DCR with
respect to external DCR include the lack of skin incision,
20
short operating time, and lower risk of interfering with

the physiological lacrimal pump mechanism, minimal
blood loss and the possibility to correct associated intra
nasal pathological conditions during the same
procedure3,6.
We describe a technique using a polypropylene
suture material as an alternative to silicone stent in
endoscopic DCR procedures. Polypropylene is
commonly used in all surgical disciplines for suturing
and meshing purposes7,8. It is a cheap material and is
readily available when compared with bicanalicular
silicone tube.
Affiliations:
*,**,
Otorhinolaryngology department,
Bangalore Medical College & Research Institute,
Bangalore, India
B.Viswanatha, MS, PhD, FACS
Professor of ENT,
Bangalore Medical College & Research Institute
Bangalore, INDIA
Email: drbviswanatha@yahoo.co.in
Mobile no: 919845942832
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
PATIENTS AND METHODS:

This prospective study was done at the tertiary
care institute between 2009 and 2014.In this study there
were ten patients (6 females and 4 males) who underwent
revision endoscopic DCR operations for complaints
of continuous epiphora and recurrent swelling near the
medial canthus after previous DCR surgery. Patients
ages ranged from 26 to 50 years. Informed consent was
obtained from the patients.All patients underwent
routine preoperative ophthalmologic and
otorhinolaryngological examination, diagnostic nasal
endoscopy and blood investigations. Lacrimal sac or
nasolacrimal duct obstruction was confirmed by the
results of lacrimal irrigation.
Fig. 1: Showing polypropylene passing through both the canaliculi.
SURGICAL TECHNIQUE:
All surgeries were performed under local
anesthesia. The nasal cavity was decongested for 15
minutes using cottonoid pledgets soaked in lidocaine 4
% with adrenaline 1:100 000.Patients were given
premedication. Inside the operating room, cottonoid
pledgets were removed from the nasal cavity. Using
nasal endoscope, 2% lidocaine with adrenaline anesthetic
solution was injected submucosally to the lateral nasal
wall corresponding to the sac location just
anterosuperior to the insertion of the middle turbinate.
Lacrimal punctum was dilated using punctum

dilator. Then 2/0 polypropylene was inserted into the
sac through both the canaliculiFig.1. Both ends of the
polypropylene were then fastened with several knotsFig.2.
Precaution was taken to ensure that the polypropylene
stayed loose in the region of the inner canthus to
prevent canalicular laceration.
Fig. 2: Showing polypropylene with multiple knots in the nasal cavity.
POSTOPERATIVE FOLLOW-UP:
The patients were discharged on the next day of
the procedure after removing the nasal pack, and given
oral antibiotics for 1 week. Nasal irrigation and topical
eye drops were given four times a day for 2 weeks.
Patients were examined endonasally in the
otolaryngology clinic in first, second, and fourth week
in the first month. Nasal endoscopy was done once a
month until the stent removal. The polypropylene stent
was removed at the end of 3 months.
The eyes with no epiphora were accepted as good
improvement. The eyes which experienced epiphora
occasionally were designated partial improvement. The
eyes that still had epiphora were placed in the no
improvement group.
Patency of the lacrimal system was assessed by rigid
nasal endoscopy and irrigation with saline. The
21
A curved incision was made at the lateral nasal

wall mucosa including periosteum, just anterior to the
attachment of the middle turbinate. A suction Freers
elevator was used to lift the mucosal flap, keeping the
mucosa between the middle turbinate and the lateral
nasal wall intact. Identification of the sac was aided by
passing a lacrimal probe through the inferior canaliculus
into the sac, or by pressing on the skin inferior and
medial to the medial canthus and observing the
movement of the sac. Vertical incision is made on the
medial wall of the sac and it was widened using cutting
punch forceps. The patency of the lacrimal drainage
system was checked with saline irrigation.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
resolution of epiphora with patent ostium during nasal

endoscopy at the end of three months was accepted as
a successful result.
RESULTS:
The age range of our patients was between 26 to
50 years. There were 10 patients who underwent
revision endoscopic DCR procedures. The patients were
followed for a period for 6 months. Success was defined
as anatomical patency with lacrimal syringing and
improvement of the epiphora complaint at the end of
3 months.
Eighty (80%) were in the good improvement
group, One patient had partial improvement and one
patient had no improvement. When the patency of
ostium and resolution of epiphora were taken into
account; the endoscopic revision DCR was successful
in 8 out of the 10 cases (80%).One patient had partial
improvement. The procedure was unsuccessful in one
patient who presented with the complaint of epiphora
and evaluation revealed total closure of rhinostomy
opening after the removal of polypropylene stent.
There were no major surgical complications.
Granulation tissue formation near the polypropylene
suture was observed in two patients.
DISCUSSION:
Endoscopic DCR is proposed to be an alternative

surgery to the external DCR operation in cases of
chronic dacryocystitis. With the introduction of high
resolution endoscopes, endoscopic endonasal DCR has
begun to gain popularity 9. Endoscopic DCR is
becoming popular as a relatively quick and easy surgery
for post-saccal obstruction of the nasolacrimal drainage
system4.
Closure of the rhinostomy opening was
considered a major factor for surgical failure in external
DCR9.Thus, insertion of silicone stents is almost
universally employed to prevent rhinostomy stenosis
and to help to stabilize epithelialization between two
mucosal surfaces having surgical continuity10. Many
surgeons may not prefer the stents if the patient has
not had a previous operation (external DCR) and if
they are available for regular postoperative visits4. Some
studies have shown that silicone stent itself is a reason
of surgical failure due to granulation tissue formation
and complications like punctual erosion and slitting of
canaliculi9.
22
The success rate depends on providing a wide

intranasal stoma with removal of adequate bone around
the stomal area, reducing the chances of postoperative
stenosis and adhesions. Inadequate bone removal is the
commonest cause of postoperative stomal stenosis11. A
bicanalicular silicone tube is the stent most often used
in DCR procedures to prevent obliteration of the
rhinostomy opening after DCR4.
In 1967, Gibbs used silicone tubes in DCR for
the first time12. Later, Keith and Quickert and Dryden
added probes to the silicone tubes13,14. Many surgeons
prefer to place bicanalicular silicone tubing to stent the
intranasal ostium, with a high success rates.
In the literature, as an alternative method to
silicone intubation, several other materials have been
used to retain the lacrimal aperture following
endoscopic DCR4.
Tamura et al15 used T-sheet made from a penrose
drain tube in seven patients18.In their study results were
very good in four patients (57%), good in two patients
(29%), and showed no change in one patient (14%).
They detected granulation tissue in two of seven patients
and reported spontaneous tube loss in the early period
in1of 7 patients.
Kishore et al16 used standard otologic T-tubes in
endoscopic DCR. Kishore et a6,19 did not observe any
granulation around the T-tube. Erkan et al 17 used
standard otologic T-tubes in endoscopic DCR. In their
study results were every good in 11 patients (50%), good
in five patients (23%), and showed no change in six
patients (27%).They reported spontaneous tube loss in
the early period in 3 of 22 eyes and they did not observe
any granulation around the T-tube.
According to guideline published by The Royal
College of Ophthalmologists (1999) freedom from
epiphora for 3 months after surgery is the marker of
successful procedure18. All our patients were under
follow-up period of 3 months after the removal of
polypropylene, and hence, our patients were under
followed-up for 6 months. Resolution of epiphora and
patent ostium after evaluation by irrigation were the
signs of successful surgery.
In the present study, polypropylene was used as
stents in endoscopic revision DCR operation in 10 eyes.
Its strength, inertness, retention of strength after
application, minimum tissue reactivity, and resistance
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
CONCLUSION:
In the present study the success of polypropylene
stenting in endoscopic revision DCR procedures was
80%. This result was similar to that of the success rate
of silicone intubation reported in the literature. When
compared to silicon stents, polypropylene is a cheap
material readily available in almost all operating theaters
and it permits tear flow into the nose following surgery.
It is a good alternative to silicone stents.
DISCLOSURES
(a)

(c)
Funding - None

REFERENCES:
1.
2.
3.
4.
5.
6.
Ambani K, Suri N, Parmar H. Study of success

rate in endoscopic dacryocystorhinostomy with
and without stenting. International Archives of
Integrated Medicine, Vol. 2, Issue 4, April, 2015.
Caldwell G. W. Two new operations of
obstructions of the nasal duct with preservation
of the canaliculi & an incidental description of a
new lacrimal probe. Am J Opthalmol,93.
Pittore B,Tan N, Salis G, Brennan PA, Puxeddu
R. Endoscopic transnasal dacryocystorhinostomy
without stenting: results in 64 consecutive
procedures. Actaotorhinolaryngologica italica
2010; 30:294-298
Aslan S, Oksuz H, Okuyucu S, Akoglu E, Dagli
S. Prolene: a novel, cheap, and effective material
in dacryocystorhinostomy. Acta OtoLaryngologica, 2009; 129: 755-759
McDonough M, Meiring JH. Endoscopic
transnasal dacryocystorhinostomy. J Laryngol
Otol 1989;/103:/585-587.
Yigit O, Samancioglu M, Taskin U, et al. External
and endoscopic dacryocystorhinostomy in chronic

dacryocystitis: comparison of results. Eur Arch
Otorhinolaryngol 2007;264:879-85.
7.
Willatt DJ, Durham L, Ramadan MF, Bark-Jones

N. A prospective randomized trial of suture
material in aural wound closure. J Laryngol Otol
1988;/102:/788-790.
8. Afonso JS, Martins PA, Girao MJ, Natal Jorge
RM, Ferreira AJ, Mascarenhas T, et al. Mechanical
properties of polypropylene mesh used in pelvic
floor repair. Int Urogynecol J Pelvic Floor
Dysfunct 2008;/19:/375-380.
9. V Kakkar, J Chugh, S Sachdeva, N Sharma,
Ramesh. Endoscopic Dacryocystorhinostomy
With And Without Silicone Stent. A Comparative
Study. The Internet Journal of Otorhinolaryngology. 2008 (9) Number 1.
10. Sadiq SA, Ohrlich S, Jones NS, Downes RN.
Endonasal laser dacryocystorhinostomy-medium
term results. Br J Ophthalmol 1997;/81:/10891092.
11. Welham RA. Management of unsuccessful
lacrimal surgery. Br J Ophthalmol 1987;/71:/152157.
12. Gibbs DC. New probe for the intubation of
lacrimal canaliculi with silicone rubber tubing. Br
J Ophthalmol 1967;51:/198.
13. Keith CG. Intubation of the lacrimal passages. Am
J Ophthalmol 1968;/65:/70-74.
14. Quickert MH, Dryden RM. Probes for
intubation in lacrimal drainage. Trans Am Acad
Ophthalmol Otolaryngol 1970;74:/431-433.
15. Tamura M, Kawasaki Y, Mori K, Noda K, Kubo
T. Endoscopic dacryocystorhinostomy using Tsheet. Laryngoscope 2003;/113:/746-748
16. Kishore A, McGarry GW. The otologic T-tube:
a cost effective dacryocystorhinostomy stent. J
Laryngol Otol 2001;/115:/992-993.
17. Erkan AN, Yilmazer C, Altan-Yaycioglu R.
Otologic T-tube in endonasal dacryocystorhinostomy: a new approach. Acta Otolaryngol
2007; 127:/1316-1320.
18. Royal College of Ophthalmologists. Guideline for
clinical governance in ophthalmology. London:
RCO, April 1999.
23
to bacterial contamination are its main advantages7.

