Ent July-September 2013 by IJCP

Asian Journal of

Online Submission

IJCP Group of Publications

Ear, Nose & Throat July-September 2013

Dr Sanjiv Chopra Prof. of Medicine and Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

FROM THE DESK OF EDITOR

Jasveer Singh

Padma Shri and Dr BC Roy National Awardee

Dr KK Aggarwal Group Editor-in-Chief Dr Veena Aggarwal MD, Group Executive Editorr Editor

Dr Jasveer Singh

FROM THE DESK OF GROUP EDITOR-IN-CHIEF

Whatâ&#x20AC;&#x2122;s New in ENT? Dr KK Aggarwal

Anand Gopal Bhatnagar Editorial Anchor

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani, Dr Thankam Verma, Dr Kamala Selvaraj Cardiology Dr Praveen Chandra, Dr SK Parashar

REVIEW ARTICLE

Current Management of ENT Infections Jasveer Singh

Paediatrics Dr Swati Y Bhave Diabetology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty ENT Dr Jasveer Singh, Dr Chanchal Pal Dentistry Dr KMK Masthan, Dr Rajesh Chandna Gastroenterology Dr Ajay Kumar, Dr Rajiv Khosla Dermatology Dr Hasmukh J Shroff, Dr Pasricha Dr Kaushik Lahiri Nephrology Dr Georgi Abraham Neurology Dr V Nagarajan, Dr Vineet Suri Orthopedics Dr J Maheshwari Journal of Applied Medicine & Surgery Dr SM Rajendran, Dr Jayakar Thomas Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce and Industry World Fellowship of Religions

CLINICAL STUDY

11 Clinical Study of Headache in Relation to Sinusitis and its Management

Anupama Kaur, Amanpreet Singh

17 Septoplasty with Adenoidectomy: A Combined Procedure for Nasal Obstruction in Children

K Mallikarjuna Swamy, KP Basavaraju

20 Common Ear, Nose and Throat Problems in Pediatric Age Group Presenting to the Emergency Clinic-Prevalence and Management: A Hospital-based Study

Kalpana Sharma, Dipen Bhattacharjya, Himajit Barman Subodh Ch Goswami

CASE STUDY

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

25 Thirty-six Cases of Vocal Polyps Treated by Microflap Phonomicrolaryngeal Surgery

Sudhir M Naik, Sarika S Naik

CASE REPORT

The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

29 An Unusual Intranasal Mass: Pleomorphic Adenoma of the Nasal Septum

Editorial Policies

The purpose of IJCP Academy of CME is to serve the medical profession and provide print continuing medical education as a part of their social commitment. The information and opinions presented in IJCP group publications reflect the views of the authors, not those of the journal, unless so stated. Advertising is accepted only if judged to be in harmony with the purpose of the journal; however, IJCP group reserves the right to reject any advertising at its sole discretion. Neither acceptance nor rejection constitutes an endorsement by IJCP group of a particular policy, product or procedure. We believe that readers need to be aware of any affiliation or financial relationship (employment, consultancies, stock ownership, honoraria, etc.) between an author and any organization or entity that has a direct financial interest in the subject matter or materials the author is writing about. We inform the reader of any pertinent relationships disclosed. A disclosure statement, where appropriate, is published at the end of the relevant article.

OK Deshmukh, ND Zingade

32 Kartagener’s Syndrome

Lakshmi Ponnathpur, Lakshmi Shantharam

MEDILAW

36 Is it Ethical for a Physician I have Never Seen to Refuse to See Me?

Note: Asian Journal of Ear, Nose and Throat does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

IJCP’s EDITORIAL AND BUSINESS OFFICES Delhi

Mumbai

Kolkata

Bangalore

Chennai

Hyderabad

Dr Veena Aggarwal 9811036687 E - 219, Greater Kailash, Part - I, New Delhi - 110 048 Cont.: 011-40587513 editorial@ijcp.com drveenaijcp@gmail.com Subscription Dinesh: 9891272006 subscribe@ijcp.com Ritu: 09831363901 ritu@ijcp.com

Mr. Nilesh Aggarwal 9818421222

Ritu Saigal Sr. BM 9831363901

H Chandrashekar GM Sales & Marketing 9845232974

Chitra Mohan Sr. BM 9841213823 40A, Ganapathypuram Main Road Radhanagar Chromepet Chennai - 600 044 Cont.: 22650144 chitra@ijcp.com

Venugopal GM Sales & Marketing 9849083558

Pravin Dhakne 8655611025, 24452066 Unit No. 210 2nd Floor Shreepal Complex, Suren Road, Near Cine Magic Cinema Andheri (E) Mumbai - 400 093 nilesh.ijcp@gmail.com

Flat 7E Merlin Jabakusum 28A, SN Roy Road Kolkata - 700 038 Cont.: 24452066 ritu@ijcp.com

Sr.: Senior; BM: Business Manager; GM: General Manager

Arora Business Centre, 111/1 and 111/2, Dickenson Road (Near Manipal Centre) Bangalore - 560 042 Cont.: 25586337 chandra@ijcp.com

H. No.16-2-751/A/70 First Floor Karan Bagh Gaddiannaram Dil Sukh Nagar Hyderabad 500 059 Cont.: 65454254 venu@ijcp.com

FROM THE DESK OF EDITOR

Dr Jasveer Singh

Visiting Consultant, City Hospital Affiliated with Sir Ganga Ram Hospital Rajinder Nagar, New Delhi

here have been the vast changes in the role of otolaryngologists in managing various health problems. Evolution from the era of ectomies (1950s-1960s) to plasties, viz septoplasty, tympanoplasty, rhinoplasty have added to the importance of the speciality and separated it from ‘Eye-ENT’ tag to ‘otorhinolaryngology’ with a separate curriculum and examination paper in MBBS. Endoscopic nasal surgery has crossed it’s boundaries and has traveled the adjacent territories i.e., eye, endoscopic dacryocystorhinostomy (DCR), orbital decompression, optic nerve decompression, skull base surgery of anterior cranial fossa, pituitary and posterior cranial fossa surgery through clivus. I just want to draw the attention of my colleagues towards the various bits of surgeries for “obstructive sleep apnea (OSA) and sleep disordered breathing (SDB) disorders”, which can improve the quality-of-life of patients with minimum efforts. As we know the manage of OSA and SDB patients, has three tailored therapies. ÂÂ

Change in lifestyle, behavior and habits

ÂÂ

Mechanical appliances

ÂÂ

Surgery

LIFESTYLE BEHAVIOR AND HABITS ÂÂ

Weight reduction

ÂÂ

Low fat diet

ÂÂ

No alcohol or beverages as these exacerbate OSA

ÂÂ

Sleep hygiene, i.e., avoidance of habits, which causes insomnia

MECHANICAL APPLIANCES Oral-based on the principle, to keep the tongue and jaw forward away from the oropharyngeal space. These have certain very positive aspects over CPAP: Less cost, better compliance, do not need power source. “oral appliances are better for snoring and OSAP” ÂÂ

Positive pressure appliances

ÂÂ

CPAP, BiPAP are costly, but effective in cases of OSA.

SURGERY Surgery is very effective and curative, patients need to adopt healthy habits after surgery. Surgery should proceed effective diagnostic procedure. The diagnostic focus should be to identify the narrow sites in the respiratory passage.

Asian Journal of Ear, Nose and Throat, July-September 2013

FROM THE DESK OF EDITOR Preoperative diagnostic ÂÂ

Nasal endoscopy: To examine the nasal cavities and to exclude mucosal hypertrophy, valvular problem.

ÂÂ

Flexible endoscopy: For nasopharyngeal narrowings.

Here I want to draw the attention of my readers, that all the points of narrowing should be listed, so that every defect is dealt effectively. Nasal surgery includes turbinate reduction and septoplasty/septal correction. Together, they can be called nasal corrective surgery. Palatal surgery is really fascinating and not very difficult. These include palatal stiffening procedure i.e., inducing fibrosis in palatal tissue thus reducing its by injections of sclerosing agents, or by cautery or radiofrequency. Palatal surgeries include uvulo-palato-pharyngoplasty, pharyngoplasty palatal advancement. Tongue plays role in obstructing the respiratory passage when it is bulky. So, the bulk of tongue needs to be reduced. Radiofrequency, tongue base excision, partial glossectomy, hyoid advancement surgery and mandubular advancement surgeries are being done for this. So, dear otolaryngologist, you should take such surgeries in your kitty happily and effectively. Jasveer Singh ■■■■

Asian Journal of Ear, Nose and Throat, July-September 2013

FROM THE DESK OF GROUP EDITOR-IN-CHIEF Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS National Vice President, Elect, IMA Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

What’s New in ENT? ÂÂ

In a randomized trial of over 400 patients with seasonal allergic rhinitis, subjects were treated with eight weeks of acupuncture, sham acupuncture, or no additional therapy.1 All had access to rescue medication with cetirizine and oral glucocorticoids if response was inadequate. Symptom reduction was statistically greater with acupuncture compared with sham or rescue medication alone, although of uncertain clinical importance and equivalent to somewhat less than the effectiveness of one cetirizine tablet daily.

ÂÂ

The anti-IgE drug, omalizumab, is approved only for the treatment of moderate-to-severe allergic asthma by most regulatory agencies, but has been studied in the treatment of other related diseases. In a randomized trial, 24 patients with both nasal polyposis and asthma (with and without sensitization to environmental allergens, including eight patients with aspirin exacerbated respiratory disease [AERD]), were treated with omalizumab or placebo for 16 weeks.2 Omalizumab resulted in significant reduction in polyp size and improvement in symptom scores, compared with placebo.

ÂÂ

Omalizumab, a monoclonal antibody to IgE, has shown promise in several types of chronic urticaria. In a large multicenter trial, 323 patients with moderate-to-severe chronic idiopathic urticaria refractory to cetirizine were randomized to three different doses of omalizumab or placebo, given monthly for 12 weeks.3

ÂÂ

Omalizumab, an anti-IgE therapy, is approved for patients with uncontrolled atopic asthma who meet specified laboratory criteria, although patient response varies dramatically. Predictors of a good response have not been identified. In a randomized trial in over 300 asthmatic patients, the rate of asthma exacerbations (the primary endpoint) was not significantly reduced by omalizumab therapy.4

REFERENCES 1. Brinkhaus B, Ortiz M, Witt CM, et al. Acupuncture in patients with seasonal allergic rhinitis: a randomized trial. Ann Intern Med 2013;158:225. 2. Gevaert P, Calus L, Van Zele T, et al. Omalizumab is effective in allergic and nonallergic patients with nasal polyps and asthma. J Allergy Clin Immunol 2013;131:110. 3. Maurer M, Rosén K, Hsieh HJ, et al. Omalizumab for the treatment of chronic idiopathic or spontaneous urticaria. N Engl J Med 2013;368:924. 4. Busse W, Spector S, Rosén K, et al. High eosinophil count: a potential biomarker for assessing successful omalizumab treatment effects. J Allergy Clin Immunol 2013;132:485. ■■■■

Asian Journal of Ear, Nose and Throat, July-September 2013

REVIEW ARTICLE

Current Management of ENT Infections JASVEER SINGH

ABSTRACT Diseases of the ear, nose and throat (ENT) are a major public health concern. They are a leading cause of physician visits, a major component of healthcare burden and are becoming serious threats because of the increase in the number of antibioticresistant bacteria. Resistance rates as high as 40% have been reported for penicillin G, erythromycin and most sulfonamides. Resistance of Streptococcus pneumoniae to penicillin as well as amoxicillin ranges from 30 to 55% in the USA. Currently, 40-55% of Haemophilus influenzae and 90-100% of Moraxella catarrhalis are resistant to penicillin because of the production of b-lactamases. The combination of cefuroxime and clavulanic acid (b-lactamase inhibitor) provides a solution for treatment of bacterial infections caused by b-lactam-resistant pathogens Keywords: ENT infections, b-lactamases, antibiotic resistance, cefuroxime, clavulanic acid

iseases of the ear, nose and throat (ENT) are a major public health concern affecting the functioning of patients, often with significant impairment of the daily life of affected patients.1 It has been envisaged that with increase in global population, infections remain the most important causes of disease, with ENT infections causing hearing loss and learning disability.2 Ear, throat and skin infections that were once easy to treat are becoming serious threats as there is an increase in antibiotic-resistant bacteria. Although antibiotics have contributed to the control of ENT infections, their over-use and misuse is now seen to cause an increase in antibiotic resistance,3 a problem continuing to gain attention from national organizations as a significant threat to the public health.4 Some of the chronic ENT diseases resistant to current antibiotics include chronic middle ear infections, chronic sinus diseases, chronic coughs and recurrent pharyngotonsillitis.5 It is important to avoid unnecessary antibiotic prescription in children because they represent a large reservoir for resistant organisms. However, when a decision to prescribe an antibiotic has been taken, empiric treatment of infections such as otitis media, sinusitis tonsillitis and pharyngitis should target the bacteria that are most often isolated in ENT. CAUSATIVE ORGANISMS Four bacteria namely, Streptococcus pneumoniae, nontypeable Haemophilus influenzae, Moraxella

