April - Gujarat Journal of Otorhinolaryngology and Head and Neck ...

Otorhinolaryngology and Head and Neck Surgery
Volume 8 Number 1 April 2011
The official publication of the Association of Otorhinolaryngologists of India, Gujarat State Branch (AOI GSB)
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OTORHINOLARYNGOLOGY AND HEAD AND NECK SURGERY
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M.P. Shah Medical College,
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Date 01-04-2011 Dr. Vikas Sinha
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Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

From th desk of editor
The journal is going strong with each passing issue. More and more research articles, case study and case reports are being sent to
the editorial office. All the articles are being subjected to scrutiny by sending to the different reviewers across all over India and
abroad. Without reviewer approval no article is being published. By this way only journal is able to sustain good quality. This year
it has been decided to publish the journal three times in a year. Although it is a big financial strain to the editorial team of journal
but for the vertical and horizontal growth of the journal it became essential to increase the publication from two to three times in
year, making effort to publish more frequently.
Dr. Vikas Sinha
Dean, Prof E.N.T.
Editor
Otorhinolaryngology and Head and Neck Surgery
Jamnagar
Cell +91 9879579193, E mail dr_sinhavikas@yahoo.co.in
Editorial Board of Gujart Journal of
Otorhinolaryngology and Head and Neck Surgery
Editor
Dr. Vikas Sinha
Treasurer
Dr. Viral A. Chhaya
Editorial Board Member
Dr. Dilavar A. Barot
Editorial Board Member
Dr. Niral Modi
Editorial Board Member
Dr. Hiten Maniyar
International Advisor
Dr. Yong Ju Jang (South Korea)
Dr. Wolfgang Gubisch (Germany)
Dr. Prepageran (Malaysia)
Dr. Khalid Mahida (Pakistan)
Executive Committee of Association of
Otolaryngologists of India Gujarat State Branch
(AOI GSB)
President
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Vice President
Dr. K. N. Pansara
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Jamnagar.
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M.P.Shah medical College
Jamnagar
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The views expressed in the article are entirely of individual author. The journal or editor bears no
responsibility about authenticity of the article or otherwise any claim howsoever.
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Otorhinolaryngology and Head and Neck Surgery
Volume 8 Number 1 April - 2011
Editorial article
Counseling the Parents of Handicapped Children- need of the hour
Anu N. Nagarkar, Nitin M Nagarkar- Chandigarh
Main article
Utility of fine needle aspiration cytology in the diagnosis and management of thyroid swellings
Ajay George, Sharan kumar Shetty, Sanjay Kumar, Ranjan Kumar – Nalgonda ( A.P.)
Bedside tracheostomy:experience of 100 cases
Santosh U.P, Sanjay B Patil,Vinay Bhat, Sunil Pai,Deepak Janardhan– Davangere ( Karnataka)
Tympanoplasty with and without cortical mastoidectomy for tubotympanic type of chronic suppurative
otitis media.
Shrinivas Shripatrao Chavan, Sunil Deshmukh, Vasant G. Pawar, Vaibhav G. Kirpan, Smita
W .Khobragade, Kaustubh V Sarvade – Aurangabad (Maharashtra)
A study of oto-acoustic emission (OAE) in 130 cases: a screening tool for hearing loss in children.
Jaymin A. Contractor, Piyush M. Vaghmashi, Rahul B. Patel, Ishwar M. Chaudhari, Dilavar A.
Barot, Neepa Jariwala- Surat (Gujarat)
Endoscopic endonasal dacryocystorhinostomy: Outcome in 81 cases
Sharan kumar Shetty, Ajay George,Sanjay Kumar ,Ranjan Kumar – Nalgonda ( A.P.)
A study of the corelation of the clinical features, radiological evaluation and operative findings in chronic
suppurative otitis media with cholesteatoma
Santosh U.P, S.M Siddalingappa, Sheeba Mathew, Vinay Bhat, Deepak Janardhan- Davangere
(Karnataka)
Tumours of maxilla
Darshan V Doshi, J. A. Contractor, I. K. Aditya- Ahmedabad, Surat (Gujarat)
Aetiological Study of 100 Cases of Hoarseness of Voice
Harvinder Kumar, Sonia Seth, Deep Kishore -Hisar (Haryana)
Case report
Malignant external otitis – an atypical presentation and management dilemma
George A. Mathew, Kamal Kishore- Ludhiana (Punjab)
Bilateral parotid abscess in a neonate
Madhavi S..Raibagkar, Meeta R. Bathla, Vipul M. Patel, Vikas Arora- Ahmedabad (Gujarat)
Gingival granular cell tumour of newborn
Tripti R.Chopade,M.V.Jagade, Ashish R.Gandhe, Dhyaneshwar Ahire-Mumbai (Maharashtra)
ExtranasopharyngealAngiofiroma in Female
Shrinivas Shripatrao Chavan ,Sunil D.Deshmukh ,Vasant G. Pawar, Vaibhav G. Kirpan ,
SmitaW.,Khobragade Kaustubh,V.Sarvade,RajanBindu-Aurangabad ( Maharashtra)
Hairy polyp of nasopharynx in adult
Ajit Daharwal,Hansa Banjara,B. R. Singh,Digvijay Singh,S.Sarkar - Raipur (Chattisgarh)
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011
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1
Editorial Article
Counseling the parents of handicapped children- need of the hour
1 2
Anu N. Nagarkar , Nitin M Nagarkar - Chandigarh
Abstract
Parents of children with serious illness and handicap usually come in contact with representatives of several clinical
professions. Many of these clinicians may never think much about the trauma the parents and family members of such a
child go through. The professional interest in parent counseling seems negligible. This paper has been aimed at describing
the role the professionals can play in helping the parents of a handicapped child come to terms with the reality and guide
them as to what best can be done for their child. Key words: Counseling,Parents,Illness,Handicap
Introduction
No society has been as responsive as ours to the plea “Heal the
hurt child”. While much more can and should be done, we are
witnessing the fruits of an unparalled marshalling of the
forces of related specialties in medicine, surgery, psychology,
social work, rehabilitation and education for the care of the
seriously ill or handicapped child. Advances in molecular
genetics research offer, in genetic counseling, the prospect of
prevention of certain genetic errors; new and innovative
diagnostic and remedial techniques are now being used in the
prenatal period; other increasingly sophisticated diagnostic
and treatment procedures are daily adding to our capability of
helping the child with a major illness or handicap, but there is,
of course, another side of the coin. There are many chronic
illnesses and physical handicaps for which the word cure is
inapplicable and for which the goal of relative adaptation
must be substituted.