Polypropylene should be tied with multiple knots to
prevent its prolapse. Granulation tissue around
polypropylene in the nasal cavity was observed in only
one patient. To the best of our knowledge, the use of
polypropylene for DCR stenting has been reported
only by Aslant et al4. This is the second prospective
case series reported in the literature.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
AUDIOLOGICAL STUDY OF AGE RELATED HEARING LOSS

*Jameel K.M.,** M. Ravi Kumar Raju,***M.A.N. Murthy,****Beena. V
ABSTRACT
The physiologic loss of hearing acuity brings with it a number of problems. Among these are the difficulties in
distinguishing age related hearing loss from hearing loss associated with long exposure to intense industrial noise
and the psychological disturbances often associated with it. We present a retrospective audiological study using
pure tone average for both ears in a period of 1year conducted in ENT OPD, KIMS, Amalapuram.
Keywords: Deafness, Pure tone average, Pure tone audiometry, Presbyacusis, Hearing loss.
INTRODUCTION
Age-related hearing loss, known as presbycusis,
affects most older adults to some degree. The most
frequent cause of age-related hearing loss is the natural
breakdown of nerve cells in the inner ear. Age-related
hearing loss can also be caused by age-related changes
that may affect the eardrum or the bones of the middle
ear, which affects how well sound can move into the
inner ear. Long-term medical conditions, such as high
blood pressure, heart disease, and diabetes, or other
problems with blood movement (circulation), may also
contribute to age-related hearing loss. The physiologic
loss of hearing acuity bring with it a number of
problems. Among these are the difficulties in
distinguishing age related hearing loss from hearing loss
associated with long exposure to intense industrial noise
and the psychological disturbances often associated with
it. Speech sounds mumbled, and conversations are hard
to understand, especially when there is background
noise. Ability to hear and distinguish high-pitched
sounds is reduced, a mans lower-pitched voice.11
Tinnitus may increase as hearing loss gets worse11.
AIM :
To find age related involvement of patients with
hearing loss.
To find sex predilection in hearing loss.
To find percentage of hearing loss in different age
groups in both male & female to compare both ears.
MATERIALS and METHODS :
Inclusion criteria : All patients who underwent
24
PTA in ENT OPD KIMS & RF, Amalapuram, in last

1 year and who have sensorineural deafness.
Exclusion criteria : All patients less than 10years
of age to eliminate congenital loss, Patients with only
conductive hearing loss
Pure tone audiogram was done in standard two
cubical sound proof audiology lab in our hospital.
Percentage of hearing loss calculated for both ears
separately with formula PTA 25 1.5, where PTA is
pure tone average taken as average of Air conduction in
500, 1000, 2000 Hz and Binaural percentage of hearing
disability is calculated using formula described by AMA
(1979) American Medical Associatiion (1979) as
[1.5(PTA25)](better ear)
+1.5 (PTA-25)(poorer ear) ]
RESULTS :
Our study revealed a majority of 55 male patients
and 29 female patients of the total 84 patients included
in the study. Maximum number of patients are between
Affiliations:
*PG Resident,**Assoc. Prof,***Prof & HOD,****P.G Resident
KIMS & RF (KONASEEMA INSTITUTE OF MEDICAL SCIENCES AND
RESEARCH FOUNDATION
Dr. M. Ravi Kumar Raju,M.S(ENT), MRCS
(GLASG), DOHNS(LON)
Assoc. Prof. ENT
KIMS & RF (KONASEEMA INSTITUTE OF
MEDICAL SCIENCES AND RESEARCH FOUNDATION
Amalapuram-533201
E.G.DT, A.P STATE
mob : 9908547999
e-mail : rajumrk@yahoo.com
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
51-60 yrs. Youngest in our study recorded is 14yrs and

oldest is 78yrs. Of the total 84 patients, 82 of them
have bilateral ear involvement with two patients having
unilateral ears of which one of them has right ear
involved and the other left ear. Making it total of 166
ears. Maximum hearing loss is seen Severe category with
71-90db loss and in 51-60 age group.
DISCUSSION :
Age related hearing loss is characterized by
degenerative changes in the hair cells of cochlea and
central auditory connections and functionally by
sensorineural hearing loss.1 The onset of auditory
system degeneration starts before the beginning of
elderly age. It is characterized by audiometric threshold
shift, deterioration in speech understanding, and speech
perception difficulties in noisy environment.2
Age related hearing loss most often occurs in both
ears affecting then equally. Risk factors such as systemic
diseases & poor habits add to the age related hearing
loss.
It is well established that there are both genetic
and environmental factors that contribute to age related
hearing loss.3 Risk factors are male gender, smoking,
noise exposure, stress, metabolic & vascular conditions
(diabetes, dyslipidaemia, systemic arterial hypertension,
atherosclerosis) and hereditary. The association between
this age related hearing loss & the risk factors. However,
it remains controversial & has not been well
documented.
These were 84 patients in our study comprising
of 55 males & 29 females. The ages ranged from 10 - 80
years excluding age group less than 10 years to minimize
congenital causes of deafness.
According to our study age related hearing

difficulties were significantly more common in men
compared to women. Our findings are in consistent
with study Rosenhall U et. al who have reported that
hearing difficulties were more prevalent in men. 4
Differential Oestrogen exposures have been suggested
as a cause for the higher prevalence of hearing difficulties
in men.5
From our study it appears that hearing loss tended
to be start manifesting in the middle ages peaked at
about fifth decade and progressed gradually over the
years. The incidence of hearing loss in people aged about
50-59 years increased 150%.6
Fransen et.al stated that age related hearing loss
occurs in elderly people in their 60s and 50% of people
in the over 70 age group.7 One third patients in our
study were within the fifth decade of life. The youngest
being 14 years and oldest being 78 year. In Great Britain
MRC study on hearing loss, median hearing threshold
levels in adults suggested that age related high frequency
hearing decline commences after 30years in men but
doesnt become apparent in women until after 50years
of age8. Average peak loss in men & women is in fifth
decade in our study. Hearing acuties also reduced with
increasing age after eighth decade may be due to fewer
number of patients above this age. In our study of 84
subjects, 82 subjects reported B/L hearing loss & 2
subjects reported U/L hearing loss each one affected
with a different ear. Hinchcliffe (1959)9 has also recorded
audiogram loss in the left ear due to rifle fire, whereas
Jacobs et. al have shown that there is no such
preponderance of left sided hearing defect in male
children. Our study didnt show any significance
Table 1 Age and sex wise distribution.
25
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
regarding hearing loss between the ears.
both male and female.
When overall percentage loss calculated, more loss

seen in males and significant loss seen between 51-80 %.
When overall percentage loss calculated, more loss

seen in males and significant loss seen between 51-80 %.
Age related changes in hearing predominantly seen

in male population compared to female population.
Peak age group affected in our study is fifth decade in
Youngest patient affected with sensorineural

hearing loss in our study is 14 years old and oldest is 78
years.
Table 2 Hearing loss(PTA) in various age groups in both sexes to compare both ears.
Table 3 Percentage of hearing loss in Right and left ears.
26
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
No significant variation in hearing loss between

right and left ears in both sexes of all age groups.
4.
Hasson D, Theorell T, Westerlund H, Canlon B:

Prevalance and characterstics of hearing problems
in a working and non working Swedish
population. J Epidemiol community health 2010,
64:453-460.
5.
Adams PF, Marano MA. Current estimates from

the national health interview survey,1994. Vital
and Health Statstics Series 10, Data from the
national survey. 1995:1.
6.
Fransen E, Lemkens N, Van Laer L, Van Camp

G. Age related hearing impairment (ARHL):
environmental risk factors and genetic prospects.
Exp Gerentol 2003;38:353-9.
7.
Davis A. Hearing in adults. Whurr publishers Ltd.

London. 1995. First ed London.
8.
Hinchcliffe, R. Acta Otolaryngologica, 1959; 50,

411.
9.
Gates GA, Mills JH. Presbyacusis. Lancet

2005;366:1111-20.
CONCLUSION :
Sensorineural hearing loss though thought to be
seen in old age, can occur in any age group due to
various factors. There is no clinical method to predict
the age related hearing loss in advance. There is neither
medical prevention nor treatment that can restore
hearing loss at this time.10 Open mind in recognizing
the problems in any age group with sound knowledge
to diagnose them at the earliest needed to minimize
morbidity.
DISCLOSURES
(a)

(c)
Funding - None
(d) No financial disclosures.

REFERENCES:
1.
Rosenhall U. presbyacusis-hearing loss in old age.

Lakartidningen.2001;98(23):2802-2806.
2.
Liu XZ, Yan D. Ageing and hearing loss . J Pathol

2007;211:188-97.
3.
Fetoni AR, Picciotti PM, Paludeti G. Troiani D.

Pathogenesis of presbyacusis in animal models: A
review. Experimental gerontology, 2011
jun.46:413-423.
[PubMed:21211561] Rosenhall U. jonsson R,
Soderlind O: self assessed hearing problems in
Sweden: a demographic study. Audiology 1999,
38:328-334.
10. Primary Medical Reviewer William H. Blahd, Jr.,

MD, FACEP-: Brian D. OBrien, MD AgeRelated Hearing : - Emergency Medicine ; Internal
Medicine Specialist Medical Reviewer Charles M.
Myer, III, MD, Otolaryngology; http://
www.healthlinkbc.ca/healthtopics/content.asp?
hwid=tf4270#tf4270-Credits.
11. Dobie RA: The AMA method of Estimation of
hearing disability; a validation study: Ear Hear2011-Nov-Dec, 32(6): 732-40.doi.10. 1097 AUD.
obo13e31822228be.
27
Table 4 % of Binaural hearing loss in both sexes.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
A CASE REPORT:
BELLS PALSY IN AN 11 MONTH-OLD INFANT
*
Lina LingChooi, MS ,**Abu BakarZulkiflee, MS*,***Narayanan Prepageran, FRCS
ABSTRACT
Objective: To report a rare case of infantile facial nerve paralysis.
Case Report:An 11 month old boy presented with history of sudden right facial asymmetry of 1 day duration.
Mother denied any history of fall or trauma. Otherwise, he was active, except for the dripping of the milk on the
affected site on feeding. On further examination, child had right facial palsy involving loss of the nasolabial fold.
However child was still able to close the eyes while sleeping. Other cranial nerve findings were normal. Child
was admitted for observation with no worsening of the facial nerve function. He was started on oral steroid
therapy for 1 week duration. Facial nerve function recovered fully after 2 weeks with no other further intervention.
Conclusion: Bells palsy in infant is relatively rare and regards as diagnosis of exclusion. Clinical improvement
is favourable within two weeks and usage of steroids remains controversial.
Keywords: Facial Nerve Palsy, Bells Palsy, Paediatrics Nerve Palsy, Steroids.
INTRODUCTION
Paralysis of the facial nerve is usually immediately

obvious. Whether it develops in a child or an adult,
facial nerve paresis or paralysis has a tremendous impact
on the patient as well as the family, particularlywhen a
paediatric patient is involved.It results in weakness of
the musculature of the face, impacting verbal
communication, social interaction with respect to facial
expression, oral competence, taste and, most
importantly, protection of the cornea and vision2.
Facial paralysis can be caused by numerous
conditions, all of which should be excluded before a
diagnosis of Bells palsy is reached. Facial nerve paralysis
which was observed, ranging in age from birth to 18
years shows that Bellspalsy was the most common cause
(42%), followed by trauma (21%), infection (13%),
congenital (8%) and neoplasm (2%)1.
CASEREPORT
An 11 month-old boy brought to the paediatrics
emergency by his parents with history of sudden right
facial asymmetry of 1 day duration. The child had 1
episode of fever the previous day and on the day of
presentation was afebrile. Mother denied any history
of fall or trauma. Otherwise, he was active, except for
28
the dripping of the milk on the affected site on feeding.