Visiting Consultant, City Hospital Affiliated with Sir Ganga Ram Hospital Rajinder Nagar, New Delhi

Asian Journal of Ear, Nose and Throat, July-September 2013

catarrhalis and Streptococcus pyogenes are responsible for the majority of ENT infections. Other bacteria recovered and implicated in acute otitis media (AOM) include Staphylococcus aureus, viridans streptococci and Pseudomonas aeruginosa. In bacterial infections of the sinuses and the middle ear S. pneumoniae, H. influenzae, M. catarrhalis and S. aureus are most frequently isolated, whereas in tonsillopharyngitis S. pyogenes is the most important pathogen.6 S. aureus is found in upto 40% in acute and chronic sinusitis and causes severe complications in otitis media.6 In 70% of patients with AOM, culture of middle ear fluid yields bacterial growth, with H. influenzae (25% of cases) and S. pneumoniae (40% of cases) being the most frequent species.7 ANTIMICROBIAL RESISTANCE IN ENT INFECTIONS The emergence of drug-resistant bacteria has dramatically changed the clinical outcome of most ENT infections. S. pneumoniae was once susceptible to almost all common antibiotics, including penicillin G, erythromycin and most sulfonamides. Alteration of the cell wallâ&#x20AC;&#x2122;s penicillin-binding protein (the antimicrobial target) has led to the appearance of multidrug-resistant S. pneumoniae (MDRSP), which is resistant to various classes of antibiotics, including penicillins, macrolides, co-trimoxazole and fluoroquinolones.8,9 Resistance of S. pneumoniae to penicillin as well as amoxicillin ranges from 30 to 55% in the USA. Currently, 40-55% of H. influenzae and 90-100% of M. catarrhalis are resistant to penicillin because of the production of b-lactamases.10 For commonly prescribed antibiotics the resistance levels of 84% have been reported for co-trimoxazole, 52% for penicillin and 25% for ampicillin.11,12

REVIEW ARTICLE Availability of antibiotics over-the-counter at most pharmacies is another concern, which has fuelled the misuse of antibiotics and resulted into rapid emergence of resistance during the recent decades. In a recent study, it was shown that antibiotics are dispensed without a medical prescription in 77.6% of the pharmacies in which sore throat and diarrhea are the chief complaints (90%) for which the antibiotics are dispensed.13 MANAGEMENT OF ENT INFECTIONS The selection of the most effective antimicrobial to treat ENT infections has become more difficult in recent years because of increasing antibiotic resistance among all the major bacterial pathogens implicated in communityacquired ENT infections.14 Owing to penicillin nonsusceptibility in S. pneumoniae, high amoxicillin doses have been advocated, with amoxicillin/clavulanic acid as a second-line treatment or in recurrent infections due to the presence of b-lactamase-producing H. influenzae.7 Troublesome strains from S. pneumoniae penicillin-resistant clones exhibiting higher amoxicillin versus penicillin minimum inhibitory concentration (MIC) and H. influenzae strains exhibiting mutations in the ftsI gene encoding penicillin-binding protein 3 (rendering strains-resistant to amoxicillin with or without clavulanic acid), are increasingly detected, reaching high rates in some European areas.15 ROLE OF CEFUROXIME PLUS CLAVULANIC ACID IN ENT INFECTIONS In this scenario of increasing antimicrobial resistance empiric treatment of ENT infections such as otitis media, sinusitis tonsillitis and pharyngitis should target S. pneumoniae, nontypeable H. influenzae and M. catarrhalis, the bacteria that are most often isolated in ENT. Also, compliance with antibiotic regimens is enhanced by selecting agents that require less frequent dosing (such as 1 or 2 times a day) and by prescribing shorter (5 days or less) treatment courses. The combination of cefuroxime and clavulanic acid (b-lactamase inhibitor), which needs to be given just twice-daily for five days only is a good therapeutic option for bacterial infections caused by b-lactamresistant pathogens.

Rationale Cefuroxime axetil is the first commercially-available second-generation broad-spectrum cephalosporin, suitable for oral route. The bactericidal action of cefuroxime results from inhibition of cell wall synthesis

by binding to essential target proteins. Its antibacterial activity includes all the pathogens usually responsible for ENT infection, with low MICâ&#x20AC;&#x2122;s: H. influenzae, S. pneumoniae, S. aureus, M. catarrhalis and S. pyogenes.16 The stability of the drug against b-lactamases, especially those produced by H. influenzae, associated with good bioavailability (50%) and tissue penetration (30%) account for the potent in vivo bactericidal activity and clinical efficacy of cefuroxime axetil.16 More than 1,000 patients had been enrolled in controlled clinical trials: The success rates yielded by cefuroxime axetil were 98%, 96% and 91%, respectively for pharyngitis/ tonsilltis, otitis media and acute sinusitis.16 Clavulanic acid is a naturally derived b-lactamase inhibitor produced by Streptomyces clavuligerus. Clavulanic acid has a similar structure to the b-lactam antibiotics but binds irreversibly to the b-lactamase enzymes produced by a wide range of gram-positive and gram-negative microorganism. Clavulanic acid binds to and inactivates them thus preventing the destruction of cefuroxime that is a substrate for this enzyme. The combination of cefuroxime and clavulanic acid (b-lactamase inhibitor) provides a solution for treatment of bacterial infections caused by b-lactamresistant pathogens.

Pharmacokinetics17 After oral administration cefuroxime axetil is absorbed from the gastrointestinal tract and rapidly hydrolyzed in the body to release cefuroxime into the circulation. Approximately 60% of an administered dose is absorbed. Optimum absorption occurs when it is administered after a light meal. The mean peak serum level of cefuroxime following a 250 mg dose in normal healthy adults, after food, was 4.1 mg/l and occurred 2-3 hours after dosing. Serum levels were significantly higher in the elderly, apparently due to slower excretion. Unhydrolyzed drug was not detected in the serum but 1-2% of the administered dose is excreted in the urine in a form, which indicates that small amounts of the intact ester are absorbed into circulation. The mean serum half-life of cefuroxime is approximately 1.2 hours. Protein-binding has been variously stated as 33-50% depending on the methodology used. Cefuroxime is not metabolized to any significant extent. Excretion occurs mainly through the kidney both by glomerular filtration and tubular secretion. Approximately 49% of an administered dose, after food, is recovered in the urine in 24 hours; urinary recovery is significantly reduced if the drug is taken on an empty stomach.

Asian Journal of Ear, Nose and Throat, July-September 2013

REVIEW ARTICLE Adverse Effects

ÂÂ

Adverse reactions to cefuroxime axetil have been generally mild and transient in nature.

Most active cephalosporin producing Haemophilus.

ÂÂ

Twice-daily dosage ensures patient compliance.

Cefuroxime axetil was evaluated for its efficacy and safety in the treatment of tonsillitis, pharyngitis, sinusitis and otitis media in general practice in the United Kingdom.18 A total of 385 patients aged 14 or over were enrolled in a randomized study to compare cefuroxime axetil 250 mg b.i.d. for five days with (amoxycillin/clavulanate) 375 mg t.d.s. for five days. Sixty-four patients treated with cefuroxime axetil were evaluable for bacteriological response: 47 (73%) of the causative pathogens were eradicated, as compared with 62 of 86 (72%) in patients treated with amoxycillin/clavulanate. Thirteen out of 181 (7%) patients treated with cefuroxime axetil experienced drug-related adverse events, including 4% with diarrhea. In the amoxycillin/clavulanate group 24 out of 204 (12%) patients had a drug-related adverse event, including 5% with diarrhea.18 It was seen that cefuroxime axetil had a better bacteriological response as compared to amoxycillin/clavulanate and had less drug-related adverse events. CONCLUSION The selection of the most effective antimicrobial to treat acute ENT infections has become more difficult in recent years because of increasing antibiotic resistance among the common causative pathogens. Empiric treatment of diseases of ENT should target S. pneumoniae, nontypeable H. influenzae and M. catarrhalis, the bacteria that are most often isolated. The combination of cefuroxime and clavulanic acid (b-lactamase inhibitor) provides a solution for treatment of bacterial infections caused by b-lactamresistant pathogens. KEY POINTS Cefuroxime has bactericidal activity against a wide range of common pathogens, including many b-lactamase-producing strains.

ÂÂ

Cefuroxime is generally well-tolerated and side effects are usually transient.

ÂÂ

Cefuroxime has b-lactamases.

ÂÂ

Unlike other second-generation cephalosporins, cefuroxime can cross the blood-brain-barrier.

b-lactamase-

REFERENCES

Clinical Efficacy

ÂÂ

for

good

stability

bacterial

Asian Journal of Ear, Nose and Throat, July-September 2013

1. Witsell DL, Dolor RJ, Bolte JM, Stinnet SS. Exploring health-related quality of life in patients with diseases of the ear, nose and throat: a multicenter observation study. Otolaryngol Head Neck Surg 2001;125(4):288-98. 2. Alberti PW. Pediatric ear, nose, and throat services’ demands and resources: a global perspective. Int J Pediatr Otorhinolaryngol 1999;44 Suppl 1:S1-9. 3. Bhattacharyya N, Shapiro J. Contemporary trends in microbiology and antibiotic resistance in otolaryngology. Auris Nasus Larynx 2002;29:59-63. 4. Spellberg B, Guidos R, Gilbert D, Bradley J, Boucher HW, Scheld WM, et al; Infectious Diseases Society of America. The epidemic of antibiotic-resistant infections: a call to action for the medical community from the Infectious Diseases Society of America. Clin Infect Dis 2008;4(2): 155-64. 5. Megale SR, Scanavini AB, Andrade EC, Fernades MI, Anselmo-Lima WT. Gastroesophageal reflux disease: its importance in ear, nose, and throat practice. Int J Paediatr Otorhinolaryngol 2006;70(1):81-8. 6. Elies W. Current therapeutical management, new antibiotics and treatment of Pseudomonas aeruginosa in bacterial ENT-infections. Laryngorhinootologie 2002;81(1):40-5. 7. Fenoll A, Aguilar L, Robledo O, Giménez MJ, Tarragó D, Granizo JJ, et al. Influence of the betalactam resistance phenotype on the cefuroxime versus cefditoren susceptibility of Streptococcus pneumoniae and Haemophilus influenzae recovered from children with acute otitis media. J Antimicrob Chemother 2007;60(2):323-7. 8. Felmingham D. Antibiotic resistance: do we need new therapeutic approaches? Chest 1995;108 (2 Suppl): 70S-805. 9. Kandakai-Olukemi YT, Dido MS. Antimicrobial resistant profile of Streptococcus pneumoniae isolated from the nasopharynx of secondary school students in Jos, Nigeria. Ann Afr Med 2009;8(1):10-3. 10. Brook I. Use of oral cephalosporins in the treatment of acute otitis media in children. Int J Antimicrob Agents 2004;24(1):18-23. 11. Nyandiko WM, Greenberg D, Shany E, Yiannoutsos CT, Musick B, Mwangi AW. Nasopharygeal Streptococcus pneumoniae among under-five year children at the Moi Teachning and Referral Hospital, Eldoret, Kenya. East Afr Med J 2007;84(4):156-62. 12. Kacou-N’douba A, Guessennd-Kouadio N, KouassiM’bengue A, Dosso M. Evolution of S. pneumoniae ntibiotic resistance in Abidjan: update on nasopharyngeal carriage from 1997 to 2001. Med Mal Infect 2004;34(2):83-5. Cont’d on page 34...