Various problems like congenital hearing loss, cerebral palsy,
mental retardation, autism, specific language impairment fall
under the purview of the pediatrician, otolaryngologist and
the audiologist/ speech & language pathologist. Breaking the
news of a permanent handicap of any sort to the parents of a
new born baby is extremely traumatic. A counselor whether a
professional from psychology, a pediatrician or an
audiologist/ speech & language pathologist has an important
role to play at such times. But of equal or even more important
is the content of our discussion. Counseling is a process of
helping parents overcome their conflicting attitudes towards
their child, which is often a difficult and time consuming
procedure.Need for Counseling Parents-Parents of children
with handicaps are just like other parents: they have their
unique assets and liabilities, their own self concepts, their
hopes and fantasies regarding their children. They had not
expected that their child would be handicapped. Each parent
will bring to the situation his own differential perceptions of
the child and his handicap, his own assets and limitations for
handling his role in the situation. Some will accept the
challenge with fervor and skill of remarkable proportions;
others will be overwhelmed, guilt ridden and impotent. To
most parents though it is painfully difficult, threatening and
highly ego-involving experience to face the reality of
handicap in a child. In this situation they need a sympathetic
and tactful professional advice from the clinician in the form
of counseling. Children reflect their parents' emotional and
social adjustment patterns. The child's disability is likely to
adversely affect the parent's personality and adaptation. So to
help the parents accept the handicap/ disability of their child,
counseling of the highest quality is a must.
Process of Couneling-The clinician has to make an effort to
give a true picture of the child's condition to the parents and
try to help them to achieve the best possible solution for it.
Once the diagnosis has been made, the first response that
follows is that of shock and disbelief. The clinician has to be
very careful and considerate about their feelings.To work with
these parents and their children with sympathy and respect,
the clinician must remember that the child with a handicap is
still a child with feelings, needs, wishes and desires to which
the parents will have to respond.
Conclusion
Parents are the linchpin of the family and counseling for the
young newly diagnosed child with a handicap needs to be
directed to them. A proper counseling can add an element of
relief and success to the otherwise grim picture. Well prepared
and well conducted discussion with parents is an important
part of the treatment and rehabilitative process
Address for Correspondence
Dr. Nitin M.Nagarkar
Prof E.N.T , Govt. Medical College, Sector 32,Chandigarh
E mail: nitinanurishabh@yahoo.com
Cell-+91 9646121546
1 Speech Pathologist, Department of Otolaryngology, Postgraduate Institute of Medical Education & Research, Chandigarh,
2 Professors, Department of Otolaryngology- Head & Neck Surgery, Government Medical College & Hospital, Chandigarh
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Introduction:
The era of modern diagnostic cytopathology began with the
publication in early 1940s by Drs G. Papanicolaou and H.
Traut of their work on the cytological diagnosis of uterine
1
cancer . Since then fine needle aspiration cytology (FNAC) of
the thyroid gland is firmly established as a first-line
diagnostic test for the evaluation of goiter and the single most
effective test for the pre-operative diagnosis of a solitary
thyroid nodule. There is now a large body of world literature
attesting to its accuracy and advantages, although the need for
caution in interpretation, meticulous attention to technique
2
and the limitations of diagnosis are also well documented .
The prevalence of palpable thyroid swellings in the
population is about 4% and fewer than 5% of these are
3
malignant . The accuracy of clinical, biochemical and
radiological investigations in distinguishing between benign
and malignant thyroid swellings is rather poor. FNAC can
reliably confirm benignity in about two-thirds of benign
swellings. The potential benefits of reducing unnecessary
surgery and reducing costs for benign lesions in this way are
4
obvious .
In this study we propose to study the utility of FNAC in the
management of patients with thyroid swellings.
Aim:To verify the efficacy of fine needle aspiration cytology
in the diagnosis and management of thyroid swellings.
Materials and methods:
The study was conducted during a 16 month period from
January, 2009 to April, 2010.
2
Main Article
Utility of fine needle aspiration cytology in the diagnosis and management of thyroid swellings
1 2 3 4
Ajay George ,Sharan kumar Shetty ,Sanjay Kumar ,Ranjan Kumar - Nalgonga (A.P.)