He had no other ear or nose symptoms. On further
examination, child had right facial palsy involving loss
of the nasolabial fold(Figure 1), however child was still able
to close the eyes while sleeping. Other cranial nerve
findings were normal. Ears, nose and oral cavity were
normal. His complete blood count was normal.
Otoacoustic emission(OAE), tympanometry and
stapedial reflex were all normal.
Child was admitted to the paediatric ward for 1
day for observation with no worsening of the facial
nerve function. He was started on oral steroid therapy
for 1 week duration. Facial nerve function recovered
Affiliations:
:*
Medical Registrar/Fellow,
**
Clinical Specialist and Lecturer,
***
Consultant Otolaryngologist, Skull Base, Head and Neck Surgeon,
Department of Otolaryngology,Faculty of Medicine,
University of Malaya Medical Centre,
Pantai Valley, 50603 Kuala Lumpur,
Malaysia.
Dr. Mohd. Zulkiflee Abu Bakar (AB Zulkiflee),
Department of Otolaryngology,
University of Malaya Medical Centre,
50603 Kuala Lumpur, MALAYSIA.
Tel: +603 7949 2062
Fax: +603 7955 6554
Email: abzulkiflee@yahoo.com
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Fig.1: An 11 month-old child presented with right facial

palsy.
Fig. 2 : Right Facial Nerve fully recovered after 2 weeks.
fully after 2 weeks with no other further

intervention(Figure 2).
location of nerve injury. Presence of the stapedial reflex

in cases of incomplete paralysis or return of the
stapedial reflex within 3 weeks of disease onset predicts
complete recovery of the nerve by 3 to 8 weeks2.
A child presenting with acute-onset facial palsy

requires a detailed history and physical examination to
rule out recognizable and treatable causes. The history
should detail the date of onset, rapidity of progression,
any preceding history of viral illness or trauma, and
associated systemic symptoms to rule out traumatic,
infectious, neoplastic, or hematologic causes. Bells palsy
is generally a diagnosis of exclusion.
The prognosis for patients with Bells palsy is
generally excellent, particularly in children, in whom
the risk of recurrence is only 7% to 10% 1. Most children
will recover within two to four weeks 3. Clinical
examination to determine whether the child has paresis
or complete paralysis, is the most important prognostic
test. Prognosis for the child presented with paresis at
onset, is invariably good.
Children with uncomplicated Bells palsy may not
usually require further testing. However,further testing
is recommended when the child presents with complete
paralysis or when no signs of initial recovery are
apparent within 3 weeks of disease onset 1 .
Topodiagnostic test which include Schirmers tear test,
the stapedial reflex test, and evaluation of salivation and
taste on the involved side is performed to assess the
Different electrophysiological tests have been

applied in adults with facial palsy to assess the
prognostic significance as it provide a more accurate
and objective prediction of subsequent improvement.
Electroneu-rography (ENoG), electromyography and
blink reflex (BR) had been found to be useful 3.
However, the value of ENoG and BR had rarely been
reported in children, probably because the majority of
children recovered, and thus they were seldom referred
to the paediatric neurologist or neurophysiologist4.
Radiologic imaging such as MRI is not routinely
indicated, because determining the site of facial nerve
involvement is not useful in predicting recovery. MRI
may be recommended in patients with apparent Bells
palsy who have paralysis persisting for more than 3
months, recurrent facial palsy, or single facial nerve
segment involvement, to rule out a neuroma or any
underlying neurologic disorder5.
It has been proposed that Bells palsy results from
inflammation and edema of the facial nerve, most likely
initiated by infection with Herpes Simplex Virus
(HSV)4. Consequently, common treatment approaches
include steroids to reduce facial nerve inflammation,
acyclovir to treat the inciting infection.
29
DISCUSSION
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
An other vital aspect of treatment is eye

care.However, due to a paucity of properly randomized
studies in children with Bells palsy, the efficacy of
steroids as well as of other therapies can only be
extrapolated from studies done in adults. Whether
corticosteroids are necessary or even more effective
than in adults remains controversial.Most pediatric
trials did not provide conclusive evidence of any benefit
in using steroid or acyclovir as treatment1.
trial of oral steroids may be offered to all patients

presenting within the first 2 to 3 weeks of onset of
facial paresis, even though there is no conclusive
evidence of their benefit.
However, steroids are generally safe and probably

effective in improving facial function outcomes. In this
infant, we commenced syrup prednisolone 1mg/kg/
day with tapering dose.
Hence, early treatment with oral steroids is

probably effective to improve facial function.Use of
acyclovir either in combination with steroid or alone
are still controversial and that acyclovir is only possibly
effective in improving facial functional outcome1.
DISCLOSURES
(a)

(c)

30
Funding - None
REFERRENCES
1.
Pratibha Singhi, Vivek Jain, Bells Palsy in

Children, Seminars in Pediatric Neurology, Vol
10, No 4 (December), 2003: 289-297.
2.
Josef Finsterer,Management of peripheral facial

nerve palsy, European Arch Otorhinolaryngol.
2008 July; 265(7): 743752.
3.
Evans AK, LicameliG, BrietzkS, Pediatric facial

nerve paralysis: Patients,management and
outcomes International Journal of Pediatric
Otorhinolaryngology 2005;69 : 15211528.
4.
Virginia Wong,Outcome of facial nerve palsy

in 24 children, Brain & Development 1995;
17:294-6.
5.
Han-sheng Tsai et al, Epidemiology and treatment

of Bells Palsyinchildren in northern Taiwan,
MicrobiolImmunolInfec. 2009, 42:351-356.
CONCLUSION
While this is a relatively rare event in the pediatric
population, Bells palsy does occur. Fortunately it is a
self-limiting condition with a favourable prognosis.
However we should not disregard other probable
diagnosis of children presenting with facial nerve palsy
as Bells palsy is still a diagnosis of exclusion. Further
investigation may not be needed but it is recommended
if the disease do not show any sign of improvement. A
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
TUBERCULOSIS OF COLLAURAL FISTULA PRESENTING AS

PAROTID ABSCESS
*Manish Chandra, **Rajeev Krishna Gupta, ***Ritika Bhatt
ABSTRACT
Collaural fistula is a rare 1st branchial cleft anomaly having 2 openings, one in external auditory canal and other
in upper part of neck.We present a case of 10 year old male boy who presented with swelling on left side of neck
in infraaural region and pit like depression in the conchal bowl on lateral most part of left external auditory
canal.Postive AFB smear of aspirated pus confirmed the swelling to be tubercular abscess.CECT neck demonstrated
a fistulous tract from left external auditory canal traversing through the parotid to upper part of neck with
parotid abscess.The rarity and diverse presentation of 1st branchial cleft anomalies have frequently led to
misdiagnosis and inappropriate treatment.We aim to highlight the clinical features of this case which can aid in
diagnosis of 1st branchial cleft anomalies.
Keywords: Collaural fistula, branchial cleft, parotid abscess.
CASE REPORT:
st
Anomalies of 1 branchial cleft includes

preauricular cysts, preauricular sinuses, collaural fistula
and branchial fistula.1 st branchial cleft anomalies
accounts for less than 8%of all branchial anomalies1.
Though these congential anomalies are not a major
problem to patient,they can become site for repeated
infection which is troublesome to a patient.Misdiagnosis
of these anomalies result in inadequate treatment,
subsequent reoccurance and definitive surgery becomes
complicated2. A highindex of suspicion, carefull history
along with thorough examination is required to make
diagnosis.
A collaural fistula is rarest of 1st banchial cleft
anomalies and is formed because of failure of resorption
of ventral part of 1st branchial groove.It courses from
external auditory meatus or tragal notch down into
neck.Opening in neck lies between angle of mandible
and sternocleidomastoid. Both the opening differ in
location in every patient. The track runs through the
parotid gland and may pass medial to lateral to or
through the facial nerve.Sinogram and Contrast
enhanced CT Sinogram help to delineate the course of
tract. Management is surgical exploration and excision
of defect with preservation of facial nerve and to
reconstruct otological structures if necessary.
A 10 year old male patient came to the OPD with

swelling on the left side of neck below and behind the
left lobule since 2 months.The swelling was painless,
progressive in size.There was history of on and off
discharge from an opening in external auditory canal
since childhood.There was history of recurrent bouts
of skin infection in upper part of neck which
responded to antibiotic treatment. On examination,
swelling was present on the left side of neck in infraaural
region and an opening was seen at 6oclock position on
conchal bowl on lateral side of left external auditory
canal(Fig1&2). There was excoriation of skin around the
opening in external auditory canal. Bilateral tympanic
membrane were intact.
A sinogram demonstrated a linear sinus tract from
infraaural region extending upto 2nd molar, probably
coursing through the terminal branches of facial nerve,
Affiliations:
*Assistant Professor,.**Resident, ***Resident,
Eras Lucknow Medical College, Lucknow.
Dr. Rajeev Krishna Gupta
Resident, Department of ENT
Eras Lucknow Medical College & Hospital,
Sarfarazganj, Hardoi road, Lucknow-226003
Email- dr.rajeevgupta11@gmail.com
Mobile No-94506890745.
31
INTRODUCTION
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
on left side, suggestive of fistulous communication with

parotid duct and gland.
CECT neck demonstrated a fistulous tract from
left external auditory canal traversing through the
parotid to upper part of neck with collection in
superficial lobe of left parotid suggestive of parotid
abscess(Fig3).
Pus was aspirated from neck swelling and sent for
culture and sensitivity and AFB. Pus smear was positive
for acid fast bacilli. Montoux test was positive. Routine
investigations were within normal limits except for
raised TLC and ESR. No investigations regarding HIV
infection suggested any positivity.
After full course of antitubercular treatment
surgery was planned.Fistulous tract was completely
Fig 3. Axial cut CECT showing parotid abscess
excised with a small cuff of external ear canal cartilage

and skin, with primary closure.
DISCUSSION:
Fig 1. Opening on lateral side of left external auditory canal
Pharyngeal arches are rod like thickening of

mesoderm present in the wall of embryonic foregut.
In the interval between two arches on inside lies the
endodermal pouches and outside lies the ectodermal
clefts. Initially there are six arches, but the fifth is
vestigial and disappears. Four branchial pouches
internally and four branchial grooves (clefts) externally,
separate the remaining five branchial arches. The
branchial apparatus were first described by Von Baer
while its anomalies were first described by Von
Ascheroni 3 . Anomaly of 1 st branchial cleft are
uncommon and account for less than 8 percentage of
all the branchial abnormalties. Collaural fistula is 1st
branchial cleft anamoly. Collaural fistula accounts for
less than 5% of branchial cleft anomalies.
Although congenital in origin, first branchial cleft
anomalies can present later in life, at a mean age of 18.9
years (range, 20days to 82 years)1. Presenting symptoms
include recurrent otorrhoea in absence of chronic otitis,
cystic swelling or discharge from the fistulous opening.
There may be history of ottitis externa, incision and
drainage of abscess around the ear.
Fig 2. Opening seen on upper part of neck.

32
On examination opening of fistula can be

appreciated as pit in external auditory canal and higher
up in neck. In our case fistulous opening in external
auditory canal was quite obvious. Fistulous opening in
external auditory canal is present in only 44% of patient
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Sinogram and contrast enhanced CT sinogram

help to delineate the course of tract.
The relationship of 1st branchial cleft anomalies
to facial nerve is variable. In a study of 10 patient, 7
lesions ran medial to facial nerve,2 were lateral and 1
ran between the branches of facial nerve4. Because of
close relationship to facial nerve, excision of these
anomalies requires identification and a wide exposure
of nerve along with facial nerve monitoring5.
After acute infective episode has cleared, surgical
exploration and excision of defect is definitive
treatment. This should be followed by repair of excised
auditory canal. Tuberculosis of parotd gland is
uncommon and only 100 cases have been reported in
literature in immuno competent patients6. In our case
we did not notice any features of HIV. The infection
of TB of collaural fistula might be primary which is
very very to occur in literature to be reported.
DISCLOSURES
(a)
(b)
(c)
(d)
REFERENCES:
1.
DSouza AR, Uppal HS, De R and Zeitoun H.

Updating concepts of first branchial cleft defect :
a literature review. International Journal of Pediatr
Otorhinolaryngology2002; 62 :103-109.
2.
Siddiq M A. Emerg. Med. J. 2003; 20: 103-104.

doi:10.1136/emj.20.1.103.
3.
De PR, Mikhail T. A combined approach excision

of branchial fistula.
4.
Solares CA, Chan J, Koltai PJ. Anatomical

variations of the facial nerve in the first branchial
cleft anomalies.Arch Otolaryngol. Head Neck
Surg. 2003; 129: 351-5.
5.
Triglia JM, Nicollas R, Ducroz V, Koltai PJ,

Garabedian EN. First branchial cleft anomalies: a
study of 39 cases and a review of the literature.
Arch Otolaryngol Head Neck Surg. 1998; 124:
291-5.
6.
Rangel AL, Coletta RD, Almeida OP, Graner E,

Lucena A, Sadiva PH, Vargas PA. parohd
mycobacteriosis is frequently caused by
mycobacterium tubercubsis in advanced AIDS.
J. oral pathol. med. 2005, Aug; 34(7): 407-12.
CONCLUSION:
Branchial cleft anomalies can present as
preauricular or postauricular or high in neck cyst,
sinuses or fistulous tract. Collaural fistula presents with
two openings one in external auditory canal and other
in upper part of neck.Although congenital in origin,
these can present latter in life. A high index of suspicion,
carefull history and thorough clinical examination is
helpful in making diagnosis. Surgical excision of defect
is treatment of choice after full treatment with
antituberculor drugs.