CLINICAL STUDY

Clinical Study of Headache in Relation to Sinusitis and its Management ANUPAMA KAUR* AMANPREET SINGH**

ABSTRACT Aim: To study relation of headache with sinusitis and its management. Material and methods: Patients clinically presenting with headache were selected. Only patients with headache due to rhinogenic causes were subjected to X-ray paranasal sinuses (PNS) and diagnostic nasal endoscopy (DNE) and were followed up to evaluate management. Results: Majority of the patients were of age group 21-30 years and it is more predominant in males. Majority of the patients with headache had deviated nasal septum (DNS) (28.9%), acute sinusitis (28.9%), osteomeatal complex disease (24.63%); few patients had nasal polyp (8.69%), allergic rhinitis (5.79%) and rarely patients had atrophic rhinitis (2.89%). Headache was localized in forehead (43.4%), more than one site (34.7%) in majority of cases and few number of patients had headache at glabella (13.04%) and top of head (8.69%). Majority of the patients who underwent antral washout were not relieved, so they underwent functional endoscopic sinus surgery (FESS), which gave dramatic results in improving symptoms of patients including headache. Conclusions: Headache is nearly a universal human experience. The lifetime incidence of headache is estimated to be at least 90%. To know whether the headache is sinogenic or not, the patient is first assessed clinically and then radiological investigations (X-ray PNS) are done. Role of FESS is huge and ultimately it is FESS that is the cure for headache due to rhinogenic causes. Keywords: Headache, sinusitis, FESS

eadache is nearly a universal human experience. The lifetime incidence of headache is estimated to be at least 90%. Moskowitz has described headache as the symptom produced by the nervous system when it perceives threat and as such is considered part of the protective physiology of the nervous system. When the cause of headache is a definable underlying pathologic process, the headache is diagnosed as a secondary headache. Causes include metabolic, infectious, inflammatory, traumatic, neoplastic, immunologic, endocrinologic and vascular entities. When no clear pathologic condition can be identified, headache is considered to be a manifestation of a primary headache syndrome. The common primary

*Assistant Professor Dept. of Physiology **Assistant Professor Dept. of ENT MM Institute of Medical Sciences and Research Mullana, Ambala, Haryana Address for correspondence Dr Amanpreet Singh Assistant Professor Dept. of ENT MM Institute of Medical Sciences and Research Mullana, Ambala, Haryana E-mail: dr.apsarora@gmail.com

headache disorders as defined by the International Headache Society are migraine, probable migraine, tension type and cluster headache.1 The term ‘sinusitis’ refers to a group of disorders characterized by inflammation of the mucosa of the paranasal sinuses (PNS). Because the inflammation nearly always also involves the nose, it is now generally accepted that ‘rhinosinusitis’ is the preferred term to describe the inflammation of the nose and PNS.2 Patients with chronic headache pain often present to a variety of specialists, including their primary care physician, neurologist, dentist, otolaryngologist and even a psychiatrist. They may present to otolaryngologist because they or their physician believe the headache to be related to underlying sinus pathology. The primary focus of the otolaryngologist is to exclude this possibility. The diagnosis of headache secondary to acute sinusitis can be relatively straightforward. Diagnosing headache related to chronic sinus disease can be much more difficult depending on patient’s presentation.3 Endoscopic techniques are now well-established. In combination with modern imaging techniques particularly computed tomography (CT), these techniques provide diagnostic possibilities unimagined a few decades ago.4

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY AIM

Time of onset of attack

To study the relation of headache in sinusitis and its management.

Treatment taken for the same.

MATERIAL AND METHODS

If the headache was suspected to be of rhinogenic or sinogenic origin, the patients then underwent detailed otorhinolaryngological examination.

The present study was conducted in the Dept. of Otorhinolaryngology in MM Medical College and Hospital, Mullana, Ambala, Haryana from October 2009 to July 2011.

ÂÂ

Routine blood investigations like hemoglobin (Hb), total leukocyte count (TLC), differential leunocyte count (DLC), erythrocyte sediment-ation rate (ESR), bleeding time (BT), clotting time (CT), urine for albumin, sugar and microscopy.

Source of Data

ÂÂ

Radiological investigations i.e., X-ray PNS (Water’s view) was advised in all patients of headache of rhinogenic or sinogenic etiology.

ÂÂ

Diagnostic nasal endoscopy (DNE) was advised to the same group of patients.

ÂÂ

Acute infections were first treated with medicines.

ÂÂ

Patients who were found to have haziness of maxillary sinuses on PNS X-ray were advised antral wash.

ÂÂ

Patients who had haziness of frontal sinuses and the patients who were not relieved of headache after antral washout were advised functional endoscopic sinus surgery (FESS).

Patients for the study were collected from the Dept. of Otorhinolaryngology, MM Medical College and Hospital, Mullana, Ambala, Haryana.

Sample Size The study included 100 patients and the cases were diagnosed based upon clinical examination and investigation.

Inclusion Criteria

Exclusion Criteria All patients presenting with clinical features other than sinusitis.

Study Procedures ÂÂ

Selected patients were subjected to a complete examination according to a defined proforma.

ÂÂ

Detailed history with thorough clinical examination was done.

ÂÂ

Patients were asked about history of headache

Mode of onset

Duration of complaint

Continuous or intermittent

Progressive or not

Site of pain and radiation

Type of pain

Associated symptoms

Aggravating and relieving factors

Duration of each attack

Frequency of attack

Asian Journal of Ear, Nose and Throat, July-September 2013

RESULTS A total of 100 patients with headache were studied for a period of about two years i.e., from October 2009 to July 2011, of which only 69 patients had headache due to rhinogenic causes. The highest incidence was in the age group of 21-30 years (59.42%), followed by 11-20 years (36.23%). Patients of age group 21-30 years were more prone (51.61%), to headache due to other causes. About 53.62% of patients 16 14 No. of cases

Patients of all age groups and sexes presenting with clinical features of sinusitis.

12 10 8 6 4 2 0

5-10

11-20 21-30 31-40 Age group (years)

41-50

51-60

DNS

Acute sinusitis

Osteomeatal complex disease

Polyp

Allergic rhinitis

Atrophic rhinitis

Figure 1. Age distribution (rhinogenic causes).

CLINICAL STUDY 8

Atrophic rhinitis (2.90%) Allergic rhinitis (5.80%) Polyp (8.70%)

No of cases

7 6 5 4

DNS (28.99%)

Osteomeatal complex disease (24.64%)

3 2 1 0

5-10

11-20

21-30

31-40

41-50

Acute sinusitis (28.99%)

51-60

Age group (years) Trigeminal neuralgia

Migraine

Tension headache

Temporomandibular joint arthritis

Figure 5. Etiology of headache with respect to clinical findings.

Figure 2. Age distribution (others).

Top of head (8.70%) Glabella (13.04%)

Male

Forehead (43.48%)

Female

No. of Cases

12 10 8 6

More than one site (34.78%)

4 2 0

Figure 6. Localization of headache. DNS

Acute Osteomeatal Polyp Allergic sinusitis complex rhinitis disease

Atrophic rhinitis

20 18

Rhinogenic causes

Figure 3. Sex distribution (rhinogenic causes).

Male

No. of cases

Female

No. of cases

10 8 6

4 3 2 1 0

Migraine

Trigeminal neuralgia

Temporomandibular joint arthritis Other causes

Tension headache

Figure 4. Sex distribution (other causes).

of headache due to rhinogenic causes were males and 46.37% were females. In headache due to other causes about 93.54% of the patients in headache due to other causes were females and 6.45% were males. 28.9% of

DNS

Acute sinusitis (under antibiotic cover) Antral washout No. of patients Relieved

OMD

Not relieved

Figure 7. Patients who underwent antral washout.

patients of headache had deviated nasal septum (DNS) and 28.9% of the patients had acute sinusitis, 24.63% of the patients had osteomeatal complex disease and 8.69% of patients had polyp, 5.79% of patients had allergic rhinitis and 2.89% of patients had atrophic rhinitis. Patients with headache in the forehead were maximum (43.4%) followed by headache at more than one site

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY Table 3. Sex Distribution (Rhinogenic Causes) (n = 69)

Completely free of pain (30%)

No benefit from surgery (33%)

Male

Significant symptom improvement (37%)

Figure 8. Patients who underwent FESS due to causes other than contact points.

Table 1. Age Distribution (Rhinogenic Causes) (n = 69) Age group (years) DNS Acute sinusitis Osteomeatal complex disease Polyp Allergic rhinitis Atrophic rhinitis

5-10 -

11-20 21-30 6 14

31-40 -

41-50 -

51-60 -

Table 2. Age Distribution (Others) (n = 31)

Female

DNS

Acute sinusitis

Osteomeatal complex disease

Polyp

Allergic rhinitis

Atrophic rhinitis

Table 4. Sex Distribution (Other Causes) (n = 31) Male

Female

Migraine

Trigeminal neuralgia

Temporomandibular joint arthritis

Tension headache

Table 5. Etiology of Headache with respect to Clinical Findings No. of cases

Rhinogenic causes (%)

DNS

28.90

Acute sinusitis

28.90

Osteomeatal complex disease

24.63

Polyp

8.69

Allergic rhinitis

5.79

Atrophic rhinitis

2.89

Age group (years) 5-10

11-20

21-30

31-40

41-50

51-60

Migraine

Trigeminal neuralgia

Temporomandibular joint arthritis

Tension headache

43.47% of the patients who underwent DNE for headache had mucosal contact points as the main pathology.

Asian Journal of Ear, Nose and Throat, July-September 2013

Localization

No. of cases

Rhinogenic causes (%)

Forehead

43.4

More than one site

34.7

Glabella

13.04

Top of head

8.69

(34.7%) and then glabella (13.04%) and top of head (8.69%). 35.08% of patients who underwent antral washout for headache and facial pain were relieved, whereas 64.92% were not relieved.

Table 6. Localization of Headache

Table 7. Patients Who Underwent Antral Washout No. of patients

Relieved (n = 20)

Not relieved (n = 37)

DNS

Acute sinusitis (under antibiotic cover)

Osteomeatal complex disease

CLINICAL STUDY Table 8. Patients Who Underwent DNE (n = 69) No. of cases

Percentage (%)

Mucosal contact points present

43.47

Mucosal contact points absent

56.52

Table 9. Patients Who Underwent FESS due to Mucosal Contact Point (n = 25) No. of cases

Percentage (%)

Total relief from headache

80.00

Significant relief

20.00

Table 10. Patients Who Underwent FESS Due to Causes Other than Contact Points (n = 30) No. of cases

Percentage (%)

Completely free of pain

30.00

Significant symptom improvement

36.6

No benefit from surgery

33.3

Out of 30 patients diagnosed as having mucosal contact points, 25 underwent FESS. Eighty percent of the patients who underwent FESS for headache due to mucosal contact points had complete relief from headache and 20% had significant relief. Out of 39 patients of headache due to causes other than contact point, 30 underwent FESS. Patients who underwent FESS for causes other than mucosal contact points showed 67% improvement in headache and facial pain. DISCUSSION According to our study, the majority of the cases of headache due to rhinogenic causes were males (54%) in the age group of 11-30 years. Similar findings were observed in the study conducted by Kumar et al (2000) wherein majority of patients of headache belonged to age group 10-30 years and 53% were males.5 Similarly, in a different study by Wenig et al6 and need Lebovics et al demonstrated a male predominance of headache due to acute frontal sinusitis in both adults and adolescents. While majority of our patients of headache due to rhinogenic causes had either DNS, acute sinusitis or osteomeatal complex disease, we also encountered patients having nasal polyps (6 patients) allergic

rhinitis (4 patients) presenting with headache. Similarly, in the study by de Frietas et al, the patients of polyps along with nasal obstruction also had facial discomfort and headache7 and according to a study conducted by Wolf, 20% of allergy patients presented with headache.8 In our study, out of 69 patients of headache due to rhinogenic causes, 30 (43.4%) patients had headache at forehead, 24 (34.7%) patients had headache at more than one site, nine (13.04%) patients had headache at glabella and six (8.69%) patients had headache at top of head. In a study conducted by Kumar et al (2000), localization of headache to forehead was 43% while headache at more than one site was seen in 19%, pain at glabella in 12% and at top of head in 9%.5 Thus, it can be concluded that headache is localized at forehead in majority of cases. We also did antral washouts in our patients of headache but only 35% of the patients were relieved. We also did DNE on 69 patients out of which 30 (43%) patients had mucosal contact points. Patients due to mucosal contact points were advised to undergo FESS. Out of 30 patients, 25 patients underwent surgery. Postoperatively, 20 patients (80%) had total relief from headache, five patients (20%) had significant relief. Various other studies in literature show similar the same results. In a study conducted by Behen et al, 23 patients underwent surgical intervention to relieve the contact points. Eighty-three percent of patients no longer complained of headache. Eight had significant relief.9 In a study conducted by Parsons et al on 34 patients who underwent surgery for contact points, a reduction in intensity was reported in 91% of patients and reduction in frequency of headache in 85% of patients postoperatively 35 (5).10 Thus, from our study and the above mentioned studies, it is clear that majority of the patients who underwent FESS for mucosal contact points were totally relieved of their symptoms. The remaining 39 patients who had pathologies other than mucosal contact points i.e., DNS, osteomeatal complex disease were also advised FESS to get rid of headache. Out of the 30 patients who underwent surgery, postoperatively, nine (30%) patients were completely free of pain, 11 (36.6%) patients had significant symptom improvement and 10 (33.3%) patients had no benefit from surgery. Thus, it showed 67% improvement and correlates with studies mentioned below: Welge-Leussen et al

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY conducted a 10-year follow-up of patients who had undergone FESS. Out of 20 patients, six (30%) patients remained completely free of pain, seven (35%) had significant improvement and seven (35%) received no benefit from surgery (65% improvement).11 In a study conducted in Dept. of Otolaryngology, Vajira Hospital, Bangkok, Thailand, 16 patients were operated on by FESS. Their principal complaint was facial pain or headache. Ten patients had no headache postoperatively (62.5%) and six patients (37.5%) had a reduction in severity.12

SUMMARY ÂÂ

A total of 100 patients presenting with headache to Dept. of ENT were recruited for the study.

ÂÂ

Out of 100 patients, 69 patients had headache due to sinogenic causes.