Abstract
Introduction: Thyroid swellings affect about 4% of the population. Fine needle aspiration cytology (FNAC) is an
established diagnostic modality in the management of thyroid swellings. Aim: To verify the utility of FNAC in the
diagnosis and management of thyroid swellings. Materials and Methods: All cases of thyroid swelling presenting to our
OPD during a 16 month period from January, 2009 to April, 2010 were included in the study regardless of age and sex. All
cases were thoroughly examined and investigated by FNAC, ultrasonography of neck and thyroid function test. Patients
requiring surgery were operated and the surgical specimen was sent for histopathological examination. Observations:
Thyroid swellings were very common in female and most commonly presented in the third decade of life. The commonest
FNAC diagnosis was colloid goiter. Confirmed malignancy was noted in 6 cases. Aspirate was inadequate for an opinion in
11 cases. Histopathological confirmation was done in the operated cases. It showed an accuracy rate of 75.89% for FNAC.
Conclusion: FNAC is the gold standard in the diagnosis of thyroid swellings.
Key words: Goiter, Fine needle aspiration cytology.
Inclusion critera-All cases of thyroid swellings presenting or
referred to the ENT out patient department.Patients of both
sexes.Patients of all age groups. Exclusion critera-Neck
swellings due to any other pathology like lymphadenopathy.
After taking a detailed clinical history, all cases underwent a
thorough ENT and head and neck examination. The clinical
findings were recorded and then the patients were referred for
fine needle aspiration cytology to the department of
pathology. For FNAC, the patients were kept in the supine
position with a pillow under the shoulder to make the thyroid
swelling prominent. 25 or 27 gauge needle was used for the
aspiration. Depending on the size of the lesion, 2 – 4 passes
were made with the needle using different angles or points of
2
entry . The FNAC specimens were immediately alcohol –
fixed to preserve their cellular characteristics.
Thyroid function tests like T3, T4 and TSH were also ordered
for. Ultrasonography of the neck was done to visualize the
nature and extent of thyroid swelling, the lobe involvement
and effect on surrounding great vessels and other important
anatomical structures.
Depending on the nature of the goiter as reported in FNAC
and depending on the thyroid function status decision was
taken regarding need for surgery and the extent of surgery.
Patients requiring thyroid surgery but having altered thyroid
function status were stabilized medically before posting for
surgery. The main indications of surgery included the report
of neoplasia, multinodular goiter and large solitary nodules
causing cosmetic deformity or compression symptoms. least
1,2 3,4
Associate Professor, Assistant professor,
Kamineni Institute of Medical Sciences, Sreepuram, Narketpally, Nalgonda,A.P.
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

number of cases i.e. 2 cases in each age group.
Patients with Hashimoto's thyroiditis were kept on follow up
and given symptomatic treatment as per individual
requirements. Some cases of Hashimoto's thyroiditis with
ungainly appearance of thyroid swelling and complaining of
pain even after stabilization by hormone therapy were also
operated on request of the patient. The surgical specimen was
sent for histopathological examination. The histopathology
report was compared with the FNAC report to look for
discrepancies. All results were collected, tabulated and
analyzed.
Observations and discussion:
Based on the above inclusion and exclusion criteria, a total of
190 cases were included during the period of the study. Out of
these 169 cases were female and the remaining male. This
overwhelming predominance of female in diseases thyroid is
a well known fact and has been documented in many studies
5
and text books . The age distribution was as shown in Table
No. 1. The commonest age group of presentation of thyroid
swellings was the 21 – 30 years group accounting for a third of
the cases. The second and fourth decades of life also had
significant number of patients with 36 (18.95%) and 44
(23.16%) cases respectively. The groups of extremes of age
like the first decade and the over sixty years age group had the
least number of cases i.e. 2 cases in each age group.
The FNAC report showed a maximum of 77 (40.52%) cases
of colloid goiter. Out of these cases 51 cases were of nodular
goiter whereas 26 cases had diffuse collide goiter. The next
commonest diagnosis was Hashimoto's thyroiditis with 72
cases (37.89%). Follicular neoplasia was diagnosed in15
cases. Confirmed malignant lesions were reported in 6 cases,
which included 4 cases of papillary carcinoma, and 1 case
each of medullary carcinoma and anaplastic carcinoma. There
were 9 cases of cysts which got reduced on aspiration. In 11
cases (5.77%) the aspirated material was found to be
inadequate for reporting. Published data suggests the rate of
6, 7
inadequate samples to be in the range of 9% - 31% . Use of
ancillary techniques like ultra sonography guided FNAC of
thyroid has been shown to reduce the proportion of
8
indeterminate samples .
Thyroid function test report revealed euthyroid state in 137
cases. 31 cases were hypothyroid and the remaining 22 cases
were hyperthyroid. Ultrasonography of the neck revealed
thyroid enlargement in all cases. There was diffuse
enlargement in 106 cases. Solitary thyroid nodule was
revealed in 54 cases. There was multinodular enlargement in
the remaining 30 cases. There was displacement of the great
vessels of neck by the thyroid swelling in 21 cases. In 3 cases
there was also lymph node enlargement most likely due to
metastases from malignant thyroid lesion.
3
Surgery was chosen as the mode of treatment in 112 cases.
These included 67 cases of colloid goiter, 12 cases of
Hashimoto's thyroiditis who had ungainly and painful neck
swelling inspite of stabilization on thyroxine
supplementation. All the cases of neoplasia were also
operated upon. Neck dissection was done together with the
thyroidectomy in the 3 cases with lymph node involvement.
Out of the 11 cases with indeterminate FNAC report 9 were
operated upon. 3 cases of thyroid cyst were also operated
upon as they were filling up repeatedly after aspiration.