Sponsorships - None
Funding - None
No financial disclosures
and even if present it may not be obvious4. There can

be associated otological anomalies.
33
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
EXTRA MEDULLARY PLASMACYTOMA OF LARYNXA RARE CASE REPORT

*K.C Mallik, **S.L Rautray,***D.Bhue, ****Ankita Joshi,*****Kamalakanta Jena
ABSTRACT
Introduction: Extra medullary plasmacytoma(EMP) is a rare neoplasm of plasma cell, described as soft tissue
outside the bone marrow. EMP represents 0.04 to 0.45% of malignant tumours of larynx.
Objective: To describe and report a case of extramedullary plasmacytoma of larynx with literature review.
Case report; A 60yr old male presenting with dyspnoea for 4 months worsening progressively with globular
mass over right lateral glosso-epiglotic fold and arye-epiglotic fold, being subjected to excisional biopsy diagnosed
as extramedullary plasmacytoma.
Conclusion: Examedullary plasmacytoma must be considered in the differential diagnosis of tumours of larynx.
It is highly curable when radiotherapy is used.
Key words: Extramedullary plasmacytoma, larynx, radiotherapy.
INTRODUCTION
Extramedullary plasmacytoma(EMP) is a rare
neoplasm of plasma cell, described in soft tissue outside
bone marrow1. The median age of presentation is 5659yr2. It occurs predominantly in males, with male to
female ratio of 3:1.3 The most commonly affected sites
are the submucosal lymphoid tissue of nose and
paranasal sinuses[1].It has been reported rarely in larynx
about i.e 10%3.
The symptoms are mainly dysphonia, dysphagia,
cough and dyspnoea when EMP affects the larynx/
laryngopharynx. The EMP of larynx are usually
submucosal.
The diagnosis of an EMP is primarily histological
based on the presence of plasma cells which in the
immunohistochemical study shows monoclonality,
pointing to its neoplastic nature 6,7. Morover the
diagnosis is based on exclusion of multiple myeloma.
EMP is a localised entity usually associated with a
long surveillance2. Nevertheless in 16% cases the disease
can progress to multiple myeloma4. It is highly radio
sensitive, so radiotherapy is the treatment of choice.
CASE REPORT
A 60yr old male with a history of smoking (15-16
packs per year) and known case of diabetes mellitus
presented to ENT dept of Shreeram Chandra Bhanj
Medical College and Hospital, Cuttack because of
dyspnoea for 2months which was progressive and not
34
associated with hoarseness of voice, dysphagia or

haemoptysis.
He has past history of excision of a globular mass
of larynx & posterior pharyngeal wall left side by
internal approach under GA in other hospital in 2005
histopathology of which had suggested plasmacytoma/
multiple myeloma which was not confirmed by
immunohistochemistry(Fig.1).
Clinically there was no external swelling, any scar
mark or any pulsation over neck. There was no palpable
cervical lymphadenopathy.
The indirect laryngoscopy revealed a globular mass
over right lateral glosso-epiglottic fold and right
aryepiglottic fold. pyriform fossa of right side was not
visible & rest part of larynx was normal. CT/MRI scan
was not done as the mass was confined to limited area
of larynx and the patient was not able to afford it(Fig.2).
The patient was hospitalised, all the investigations
were done and he was prepared for excision of the mass
under General Anaesthesia.
First of all under Local anaesthesia tracheostomy
was done. GA was then given through PVC cuffed
Affiliations:
*Associate professor, **Assistant professor, ***Senior Resident,
****PG Resident, *****PG Resident
Dr K C Mallik
Associate Professor
Dept of ENT, SCB Medical College
Cutack, Odisha
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Fig. 1: Pre-operative photo as seen through Laryngeal

endoscopy 2005
Fig.2: Pre-operative image through Laryngeal endoscopy 2014
Fig. 3 (a) Operative photographs.
Fig. 3 (b) Operative photographs.
tube. Horizontal skin incision was given over neck at

the level of mid part of thyroid cartilage. An apron
flap was elevated upto hyoid bone above and cricoid
cartilage below.Sternohyoid and thyrohyoid muscles
were cut and larynx was skeletonised. Laryngotomy
was done through thyrohyoid membrane on right side
and from aryeepiglottic & glossoepiglottic fold by
dissecting through the mucosa mass was excised and
delivered(Fig.3a,b). No lymph node were found involved
peroperatively. Haemostasis was maintained, Romovac
drain was placed and wound was closed in three layers.
Nasogastric tube was inserted. After excision of mass,
patient was relieved symptomatically. He was under
broad spectrum antibiotic for 10 days. The stitches were
removed on 10th day. There was wound dehiscence
which was repaired by secondary suturing which was
found healed on 20th day. The patient was discharged
after decannulation on 25th day.
Post operative histopathology study was consistent
with the diagnosis of plasmacytoma. Multiple myeloma
was excluded as negative results were obtained both in
the blood protein electrophoresis and urine
immunofixation studies(Fig.4&5).
The patient then underwent Radiotherapy after
confirmation of diagnosis but he did not come for
follow up study and went away to his village.
DISCUSSION
A plasmacytoma is a discrete solitary mass of
neoplastic monoclonal plasma cell in either bone or soft
tissue(extramedullary).
The types of plasmacytoma are as follows-7
Solitary bone plasmacytoma
Soft tissue/extramedullary plasmacytoma
Multifocal form of multiple myeloma
Multiple myeloma
Plasmablastic sarcoma
Fig. 4: Histopathological section.
35
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Fig. 5: Post-operative photo as seen through Laryngeal

endoscopy.
Diagnostic criteria for EMP are-9
Tissue biopsy showing monoclonal plasma cell on

histology
BM plasma cell infiltration not exceeding 5% of

all nucleated cell
No evidence of myeloma or osteolytic lesion
Absence of hypercalcemia or renal failure
Low serum M protein,even if present

EMP usually presents as a mass growing in
aerodigestive tract in 80-90% cases often with spread to
lymph node. Most of the presenting symptoms are due
to compression or invasion to surrounding structures.
Common complaints include swelling, headache,
nasal discharge, epistaxis, nasal obstruction, sore throat,
hoarseness, dysphonia, dysphagia, dyspnoea,
hemoptysis and epigastric pain.
The etiology may be related to chronic stimulation
of inhaled irritants or viral infection.
The most common sites of laryngeal plasmacytoma
are in the decreasing order of frequency are: epiglottis,
vocal cord, ventricular band, areytenoid and subglottis5.
Wittshaw classified soft tissue plasmacytoma into
three clinical stages8
Stage I- Limited to an extramedullary site
Stage II- Involvement of regional lymph node
Stage III- Multiple metastasis
In our case the patient was in Stage I.
The accepted treatment for EMP is radiotherapy6.
The optimal dose for local control is 40-50
Gy(depending on tumour size) delivered over 4-6
weeks 6. Because of high rates of lymph node
involvement these areas should be included in radiation
field. Adjuvant radiotherapy should be given to patient
with positive surgical margin. Chemotherapy should
be considered for refractory or relapsed cases. Adjuvant
chemotherapy for tumour >5cm as well as those with
high grade histology is needed.
36
CONCLUSION
EMP should be considered in the differential
diagnosis of rare tumours of larynx.It is highly curable
when radiotherapy is used. Moderate radiation dose &
limited field ensure excellent cosmetic and functional
result.
DISCLOSURES
(a) Competing interests/Interests of Conflict- None
(c) Funding - None
REFERENCES
1.
K. Lewis, R. Thomas, R. Grace, C. Moffat, G. Manjaly,

and D. C. Howlett, Extramedullary plasmacytomas of
the larynx and parapharyngeal space: imaging and
pathologic features, Ear, Nose and Throat Journal, vol.
86, no. 9, pp. 567569, 2007.
2.
I. G. Guijarroa, L. D. Gonzlez, N. R. Acevedoa, and E.

P. Pallasa, Plasmocitoma extramedular de laringe. A
propsito de un caso Extramedullary plasmacytoma of
the larynx. A case report, Acta Otorrinolaringolgica
Espaola, vol. 62, no. 4, pp. 320322, 2011
3.
J. N. Wise, R. F. Schaefer, and R. C. Read, Primary

pulmonary plasmacytoma: a case report, Chest, vol.
120, no. 4, pp. 14051407, 2001.
4.
P. Strojan, Extramedullary plasmacytoma of the larynx:

a report of three cases, Radiology and Oncology, vol.
36, no. 3, pp. 225254, 2002.
5.
R. Saad, S. Raab, Y. Liu, P. Pollice, and J. F. Silverman,

Plasmacytoma of the larynx diagnosed by fine-needle
aspiration cytology: a case report, Diagnostic
Cytopathology, vol. 24, no. 6, pp. 408411, 2007.
6.
D. Velez, A. Hinojar-Gutierrez, S. Nam-Cha, and A.

Acevedo-Barbera, Laryngeal plasmacytoma presenting
as amyloid tumour: a case report, European Archives
of Oto-Rhino-Laryngology, vol. 264, no. 8, pp. 959961,
2007.
7.
M. Hughes, et al., Guidelines on the diagnosis and

management of solitary plasmacytoma of bone,
extramedullary plasmacytoma and multiple solitary
plasmacytomas: 2009 update.
8.
Dimopoulos MA, Kiamouris C, Moulopoulos LA.

Solitary plasmacytoma of bone and extramedullary
plasmacytoma. Hematol Oncol Clin North Am. Dec
1999;13(6):1249-57.
9.
Galieni P, Cavo M, Pulsoni A, et al. Clinical outcome

of extramedullary plasmacytoma. Haematologica. Jan
2000;85(1):47-51.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
ANCIENT SCHWANNOMA OF CERVICAL

SYMPATHETIC CHAIN - A RARE ENTITY
*Tanvi Anoop Lohiya, **Kshitij Dhaval Shah, ***Ashutosh Vishwasrao Patil, ****Renuka Anil Bradoo
ABSTRACT
Schwannomas arising from the cervical sympathetic chain in the parapharyngeal region, are a rare entity. Among
the various histological types of schwannomas reported to date, the ancient (degenerative) variant is the most
rare. The treatment of choice is excision of the tumour. We describe a case of a schwannoma arising from the
cervical sympathetic chain, with the rare histopathology of ancient schwannoma.
Keywords: Schwannoma; ancient schwannoma; cervical sympathetic chain.
Cervical sympathetic schwannoma is a rare ,

benign, slowly growing tumour which develops from
the schwann sheath of peripheral nervous system nerve
fibres. Schwannomas in the parapharyngeal space may
arise from cranial nerves 9th, 10th, 11th and 12th or
the autonomic nerves, the vagus being the most common
site2. Schwannomas have been classified histologically
into five types: common, plexiform, cellular, epithelioid
and ancient. Among these, the ancient schwannoma is
the most rare3. The term ancient is given to cases
showing typical neurilemmoma features with
hyperchromatic areas and bizarre nuclei. Due to their
longstanding course, these tumours develop
degenerative (ancient) changes in the form of cystic or
myxoid degeneration.
CASE REPORT:
A 40 year old female presented with complaints
of painless swelling on the left side of the neck since 3
months. The swelling was insidious in onset and
gradually progressed to its current size. There were no
complaints of dysphagia, dysphonia or neurologic
deficit. On examination, there was a 4 x 3 cm firm,
non tender mobile swelling with normal overlying skin
in the left carotid triangle.An MRI with gadolinium
contrast revealed a 5 x 2.9 x 3.2 cm sized well defined
T2 STIR hyperintense oval lesion in the left carotid
space posteromedial to the carotid bulb, ICA and ECA
extending from C2 vertebra superiorly to superior
endplate of C5, showing intense heterogenous post
contrast enhancement in venous and delayed phases with