ÂÂ

Headache can occur at any age. But, the highest incidence was noted in the age group 21-30 years followed by 11-20 years.

ÂÂ

Sex incidence is slightly more in males (53.62%).

ÂÂ

In patients of headache due to sinogenic cause, 20 patients (28.9%) had acute sinusitis, 20 patients (28.9%) had DNS, 17 patients (24.63%) had osteomeatal complex disease, six patients (8.69%) had polyps, four patients (5.79%) had allergic rhinitis and two (2.89%) had atrophic rhinitis.

ÂÂ

Headache was localized to forehead in 30 patients (43.4%) and more than one site in 24 patients (34.7%), at the glabella in nine patients (13.04%) and at the top of head in six patients (8.69%).

ÂÂ

Out of 69 patients of headache due to sinogenic causes, 57 underwent antral washout, 20 patients were relieved of their headache and facial pain (35.08%) and 37 patients (64.9%) were not relieved.

ÂÂ

All the 69 patients underwent DNE out of which 30 patients (43.47%) were found to have mucosal contact points.

ÂÂ

Out of 30 patients of headache due to mucosal contact points, 25 underwent FESS; of these, 20 patients (80%) had total relief from headache and five patients (20%) had significant relief.

ÂÂ

Out of the remaining 39 patients of headache, 30 patients underwent FESS, nine patients (30%) had complete relief from pain, 11 patients (36.6%) had significant symptom improvement, 10 patients (33.3%) had no benefit from surgery. This showed that 67% of patients had improvement of headache after undergoing FESS.

ÂÂ

Endoscopic management of headache due to sinogenic causes provides a tool to the surgeon by which he can accurately diagnose meticulously and with minimal trauma operate and precisely provide postoperative care and follow-up.

ÂÂ

The use of microdebrider provides an excellent surgical result with fewer complications and faster healing than traditional techniques in FESS.

Thus, from the present study and the above mentioned studies, an improvement in headache in 63-67% of patients operated should be expected after the patients undergo FESS for headache. CONCLUSION Sinusitis refers to a group of disorders characterized by inflammation of the mucosa of the PNS. Now-adays rhinosinusitis is the preferred term to describe the inflammation of the nose and PNS. Headache is nearly a universal human experience. The lifetime incidence of headache is estimated to be at least 90%. Before treating the headache it should be known if the headache is primary (when no clear pathologic condition can be identified) or secondary (metabolic, infectious, inflammatory, traumatic, neoplastic, immunologic, endocrine, vascular). To know whether the headache is sinogenic or not, firstly the patient is assessed clinically, then radiological investigations (X-ray PNS) are done. Patients also undergo DNE. Medical line of treatment with antibiotics, antihistamines, anti-inflammatories, nasal decongestants will be beneficial only in acute cases of sinusitis without any anatomical variation. Most cases of sinusitis presenting with headache are acute cases or acute-on-chronic sinusitis. Antral lavage can be a relief from headache for some patients. Role of FESS is huge when no obvious clinical abnormality is made out and ultimately it is FESS that is the cure for headache due to rhinogenic causes. Now-a-days suction irrigation endoscopy should be used for visual control during surgery. Microdebrider should be used for FESS as it provides atraumatic dissection with minimum bleeding, which enables decreased surgical time and faster postoperative healing.

Asian Journal of Ear, Nose and Throat, July-September 2013

REFERENCES 1. Cady RK, Schreiber CP. Sinus headache: a clinical conundrum. Otolaryngol Clin North Am 2004;37(2): Cont’d on page 24... 267-88.

CLINICAL STUDY

Septoplasty with Adenoidectomy: A Combined Procedure for Nasal Obstruction in Children K MALLIKARJUNA SWAMY*, KP BASAVARAJU**

ABSTRACT Nasal obstruction in children is caused by numerous and diverse factors but the symptoms are essentially snoring, mouth breathing, sleep disturbances and rhinorrhea. The commonest causes of nasal obstruction in children are septal deviation and adenoid hypertrophy. Nasal septal deviation in children is usually due to some form of injury. Performing septoplasty alone in this age group without addressing adenoids may lead to recurrence of symptom i.e., nasal obstruction may lead to failure of procedure. Both procedures can be combined in a single sitting. We present herein a study of combined septoplasty with adenoidectomy for relief of nasal obstruction in children aged 9-15 years. Keywords: Septoplasty, adenoidectomy, nasal obstruction, children, combined procedure

he commonest causes of nasal obstruction in children are septal deviation and adenoid hypertrophy. Adenoids may be implicated in upper respiratory tract disease due to partial or complete obstruction of the nasal choanae. Nasal obstruction in children is caused by numerous and diverse factors but the symptoms are essentially snoring, mouth breathing, sleep disturbances and rhinorrhea. During the development years of the child, mouth breathing may lead to severe physical developmental disorder (facial, oral nasal and thoracic), which may lead to cognitive impairment.1 Nasal septal deviation in children is usually due to some form of injury. There is much debate as to whether septal surgery is appropriate in the growing nose.2 The main nasal growth center of the nose is the contact area between quadrangular cartilage and vomer1 and even a minor disruption here can lead to significant problems with final midfacial contour. Furthermore, evidence is available which states that not performing surgery on children affected by nasal

*Assistant Professor **Professor Dept. of ENT JJMMC, Davangere, Karnataka Address for correspondence Dr K Mallikarjuna Swamy Assistant Professor Dept. of ENT E-mail: drkmallikarjuna1980@gmail.com

septal deviation can lead to dental malocclusion, facial abnormalities and respiratory morbidity. Therefore, not performing septal surgery in children affected by septal deviation may be more detrimental.2 Generally, if symptoms are significant, a limited septoplasty with minimal removal of cartilage is acceptable.1 Performing septoplasty alone in this age group without addressing adenoids may lead to recurrence of symptom i.e., nasal obstruction may lead to failure of procedure;1 so we should combine both procedures in single sitting. Only septoplasty with adenoidectomy done separately leads to recurrence or persistence of nasal obstruction in children. OBJECTIVE This is a study of combined septoplasty with adenoidectomy for relief of nasal obstruction in children aged 9-15 years. MATERIAL AND METHODS This study included 20 children between the ages of 9-15 years undergoing adenoidectomy with septoplasty for their obstructive symptoms in Chigateri General District Hospital, Davangere, Karnataka from November 2010 to February 2012. Among this group, there were 12 boys and eight girls. Informed written consent was taken from parents/guardians. Children included in this study met the following criteria: Ă&#x201A;Ă&#x201A;

Continuous nasal obstruction for at least three months due to deviated nasal septum (DNS).

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY ÂÂ

Children without allergic rhinitis.

Exclusion criteria

Table 1. Symptoms Symptoms

No. of patients Percentage (%)

ÂÂ

Isolated adenoid hypertrophy cases.

Nasal obstruction

100

ÂÂ

Use of topical intranasal/systemic decongestants or steroids.

Mouth breathing

Snoring

Rhinorrhea and headache

Caudal dislocation

The patients had history of mouth breathing, snoring, headache and rhinorrhea. A lateral nasopharyngeal soft tissue X-ray was taken to evaluate the size of the adenoids. All children had considerably enlarged adenoids. Adenoid facies and voice were evaluated. The ear was examined to look for eustachian tube dysfunction and its effects. X-ray paranasal sinuses (PNS) was taken to rule out associated sinus infection. Nasal endoscopy was also done if required to rule out other causes like nasal polyps. Complete examination of ear nose and throat examination was done.

Table 2. Clinical Examination Sign

No. of patients

Percentage (%)

Septal deviation

100

Adenoid facies

Rhinorrhea

All children were operated under general anesthesia, the septoplasty procedure was performed with minimal removal of cartilage with septal repositioning done (upto 5 mm of inferior strip and posterior end of the cartilage was removed); nasal cavity was packed with Vaseline gauze. The children were then put in Rose position and traditional adenoidectomy done, using the technique of curettage. Assessment of the adenoids was made digitally prior to curetting and hemostasis achieved with gauze tamponade. The relief of nasal obstruction was assessed subjectively by follow-up of the children or parents postoperatively. The children were discharged on third day of surgery and advised for follow-up once weekly for 2-3 weeks and once in a month upto six months.

Figure 1. Gross DNS to the left with caudal dislocation in a 10-year-old patient.

RESULTS All the 20 children included in the study had nasal obstruction. Mouth breathing was seen in 18 children (90%). Snoring 20 percent children had rhinorrhea and headache was the associated complaint in 16 children (80%) (Table 1). On clinical examination, all 20 children had septal deviation of various degrees. Rhinorrhea was seen in 16 children (80%), eight patients had adenoid facies (40%). None of the children had caudal dislocation (Table 2). Out of 20 children, three children could not be assessed for outcome of surgery since they dropped out of their follow-up; of the 17 patients, nine children showed improvement after one week of surgery. The remaining eight children showed relief of symptoms on the 2nd follow-up. Of these, four patients who complained of

Asian Journal of Ear, Nose and Throat, July-September 2013

Figure 2.

snoring and restless sleep, showed marked symptom reduction (as observed by the parents). Overall the combined procedure of septoplasty with adenoidectomy yielded good results in in terms of

CLINICAL STUDY Adenoidectomy appears helpful as a part of management of obstructive sleep apnea syndrome (OSAS) and sleep disordered breathing (SDB), but cross-sectional studies support the benefit of adenoidectomy and tonsillectomy performed together for OSAS and SDB.3

Figure 3. X-ray nasopharynx showing adenoid hypertrophy.

Therefore, a detailed examination is advised to exclude another cause or co-existing pathology i.e., adenoid hypertrophy prior to considering septoplasty.2 During our clinical examination in outpatients, we have found adenoid hypertrophy even in children above 10 years of age. Septal deviations in children are very common and contribute significantly to nasal obstruction. In children who have septal deviations along with adenoid hypertrophy, either septoplasty or adenoidectomy alone may not give satisfactory results. Hence, septoplasty with adenoidectomy helps in relieving nasal obstruction in such children without any major complications. CONCLUSION

nasal obstruction, mouth breathing and snoring. No major complications like postnasal bleeding, septal perforation or external deformity were seen.

We performed combined septoplasty with adenoidectomy in 20 children between 9-15 years of age with good results without any major complications. Subjective and clinical assessment in these children showed significant improvement in nasal obstruction and mouth breathing. There was also marked improvement in general health and scholastic performance after long-term follow-up. Septoplasty with adenoidectomy when done separately leads to recurrence or persistence of nasal obstruction in children. So, we conclude that combined procedure septoplasty with adenoidectomy is required for relief of nasal obstruction in children aged 9-15 years.

DISCUSSION

REFERENCES

The empirical indication for adenoidectomy includes obstructive sleep apnea, recurrent rhinosinusitis and otitis media with effusion.2 The adenoids when diseased may act as source of infection, supporting bacteria in a biofilm with resultant inflammatory changes in the mucosa of nose, nasopharynx, PNS and middle ear.

2. Lawrence R. Pediatric septoplasy: a review of the literature. Int J Pediatr Otorhinolaryngol 2012;76(8):1078-81.

Figure 4. Endoscopic view showing DNS with adenoid in a 9-year-old patient.

Surgery is recommended by American Association of Otolaryngology-Head and Neck Surgery (AAO-HNS) for infective causes including adenoiditis, where two courses of antibiotics have failed and for recurrent rhinorrhea on four occasions.3 A DNS alone is rarely significant enough to be the sole cause of obstructive breathing.

1. Verucchi F, Caropreso CA. Indications and contraindications for septoplasty in children. VI IAPO Manual of Pediatric Otorhinolaryngol Published Online: http:// www.iapo.org.br/manuals/VI_manual_en_Fulvio.pdf.

3. Cervera Escario J, Castillo Martín FD, Gómez campderá JA, Gras Albert JR, Pérez Piñero B, Villafruela Sanz MA. Indications for tonsillectomy and adenoidectomy: consensus document by the Spanish Society of ORL and the Spanish Society of Pediatrics. Acta Otorrinolaringol Esp 2006;57(2):59-65. 4. Adams DA, Cinnamon MJ. Pediatric otolaryngology. Volume 6. Scott-Brown’s Otorhinolaryngology: Head and Neck Surgery. 6th edition, ButterworthHeinemann. 1997 nasal Obstruction and rhinorrhea in infants and children, 6w/17/1-14.