Though contemporary literature is very clear that the
optimum managment of Hashimoto's thyroiditis is by
thyroxine, there have been reports where thyroidectomy has
9, 10
been done for Hashimoto's thyroiditis . The indication for
surgery in these reports was painful swelling.
Histopathology report of the surgical specimen revealed
colloid goiter in 71 cases, Hashimoto's thyroiditis in 12 cases,
follicular adenoma in 17 cases, follicular carcinoma in 3 cases
and thyroid cyst in 3 cases. The 6 cases of malignancy
detected by FNAC were confirmed after histopathology. A
different diagnosis from that reported by FNAC was noted in
3 cases. These included 2 cases of colloid goiter and one case
of Hashmoto's thyroiditis which were found to be follicular
adenoma. Out of the 15 cases of follicular neoplasia reported
on FNAC, 12 had follicular adenoma and the remaining three
had carcinoma. Out of the 9 cases in which no diagnosis could
be reached by FNAC, 6 cases turned out to be colloid goiter. 2
cases had follicular adenoma and the remaining 1 case had
Hashimoto's thyroiditis. Traditionally it has been
contentiously believed that most of the cases which are
11
indeterminate by FNAC turn out to be follicular neoplasia .
In our study majority of these cases i.e. two thirds of them
turned out to be colloid goiters. Thus 9 cases out of the 112
cases (8.05%) with histopathological confirmation turned out
to be malignancy. This is somewhat more than the 3.9%
12
reported by Lin et al in their large series of over 21,000 cases.
The smaller sample size of the present study could be the
cause of this discrepancy.What is most notable here is that in
the present study FNAC did not miss any case of malignancy
other than follicular which anyway cannot be diagnosed by
FNAC. What is even more notable is that there also were no
false positives as far as malignancy was concerned. But this
accuracy of 100% achieved in the present study is somewhat
on the higher side. Contemporary literature on this topic
13, 14
report accuracy in the range of 80% .
Thus in the present study FNAC could give a conclusive and
correct diagnosis in 85 out of the 112 cases on which full data
is available. This gives an accuracy rate of 75.89%. The
accuracy rate achieved in our study compares favorably with
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

15 16
that achieved by Bajaj et al (74.3%) and Morgan et al.
(67.2%).
Conclusion
Fine needle aspiration cytology is a very useful investigation
in the diagnosis and management of thyroid swellings. It
gives precise information for the decision making regarding
surgery for goiter. The pitfalls in the use of FNAC in thyroid
swellings are well known and well documented and hence can
be anticipated. The use of ancillary techniques together with
FNAC and clinical co-relation can further optimize the utility
of FNAC in the diagnosis and management of thyroid
swellings.
References
1. Grunze H., Spriggs AI. History of clinical cytology – a
selection of documents. Darmstadt: E. Giebeler; 1980.
2. Thyroid. In: Orell S.R., Sterrett G.F., Whitaker D. Fine
Needle Aspiration Cytology. 4th edn. New Delhi:
Elsevier; 2005; p.125.
3. Gharib H., Goellener JR. Fine-needle aspiration biopsy
of the thyroid: an appraisal. Ann Intern Med. 1993; 118:
282 – 289.
4. Melcher NL. To operate or not to operate? The value of
fine needle aspiration cytology in the assessment of
thyroid swellings. J Clin Pathol. 1997; 50: 941 – 943.
5. Shaheen O.H. The thyroid gland. In: Hibbert J. ed.
Scott-Brown's Otolaryngology. 6th edn. Oxford:
Butterworth-Heinemann; 1997; p. 5/18/7.
6. Caraway NP, Sniege N, Samaan NA. Diagnostic
pitfalls in thyroid fine needle aspiration: a review of
394 cases. Diag. Cytopathology.1993, 9:345-350.
7. Burch HB, Burman KP, Reed HL et al. Fine needle
aspiration biopsy of thyroid nodules: determinants of
insufficiency rate and malignancy yield at
thyoiddectomy. Acta Cyto.1996, 40:1176-1183.
8. Cai XJ, Valiyaparambath N, Nixon P. et al. Ultrasoundguided
fine needle aspiration cytology in the diagnosis
and management of thyroid nodules. Cytopathology.
2006 Oct;17(5):251-6.
9. Ohye H, Fukata S, Kubota S. et al. Successful
treatment for recurrent painful Hashimoto's thyroiditis
by total thyroidectomy. Thyroid. 2005 Apr;15(4):340-5.
10. Kon YC, DeGroot LJ. Painful Hashimoto's thyroiditis
as an indication for thyroidectomy: clinical
characteristics and outcome in seven patients.J Clin
Endocrinol Metab. 2003 Jun;88(6):2667-72.
11. Pang T, Gill A, McMullen T. et al. Correlation between
indeterminate aspiration cytology and final
histopathology of thyroid neoplasms. Surgery. 2010 Mar
15. [Epub ahead of print.
12. Lin JD, Chao TC, Huang BY et al. Thyroid cancer in
4
the thyroid nodules evaluated by ultrasonography and
fine-needle aspiration cytology. Thyroid. 2005 Jul;
15(7):708-17.
13. B. Mundasad, I. Mcallister, J. Carson et al. Accuracy
Of Fine Needle Aspiration Cytology In Diagnosis Of
Thyroid Swellings. The Internet Journal of
Endocrinology. 2006; 2(2).