multiple non enhancing foci within, suggestive of a
nerve sheath tumour like a schwannoma/neurofibroma
(figure 1 a b & c)
. A USG confirmed no vascularity, hence
ruling out the possibility of a paraganglioma. The
patient was counselled and advised surgical excision of
the tumor. After obtaining valid informed consent, the
surgery was performed under general anaesthesia. A
transverse skin crease neck incision was used and
subplatysmal flaps were elevated. The anterior border
of sternocleidomastoid was delineated and the internal
jugular vein and carotid artery were identified and
delineated. Carotid artery bifurcation was exposed and
retracted by umbilical tape slings to expose the
tumour(fig 2a). The tumour was visualised arising from a
nerve trunk, viz., the sympathetic chain. Decision was
taken to sacrifice the nerve trunk as the tumour was
intracapsular. Tumour was dissected and delineated
from all sides. Nerve trunk was cut and the specimen
INTRODUCTION
Affiliations:
*Senior Registrar,**Assistant Professor,
***Registrar,****Professor & Head
Department of E.N.T,
Lokmanya Tilak Municipal Medical College
and General Hospital, Sion, Mumbai - 22
Dr Tanvi Lohiya
Senior Registrar,
Department of E.N.T,
Lokmanya Tilak Municipal Medical College
and General Hospital, Sion, Mumbai - 22
Row House no. 4, Kanakia Spaces, Eternity,
Teen Haath Naka, Thane, Maharashtra, 400604
37
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
was delivered(fig 2b). A suction drain was placed and the

wound was closed in layers. Patient recovered well from
the surgery.
The excised specimen was sent for histopathological
assessment which was reported as spindle cells with
elongated nucleus in a prominent myxoid extracellular
matrix along with Verocay bodies, suggestive of
Ancient schwanomma arising from the sympathetic
trunk(fig 3).
may represent degenerated Antoni A tissue are the main

features of Type B. Occasionally schwannomas may
present with hyperchromatic areas and bizarre nuclei.
These cellular changes reflecting degeneration are
classical of the so-called ancient schwannoma. Sparse
mitotic hyperchromatic nuclei and degenerative
changes, such as cyst formation, calcification, with only
occasional sites of hemorrhage are the major
histopathological characteristics of the ancient forms
The patient developed Horners syndrome post

surgery, in the form of ptosis of the left eyelid(fig 4) which
recovered gradually.
DISCUSSION:
Cervical schwannoma was first reported by Ritter
in 1899. They are typically solitary, well-encapsulated,
benign tumours characteristically running along the
course of a nerve or attached to peripheral, cranial, or
sympathetic nerves. Although the head and neck region
accounts for 2540% of the schwannomas, it is
extremely rare to develop an ancient schwannoma in
the parapharyngeal region. The term ancient
schwannoma was first coined by Ackerman and Taylor
in their review of 48 neurogenic tumours of the thoracic
region5.
Fig. 2: (a) Tumour delineated after retraction of IJV Nerve of

Origin sympathetic chain shown by the arrow, (b) Cut ends
of the nerve after excision of the nerve.
Microscopically, schwannomas have a distinctive

pattern of compact cellularity arranged with palisading
nuclei (Antoni A pattern) alternating with a more
loosely arranged hypocellular pattern (Antoni B
pattern). Nuclear palisading and associated Verocay
bodies, which may reflect their prominent extracellular
matrix and secretion of laminin are the dominant
characteristics of Type A tissue, whereas a loose
organization with myxomatous and cystic changes that
Fig. 3: Gross & Microscopic images (H & E stain, 40
Fig. 1: Imaging a) Contrast enhanced CT (b)T1 weighted

MRI axial view (c) T2 weighted MRI sagittal view
38
Fig. 4: Post operative Horners syndrome.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
CONCLUSION:
Schwanomma arising from cervical sympathetic
chain in the parapharyngeal region is a rarity. Ancient
schwanomma, a pathological variant, is found rarely.
We have reported this case due to its rarity of
anatomical site of origin and pathology. The

management remains the same as that of a schwanomma
in any other part of the body.
DISCLOSURES
(a)

(c)
Funding - None

REFERENCES
1.
Sheridan MF, Yim DWS. Cervical sympathetic

schwannoma:a case report and review of the English
literature. Otolaryngol Head Neck Surg. 1997;
117(Suppl): 206-10Al-Ghamdi S, Black M, Lafond
G. Extracranial head and neck schwannomas. J
Otolaryngol 1992;21:186-8.
2.
Bozec A, Dassonville O, Poissonnet G, et al.

Laryngeal schwannoma: a case report. Ann
Otolaryngol Chir Cervicofac :2003;120:404.
Weiss SW, Goldblum JR. ParotisSchwannoma.

In: Enzinger FM, Weiss SW, eds.Soft Tissue
Tumors. 4th edn. Saint Louis: Mosby; 2001.pp1,
1461,167.
4.
Walther LE, Mentzel T, Sens A, Beleites

E.Degenerative changes in parapharyngealschwannoma ancient schwannoma. Case
report and review of the literature. HNO 2001;
49: 5458.
5.
Ackerman LV, Taylor FH. Neurogenoustumors

within the thorax; aclinicopathological evaluation
of fourty- eight cases. Cancer 1951; 4: 669691.
6.
Verma RK, Sunku SK, Panda NK. Contrasting

radiological presentation of cervical sympathetic
chain schwannoma: case series of two cases.
Otolaryngol Pol. 2014SepOct; 68(5): 2715.doi:
10.1016/j. otpol.2013.12.002. Epub 2013 Dec
13.PubMed PMID: 25283326.
39
of schwannomas.One of the most misleading aspects

of this tumor is the degree of nuclear atypia. These
tumors behave as ordinary neurilemomas and therefore
the nuclear atypia can be regarded as a purely
degenerative change.A contrast enhanced CT or MRI
is the investigation of choice. Anteriorly displaced
internal carotid artery is characteristic of neurogenic
and vagal paraganglioma, whereas salivary gland tumors
generally cause posterior displacement. On CT
examination without contrast, a Schwannoma is
generally hypodense compared to the muscle; with
contrast, this lesion shows some degree of enhancement.
MRI reveals low signal intensity on T1 and high signal
intensity on T2-weighted images. Paraganglioma, on
the other hand, is classically isodense when compared
to muscle on pre-contrast CT, with more reliable
homogeneous enhancement post-contrast. The postgadolinium MRI sequences of paraganglioma show
extremely bright contrast enhancement in a
characteristic salt and pepper pattern, representing the
low signal intensity of vascular flow voids which is not,
however, pathognomic for paraganglioma, but may be
found with hypervascular lesions. But rarely, cervical
sympathetic schwannomas can also cause splaying of
the ECA and ICA and mimic the Lyre sign, giving
rise to false-positive Lyre sign6. The definitive treatment
is surgical excision. Horners syndrome is to be expected
following removal of the tumour, due to the necessary
division of the cervical sympathetic chain, but this does
not appear to have an adverse effect on the patient.
The ptosis due to paralysis of Mllers muscle can be
repaired through slight advancement of the levator
aponeurosis, or resection of the conjunctiva and
Mllers muscle.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
CONGENITAL PAROTID SALIVARY FISTULA FROM

STENSONS DUCT
*Mayashankar B. Vishwakarmam, **Hemantkumar O. Nemade ,
***Subhalakshmi A. Jaiswal, ****Shankar Kothule
ABSTRACT
Congenital parotid gland fistulas are extremely rare and they can be arising from the ectopic parotid tissue and
are more infrequently from the normal salivary gland forming sialo-cutaneous fistula. Here we present a unique
case in which 15 years old female patient presented with small pit near left oral commissure draining the salivary
flow which was communicating with the normal ductal system of the parotid gland and with intact Stensens
duct opening in the oral cavity.
The patient was investigated to confirm the origin of the fistula by fistulogram which revealed the fistula
communicating the normal ductal system of the parotid gland. Patient was operated with prior cannulation of
the fistula with the 26 G needle one and half inch needle and dissected around it till the parotid gland is excised
completely along with small amount of parotid gland after ligating it with non absorbable suture material.
This is an extremely rare condition posing diagnostic and therapeutic challenges to the treating physician.
Keywords: salivary gland, sialo-cutaneous fistula, congenital anomalies.
INTRODUCTION
Parotid fistulas are most commonly acquired and
are secondary to the trauma, surgery, malignancies and
inflammation. Congenital parotid fistulas are extremely
rare. They can arise from the ectopic parotid gland and
less frequently from the normal salivary gland
communicating with its ductal system.
CASE REPORT:
15 year old female patient presented to our OPD
with small pit near left angle of mouth complaining
serous discharge from the pit since birth. There was no
history of trauma or previous surgery. There was no
history of increase in the discharge with food intake.
There was no history of local swelling in past. On
inspection pinpoint opening seen 2 cm lateral to left
oral commissure(figure 1). Drops of clear fluids were
expressed from the opening when digital pressure on
the ipsilateral parotid region is given(figure 2). On intraoral
examination both Stensens duct opening seen. No other
anomalies were found. Fistulogram was done which
revealed dye reaching to the normal ductal system of
the parotid gland. The contrast dye injected through
the fistula enhanced the parotid gland(figure 3). Patient was
posted under general anesthesia for excision of fistula.
40
The fistula was canulated with the 26 G one and half

inch needle. 2 ml methylene blue dye was injected
through the fistula to identify the branches if any. Small
elliptical incision taken with long axis along the
nasolabial furrow around the opening of the fistula.
The dissection of the complete fistula tract was aided
by the needle inside the fistula(figure 4). Dissection done
till the normal parotid gland was exposed and the
complete fistula tract along with the small amount of
parotid tissue ligated with non absorbable suture (silk
3-0) and excised. The wound was closed in layers.
Postoperative course was uneventful. Patient was
followed up for six months without any complaints.
DISCUSSION:
All of the major salivary glands are derived from
oral cavity epithelium, which proliferates and burrows
Affiliations:
*Assistant professor ,**Assistant professor,***Professor & Head ,****PG
resident P.G.Dept of ENT & Head & Neck Surgery Dr.Vaishayampayan
Memorial Government Medical College, Solapur, Maharashtra, India.
Dr. Shankar Kothule, MD,
PG Resident, ENT dept, 2nd floor, B block, Civil hospital,
Solapur-413003
Email id: - shankarkothule@gmail.com
Contact no: - +91 9552609914
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Fig 1 :-Discharging fistula lateral to left ant. Commissar.
Fig.5 :-Intraoperative photo of excision of fistula.
Fig. 3:- Contrast dye injected through the fistula enhanced the
parotid gland.
The exact aetiology of the congenital salivary

fistula is not known. Yamasaki et. al.1 proposed that
excess parotid anlage may have proliferated from the
original epithelium of the oral fossa and grown
posteriorly and superiorly apart from the original
parotid gland to form accessory parotid gland. Gilbert
et. al.2 considered that it was possible that the primitive
parotid bud developed from the edge of the maxillary
processes in such a way that subsequent fusion of the
processes leaves the parotid opening external rather than
internal.
Sun Z et. al.3 described two cases of parotid fistula
in cheek in cases of Goldenher syndrome and suggested,
a congenital cheek salivary fistula of an accessory parotid
gland should be considered indicative of Goldenhar
syndrome.
Fig. 4:- Contrast dye injected through the fistula enhanced the
parotid gland.
The diagnosis of the parotid fistula in our case

was done by fistulogram. Gadodia et. al.4 put forth the
importance of the sialography, magnetic resonance
41
Fig. 2 :- Drop of clear fluid on digital pressure.
into the surrounding mesenchyme to form a solid cord.

Extensive branching occurs during embryogenesis to
form the acini of the glands, and a lumen develops
within the main trunk to form the excretory duct. After
fusion of the maxillary and mandibular processes, which
are both derived from the first branchial arch, the
parotid duct takes its normal position inside the mouth
at the level of the superior second molar. Congenital
salivary fistulas from the parotid gland and from the
accessory parotid gland are rare; when they do occur,
they usually open at the facial skin near the angle of
the mouth.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
sialography and computed tomography sialography

with fistulography in delineating the ductal anatomy.
But these investigations are expensive and not required
in all cases for diagnosis.As this condition is rare, there
is no standardization of the treatment. Most of the cases
in the literature are from the accessory parotid duct
fistula which were treated by dissection and reposition
of the parotid fistula into oral cavity by Delores
method1. Woo Kyung Moon in their case report treated
the accessory parotid fistula by fistulectomy with
excision of accessory parotid gland5. J. Hun Hah treated
the accessory parotid fistula by chemocauterization by
40% trichloroacetic acid6. In our case dissection of the
tract was carried out by placing a needle in the tract,
excessive dissection was avoided to damage to terminal
branch of facial nerve.
REFERENCES:
1.
Yamasaki H, Tashiro H, Watanabe T. Congenital

parotid gland fistula. Int J Oral Maxillofac Surg
1986;15(4):492-4.
2.
Gilbert PM. Congenital external fistulae of the

parotid duct. Br J Plast Surg 1987;40(1):99-101.
3.
Sun Z, Sun L, Zhang Z, Ma X. Congenital

salivary fistula of an accessory parotid gland in
Goldenhar syndrome. J Laryngol Otol 2011;Oct
28:1-5.
4.
Gadodia A, Seith A, Sharma R, Thakar A.