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY

Common Ear, Nose and Throat Problems in Pediatric Age Group Presenting to the Emergency Clinic-Prevalence and Management: A Hospital-based Study KALPANA SHARMA*, DIPEN BHATTACHARJYA**, HIMAJIT BARMAN†, SUBODH CH GOSWAMI‡

ABSTRACT Ear, nose and throat (ENT)-related diseases form a significant portion of ailments in pediatric age group. Many of them present in emergency clinics with acute symptoms requiring urgent management. A prospective study was carried out in the Dept. of ENT, Gauhati Medical College, Guwahati, Assam in patients below 16 years of age, to determine the hospital prevalence of ENT emergencies in pediatric age group and their management protocol as followed in a tertiary center. Emergencies relating to ear were the most common followed by nasal and pharyngoesophageal conditions. Foreign bodies were most common among aural and nasal emergencies. A considerable number of patients presented with faciomaxillary and orodental injuries. Though, mortality is low in such emergency group, morbidity may be very high at times. In management of such emergencies, particularly where operative intervention is required, expertise of an ENT specialist is necessary. Keywords: ENT emergency, foreign body, injury

ediatric population forms a considerable proportion of the total population in our state of Assam. All health-related issues of pediatric age group are considered to be of great importance and they also give us data for understanding the healthrelated problems and for assessing the health status of a community. According to the Census Report 2011, the total population of Assam is 31,169,272. Out of which 4,511,307 (14.47%) belong to the age group of 0-6 years.1 In Kamrup (rural) district, pediatric population belonging to the age group of 0-6 years forms 12.85% of the population. The same is 9.56% in Kamrup (metro) district, which has a total population of 1,260,419.1

*Associate Professor **Postgraduate Trainee †Registrar ‡Professor Dept. of ENT Gauhati Medical College and Hospital, Guwahati, Assam Address for correspondence Dr Kalpana Sharma Ashirwad Apartment Basisthapur, Bye Lane No. 3 Near Regional Passport Office, Guwahati, Assam -781 028 E-mail: kalpanasharmak@yahoo.co.uk

Asian Journal of Ear, Nose and Throat, July-September 2013

Children frequently suffer from diseases relating to ear, nose and throat (ENT). Some ENT diseases like acute suppurative otitis media (ASOM) are more common in children than in adults. The same is the case with adenoid, acute tonsillitis, acute rhinitis of viral origin, acute epiglottitis and acute laryngotracheobronchitis. It may be due to various factors like wider and horizontally placed eustachian tube, poorly developed immunity, malnutrition, poor hygiene, overcrowding, lower socioeconomic status of the family and parental ignorance.2 In addition to attending OPD of a hospital, many children are brought by their parents to the emergency clinic of a hospital with history of ENT-related diseases. All of these require urgent management. In Indian scenario, foreign body impaction in ENT region are found to be a common emergency and sometimes, they may produce even fatal outcomes. It should always be kept in mind that management of ENT emergencies is a specialized job and special instruments and equipments are needed to manage such situations.3 OBJECTIVE The study was undertaken to determine the hospital prevalence of ENT-related emergency conditions in

CLINICAL STUDY children. The management protocol as followed in a tertiary center is also discussed.

ÂÂ

Number of cases requiring general anesthesia and operation theater facilities.

All results were expressed in number and percentage.

MATERIAL AND METHODS A prospective study was conducted in the Dept. of ENT, Gauhati Medical College and Hospital, Guwahati Assam between 1st July 2011 to 30th June 2012. All patients below 16 years of age were enrolled in the study. These patients presented to emergency clinics of the department with acute presentation. The patients were examined in detail using: Bull’s eye lamp, head mirror, otoscope, nasal speculum and tongue depressor. The cases with faciomaxillary, orodental injuries and epistaxis were made to lie down on a couch and were carefully examined under operating light. The cases with impacted aural foreign bodies were examined under operating microscope and all esophageal foreign body cases were assessed by radiographic examination. The information that was included in the study: ÂÂ

Age group

ÂÂ

Male or female preponderance

ÂÂ

Presenting illness

ÂÂ

Number of cases managed on outpatient basis

ÂÂ

Number of cases requiring admission

RESULTS A total of 251 patients were examined during this time period. Among these, 155 were male (61.75%) and 96 were female (38.24%). So, there is an overall male preponderance. Ninety-five cases (37.84%) presented with complaint relating to ear. Eighty-three cases (33.06%) presented with problems relating to nose. Twenty-six cases (10.35%) presented with pharyngoesophageal complaint. Forty-seven cases (18.72%) presented with other complaints, which included injuries and acute parotitis. From the Table 1, it is clear that highest number of cases presented with foreign body nose, followed by foreign body ear and injuries. Among the pharyngoesophageal emergencies, the most common was acute tonsillitis followed by foreign body esophagus. Nasal foreign bodies included plastic beads, piece of paper, color pencil, piece of chalk, cereals, grams, seeds of orange and piece of rubber. Aural foreign bodies included plastic beads, foil of chocolate, insects and rice grains. Among the esophageal foreign bodies, six cases (66.66%) were of

Table 1. Presenting Diseases Diseases

Male

Female

Total numbers

Percentage (%)

Foreign body nose

23.90

Foreign body ear

19.12

Injuries

16.73

Epistaxis

9.16

Acute otitis media

7.96

Impacted wax

6.37

Otitis externa

4.38

Acute tonsillitis

3.98

Foreign body esophagus

3.58

Foreign body throat

2.78

Acute parotitis

1.99

Table 2. Causes of Injury Causes of injury

Male

Female

Total numbers

Percentage (%)

Self fall

76.19%

Sport injury

23.80%

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY coin, one case each of safety pin, meat bone and nail. All foreign bodies in throat were impacted fish bone. Table 2 describes the causes of injury. Forty-two cases presented with various types of injuries in faciomaxillary and orodental regions. Out of 42 cases, 32 (76.19%) were males and 10 (23.80%) were females. Self fall was exclusively common (76.19%) as a cause of injury; others were results of outdoor sport. From Table 3, it can be seen that the most common form of injury was lip laceration and abrasion of maxillary region (80.95%). From the Table 4, it is clear that diseases, that were exclusively common in infants and toddlers were foreign body esophagus, foreign body nose, foreign body ear, otitis externa and epistaxis. Some cases of injury were also found in this age group. In the preschool age group almost all the diseases were found. Injuries were common among schoolgoing children. Wax, foreign body throat and acute parotitis were also found in this age group.

All nasal, aural and pharyngeal foreign bodies were removed under direct vision using good light source. Thirty-three cases (68.75%) of aural foreign body and all nine cases (100%) of esophageal foreign body required removal under general anesthesia in operation theater using operating microscope and esophagoscope, respectively. So, a total of 42 cases (16.73%) were managed in operation theater under general anesthesia. All injuries were repaired carefully. Epistaxis was treated using hemocoagulase solution and application of Merocel. Out of 23 cases of epistaxis, six (26.08%) required insertion of Merocel. Out of 16 cases of impacted wax, wax was removed by Jobson-Horneâ&#x20AC;&#x2122;s probe in four cases (25%); remaining 12 cases (75%) were prescribed wax dissolving solution followed by removal of wax under microscopic examination. Cases presenting with acute infection were treated conservatively. Nine cases of esophageal foreign body, 10 cases of epistaxis and two cases of injury were admitted. So, a total of 21 cases (8.36%) required admission. No complication was observed in patients treated during this period.

Table 3. Various Types of Injuries Type of injury

Male

Female

Total numbers

Percentage (%)

Lip laceration and abrasion of maxillary region

80.95

Buccal mucosa laceration

2.38

Palatal laceration

2.38

Tongue laceration

4.76

Alveolar injury

77.14

Pinna laceration

2.38

Total

Table 4. Age-wise Distribution of All ENT Emergencies Presenting illness

0-3 years (infants and toddlers)

3-6 years

6 years and above

Foreign body nose

(pre-school age)

(schoolgoing age)

Foreign body ear

Injuries

Epistaxis

Acute otitis media

Impacted wax

Otitis externa

Acute tonsillitis

Foreign body esophagus

Foreign body throat

Acute parotitis

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY DISCUSSION Foreign bodies, animate or inanimate, in external auditory canal and nasal cavity are commonly found in children. They are especially common in young children who tend to insert foreign bodies when they are playing or when they get bored.2 In our study, maximum number of foreign bodies was found in the age group of 0-6 years. It was relatively uncommon in children above six years of age. In one previous study carried out by ED Kitcher in 2007, the peak age incidence was observed in 0-9 years of age.4 The range of foreign bodies is extensive including food particles, vegetable matter and inorganic objects like paper, plastic beads, chalks and coins (in esophagus). Aural and nasal foreign bodies are mostly of inanimate type.3 Coin is a common foreign body, which gets impacted in esophagus and is particularly common in children.3 In our study, all aural and nasal foreign bodies were inanimate and the most common esophageal foreign body was coin (66.66%). It was observed that all nasal foreign bodies could be removed using foreign body hook or Tilleyâ&#x20AC;&#x2122;s forceps. Out of 48 cases of aural foreign bodies, 33 cases (68.75%) required general anesthesia for removal. Skill of an ENT specialist is very necessary for removal of aural foreign body, because unskilled removal of aural foreign bodies may injured eardrum, ossicles or even facial nerve.3 In one study carried out by Mackle et al, it was found that though 65% of nasal foreign bodies can be removed in emergency clinics, but it was not so in the case of aural foreign bodies, 96% of which required removal under anesthesia and skill of an ENT surgeon.4 In our study, 68.75% of aural foreign bodies required operation theater facilities and general anesthesia for their removal. All esophageal foreign bodies need urgent esophagoscopy and removal under general anesthesia. Esophagoscopy is a difficult procedure, especially when tried by unskilled person. Fatal accidents can occur by slightest trauma due to thinness of esophageal wall.3 In our study, a considerable number of cases presented with faciomaxillary and orodental injuries, most of which were result of self fall (76.19). All types of injuries were common in males, over 76.19%. Most common injury, which was found in our study was laceration of lip and abrasion of maxillary region (80.95%); the highest incidence was observed in the age group of schoolgoing children (6 years and above). In a previous

study conducted by Khan on ENT injuries in children, highest incidence were observed in the age group of 10-15 years and a male preponderance. It was probably due to more outdoor activity on the part of male. Most common etiology was self fall (32%) and nasal bone fracture was the most common type of injury.5 ENT injuries in children can give rise to facial deformities and in the long run, can cause functional, cosmetic and psychological problems. In developing countries like India, most of the deaths below five years of age is due to communicable diseases, respiratory infection and diarrhea and very few are due to injuries.6 But, injuries should always be treated well as it is an avoidable cause of disability.7 Acute infection of various sites in ENT is one of the commonest causes of emergencies in children. In our study, the cases that were found are: Acute otitis media, otitis externa, acute tonsillitis and acute parotitis. Among these, acute otitis media was a presenting illness in highest number of cases. The incidence was more or less same in all groups as far as our study is concerned. Acute otitis media is common in infants due to wider and horizontally placed eustachian tube and it comprises of one-third of problems seen in pediatric practice during first five years of life.8 It is recommended that there is a need for otosopic examination of all pyretic children as the resultant hearing loss due to acute suppurative otitis media is related to difficulties in language acquisition in children below two year of age. It also affects literacy and school achievements. CONCLUSION ENT emergencies in pediatric age group are not uncommon. Mortality is low, but a numbers of complications may arise, which may include perforation of drum, aspiration, airway obstruction and long-term complication like nasal and facial deformity. Hence, proper management of ENT emergencies is of utmost importance. The most common ENT emergency in pediatric age group is foreign body, which can be removed and patients can be disposed on outpatient basis. As operative intervention is required in a significant number of ENT emergencies; expertise of an ENT specialist is necessary in management of these cases. REFERENCES 1. Census of Assam 2011. Online.assam.gov.in. 2. Moran AGD. Logan Turnerâ&#x20AC;&#x2122;s Diseases of the Nose, Throat and Ear. 10th edition, 2007.

Asian Journal of Ear, Nose and Throat, July-September 2013

CLINICAL STUDY 3. Saha S, Chandra S, Mondal PK, Das S, Mishra S, Rashid MA, et al. Emergency Otorhinolaryngolocal cases in Medical College, Kolkata - A statistical analysis. Indian J Otolaryngol Head Neck Surg 2005;57(3):219-25. 4. Mackle T, Conlon B. Foreign bodies of the nose and ears in children. Should these be managed in the accident and emergency setting? Int J Pediatr Otorhinolaryngol 2006;70(3):425-8. 5. Khan AR, Arif S. Ear nose and throat injuries in children. J Ayub Med Coll Abbottabad 2005;17(1):54-6.

9. Alabi BS, Abdulkarim AA, Fatai O, Abdulmajeed SO. Prevalence of acute otitis media among children with pyrexia in a Nigerian hospital. Auris Nasus Larynx 2009;36(5):532-5. 10. Ngo A, Ng KC, Sim TP. Otorhinolaryngeal foreign bodies in children presenting to the emergency department. Singapore Med J 2005;46(4):172-8. 11. Kitcher E, Jangu A, Baidoo K. Emergency ear, nose and throat admissions at the korle-bu teaching hospital. Ghana Med J 2007;41(1):9-11.

6. Agarwal V, Gupta A. Accidental poisonings in children. Indian Pediatr 1974;11(9):617-21.

12. Al-Mazrou KA, Makki FM, Allam OS, Al-Fayez AI. Surgical emergencies in pediatric otolaryngology. Saudi Med J 2009;30(7):932-6.