14. Cap J, Ryska A, Rehorkova P, Hovorkova E, et al.
Sensitivity and specifity of the fine needle aspiration
biopsy of the thyroid: clinical point of view. Clinical
Endocrinology 1999, 51(4):509-51.
15. Bajaj Y., De M., Thompson A. Fine needle aspiration
cytology in diagnosis and management of thyroid
diseases. J. Laryngol. Otol. 2006 Jun; 120(6): 467 – 9.
16. Morgan JL, Serpell JW, Cheng MS. Fine-needle
aspiration cytology of thyroid nodules: how useful it
is? ANZ J. Surg. 2003 Jul; 73(7): 480-3.
Address for correspondence
Ajay George
Department of ENT,
Kamineni Institute of Medical Sciences, Sreepuram,
Narketpally, Nalgonda,Andhra Pradesh – 508254.
E mail – doc_ajay@yahoo.com ,Cell+918980178187
35th Annual Conference of
Otolaryngologists of India
Gujarat State Branch
Rajpath Club Ahmedabad.
th th th
16 ,17 , 18 December 2011.
Organising Chairman
Dr. Atul Kansara
Organising Secretary
Dr. Navin Patel, Dr. Kalpesh Patel.
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

5
Main Article
Bedside tracheostomy:experience of 100 cases
1 2 3 4 5
Santosh U.P , Sanjay B Patil , Vinay Bhat , Sunil Pai , Deepak Janardhan – Davangere (Karnataka)
Abstract
Introduction: Tracheostomy is probably the most common surgical procedure performed on critically ill patients.
Approximately 10 percent of mechanically ventilated critically ill patients undergo tracheostomy to facilitate prolonged airway
and ventilatory support. Traditionally elective tracheostomies have been performed in operating room by using standard
surgical techniques originally described by Jackson. The concept of bedside tracheostomy is attractive and surgeons have
started performing open bedside tracheostomy. It is found to be safe in selected patients. The primary objective of this study was
to determine safety of bedside tracheostomy in patients under prolonged mechanical ventilation.
Materials and methods: It is a descriptive study conducted in two hospitals of Davangere (India) for the period of five years
between April 2005 and January 2010. . Bedside open tracheostomy was performed in patients under prolonged mechanical
ventilation by conventional open surgical technique under local anesthesia with patient's vitals and oxygen saturation being
monitored by an intensivist. Complications of bedside tracheostomy were recorded for up to 60 days after the procedure.
Results: During the study period total of 100 patients underwent bedside tracheostomy during the course of mechanical
ventilation. Reasons for mechanical ventilation in above patients included poly trauma, head injury, organo-phosphorous
poisoning, hanging, stroke, multi organ failure with septicemia, dengue encephalitis, ARDS and Rheumatic heart disease in
respiratory failure. Overall 10 patients developed complications during the study period.
Conclusion: In patients with prolonged mechanical ventilation, bedside tracheostomy seems to be safe, simple and least
expensive procedure and should always be considered as an option for these patients
Keywords: Bedside tracheostomy, Mechanical ventilation, complications
Introduction
Tracheostomy is probably the most common surgical
procedure performed on critically ill patients. Approximately
10 percent of mechanically ventilated critically ill patients
undergo tracheostomy to facilitate prolonged airway and
1
ventilatory support . Most critically ill patients with
respiratory failure tolerate tracheal intubation for short
duration with minimal complications, but longer duration (>
1week) of mechanical ventilation will have adverse
2
outcomes . Several new interventions such as low tidal
volume ventilation, patient positioning, weaning and
sedation protocols have been adopted to reduce the morbidity
and mortality in patients with prolonged mechanical
3
ventilation . However tracheostomy is electively performed
in many critically ill patients requiring prolonged mechanical
ventilation or frequent broncho-pulmonary toilet or to help
with weaning from mechanical ventilation. It is better
tolerated than oral or nasal tracheal intubation and is thought
to reduce sedation requirements and time in the intensive care
unit (ICU).
Traditionally elective tracheostomies have been performed in
operating room by using standard surgical techniques
originally described by Jackson. The concept of bedside
tracheostomy is attractive and surgeons have started
performing open bedside tracheostomy. It is found to be safe
in selected patients.The primary objective of this study was to
determine safety of bedside tracheostomy in patients under
prolonged mechanical ventilation.
Material and Method
It is a descriptive study conducted in two hospitals of
Davangere (India) for the period of five years between April
2005 and January 2010. During the study prior to bedside
tracheostomy brief history of the patients were noted with
special emphasis on indications for mechanical ventilation
and duration of mechanical ventilation. A general physical
and systemic examination was carried out and thorough local
examination of the neck was done. Appropriate investigations
were ordered prior to tracheostomy with special emphasis on
coagulation profile. Informed consent was taken for the
procedure from the patient's relative. Bedside open
tracheostomy was performed by conventional open surgical
technique under local anesthesia with patient's vitals and
oxygen saturation being monitored by an intensivist. Duration
of the procedure and peri-operative complications were
1 2 3,4,5
Professor, Reader, Residents, Department Of Otorhinolaryngology ,
J.J.M. Medical College Davangere,Karnataka
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

noted. Cuffed tracheostomy tubes (Portex®) were used in all
patients and tube size varied from 7.0 to 9.0. Proper
positioning of the tube was confirmed by demonstrating
symmetrical movement of chest wall and maintenance of
normal airway pressures, expiratory volumes and satisfactory
oxygen saturation with a pulse oxymeter. Chest radiography
was obtained on the first post-operative day to confirm proper
positioning of tracheostomy tube and to exclude
pneumothorax. Complications of bedside tracheostomy were
recorded for up to 60 days after the procedure. Complications
were classified as early complications, for events directly
related to the surgical procedure occurring during
tracheostomy tube placement and up to 24 hours after the
procedure. Late complications included those occurring
during the hospital stay or at home after discharge. Each
complication was classified as major or minor according to its
clinical relevance and whether or not it was life threatening.