Congenital salivary fistula of accessory parotid
gland: Imaging findings. J Laryngol Otol
2008;122(3):e11.
5.
W.K. Moon, M.H. Han, I.O. Kim, et al.,

Congenital fistula from ectopic accessory
parotid gland: diagnosis with CT sialography
and CT fistulography, Am. J. Neuroradiol. 16
(1995) 997999.
6.
J. Hun Hah et al., clinical and experimental

otorhinolaryngology Vol 1, No. 2: 113-115, june
2008.
CONCLUSION:
Congenital parotid fistula is rare and that from
stensons duct is further rare entity which usually
follows trauma.
DISCLOSURES
(a)
(b)
(c)
(d)
42

Sponsorships - None
Funding - None
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
PLEOMORPHIC ADENOMA LOCATED OVER THE NASAL

DORSUM: A RARE PRESENTATION
*Ehrlson de Sousa, **Sai Spoorthi Naik, ***Manu Wilfred, ****Saumyata Neeraj
INTRODUCTION
Pleomorphic adenoma is the commonest benign
tumour of the salivary gland. It is usually found in the
major glands namely the parotid followed by the
submandibular gland. Besides that , minor salivary
glands which are scattered in the upper aerodigestive
tract e.g. in the oral cavity, oropharynx and
hypopharynx are also subjected to this benign pathology
. Pleomorphic adenoma occurring in the skin of the
head and neck area is extremely rare.
These neoplasms affect females more than males
and are commonly seen in the 3rd to the 6th decades of
life. While pleomorphic adenomas are highly
uncommon in the nasal cavity, approximately 80% of
nasal pleomorphic adenomas are detected in the nasal
septum while the remaining 20% are found in the lateral
wall or turbinate despite the fact that a significant
proportion of mucous and serous glands are confined
to the lateral nasal wall.
CASE REPORT
A 27 year old male presented with a 6 month
history of painless swelling over the nasal dorsum. The
swelling had gradually increased in size. There was no
history of nasal obstruction, discharge, epistaxis or any
constitutional symptoms. Examination revealed a 2 x2
cm mobile cystic mass over the nasal dorsum. The mass
was firm in consistency and non tender and surrounding
skin was healthy. No pus, discharge or fistula was noted.
Intranasal endoscopy revealed normal findings .
CT scan revealed a superficial cyst with intact
underlying nasal bone. The patient underwent excision
biopsy of the mass under local anaesthesia.
Histopathological examination showed features of a

pleomorphic adenoma of minor salivary gland.
Histologically the specimen showed a fairly well
circumscribed nodular mass composed of tubular
structures surrounded by fibromyxoid stroma with
clear histological margins. The tubules were lined by 2
layers of cells (ductal cells and myoepithelial cells) with
foci of squamous differentiation. There was no evidence
of malignancy. The incision site healed well with
minimal scar visible at 1 month follow up(Fig.1,2,3).
DISCUSSION
Tumours arising in the minor salivary gland
accounts for 22% of all salivary gland neoplasm.
Majority of them are malignant with only 18% of them
being benign. Of the benign tumours, pleomorphic
adenoma is the commonest.(1) Pleomorphic adenoma is
a benign slow growing tumour that affects the major
salivary glands. Besides parotid and submandibular,
involvement of minor salivary gland does occur. The
commonest site for pleomorphic adenoma in the upper
respiratory tract is the nasal cavity.[2]
Although most of the minor salivary glands are
located in the lateral nasal wall, intranasal pleomorphic
adenoma usually arises from the septum.[3,4]
Affiliations:
*Senior Resident Department of ENT, **Senior Resident,
***Junior resident, ****Junior resident
Goa Medical College Bambolim, Goa- 403202
Dr. Ehrlson de Sousa
Junior Resident Department of ENT
Goa Medical College, Bambolim
Goa- 403202, Mob: 9822920729
Email: ehrl218@gmail.com
43
ABSTRACT
Pleomorphic adenoma predominantly occurs in major salivary glands. Besides parotid being its commonest site,
few case of pleomorphic adenoma in submandibular gland and other minor salivary glands have been reported.
We report a rare case of a swelling over nasal dorsum which clinically was a superficial cyst. Complete excision
was performed and histopathological examination of the specimen showed findings suggestive of pleomorphic
adenoma.
Keywords: Nasal dorsum, minor salivary glands, pleomorphic adenoma.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Fig.1: Clinical photograph showing swelling over nasal dorsum.
Fig.2 : Intraoperative finding of cystic lesion over nasal

dorsum.
Fig.3 : Histopathological picture showing tubular

structures surrounded by fibromyxoidstroma.
Pleomorphic adenoma in the skin are rare but can
be found in various sites in the head and neck region
including scalp , eyelids, nose , cheek , upper lip ,
external ear and external auditory canal .[5]
Histopathologically, pleomorphic adenoma is an
epithelial tumor of complex morphology possessing
epithelial and myoepithelial elements arranges in a
variety of patterns and embedded in a
mucopolysaccharide stroma. Formation of the capsule
is a result of fibrosis of the surrounding salivary
parenchyma which is compressed by the tumour and
is referred to as False capsule(6)
Histologically, pleomorphic adenomas of the nasal
cavity differ in certain characteristics. The nasal cavity
tumours have greater cellularity and contain more
44
epithelial components than the chondroid, myxoid and

collagenous stromal components that are seen in
pleomorphic adenomas of the parotid gland.
If the lesion is diagnosed preoperatively, attempt
should be made to do a complete surgical excision with
histological clear margins as there is a potential
recurrence. In this case the mass was excised completely.
However the patient still needs a long follow up as
recurrence has been reported.[7]
CONCLUSION
Pleomorphic adenomas of the nasal cavity are
extremely rare. All attempts should be made to do a
complete surgical excision with histological clear
margins. Nevertheless, post operative follow up is
mandatory in view of its potential for recurrence.
DISCLOSURES
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None ,
(c) Funding - None
REFERENCES
1. Spiro RH: Salivary Neoplasms: overview of a 35
year experience with 2807 patients. Head Neck
Surgery 1986, 8:177-84
2. Uguz MT, Oral K , Demirey U, Ekinci N.
Tumoral mass presenting in the nasomalar region
arising from the lateral wall: Pleomorphic
adenoma Evr Arch Otorhinolaryngology 2007 ;
264 : 1377-1379.
3. Suzuki K, Moribe K , Baba S. A rare case of
pleomorphic adenoma of lateral wall of nasal cavity
with special reference of stastistical observation of
pleomorphic adenoma of nasal cavity in Japan J
Otorhinolaryngology sac JPN 1990; 93(5): 740-45.
4. Campagno J , Wong RT , Iintranasal mixed
tumours
(pleomorphic
adenoma):
a
clinicopathologic study of 40 cases. Am J clinical
pathology 1977; 68(2) : 213-18.
5. Nishimura S, Murofushi T, Sugasaw M .
Pleomorphic adenoma of the auricle .Eur.Arch
Otorhinolaryngology 1999 ; 296 : 22-24.
6. Heeneman H. Parapharyngeal Space Tumours. Scott
Browns Otolaryngology. 5th edition. Edited by Kerr
AG. Butterworth & Co Ltd; 1987: 380-91.
7. Irfan Mohammad , Jamal Sazly Jamaluddin,
Mukarramah Che Ayub. Nasal dorsum as an
unsual location of pleomorphic adenoma.
International medical journal (2011;18(3):250-51.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
A RARE CASE OF NASAL B CELL LYMPHOMA

A CASE REPORT
*Lokanath K.V.,**Srijoya Gupta
ABSTRACT
Lymphomas arising in nasal cavity are relatively uncommon. Their rarity makes them dismissible compared to
benign inflammatory lesions. Therefore while evaluating a nasal mass, clinician should keep nasal lymphoma in
mind as it influences management and prognosis. A male patient presented with right nasal obstruction, hyposmia
and one episode of epistaxis. Examination revealed a solitary reddish mass filling the right nasal cavity. Computed
Tomography scan and Histopathological examination were both inconclusive in a diagnosis.
Immunohistochemistry revealed Non Hodgkins lymphoma- B cell neoplasm [Extraosseous Plasmacytoma]
Keywords: Nasal mass, Non Hodgkins lymphoma, Immunohistochemistry.
Primary Non-Hodgkin Lymphomas of the nasal

cavity or paranasal sinuses are defined as lymphoid cell
neoplasms in which the bulk of the disease occurs in
these anatomic sites. Extramedullary plasmacytoma is
a mass forming lesion of monoclonal plasma cells that
occurs outside the bone and bone marrow1. Carcinomas
of nasal cavity and paranasal sinuses account for 0.2-0.8
% of all malignant neoplasms. Malignant lymphomas
account for 14% of all cancers in the nose and paranasal
sinuses. They account for 2.6 to 6.7 % of all
lymphomas 2. Non-Hodgkin lymphomas broadly
comprise of NK/T or T cell lymphomas and B cell
lymphomas. In Asians 29% of all primary nasal cavity
lymphomas are of B cell type 1. Extramedullary
plasmacytoma is a part of Non-Hodgkins Lymphoma
(B cell type) and can be classified into well, moderately
or poorly differentiated.
present on and off since 2 months. He also gives history

of 1 episode of bleeding from the nose 1 month back.
Clinical Examination showed a solitary mass filling
the right nasal cavity and partially obscuring the view
of inferior turbinate, reddish and was bleeding on
touch. The mass could be probed medially and along
the floor and the roof of the nasal cavity [Fig. 1]. Cold
spatula test showed decreased fogging on the right side.
Olfaction was reduced on the right side.There were no
palpable cervical lymph nodes
Full blood count, Peripheral smear, renal and liver
function tests done were normal. Endoscopic
examination of the nasal cavity was suggestive of a mass
arising from the posterior end of the middle turbinate
filling the nasal cavity. Computed Tomography scan
of the Nose and Paranasal Sinus showed a mass in the
right nasal cavity without any intracranial extension
abutting the septum and middle turbinate suggestive
of an exophytic papilloma. [Fig. 2]
CASE REPORT:
A patient aged 31 years, a farmer by occupation
presented with complaints of right sided nasal
obstruction since 2 months which was insidious in onset
and gradually progressive. He also complained of
difficulty in breathing since 2 months which was
gradually progressive and a reduced sense of smell since
2 months which was associated with watery nasal
discharge. Episodes of headache, heaviness of head were
Affiliations:
*
Professor,
**
Postgraduate,
Department of ENT & Head & Neck Surgery, JJM Medical College,
Davangere-577004
Dr. K.V. LOKANATH
Professor and head, DeptOf ENT,
JJM Medical College, Davangere- 577004
Email: loksy82@gmail.com
srijoy666@gmail.com
Phone: +91 9886462373/ +91 9972224871
45
INTRODUCTION:
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Nasal Mass was excised under Endoscopic guidance

and sent for histopathological examination and nasal
cavity was packed to control post-operative epistaxis.
Histopathological Examination showed metaplastic
squamous epithelium overlying diffusely distributed
single cells and nests of pleomorphic cells with nuclear
infoldings, many binucleate and multinucleate cells.
Diffuse sprinkling of plasma cells and lymphocytes were
also seen. Few bits showed columnar epithelium with
seromucinous glands in subepithelium. These features
suggested possibility of a poorly differentiated
carcinoma (lymphoepithelial type)/ Non Hodgkin
Lymphoma.
Fig 2: CT scan showing right homogenous nasal cavity mass
These photomicrographs depict a diffusely