7. Singh I, Gathwala G, Gathwala L, Yadav SPS, Wig U. Ear, nose and throat injuries in children. Pak J Otolaryngol 1993;9:133-5.

13. Mohan D. Childhood injuries in India: extent of the problem and strategies for control. Indian J Pediatr 1986;53(5):607-15.

8. Pestalozza G, Romagnoli M, Tessitore E. Incidence and risk factors of acute otitis media and otitis media with effusion in children of different age groups. Adv Otorhinolaryngol 1988;40:47-56.

14. Ghosh P. Foreign bodies in ear nose and throat (predictions and management). Indian J Otolaryngol 1999:p.2-5. 15. Bernius M, Perlin D. Pediatric ear, nose, and throat emergencies. Pediatr Clin North Am 2006;53(2):195-214.

■■■■

...Cont’d from page 16

2. Michaels B. Rhinosinusitis. Scott-Brown’s Otorhinolaryngology HNS. 7th edition, p.1439-48. 3. Seiden AM, Martin VT. Headache and the frontal sinus. Otolaryngol Clin North Am 2001;34(1):227-41. 4. Stammberger H. Functional Endoscopic Sinus Surgery: The Messerklinger Technique. Mosby-Year Book: St. Louis 1991:p.70-6. 5. Kumar P, Chawla P. A Correlative study of sinusitis versus headache. Indian J Otolaryngol Head Neck Surg 2000;52(2):125-7.

8. Donald J, Dalessio. Allergy, atopy, nasal diseases and headache, Wolf’s Headache and other Head Pain. 5th edition. 9. Behin F, Behin B, Behin D, Baredes S. Surgical management of contact point headaches. Headache 2005;45(3):204-10. 10. Parsons DS, Batra PS. Functional endoscopic sinus surgical outcomes for contact point headaches. Laryngoscope 1998;108(5):696-702.

6. Wenig BL, Goldstein MN, Abramson AL. Frontal sinusitis and its intracranial complications. Int J Pediatr Otorhinolaryngol 1983;5(3):285-302.

11. Welge-Luessen A, Hauser R, Schmid N, Kappos L, Probst R. Endonasal surgery for contact point headaches: a 10-year longitudinal study. Laryngoscope 2003;113(12):2151-6.

7. Freitas MR, Giesta RP, Pinheiro SD, Silva VC. Antrochonal polyp: a review of sixteen cases. Rev Brasi Otolaryngol. 2006;72(6):831-35.

12. Boonchoo R. Functional endoscopic sinus surgery in patients with sinugenic headache. J Med Assoc Thai 1997;80(8):521-6.

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE STUDY

Thirty-six Cases of Vocal Polyps Treated by Microflap Phonomicrolaryngeal Surgery SUDHIR M NAIK*, SARIKA S NAIK**

ABSTRACT Background/Objective: Vocal fold polyps usually occur on the anterior or middle part of the membranous vocal fold and are the commonest laryngeal pathology requiring surgical removal. Phonomicrosurgery is superior to conventional microlaryngeal techniques in treating vocal polyps as collateral tissue damage and scarring is minimal. Setting: Dept. of ENT, Head and Neck Surgery, KVG Medical College and Hospital, Sullia, Karnataka, India. Material and methods: Thirty-six patients with hoarseness and diagnosed vocal polyps on laryngoscopic examination were included in the study. All other causes of hoarseness and other benign vocal cord lesions were excluded from the study. Results: All the 36 cases (23 males, 13 females) operated had very good improvement in hoarseness and were followed for 3-12 months. No complications and recurrence were reported. Conclusion: The surgical outcome depends on accurate diagnosis of the vocal polyps with comprehensive voice evaluation. Patient selection and counseling, adequate pre- and postoperative care and meticulous microflap technique determine the success of the surgery. Keywords: Vocal polyp, phonomicrosurgery, hoarseness, microflap technique

ocal polyps are one of the most common benign lesions of the true vocal folds.1 The incidence of vocal polyps range from 11 to 51% among the benign lesions of the vocal folds.2

Intermittent, severe voice abuse is the most common etiology and incidence are more among men in 3-6th decade.3,4 The exact pathogenesis of vocal polyp formation is not known but voice abuse seems the prime etiology.5,6 Vocal abuse leads to vibratory trauma to the membranous vocal folds which cause disturbance in their microcirculation and damage the superficial vessels inducing vocal fold hemorrhages.5,6 They result in inflammatory reactions which result in malformed neovascularized masses called vocal polyps.5,6 The polyp typically occurs as a unilateral mass at the free edge of the mid-membranous vocal fold, but it may also be bilateral.7 Sometimes the polyps are bilateral and histopathological and stroboscopic examination should be done to differentiate it from vocal nodules.7,8 Small polyps can be managed by conservative voice therapy

* Dept. of ENT, Head and Neck Surgery **Dept. of Anesthesia KVG Medical College, Sullia, Karnataka

only and moderate- to large-sized polyps should be managed by phonomicrosurgery.4 Also, small polyps unresolved with voice therapy should be treated surgically to restore normal vocal cord appearance and vibratory function.4 We report 36 cases of vocal polyps managed by phonomicrolaryngeal surgery techniques. MATERIAL AND METHODS This is a retrospective study of 36 cases of vocal polyps managed in Dept. of ENT, Head and Neck Surgery, KVG Medical College and Hospital, Sullia, Karnataka from December 2006 to December 2010. Thirty-six cases of vocal polyps were managed by phonomicrolaryngeal techniques during the 49 months study period. The patients were screened for hoarseness by indirect laryngoscopic examination and rigid 90째 laryngoscopic examination in the OPD. All other benign lesions were excluded from the study. All patients were advised phonomicrosurgery, but seven patients wanted to delay the surgery. These seven patients were put on medical line of treatment which included two weeks of tapering doses of prednisolone 10 mg tablets, 20 mg rabeprazole and antihistamines. All were advised steam inhalation. But, maximal

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE STUDY benefit was not seen with medical line and so later phonosurgery was done in all the 36 patients. RESULTS All the patients were in the 4-6th decade with the youngest patient being 36-year-old female and the oldest being 71-year-old male. There were 23 males and 13 females in the study group and the average group age was 52 years. Mean duration of hoarseness was 2.5 months and all the 23 males gave history of smoking and voice abuse for a period of more than 10 years. Most of the patients were manual laborers (29), two school teachers and five housewives. Hoarseness was seen in all cases with half of them having insidious onset and the rest faster in onset. The duration of symptoms varied from 2 to 15 months. Twenty-three patients were cigarette or bidi smokers, 11 were occasional alcoholics and four complained of recent upper respiratory tract infection flaring their hoarseness. All of our patients had unilateral vocal cord lesions. Size of the polyp varied from small to moderate and most of them were sessile. None of the patients had improvement with voice rest and medical line of therapy. All the patients were operated under general anesthesia with endotracheal intubation. All the postoperative specimen were sent for histopathological examination to rule out malignant changes in the polyps. Polyps were of fibroepithelial variety in 15 cases and were fibrovascular variety in 21 cases on histopathological examination. Postoperative period was uneventful in all cases and the patients were discharged on the third day. The follow-up was done for 3-12 months and all the patients had phenomenal voice improvement without complications.

The hyperfunctioning glottis during voice abuse induces shearing stresses in the superficial lamina propria.11 These stress leads to hemorrhagic inflammation and neovascularization.11 Healing leads to remodeling of the superficial layer of the lamina propria which results

Figure 1. Small vocal polyp on the left anterior one-third of vocal cord.

Figure 2. Vocal cord after phonomicrosurgery.

DISCUSSION Vocal polyps are usually unilateral pedunculated or sessile outgrowths of different sizes which appear on the anterior two-third of the vocal cords.9,10 The polyp affects glottal closure and causes aperiodic vocal-fold vibrations thus producing clinical features like hoarseness, voice breaks and diplophonia.9,10 Vocal overuse, abuse and misuse leads to excessive mechanical stress and trauma in the mid-membranous vocal fold, resulting in inflammation.9,10 Voice abuse causes acute and chronic trauma to the microvasculature of the superficial lamina propria.11

Asian Journal of Ear, Nose and Throat, July-September 2013

Figure 3. Phonomicrolaryngeal surgery being done.

CASE STUDY As the pathogenesis of polyp formation is not clearly understood, two main theories have been proposed.12 One theory suggest that a local increase in pressure is induced on the epithelium by edema and infiltration in the early stages causing a rupture of epithelium with granulation tissue formation.12

Figure 4. Microscope with 200 mm lens with suspension laryngoscope.

This granulation tissue will be later lined by pseudostratified columnar or squamous epithelium leading to polyp formation.12 The other suggests that local pressure on the epithelium may increase the inflammation and allergy resulting in subepithelial mass herniation and polyp formation.12 The polyps are divided into fibrous polyps, telangiectatic polyps and hyaline polyps depending on their microscopic features.13 Molecular changes in the extracellular matrix in the vocal polyps show an up-regulation of gene procollagen 1 which is a marker of new collagen formation.14 Matrix metalloproteinases 12 and 1, responsible for elastin breakdown and enzyme degradation, are downregulated in the polyps.14 The up-regulated expression of fibroprotein in polyps is associated with increased stiffness in the lamina propria on videostroboscopy.14

Figure 5. Instruments used in phonomicrolaryngeal surgery.

in the vocal polyp formation.9,10 Tobacco smoking and chewing does not have any documented association with polyp formation.4 Vocal polyps are well-defined benign lesions of the laryngeal mucosa, with typical histological characteristics.1 Dynamic changes in the way of life and diverse unfavorable ecological changes caused by pollution and industrialization have increased the incidence of polyps.1 Increase in level of medical education among the masses help detect these laryngeal lesions at an earlier stage.1 On histopathological examination, various stages of hyperplasia and atrophy is seen in the epithelium.1,5 Exudate with basophils, hyaline degeneration, angiectatic vessels and fibrosis are seen in the subepithelial tissue.1,5 Vocal abuse and co-incident upper respiratory infections causes vasodilatation which increases capillary permeability and interstitial edema.2,5 The protein rich content in the exudates leads to degeneration and fibrosis.1,5

The patient presents with persistent hoarseness which is insidious in onset, progressive and unremitting in nature with lowered voice intensity and frequency range.4 Pedunculated polyps hanging in the subglottic space may have normal voice but may suddenly have hoarseness if it impacts the glottis.4 The degree of vocal disability varies with the size, site, nature and pedunculation of the polyps.4 The first-line treatment for vocal polyps is behavioral intervention in form of voice rest and medical therapy, with the goal of reducing tine vibratory trauma underlying and exacerbating these masses.15 Contributory factors of dysphonia such as laryngopharyngeal reflex and poor vocal hygiene should also be treated.15 Larger polyps and polyps showing no improvement to maximal behavior therapy, voice rest and medical management should be considered for phonomicrosurgery.15 Small hemorrhagic polyps in their early stages sometimes resolve spontaneously with low-dose steroid therapy and voice rest, although surgical removal is typically required to return the vocal fold to its normal appearance and vibratory functions.3,16

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE STUDY Phonomicrosurgery using suspension microlaryngoscopy and fine microlaryngeal instrumentation under general anesthesia has led to precession surgery with stable magnified surgical field.17 Surgical technique of microflaps is possible as the vocal polyp pathology is limited to the superficial lamina propria only.17 Its a microsurgery to remove pathology without scar formation on the surface of the vocal folds, the principle of which lies in maximal preservation of Layered microstructure of the vocal fold, that is the epithelium and superficial lamina propria.17 It avoids injury to the deeper layers of the lamina propria and stimulates the fibroblasts resulting in minimal scar with proper voice quality.17 Use of videostroboscopy in analyzing the vocal fold oscillations have led to substantial improvements in microlaryngeal vocal fold surgery.17 Phonomicrosurgery using microflaps techniques has revolutionized the voice surgery.17 These procedures are designed to improve aerodynamic efficiency and voice quality by creating a smooth vocal fold edge that is not excavated with overlying flexible epithelium.17 The surgery is a physiological based approach for vocal polyps and has evolved as a result of convergence of microlaryngeal surgery techniques and mucosal wave theory of laryngeal sound production.17 Laser is most commonly used for more vascular and larger polyps.17 The collateral thermal trauma to the delicately loosely arranged elastic tissue of superficial lamina propria outweigh its advantage in smaller polyps.17 CONCLUSION Phonomicrosurgery has proved its superiority over the conventional microlaryngeal techniques with its minimal tissue damage, minimal scarring in dysphonic patients particularly in voice professionals. The outcome depends on accurate diagnosis of the vocal polyps with comprehensive voice evaluation. Patient selection and counseling, adequate pre- and postoperative care and meticulous microflap technique determine the success of the technique.