Patient's relatives were educated by the intensivist and ICU
nurse regarding routine tracheostomy care, changing the
tracheostomy tube and possible complications that could be
experienced and their management. Patients needing short
term tracheostomy were decannulated before discharge.
Patients who maintained oxygen saturation of more than 90
percent in room air were considered to be eligible for
decannulation. Other patients were followed up regularly to
determine the necessity for continuation of tracheostomy.
When primary pathology allowed decannulation, it was
performed in hospital setting.
were ordered prior to tracheostomy with special emphasis on
coagulation profile. Informed consent was taken for the
procedure from the patient's relative. Bedside open
tracheostomy was performed by conventional open surgical
technique under local anesthesia with patient's vitals and
oxygen saturation being monitored by an intensivist.
Duration of the procedure and peri-operative complications
were noted. Cuffed tracheostomy tubes (Portex®) were used
in all patients and tube size varied from 7.0 to 9.0. Proper
positioning of the tube was confirmed by demonstrating
symmetrical movement of chest wall and maintenance of
normal airway pressures, expiratory volumes and satisfactory
oxygen saturation with a pulse oxymeter. Chest radiography
was obtained on the first post-operative day to confirm proper
positioning of tracheostomy tube and to exclude
pneumothorax. Complications of bedside tracheostomy were
recorded for up to 60 days after the procedure. Complications
were classified as early complications, for events directly
related to the surgical procedure occurring during
tracheostomy tube placement and up to 24 hours after the
procedure. Late complications included those occurring
6
during the hospital stay or at home after discharge. Each
complication was classified as major or minor according to its
clinical relevance and whether or not it was life threatening.
Patient's relatives were educated by the intensivist and ICU
nurse regarding routine tracheostomy care, changing the
tracheostomy tube and possible complications that could be
experienced and their management. Patients needing short
term tracheostomy were decannulated before discharge.
Patients who maintained oxygen saturation of more than 90
percent in room air were considered to be eligible for
decannulation. Other patients were followed up regularly to
determine the necessity for continuation of tracheostomy.
When primary pathology allowed decannulation, it was
performed in hospital setting.
Results
During the study period total of hundred patients underwent
bedside tracheostomy during the course of mechanical
ventilation. Reasons for mechanical ventilation in above
patients included poly trauma, head injury, organophosphorous
poisoning, hanging, and stroke, multi organ
failure with septicemia, dengue encephalitis, ARDS and
Rheumatic heart disease in respiratory failure
In the study group seventyeight patients were male and
twentytwo were female with male to female ratio of 3.5:1,
Youngest being eighteen years and oldest eightyfive years.
Median incubation period before tracheostomy was seven
days with range being 5-28 days. Overall 10 patients
developed complications. Three patients developed early
complications and all were major complications. One patient
developed cardiac arrest during the procedure and patient was
revived successfully then procedure was completed. One
patient developed surgical emphysema involving face, neck
and upper chest during first post operative day. It was
managed conservatively and it subsided after three days.
Difficulty in placement of tracheostomy tube was
encountered in one patient for whom small sized tube was
placed successfully. Seven patients developed late
complications of which four were major and three were
minor. Major complications included pneumothorax and
tracheo-oesophageal fistula, where as minor complications
included bleeding from tracheostomy site and tracheocutaneous
fistula. Pneumothorax was managed by placement
of intercostal drainage tube. Patients with tracheooesophageal
fistula were referred to thoracic surgeon for
further management. Bleeding from tracheostomy site was
managed by ligation of bleeding vessels. Trachea-cutaneous
fistula was repaired by excision of fistulous tract and
secondary suturing. During the time of this presentation
seventu two patients were alive and successfully
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

decannulated. Thirteen patients are still alive with
tracheostomy tube. Total of fifteen patients succumbed to
their underlying primary disease.
Discussion
Tracheostomy is performed primarily in critically ill patients
who require prolonged mechanical ventilation and/or in
whom multiple attempts in weaning from mechanical
4
ventilation have been unsuccessful for 14-21 days .
Tracheostomy facilitates weaning by decreasing the work of
5
breathing in patients with limited respiratory reserve .
Tracheostomy reduces sedation requirements and allows for
early patient mobilization and feeding. Prolonged tracheal
intubation has been associated with hazards such as ventilator
associated pneumonia, subglottic stenosis and adverse effects
6
of persistent sedation. In a study conducted by Pena et al 86
percent of all patients presenting with subglottic stenosis had
prior history of prolonged tracheal intubation with a mean
duration of 17 days. The optimal timing for tracheostomy in
patients under mechanical ventilation is still controversial and
the current trend seems to be early tracheostomy usually
carried out within 7 days of tracheal intubation. Previously
tracheostomy was traditionally performed by open technique
in operating room. Performing surgical tracheostomy on
bedside in ICU setup eliminates the need for transporting
critically ill patients to the operating room. In this way
hazards like emergency intubations and detachments of the
vascular line can be avoided and the patient is not subjected to
inconvenience of transportation.