arranged group of pleomorphic cells with enlarged
nucleus and moderate amount of cytoplasm. Some cells
exhibit prominent nucleolus. Few binucleate forms are
seen. Nasal mucosa is also noted. [Fig 3] [Fig 4]
Immunohistochemistry staining showed cells
positive for CD 138 [Fig 5] and CD 45 and negative
for CD 20 and Cytokeratin. There was patchy positivity
for CD 19 in the tumor cells.
Immunohistochemistry confirmed a diagnosis of
B cell Non Hodgkin Lymphoma- Extra Osseous
Plasmacytoma involving the nasal cavity.
Fig 3: Microphotographs showing pleomorphic cells, plasma

cells and nasal mucosa (40x).
Patient had been relieved of nasal obstruction and

his other symptoms. The post operative period was
uneventful. Patient has been planned for further chemo
and radiotherapy as per the guidelines stated by national
cancer institute.
Fig 4: Pleomorphic cells with enlarged nucleus along with

nuclear infoldings (100x Oil Immersion).
Fig 1: Right sided nasal cavity reddish mass seen on anterior

rhinoscopy.
46
Fig 5: CD 138 staining positive IHC, 40x.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Non Hodgkin Lymphomas of the nasal cavity or

paranasal sinuses are haematolymphoidtumours with
the bulk of the disease in these sites. Non Hodgkins
Lymphoma of the sinonasal tract are uncommon
malignancies representing 3 to 5% of all malignancies
and accounts for 60% of all lymphomas.
Extramedullary plasmacytomas (EMPs) are a mass
forming lesion of monoclonal plasma cells that occurs
outside the bone and bone marrow. They are seen in
the age group of 34-78 years with a male predominance
of 4:1. In the Asian population 90% of sinonasal
lymphomas are T cell in origin unlike in this case. The
nasal cavity is the most common site of occurrence for
head and neck Extramedullary Plasmacytomas (28%)
as was seen in this patient. In Asian patients the nasal
cavity is more common as a primary site for lymphomas
compared to the paranasal sinus unlike in the Western
population. Presenting features are soft tissue mass
(80%), airway obstruction (35%) as in this case, epistaxis
(35%), local pain (20%), proptosis (15%), nasal discharge
(10%), regional lymphadenopathy (10%)1.
The investigations of choice are usually Computed
Tomography scan of nose and Paranasal Sinus to check
extent of lesion and bony erosions. Biopsy of lesion
and Immunohistochemistry can confirm the diagnosis
of Lymphoma.
Radiographically these tumors mimic carcinomas
and other neoplastic conditions which are more
prevalent, therefore the surgeon will have a low
suspicion of lymphoma. Even the gross appearance is
misleading. They can be smooth, lobulated or nodular
with a fleshy or rubbery consistency2.
Superficial sampling of lesion may not diagnose
lymphoma as they are subepithelial and more deeper
biopsies are required.Angiocentricity and angioinvasion
are features which can be detected in deeper biopsies3.
Sometimes due to ischaemia and necrosis initial biopsy
may be negative requiring immunophenotyping4.
Histopathology shows a diffuse infiltrate of
neoplastic plasma cells in the subepithelial tissue,
accompanied by a scant vascularized stroma. The
tumour can be well, moderately or poorly
differentiated. Atypical plasma cells are usually seen
which can be recognized by their eccentrically placed
nuclei, coarsely clumped clock-face chromatin in
some nuclei, and amphophillic cytoplasm with a

paranuclearhof (Golgi zone)1. In this case pleomorphic
cells along with variably sized nuclei were seen along
with a diffuse sprinkling of plasma cells.
Moderately and Poorly differentiated EMPs cause
significant difficulties in differentiating from large cell
lymphoma, carcinoma, melanoma and olfactory
neuroblastoma. These reasons initially produced the
diagnosis of a lymphoepithelial carcinoma (poorly
differentiated) in this case. Immunohistochemistry
staining becomes essential to come to a definitive
diagnosis. Poorly differentiated EMPs comprise large
cells that are often barely recognizable as being plasma
cells.
Immunohistochemistry of extramedullary
plasmacytoma shows CD 20 negative and CD 138
positive as in this case. There is also usually expression
of CD 38, VS38 but they are not specific for plasma
cells. PAX-5 is negative, while Oct-2 and Bob.1 are
frequently positive. Plasma cell neoplasms show
positivity in CD 45 staining. These are proteins detected
by immunohistochemical staining. Unlike in this case
Cytokeratin positivity may be present which can lead
to a misdiagnosis of carcinoma.
In terms of differential diagnosis Epstein Barr virus
(EBV) studies can be very helpful. Nasal lymphomas
of B cell origin have only a weak association with
Epstein-Barr virus. Lymphomatoid granulomatosis is
EBV positive, it is a B cell lymphoproliferative disease5.
After confirming the diagnosis by
immunohistochemistry the treatment of choice is
Chemoradiotherapy sometimes with multiple
chemotherapeutic agents or Radiotherapy alone
depending on the stage of lesion [1] [6]. Majority of the
patients with Nasal Lymphoma (Non Hodgkins type)
present at an early stage with localized disease without
any metastasis. Approximately 20% of patients with
primary Extramedullary Plasmacytoma will develop
Multiple Myeloma but it is not possible to predict
which cases will progress1.
Unlike NK/T cell lymphoma or Diffuse large Bcell lymphoma (DLBCL), extramedullary
plasmacytoma has a better prognosis. Unlike DLBCL
which has a poor prognosis when associated with
lymphatic metastasis7, this tumor of B cell origin
responds well to treatment.
47
DISCUSSION:
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
Several other differential diagnosis should be kept

in mind while evaluating a nasal mass such as
Carcinoma- squamous cell carcinoma, lymphoepithelial
type, Melanoma, Papilloma, Olfactory neuroblastoma,
Rhinoscleroma and Wegeners granulomatosis.
2.
Vidal RW, Devaney K, Ferlito A, Rinaldo A,

Carbone A. Clinicopathologic Consultation
Sinonasal Malignant Lymphomas: A Distinct
Clinicopathological Category. Ann OtolRhinolLaryngol 1999;108:411-8
CONCLUSION:
3.
Campo E, Cardesa MD, Alos L, et al. Non

Hodgkins lymphomas of nasal cavity and paranasal
sinuses. Am J ClinPathol 1991;96:184-90.
4.
Sharma A, Dandekar M, Deshmukh S, Dabholkar

J. Nasal extranodal natural killer T cell lymphoma:
an atypical presentation. The Journal of
Laryngology& Otology 2011;125:1181-4.
5.
Wood PB, Parikh S, Krause JR. Extranodal NK/

T-cell lymphoma, nasal type. Proc (BaylUniv Med
Cent). Jul 2011; 24(3): 251-4
6.
Cleary KR, Batsakis JG. Pathology Consultation

Sinonasal Lymphomas. Ann OtolRhinolLaryngol
1994;103:911-4
7.
Ning-Ning Lu et al. Clinical Behavior and

Treatment Outcome Of Primary Nasal Diffuse
Large B-Cell. Lymphoma. Cancer 2012;
118:1593-8.
Lymphomas arising in the nasal cavity are

relatively uncommon. Incidence of cancer of the nasal
cavity and Paranasal sinuses is low (<1.5/100,000) of
which 14% are lymphomas. This rarity causes clinicians
to dismiss them as a benign inflammatory infiltrate.
Furthermore routine blood investigations may be
normal and radiographic images may be misleading.The
importance of immunohistochemistry in the diagnosis
of lymphomas cannot be overstated especially owing
to its rarity. Therefore, while evaluating a nasal mass, a
clinician should keep nasal lymphoma in mind as it
influences management and prognosis.
DISCLOSURES
(a)
(b)
(c)
(d)

Sponsorships - None
Funding - None
REFERENCES:
1.
48
Barnes L, Eveson JW, Reichart P, Sidransky D.

Pathology & Genetics, Head & Neck Tumours
Lyon: IARC Press(World Health Organization
Classification of Tumours Vol.9) 2005, p.58-63.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
UNUSUAL FOREIGN BODY IN AIRWAY

TWO CASE REPORTS
*Khageswar Rout,**K. K. Samantaray, ***R. N. Biswal
ABSTRACT
Tracheobronchial foreign body aspiration can be life threatening emergency, which is associated with significant
morbidity and mortality. Aspiration of foreign bodies is common in pediatrics age group. The diagnosis and
treatment of foreign bodies in airway are a challenge for ENT surgeon. Despite improvements in medical care
and people awareness, approximately 3000 death1 occurs every year for foreign body aspiration. In this case
report, we describe two interesting cases of unusual presence of foreign body. a) Cardboard pin in trachea, b) A
dead Snail in the sub glottic region.
INTRODUCTION
Foreign body in airway still remain a diagnostic
and therapeutic challenge despite significant advance in
Endoscopic technique. It is very common in children
below the age of 6yrs. Sudden aspiration of foreign
body into airway may result in acute respiratory
distress, chronic pulmonary infection, atelectasis and
death. Diagnostic work up of foreign body aspiration
include a definitive history and comprehensive
radiological investigation.
Foreign body inhalation is best managed by rigid
bronchoscopy which in expert hands is very simple,
almost free of complications and successful. Sometimes
foreign body in airway may present without any
symptoms and normal chest radiograph. Here we are
reporting two interesting cases of foreign body a) card
board pin which was found inserted into tracheal wall
and its plastic head was moving inside the tracheal lumen
during respiration, b) A dead Snail in the sub glottic
region, These foreign bodies were retrieved successfully
by rigid bronchscopy.
CASE REPORT: 1
An 8 yrs old boy accidentally inhaled a cardboard
pin & developed bouts of cough, which settled after

few minutes. He didnt have any foreign body sensation
in throat, haemoptysis, cough, chest pain or difficulty
in breathing. Parents of the child believed the foreign
body had been coughed out. Patient was brought to
ENT OPD, Kalinga Institute of Medical Sciences after
5days on advice of a Pediatrician who was the family
physician of that child. A detailed ENT Examination
was done. Indirect Laryngology was normal. On
respiratory system examination bilateral airway was
normal and no added sound was found. X-ray of neck
and chest was done immediately which revealed a linear
metallic opacity over mediastinum area. Patient was
taken up for pediatic rigid bronchoscopy under C-Arm
guidance under general anesthesia. Luckily Red colored
plastic head of the pin was visualized in the tracheal
lumen just above the carina and was removed using
Affiliations:
*Assistant Professor, **Associate Professor,
***Professor & HOD
Kalinga Institute of Medical Sciences,
Bhubaneswar,Odisha
Dr. Khageswar Rout,
Assistant Professor
Kalinga Institute of Medical Sciences,
Bhubaneswar, Odisha
49
Keywords- Bronchoscopy, foreign body, trachea.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
forceps. The post operative period was uneventful.