2. Dikkers FG. Nodules, polyps, Reinke edema, metabolic deposits and foreign body granulomas. In: Diseases of the Larynx. Ferlito A (Ed.), Arnold: London 2000:287-93. 3. Bastian RW. Benign vocal fold mucosal disorders. In: Otolaryngology Head and Neck Surg. 3rd edition Cumming CW, Fredrickson JM, Harker LA, Krause CJ, Richardson MA, Schuller DE (Eds.), Mosby: St Louis 1998:2096-129. 4. Benjamin B. Vocal cord polyps. In: Endolaryngeal Surgery. Benjamin B (Ed.), Martin Dunitz: London 1998:237-40. 5. Kleinsasser O. Pathogenesis of vocal cord polyps. Ann Otol Rhinol Laryngol 1982;91(4Pt 1):378-81. 6. Kambic V, Gale M. Epithelial hyperplastic lesions of the larynx. Elsevier, Amsterdam 1995:197-208. 7. Wallis L, Jackson-Menaldi C, Holland W, Giraldo A. Vocal fold nodule vs. vocal fold polyp: answer from surgical pathologist and voice pathologist point of view. J Voice 2004;18(1):125-9. 8. Dikkers FG, Nikkels PG. Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol 1995;104(9 Pt 1):698-703. 9. Titze IR. Mechanical stress in phonation. J Voice 1994;8(2):99-105. 10. Steinberg BM, Abramson AL, Kahn LB, Hirschfield L, Freiberger I. Vocal cord polyps: biochemical and histologic evaluation. Laryngoscope 1985;95(11):1327-31. 11. MilutinoviĆ Z. Phonosurgical treatment of vocal cord polyps. Srp Arh Celok Lek 1996;124(11-12):311-3. 12. Tos M, Mogensen C. Pathogenesis of nasal polyps. Rhinology 1977;15(2):87-95. 13. Mossallam L, Kotby MN, Ghaly AF, et al. Histopathological aspects of benign vocal fold lesions associated with dysphonia. In: Vocal Fold Histopathology. Col-Hill Press: San Diego; 1986. 14. Thibeault SL, Gray SD, Li W, Ford CN, Smith ME, Davis RK. Genotypic and phenotypic expression of vocal fold polyps and Reinke’s edema: a preliminary study. Ann Otol Rhinol Laryngol 2002;111(4):302-9. 15. Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surg 2003;11(6):456-61.

REFERENCES

16. Sataloff RT. Structural abnormalities of the larynx. In: Professional Voice: The Science and Art of Clinical Care. 2nd edition, Sataloff RT (Ed.), Singular Publishing Group: San Diego 1997:p.509-40.

1. Kambic V, Radsel Z, Zargi M, Acko M. Vocal cord polyps: incidence, histology and pathogenesis. J Laryngol Otol 1981;95(6):609-18.

17. Kumar P, Murthy S, Kumar R. Phonomicrosurgery for benign vocal fold lesions. Indian J Otolaryngol Head Neck Surg 1970;55(3)184-6.

■■■■

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE REPORT

An Unusual Intranasal Mass: Pleomorphic Adenoma of the Nasal Septum OK DESHMUKH,* ND ZINGADE**

ABSTRACT Pleomorphic adenomas are the most common salivary glands tumors that occur predominantly in major salivary glands with highest incidence in the parotid gland. Rarely, they may also be seen arising from the minor salivary glands present in the upper aerodigestive tract. Though they can occur at any age, the peak incidence is in 3rd-6th decade and are seen more commonly in females. A wide variety of tumors arise in the nasal cavity. A majority of them develop from the nasal mucosa; however, some also arise from the olfactory, neuroendocrine or minor salivary gland tissue. Pleomorpic adenoma is a tumor arising from the salivary glandular tissue with wide cytomorphologic diversity. Recognition of an epithelial, myoepithelial and a stromal component on histopathology is essential for diagnosis. Nasal pleomorphic adenomas are extremely rare, more so at a younger ages. Accurate clinical diagnosis is difficult owing to overlapping presenting features with other nasal tumors. Herewith we discuss clinical presentation, histopathologic peculiarities, diagnosis and management of nasal pleomorphic adenoma. Keywords: Pleomorphic adenoma, nasal septum, wide excision

leomorphic adenomas are the most common salivary gland tumors. They comprise upto 70% of parotid gland tumors and 50% of the submandibular salivary gland tumors. Though, they predominantly develop in major salivary glands, a small minority (8%) arise from the minor salivary glands and are located in oral cavity, neck and nasal cavity.1 These tumors have their peak incidence in 3rd-6th decade and occur more commonly in females.2,3 We present a rare case of pleomorphic adenoma in relatively younger age group arising from the nasal septum of an 18-year-old male.

Majority of the nasal septal tumors arise from the nasal mucosa. Septal tumors include benign as well as malignant lesions such as chondrosarcoma, squamous cell carcinoma, adenocarcinoma, sinonasal melanoma, inverted papilloma, juvenile angiofibroma, leiomyoma, osteochondroma, transitional cell papilloma and minor salivary gland tumor. Owing to the wide variety of nasal tumors, common presenting features, intricate anatomy of the nasal cavity and limited access, accurate clinical diagnosis of nasal masses is still a considerable challenge.

Each of the mesenchymal tissues of the sinonasal tract can give rise to benign and malignant neoplastic lesions. Epithelial neoplasia may arise from the lining mucosa (e.g., papillomas, squamous carcinomas, intestinal type adenocarcinoma), neuroendocrine tissue (e.g., sinonasal neuroendocrine carcinoma), olfactory mucosa (olfactory neuroblastoma) and minor salivary tissue, which includes the whole array of benign and malignant minor salivary tumors.

CASE REPORT

* Postgraduate **Professor and Unit Head Dept. of ENT and HNS JN Medical College, Belgaum, Karnataka Address for correspondence Dr ND Zingade Professor and Unit Head Dept. of ENT and HNS JN Medical College, Belgaum, Karnataka E-mail: okdeshmukh@gmail.com

An 18-year-old boy, presented with progressive nasal obstruction on the right side, nasal discharge and occasional epistaxis for the past six months. Physical examination revealed a nontender, firm, polypoid mass covered by mucosa arising from the septum obstructing the right nasal cavity extending caudally upto the internal nasal valve area. On anterior rhinoscopy, a probe could be passed all around the mass except in its medial aspect, where it was attached to the septum. There was hardly any change in the size of the mass on nasal decongestion. The mass did not bleed on probing. A computed tomography (CT) scan of the nose and the paranasal sinuses revealed a lobular mass with soft tissue density occupying the anterior aspect of the right nasal cavity (Figs . 1 a-c). The mass was seen to displace the anterior part of the septum towards the left. The

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE REPORT

Figure 1a. CT scan of the nasal cavity, coronal section, showing homogeneous spherical mass occupying the right nasal cavity.

Figure 2a. Roughly spherical mass excised from the right nasal cavity. The mass was about 1.5 cm in diameter and was covered by mucosa.

Figure 1b. CT scan showing an axial view of the nasal cavity.

Figure 2b. H&E stained section at 10x magnification showing epithelial element dispersed in a background of myxoid stroma.

Figure 2c. CT scan showing incidental findings of bilateral concha bullosa.

Figure 2c. H&E stained stained section at 40x magnification showing spindle-shaped myoepithelial cells.

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE REPORT paranasal sinuses seemed to be well-pneumatized with no evidence of any opacification or mucosal changes. An incidental finding of bilateral concha bullosa was also appreciated. After confirming the origin and extent, a roughly spherical pink colored mass about 1.5 cm in diameter was excised in totality and sent for histopathlogical examination (Fig. 2a). Light microscopy of the hematoxylin and eosin (H&E) stained sections revealed spindle shaped myoepithelial cells and glandular epithelial cells dispersed in a background of myxomatous stroma (Figs. 2 b and c). The diagnosis of pleomorphic adenoma of the nasal septum was made. DISCUSSION

diagnosing pleomorphic adenomas. Nasal salivary gland tumors generally appear as a spherical mass rather than more typical polypoid lesion associated with most other tumors. On CT, pleomorphic adenomas may appear nonhomogeneous because of mesenchymal stroma, cystic degeneration or necrosis but nasal pleomorphic adenomas appear homogeneous accounting to their high cellularity,5 a finding consistent with the CT image of the presented case. Bone remodeling may also be seen on some instances. On MRI, T1-weighted images tend to have intermediate signal intensity for these tumors. The T2-weighted signal intensity depends on the cellularity of the neoplasm; highly cellular types usually have an intermediate signal intensity.6 CONCLUSION

Salivary gland tumors account for 2-4% of the total head and neck neoplasms.4 Most (70%) salivary gland tumors originate in the parotid gland. The remaining tumors arise in the submandibular gland (8%) and minor salivary glands (22%). Majority of the minor salivary gland tumors are malignant. Minor salivary gland tumors can be located almost anywhere in the upper aerodigestive tract, though the most frequently affected location is the oral cavity and particularly the palate, where the concentration of minor salivary glands is greater. Such lesions also can be found in the cheek mucosa, in the region of the retromolar trigone, the lips, the oropharynx or rarely in the nasal cavities and paranasal sinuses.

In summary, pleomorphic adenomas are rare tumors of the nasal cavity that are difficult to diagnose. They have a higher epithelial and lower stromal component compared to their major salivary gland counterparts and may be misdiagnosed at an early stage. We suggest consideration of this diagnosis if the patient has unilateral nasal obstruction and epistaxis with homogeneous appearing mass on CT even in younger age group patients. In view of the potential for tumor recurrence, complete surgical excision with underlying septal perichondrium, long-term follow-up and careful examination of the nose are necessary. REFERENCES

Pleomorphic adenoma also referred as benign mixed tumor exhibits wide cytomorphologic variability. However, identification of three histological components namely the epithelial cell, myoepithelial cell and mesenchymal or stromal component is essential to establish the diagnosis of pleomorphic adenoma. Epithelial component produces glandular or ductal pattern and abundant chondromyxoid matrix, peculiar to this tumor, which is produced by the myoepithilial component. These tumors also differ in cellularity, which is greater when it arises in the nasal cavity.2 Immunohistochemical expression of cytokeratin and S-100 are used to confirm the diagnosis.

1. Gana P, Masterson L. Pleomorphic adenoma of the nasal septum: a case report. J Med Case Rep 2008;2:349.

CT scan and magnetic resonance imaging (MRI) are useful imaging modalities, however these studies primarily contribute to tumor mapping rather than

6. Motooria K, Takanoa H, Nakano K, Yamamoto S, Ueda T, Ikeda M. Pleomorphic adenoma of the nasal septum: MR features. AJNR Am J Neuroradiol 2000;21(10):1948-50.

2. Lo SH, Huang SH, Chang YL. Pleomorphic adenoma of the nasal septum: a case report. Tzu chi Med J 2005;17:47-9. 3. Ahmad S, Lsteef M, Ahmad R. Clinicopathological study of primary salivary-gland tumors in Kashmir. JKPractitioner 2002;9(4):231-3. 4. Pons Vicente O, Almendros Marqus N, Berini Aytes L, Gay Escoda C. Minor salivary gland tumors: A clinicopathological study of 18 cases. Med Oral Patol Oral Cir Bucal 2008;13(9):E582-8. 5. Öztürk E, Saglam Ö, Sönmez G, Cüce F, Haholu A. CT and MRI of an unusual intranasal mass: pleomorphic adenoma. Diagn Interv Radiol 2008;14(4):186-8.

■■■■

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE REPORT

Kartagenerâ&#x20AC;&#x2122;s Syndrome LAKSHMI PONNATHPUR*, LAKSHMI SHANTHARAM**

ABSTRACT Kartagener`s syndrome, a rare autosomal recessive disorder is a type of primary ciliary dyskinesia (PCD) associated situs inversus, bronchiectasis, sinusitis and male infertility. We present a case of a 12-year-old boy who came with features of bilateral glue ear, recurrent sinusitis, adenotonsillitis, obstructive sleep apnea and situ inversus. He was diagnosed to have Kartagener`s syndrome and was treated with bilateral grommet insertion, bilateral antral lavage and adenotonsillectomy to alleviate his symptoms. Keywords: Kartagener`s syndrome, situs inversus, primary ciliary dyskinesia

CASE REPORT A 12-year-old boy presented with history of recurrent nasal discharge, nasal obstruction and poor hearing since six months. The nasal discharge was thick, mucoid type. He also gave history of frequent sore throat, snoring and disturbed sleep at night. On examination, he was a normally built and nourished boy with delayed secondary sexual characteristics. On ENT examination, he had bilateral glue ear kind of picture with conductive hearing loss. He was a mouth breather with adenoid facies and had thick mucopus in both middle meati without any polyps. Examination of throat revealed huge tonsils compromising the oropharyngeal space. A diagnosis of obstructive sleep apnea secondary to chronic adenotonsillitis and chronic sinusitis and bilateral serous otitis media was made.