Various studies have been undertaken to compare the benefits
and complications of tracheostomy and prolonged tracheal
7
intubation in mechanically ventilated patients. Stauffer et al
conducted a study comparing complications of early
tracheostomy with complications of prolonged tracheal
intubation and concluded that complication rate of
tracheostomy was more and severe. They recommended not
to undertake tracheostomy for initial 3 weeks of mechanical
8
ventilatory support.Hefner et al advocated tracheostomy in
patients who were expected to require more than one week of
9
mechanical ventelation. Brooks et al found that the duration
of mechanical ventilation and total cost of hospitalization
were significanty lower in early tracheostomy group. In our
series overall complication rate was 10 % of which 6 % were
major and 4 % were minor. None of our patients succumbed to
complications directly related to the procedure. In our study ,
the difficulties encountered during bedside procedure, were
practically nil due to the cumulative experience and
teamwork of nursing staff and the respiratory therapist, along
with the improved monitoring facilities. Though additional
resources have been utilized in terms of staff and materials,
the costs and risks associated with transport of critically ill
patients were avoided. Moreover, improved utilization of OT
time and avoidance of delays in treatment was achieved with
flexibility of being available to perform bedside tracheostomy
.However absence of control group limits the power of our
conclusions and absence of some information such as
APACHE II scores, ventilatory parameters, coagulation
disorders and intra-operative bleeding quantification
weakens our conclusions. A study which considers the above
parameters would allow statistical analysis and would be of
great interest.
7
Conclusion
Bedside tracheostomy, though old fashioned, it is the
simplest, safest and least expensive procedure, equivalent to
that being undertaken in operation theatres, provided sound
and consistent technique is adopted, especially in patients
with prolonged mechanical ventilation.
References
1. Frutos-Vivar F, Esteban A, Apezteguía C, Anzueto A,
Nightingale P, González M, Soto L, Rodrigo C, Raad J,
David CM, Matamis D, D' Empaire G, International
Mechanical Ventilation Study Group: Outcome of
mechanically ventilated patients who require a
tracheostomy. Crit Care Med 2005, 33:290-298.
2. Hubmayr RD, Burchardi H, Elliot M, et al, American
Thoracic Society Assembly on Critical Care, European
Respiratory Society, European Society of Intensive Care
Medicine, Societe de Reanimation de Langue Francaise.
Statement of the 4th International Consensus Conference
in Critical Care on ICU-Acquired Pneumonia—Chicago,
Illinois, May 2002. Intensive Care Med. 2002;28:1521-
1536
3. Acute Respiratory Distress Syndrome Network.
Ventilation with lower tidal volumes as compared with
traditional tidal volumes for acute lung injury and the
acute respiratory distress syndrome. N Engl J Med.
2000;342:1301-1308.
4. Heffner JE. The role of tracheotomy in weaning. Chest.
2001;120(6,suppl):477S-481S.
5. Davis K Jr, Campbell RS, Johannigman JA, Valente JF,
Branson RD. Changes in respiratory mechanics after
tracheostomy. Arch Surg. 1999;134: 59-62.
6. Pena J, Cicero R, Marin J, Ramirez M, Cruz S, Navarro F.
Laryngotracheal reconstruction in subglottic stenosis: an
ancient problem still present. Otolaryngol Head Neck
Surg. 2001;125:397-400.
7. Stauffer JL, Olson DE, Petty TL. Complications and
consequences of endotracheal intubation and
tracheotomy: a prospective study of 150 critically ill adult
patients. Am J Med. 1981;70:65 76.
8. Heffner JE. Timin tracheotomy : calender watching or
individualization of care ? [editorial] Chest 1998 : 114:
361-363
9. Brook AD, Sherman G, Malen J. Kollef. Early versus late
tracheostomy in patients who require prolonged
mechanical vntilation. Am J Crit Care. 2009:9:352-359.
Address for correspondence
Dr. Santosh U.P
'SAAVAN' No 4123
th
14 cross, Anjaneya layout
DAVANGERE -577004
PH-0091-8192-222422,
CELL-0091-9845155223
Email – drsantoshup@gmail.com
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

8
Main Article
Tympanoplasty with and without cortical mastoidectomy for tubotympanic type of chronic
suppurative otitis media.
1 2 3 4
Shrinivas Shripatrao Chavan , Sunil D .Deshmukh , Vasant G. Pawar , Vaibhav G. Kirpan , Smita W
5 6
.Khobragade , Kaustubh V Sarvade – Aurangabad (Maharashtra)
Abstract: There are various theories for surgical management for; Chronic suppurative otitis media(C.S.O.M.). One theory
suggest cortical mastoidectomy combined with tympanoplasty is helpful for both dry and wet ear, the second theory suggest
cortical mastoidectomy with tympanoplasty is helpful for discharging ear but not for dry ear and the third theory suggests
cortical mastoidectomy is not helpful either for dry ear and discharging ear. The purpose of this study is to compare the surgical
outcome of tympanoplasty verses cortical mastoidectomy with tympanoplasty done for tubotymapnic type of C.S.O.M.
Study design : Retrospective design.
Setting: Tertiary referral hospital .
Patient and Method: 150 cases of C.S.O.M. underwent surgery tympanoplasty with cortical mastoidectomy [75 cases ] Group A
and tympanoplasty without cortical mastoidectomy [75 cases ] Group B . The results were analyzed at 2 weeks, 1 months and 4
th
months post operative follow up. The success rate of surgical outcome was judged by graft uptake at 4 month follow up by
doing otoscopic examination and EUM on every postoperative visit.