Patient was discharged after 24hours(Fig1).
CASE REPORT: 2
A six year old boy accidentally inhaled a dead snail
while playing with friends. He developed cough, mild
respiratory distress. He was brought to the casualty of
Hospital. Detailed ENT examination was done. There
was bi-phasic stridor on close observation, bilateral air
entry was normal. X-ray neck lateral view showed a
radio opaque foreign body in subglottic area. Patient
was taken to Operation Theater for removal under GA
With mask ventilation. On laryngoscope the foreign
body was visualized in subglottic region. Endotracheal
intubation was avoided as it could push the foreign
body in to the bronchus. Tracheostomy was done and
foreign body retrieved successfully. As it was a dead
Fig 3: Patient undergone tracheostomy.
snail with a hole in it, air was passing freely in subglottic

region Tracheostomy was closed after 24 hours and
child was discharged after 48 hours. Post operative
period was uneventful(Fig2,3).
DISCUSSION:
Fig 1: The cardboard pin removed after bronchoscopy.
Fig 2: Dead snail removed.
50
Aspirated foreign bodies are responsible for a

significant amount of mortality and morbidity in
children despite the improvement in anesthetic and
endoscopic technique. It is the 5th leading cause of death
the children in USA2, among children younger than 15
years. Toddlers seem to be the most vulnerable for
foreign body aspiration with peak age of 1-3 years3.
According to the study conducted by Gross the
clinical history in such cases was emphasized, especially
the first paroxysm of notable cough and a severe
suffocation which occurred with the aspiration of
foreign object. There may be a symptomless period
after first paroxysm which may vary in duration from
few days to even months. However, subsequent
wheezing, cough, chocking and sudden onset of asthma
points towards a possible foreign body aspiration. Plain
X-ray chest remains the initial diagnostic modality. It
has been reported that imaging studies4 have sensitivity
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
of 73% and specificity of 45%, though up to 20% of

patient have negative history and negative radiological
evaluation.
Advantage of rigid bronchoscopy for removal of
tracheobronchial foreign body is already established
due to its large lumen usage of alligator forceps for
grasping. Assisted ventilation under GA is always
comfortable and safe.
DISCLOSURES
(a)

(c)
Funding - None

1.
Allan D Murroy, MD, Foreign body aspiration

over view, E-Medicine. Medscope.com, article /
872498
2.
Muntz, Horlan (2009), Pediatric oto Laryngology

for the clinician, foreign body management, Page
no:215-222.
3.
Yadav SP, Singh J, Aggrawal N, Goel A

(Sep2007), airway foreign body in children.
4.
Thomas SH, White BA foreign body, Walls RM,

et al (2009) emergency medicine 7 th Edition,
chapter 57 (Page: 24-27).
REFERENCE
51
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
A RARE CASE REPORT OF

PLEXIFORM NEUROFIBROMA OF THE SUBLINGUAL GLAND
*Satyajit Mishra, **Smrutirekha Sahu
ABSTRACT
Plexiform neurofibroma of sublingual gland is a very rare finding. It is a benign,slow growing tumor with not
much morbidity. Here we present a case of 7 yrs old male with soft non tender swelling in floor of mouth which
was finally diagnosed as plexiform neurofibroma.
Key words: Plexiform neurofibroma, sublingual.
INTRODUCTION
Neurofibroma (NF) of the salivary glands is very

rare and it accounts for 0.4% of all salivary gland
neoplasms, 14% of all benign mesenchymal tumours
and 10% of non epithelial salivary gland tumours(1,2).
There are two distinct forms of neurofibromatosis.
These tumours either present as solitary form or
generalised form. Neurofibromatosis type 1 is referred
to as von Recklinghausens disease-a neurocutaneous
disorder- manifested by melanin pigmentation of the
skin, neurofibromas,hamartomas of the iris and other
defects of skeletal and nervous system.
Neurofibromatosis type 2 presents as bilateral acoustic
neuromas with CNS and cutaneous manifestations(3).
Out of the three major salivary glands, parotid is the
one most commonly affected, followed by
submandibular and rarely is sublingual glands(4,5).
which was soft, smooth surfaced, non-tender, nonbleeding, pushing the tongue superiorly. There was no
cervical lymphadenopathy. The patient undergone
excision of the sublingual mass along its pseudo capsule
through an elliptical incision in the floor of the mouth
preserving Whartons duct and lingual nerve. The
wound was closed with 4-0 chromic catgut sutures. Not
much bleeding occurred intraoperatively.
Pathological examination revealed a plexiform
neurofibroma in the sublingual gland containing
ganglion cells. Multinodular, solid, pink, homogenous
tissue present made of salivary gland tissue distorted
by growth of interglandular nerves. Glandular and
Neurofibroma can occur anywhere in the body.

But, its occurrence in sublingual region is extremely
rare. We came across a case of Neurofibroma present
in the floor of mouth as a solitary swelling which is
described below.
CASE REPORT:
A 7 years old male child presented to the
Outpatient department of otolaryngologyV.S.S.institute of medical science & research, Burla with
a complain of sublingual swelling of 7 years duration.
The swelling was very slowly growing. The general
examination of the patient was unremarkable. On intra
oral examination, a swelling of size 4x3x2 cm noted
52
Fig 1: Picture showing sublingual tumour

Affiliations:
*Assistant Professor, dept of ENT, V.S.S MCH,Burla
**PG Student, dept of ENT, V.S.S MCH,Burla
Smrutirekha sahu
Post graduate department of ENT
& Head & Neck Surgery, VIMSAR
PH:9861777008
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
ductal units are distinct from the neural units. There

was no significant inflammation,cyst or mucoid
material.
DISCUSSION
NF-1 is caused by an alteration of the NF-1 gene.
This gene is a tumor suppressor located on the long
arm of chromosome 17 (17q11.2).[6,7] Loss of this genes
function due to a mutation leads to an increase in cell
proliferation and development of tumors.
The NF1 gene encodes neurofibromin, a
cytoplasmic protein that is predominantly expressed
in neurons, Schwann cells, oligodendrocytes, and
leukocytes. It is a multidomain molecule with the ability
to regulate several intracellular processes, including the
RAS-cyclic AMP pathway, ERK / MAP kinase cascade,
adenylyl cyclase, and the cytoskeletal assembly.(9)
Neurofibromas are benign complex tumors. They
arise from peripheral nerve sheaths and constitute one
of the main manifestations of NF1. A solitary

neurofibroma may occur in an individual who does
not have NF1, but multiple neurofibromas tend to
develop in a person with NF1. Clinical observations
suggest that there are at least two major types of
neurofibroma which may differ widely in their natural
history: Discrete or localized and plexiform
neurofibroma.6,8
Neurofibromas are found mostly on the skin.
Nevertheless, many organs may be involved, including
the stomach, intestines, kidney, bladder, larynx, and
heart. In the head and neck region, the most commonly
affected sites are the scalp, cheek, neck, and oral cavity.
Although neurofibroma is rare in salivary glands
it should be considered in patients with von
Recklinghausen disease.
Plexiform neurofibroma of the salivary glands may
present as a soft sublingual mass which is painless and
slowly increases in size with no neurological
manifestations.
On gross examination the tumour is round to
ovoid, multilobulated and composed of homogenous,
glistening, smooth grey white tissue. Microscopically
presence of multiple nerve fibre bundles found.
Plexiform neurofibroma of the sublingual gland
is a rare entity that presents as a mass on the floor of
the mouth either in a solitary form or as an oral
manifestation of Neurofibromatosis 1. As malignant
transformation chance is 2% to 13%(1)Surgical excision
with a close follow up is the standard treatment.
Fig 2: Post-operative specimen and photo
Plexiform neurofibroma is a very rare slow

growing tumour in sublingual region. It is more
common in children. CT is somewhat diagnostic.
FNAC may be helpful. Final diagnosis can be achieved
by excisional biopsy.
DISCLOSURES
(a)

(c)
Funding - None

REFERENCE
1.
Fig 3: (Histopathological slide of biopsy specimen)
McDaniel RK Benign mesenchymal neoplasms.

In: Ellis GL, Auclair PL, GneppDR,
53
CONCLUSION
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
editors. Surgical pathology of the salivary

glands. Philadelphia: WB Saunders;1991. p. 496.
Seifert G,Miehlke A, Haubrisj J, et al. Disease of
the salivary glands. In:Pathology, diagnosis,
treatment, facial nerve surgery. New York: Georg
Thieme Verlag; 1986. p. 171301.
3.
Geist JR, Gander DL, Stefanac

S
Oral
manifestations of neurofibromatosis types I and
II. Oral Surg Oral Med Oral Pathol 1992; 73:376
82.
4.
Krolls SO, Trodhal GN, Borjers RC Salivary

gland lesions in children: Survey of 430
cases. Cancer 1972; 30:45969. Weitzner S.
Plexiform neurofibroma of major salivary glands
in children. Oral Surg Oral Med Oral
Pathol 1980; 50:537.
5.
Cunha KS, Barboza EP, Dias EP, Oliveira FM.

Neurofibromatosis type I with periodontal
manifestation. A case report and literature
review. Br Dent J. 2004;196:45760. [PubMed]
6.
Bongiorno MR, Pistone G, Aric M.

Manifestations
of
the
tongue
in
Neurofibromatosis type 1. Oral Dis.2006;12:125
9. [PubMed]
7.
Garca-de Marcos JA, Dean-Ferrer A, AlamillosGranados F, Ruiz- Masera JJ, Garca-de Marcos
MJ, Vidal-Jimnez A, et al. Gingival neurofibroma
in a neurofibromatosis type 1 patient. Med Oral
Patol Oral Cir Bucal.2007;12:E28791. [PubMed]
8.
Trovo-Marqui AB, Tajara EH. Neurofibromin:

A general outlook. Clin Genet. 2006;70:1
13. [PubMed].
2.
54
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
The Orissa Journal of otolaryngology and Head &
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2
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8.
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abbreviations.
9.
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parentheses.
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of the article on a separate sheet of paper. The names of
the journals should be underlined and should appear
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least three authors, if the authors are more than three of
write the names of all the authors.
Examples: Sheaj.j., Sanabria, Fand Smyth, G.D.L. (1962)

Teflon piston operation for otosclerosis. Archives of
Otolaryngology 78.516.
Boies, L.R. (1954): Fundamentals or Otolaryngology,

Philadelphia, W.B. Saunders Co, 376-385.
The Bibliography should be titled References and the

quoted articles should be listed in the surname of the
first authors.
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over 2 diagrams or 2 tables or 1 diagram and 1 table is
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)

Indexed in Index Copernicus International plc, Poland (http://indexcopernicus.com),

Vol.-9, Issue-II, July-Dec. - 2015

NATIONAL EDITORIAL ADVISORY BOARD

Prof. Bachi T. Hathiram

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

Prof P.S.N. Murthy,

INTERNATIONAL EDITORIAL ADVISORY BOARD

Vol.-9, Issue-II, July-Dec. - 2015

Prof. Ashutosh Kacker M.D

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

STATISTICAL ADVISORY BOARD

Dr. Sandeep Kumar Panigrahi

Owner of the Journal

Vol.-9, Issue-II, July-Dec. - 2015

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

Tittle and authors

EVALUATION OF LONG-TERM QUALITY OF LIFE OUTCOMES IN PATIENTS WITH RECURRENT

A CASE REPORT: BELLS PALSY IN AN 11 MONTH-OLD INFANT

Vol.-9, Issue-II, July-Dec. - 2015

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

A TAILOR MADE APPROACH TO ENDOSCOPIC SINUS SURGERY FOR

Vol.-9, Issue-II, July-Dec. - 2015

to the technological advances in the form of thru cut forceps,

Fig1. Image guided endoscopic sinus surgery

with healthy sinus clinically and CT suggesting small size

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

Isolated sinusitis: Often we find isolated sinusitis

Since balloon device is quite expensive in developing

Fig-3. Showing enlargement of maxillary ostium with intact drainage pathway

Vol.-9, Issue-II, July-Dec. - 2015

disease, a maxillary sinusostomy was carried out while

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

lamella is again opened infero-medially. The remnant of the

J. Woodham: History of the development of surgery for

M. Reichert: ber eine neue Unterscuhungsmethode

W. Spielberg: Antroscopy of the maxillary sinus;

Messerklinger W: Endoscopy of the Nose. Baltimore,

Kennedy DW (Oct 1985). Functional endoscopic sinus

Stammberger H: Endoscopic endonasal surgery

Nayak etal : Endoscopic physiological approach to

Friedman & Schalch; Op Tech Otolaryngol Head Neck

Zinreich SJ, Kennedy DW, Rosenbaum AE. Paranasal

Kennedy DW: Prognostic factors, outcomes and staging

Lund VJ, Kennedy DW: Staging for Rhinosinusitis; 1997

Setliff RC, Parsons DS:The Hummer: new

Kennedy DW: Technical innovations and the evolution

Setliff Reuben: Minimally invasive sinus surgery: the

A Tailor made ultraconservative sinus surgery with

Nayak D R & Balakrishnan R : De novo bacterial

Yogesh M. Seth W, Peter C: Management of early nasal

A Resorbable nasal dressing available as Nasopore can

Vol.-9, Issue-II, July-Dec. - 2015

The author has followed the above described surgical

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

EVALUATION OF LONG-TERM QUALITY OF LIFE OUTCOMES IN

Vol.-9, Issue-II, July-Dec. - 2015

*D Carlson DO,**B Fennessy MD,***PJ Catalano MD, FACS

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.2

substantial benefit in quality of life measures when

D Carlson DO,B Fennessy MD,PJ Catalano MD, FACS