Chest X-ray revealed dextrocardia and right-sided fundal gas shadow suggesting situs inversus (Fig. 1). X-ray of paranasal sinuses revealed bilateral haziness of maxillary sinuses. There was no evidence of bronchitis on chest X-ray. On further questioning, the child was known to have a heart on right side of chest and he also had features of hypogonadism. With all these clinical and radiological findings a diagnosis of Kartagener`s syndrome was made. To alleviate his suffering and to improve his qualityof-life, adenotonsillectomy, bilateral antral lavage and bilateral grommet insertion was done. His post-op period was uneventful. He was greatly relieved of his nasal obstruction and snoring. His hearing also improved. Parents were adviced to consult a genetic counselor. However, he was lost to follow-up as he was an NRI patient.

Hematological investigations such as complete hemogram, bleeding time, clotting time, prothrombin time and activated partial thromboplastin time (APTT) and platelet count were done as preoperative work-up. Pure tone audiometry showed mild conductive deafness and impedance audiometry showed bilateral B type tympanogram with absent reflexes, which suggested bilateral glue ear.

*Senior Consultant Sagar Hospitals and Skin, Cosmetic and ENT Care Center, Jayanagar, Bangalore Honorary Consultant, Indira Gandhi Institute of Child Health, Bangalore **Junior Consultant, Skin, Cosmetic and ENT Care Center, Jayanagar, Bangalore Address for correspondence Dr Lakshmi Ponnathpur 742, Bhagyashree, 18th Main, 37th F Cross, 4th T Block Jayanagar, Bangalore - 560 041, Karnataka E-mail: ponnathpurlakshmi@gmail.com

Asian Journal of Ear, Nose and Throat, July-September 2013

Figure 1. Chest X-ray showing dextrocardia and situs inversus.

CASE REPORT DISCUSSION

Figure 2. Intraoperative picture - the ECG leads put on right side due to dextrocardia.

Kartagener`s syndrome is a triad of situs inversus, chronic sinusitis and bronchiectasis.1 It is a rare autosomal recessive disorder occurring in 1:15,000 live births.2 There is difficulty in clearing mucous secreted from the respiratory tract. It also affects the motility of spermatozoa resulting in male infertility. Patient can present to the otorhinolaryngologist with nasal obstruction, rhinorrhea and deafness. Nasal polyps as a result of allergy is more common in cystic fibrosis.3 Otitis media with effusion is the most common otolaryngeal problem in primary ciliary dyskinesia (PCD), but may stabilize by adolescence.4 Dextrocardia may be detected in routine general examination of patient or during pre-anesthetic check-up. Finding of dextrocardia on general examination or on X-ray points to a possible diagnosis of Kartagener`s syndrome. Radiology in the form of chest X-ray not only shows dextrocardia but also reveals situs inversus by showing right-sided fundal gas shadow. As our patient did not have any pulmonary changes, CT scan of chest and spirometric assessments were not done. Medical management consists of controlling the infections and antibiotic prophylaxis. Special consideration is required at the time of anesthesia. Care should be taken to avoid nasal tubes and airways. Strict aseptic precautions should be followed.5 Electron microscopy of nasal or bronchial biopsy can reveal defective ciliary structure. There will be defect in the dynein arm of chromosomes. Mutations in the DNA H 5 and DNA 11 have been confirmed.6

Figure 3. Adenoids and tonsils after excision.

Genetic testing is available in specialized laboratories. Primary epithelial cell culture can be done for both gene testing and electron microscopy.7 Transmission electron microscopy remains the most definitive method of establishing the diagnosis of PCD, as exact structural changes can be visualized. Ciliary beat frequency and ciliary beat pattern analysis by high speed videophotography, electron microscopy of ciliary ultrastructure and measurement of ciliary disorientation are recommended wherever facilities exist.8-10 Gene testing and electron microscopy are out of reach for most patients of PCD. Treatment is tailormade according to the needs of the patient; majority of patients enjoy a normal or near normal life.4 CONCLUSION

Figure 4. Ear with grommet in situ.

Kartagener`s syndrome is a rare condition, occasionally picked up by the otorhinolaryngologist. It may prove challenging if high index of suspicion is not made.

Asian Journal of Ear, Nose and Throat, July-September 2013

CASE REPORT Thorough clinical evaluation, adequate investigations, simple surgical treatments in the form of FESS, Bilateral antral washout, adenotonsillectomy, grommet insertion, etc. go a long way in alleviating the patient`s symptoms, reducing the morbidity and improving the quality-of-life.

Ackowledgments

4. Bush A, Chodhari R, Collins N, Copeland F, Hall P, Harcourt J, et al. Primary ciliary dyskinesia: current state of the art. Arch Dis Child 2007;92(12):1136-40. 5. Ho AM, Friedland MJ. Kartagener’s syndrome: anesthetic considerations. Anesthesiology 1992;77(2):386-8. 6. Geremek M, Witt M. Primary ciliary dyskinesia: genes, candidate genes and chromosomal regions. J Appl Genet 2004;45(3):347-61.

We would like to thank Senior Anesthesiologist Dr PM Chandrashekar for his involvement in the surgery and Sagar Hospitals, Bangalore where the patient was operated.

7. Jorissen M, Willems T, Van der Schueren B, Verbeken E, De Boeck K. Ultrastructural expression of primary ciliary dyskinesia after ciliogenesis in culture. Acta Otorhinolaryngol Belg 2000;54(3):343-56.

REFERENCES

8. Afzelius BA. Cilia-related 2004;204(4):470-7.

1. Afzelius BA, Stenram U. Prevalence and genetics of immotile-cilia syndrome and left-handedness. Int J Dev Biol 2006;50(6):571-3. 2. Bush A, Cole P, Hariri M, Mackay I, Phillips G, O’Callaghan C, et al. Primary ciliary dyskinesia: diagnosis and standards of care. Eur Respir J 1998;12(4):982-8. 3. Marsden D. Nasal polyposis in children. Southern Med J1978;71(8):911-3.

diseases.

Pathol

9. Stannard W, Rutman A, Wallis C, O’Callaghan C. Central microtubular agenesis causing primary ciliary dyskinesia. Am J Respir Crit Care Med 2004;169(5):634-7. 10. Teknos TN, Metson R, Chasse T, Balercia G, Dickersin GR. New developments in the diagnosis of Kartagener’s syndrome. Otolaryngol Head Neck Surg 1997;116(1): 68-74.

■■■■

...Cont’d from page10

13. Bin Abdulhak AA, Altannir MA, Almansor MA, Almohaya MS, Onazi AS, Marei MA, et al. Non prescribed sale of antibiotics in Riyadh, Saudi Arabia: a cross sectional study. BMC Public Health 2011;11:538. 14. Goldstein F, Bryskier A, Appelbaum PC, Bauernfeind A, Jacobs M, Schito GC, et al. The etiology of respiratory tract infections and the antibacterial activity of fluoroquinolones and other oral bacterial agents against respiratory pathogens. Clin Microbiol and Infect 1988;4 Suppl 2:S8-18. 15. Jansen WT, Verel A, Beitsma M, Verhoet FJ, Milatovic D. Longitudinal European surveillance study of antibiotic resistance of Haemophilus influenzae. J Antimicrob Chemother 2006;58(4):873-7.

Asian Journal of Ear, Nose and Throat, July-September 2013

16. Westphal JF. Cefuroxime axetil, a new oral cephalosporin for treating infections of the ORL field: clinical synthesis. Rev Laryngol Otol Rhinol (Bord) 1990;111(5):503-5. 17. National Committee for Clinical Laboratory Standards. Methods for Dilution Antimicrobial Susceptibility Tests for Bacteria that Grow Aerobically. 3rd edition, Approved Standard NCCLS Document M7-A3, Vol. 13, No. 25. : NCCLS, Villanova Pa; 1993. 18. Hebblethwaite EM, Brown GW, Cox DM. A comparison of the efficacy and safety of cefuroxime axetil and augmentin in the treatment of upper respiratory tract infections. Drugs Exp Clin Res 1987;13(2):91-4.

MEDILAW

Is it Ethical for a Physician I have Never Seen to Refuse to See Me? AMA Code of Ethics: Opinion 10.05, “Potential Patients” defines circumstances in which a physician may ethically decline to accept specific patients before a patient-physician relationship has been established. OPINION 10.05 - POTENTIAL PATIENTS Physicians must keep their professional obligations to provide care to patients in accord with their prerogative to choose whether to enter into a patient-physician relationship. The following instances identify the limits on physicians’ prerogative: ÂÂ

ÂÂ

Physicians should respond to the best of their ability in cases of medical emergency (Opinion 8.11, “Neglect of Patient”). Physicians cannot refuse to care for patients based on race, gender, sexual orientation, or any other criteria that would constitute invidious discrimination (Opinion 9.12, “Patient-Physician Relationship: Respect for Law and Human Rights”), nor can they discriminate against patients with infectious diseases (Opinion 2.23, “HIV Testing”). Physicians may not refuse to care for patients when operating under a contractual arrangement that requires them to treat (Opinion 10.015, “The Patient-Physician Relationship”). Exceptions to this requirement may exist when patient care is ultimately compromised by the contractual arrangement.

In situations not covered above, it may be ethically permissible for physicians to decline a potential patient when: ÂÂ The treatment request is beyond the physician’s current competence. ÂÂ The treatment request is known to be scientifically invalid, has no medical indication, and offers no possible benefit to the patient (Opinion 8.20, “Invalid Medical Treatment”). ÂÂ A specific treatment sought by an individual is incompatible with the physician’s personal, religious, or moral beliefs. Physicians, as professionals and members of society, should work to assure access to adequate health care (Opinion 10.01, “Fundamental Elements of the PatientPhysician Relationship”).* Accordingly, physicians have an obligation to share in providing charity care (Opinion 9.065, “Caring for the Poor”) but not to the

Asian Journal of Ear, Nose and Throat, July-September 2013

degree that would seriously compromise the care provided to existing patients. When deciding whether to take on a new patient, physicians should consider the individual’s need for medical service along with the needs of their current patients. Greater medical necessity of a service engenders a stronger obligation to treat. (I, VI, VIII, IX)

MCI Code of Ethics MCI Oath: I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient. 7.15 The registered medical practitioner shall not refuse on religious grounds alone to give assistance in or conduct of sterility, birth control, circumcision and medical termination of Pregnancy when there is medical indication, unless the medical practitioner feels himself/herself incompetent to do so. In emergency no one can refuse (Supreme Court of India) 2.1.1 Though a physician is not bound to treat each and every person asking his services, he should not only be ever ready to respond to the calls of the sick and the injured, but should be mindful of the high character of his mission and the responsibility he discharges in the course of his professional duties. In his treatment, he should never forget that the health and the lives of those entrusted to his care depend on his skill and attention. A physician should endeavour to add to the comfort of the sick by making his visits at the hour indicated to the patients. A physician advising a patient to seek service of another physician is acceptable; however, in case of emergency a physician must treat the patient. No physician shall arbitrarily refuse treatment to a patient. However for good reason, when a patient is suffering from an ailment which is not within the range of experience of the treating physician, the physician may refuse treatment and refer the patient to another physician. e. 2.4 The Patient must not be neglected: A physician is free to choose whom he will serve. He should, however, respond to any request for his assistance in an emergency. Once having undertaken a case, the physician should not neglect the patient, nor should he withdraw from the case without giving adequate notice to the patient and his family. Provisionally or fully registered medical practitioner shall not willfully commit an act of negligence that may deprive his patient or patients from necessary medical care.

Asian Journal of

Ear, Nose & Throat Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Ear, Nose and Throat strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter – The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. – Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. – Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript. Manuscript – Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). –

–

The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

All pages should be numbered consecutively beginning with the title page. Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used. – The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary. – A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included. – The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. – A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text. Summary – The summary of not more than 200 words. It must convey the essential features of the paper. – It should not contain abbreviations, footnotes or references. Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives. Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others. – Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected. – Method of selecting the sample (cases, subjects, etc. from the statistical universe). – Method of allocating the subjects into different groups. – Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques. – Confidence intervals for the measurements should be provided wherever appropriate.

Asian Journal of Ear, Nose and Throat, July-September 2013

Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text. Discussion – This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost. References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111. Books Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985. Articles in Books Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470. Tables – These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table. Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

Asian Journal of Ear, Nose and Throat, July-September 2013

– The legend must include enough information to permit interpretation of the figure without reference to the text. Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. – All photomicrographs should indicate the magnification of the print. – Special features should be indicated by arrows or letters which contrast with the background. – The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. – Color illustrations will be accepted if they make a contribution to the understanding of the article. – Do not use clips/staples on photographs and artwork. – Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)____________________________ 2. Total number of pages ______________________ 3. Number of tables __________________________ 4. Number of figures _________________________ 5. Special requests __________________________ 6. Suggestions for reviewers (name and postal address) Indian 1._____________Foreign 1.______________ 2._____________ 2.______________ 3._____________ 3.______________ 4._____________ 4.______________ 7. All authors’ signatures______________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers _______________________________________ Issue Editor Dr Jasveer Singh Asian Journal of Ear, Nose and Throat

Online Submission Also e- Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Asian Journal of Ear, Nose and Throat E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com