Results: 150 cases of Tubotympanic type of C.S.O.M. were operated. The mean age was 28 years. There was male
preponderance. The X ray mastoid Schuller's view showed sclerotic mastoid in 140 (93.33%) cases. 75 cases were operated by
doing Tympanoplasty without cortical mastoidectomy and another 75 cases were operated by tympanoplasty with cortical
nd
mastoidectomy. The success rate was 100% in both the study group at 2 week of postoperative follow up. At 1 month of
postoperative follow up the success rate was 100 % in tympanoplasty with cortical mastoidectomy and 97.33 % in
tympanoplasty without cortical mastoidectomy. At 4th month the success rate was 97.33 % in tympanoplasty with cortical
mastoidectomy and 93.33 % in tympanoplasty without cortical mastoidectomy.
Keywords: Tubotympanic type; Chronic Suppurative Otitis Media ; Tympanoplasty ; with and without cortical mastoidectomy.
Introduction:
C.S.O.M. defined as chronic infection confined to middle ear
mucosal cleft which is composed of eustachain tube,
hypotympanum , mesotympanum , epitympanum, aditus and
mastoid air cells. Clinically three varieties of C.S.O.M has
described 1] Tubotympanic type 2] Atticoantral type 3]
[1]
Tuberculous type. Perforation is a breach in integrity of
tympanic membrane and is nature mechanism to achieve
.[2]
ventilation in face of middle ear inflammation The surgical
application of the operating microscope, first by Nylen in
1921 as a monocular instrument, and then by Holmgren, who
introduced the binocular operating microscope in 1922,was
an important advance destined to play an increasing role in the
.[3]
perfection of technique of tympanoplasty The surgical
methods and indication of tympanoplasty have come a long
way since the days of Wullestein who in year 1953 coined and
described tympanoplasty as repair of the tympanic
[4,5]
membrane using spilt thickness graft. In the following year
much modification took place in surgical steps of
tympanoplasty and so is the use high end operating
microscope and microsurgical instrument so tympanoplasty
had redefined by American Academy of Otolaryngology and
Ophthalmology subcommittee on conservation of hearing as a
procedure to eradicate disease in middle ear and to reconstruct
[6]
hearing mechanism. The two opposing demands of
tympanoplasty namely eradicate the disease and at the same
phase trying to maintain as much as normal tissue as possible
to facilitate reconstruction of hearing mechanism is a
demanding task. As long as the infection is lurking in and
around the middle ear cleft and mastoid antrum any attempt at
[2]
reconstruction may seem futile. In this context cortical
mastoidectomy seem to be an integral part of every
tympanoplasty. Schwartz was the first who described cortical
[7]
mastoidectomy. The aim of our study is to share our
experience by comparing results of tympanoplasty with
cortical mastoidectomy verses tympanoplasty without
1 2 3 4,5,6
Assistant Prof. Prof & Head, Sr. Resident, Resident, Govt. Medical college, Aurangabad (M.S.)
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

cortical mastoidectomy done for tubotympanic type of
CSOM.
Materials and Methods:
A retrospective study was conducted by Otorhinolaryngology
department of Government Medical College and hospital
Aurangabad from a period of Sep 2008 to Sep 2010. The
inclusion criteria of our study patient were tubotympanic type
of C.S.O.M., central and subtotal type of perforation, mild
and moderate hearing loss and sclerotic mastoid depicted by
X ray mastoid. While exclusion criteria were atticoantral type
of C.S.O.M., total and marginal perforation, severe and
profound hearing loss, revision tympanoplasty. A
preoperative preparation of all the cases were done by giving
them antibiotics, antihistaminics , topical antibiotics and
instructed them to keep the ear dry by frequently changing the
sterile cotton plug in the diseased ear in an aim to achieve dry
ear preoperatively. A series of 150 patient were included in
our study among which 80(53.33%) were males and
70(46.66%) were females between the age group of 18 to 70
years. The pools of patients were randomized into two groups.
A group A [n = 75] consisting of tympanoplasty with cortical
mastoidectomy and group B[n = 75] consisting of
tympanoplasty without cortical mastoidectomy. All patients
were operated under general anaesthesia. The preoperative
preparation of disease ear was done by shaving the mastoid
area. The area was prepared and draped. The local infiltration
in a form of 2% lignocaine with adrenaline was given. The
Retroauricular (Wildes) incision was taken using scalpel
blade No 20. The temporalis fascia graft was harvested. The
meatotomy was done using scalpel blade No 15. Now further
surgical steps were done under high end microscope. The
perforation margin was refreshened by using sickle knife and
Bulluchi scissors. The TM flap elevated by circular knife. The
annulus was lifted from posterior superior side by sickle
knife. The chorda tympani nerve was delineated. The incudostapeadial
joint mobility was tested. In Group B the
temporalis fascia graft was placed by under lay technique.
The air insufflation in the middle ear was done by elevating
the TM flap with temporalis fascia graft and reposting. In the
Group A, 25 patients showed mucus otitis media [glue ear]
intra operatively on elevating the TM flap. The cortical
mastoidectomy was done in the entire group A patient. The
temporalis fascia was placed by under lay technique. In both
the group while placing the temporalis fascia graft the
anaesthetist were told to shut off the nitrous oxide gas supply
to patient so as to avoid diffusion of gas in middle ear and to
avoid graft displacement. The medicated gelfoam was placed
in the external auditory canal. The suturing was done and
mastoid dressing was given.
9
Postoperative care and followup : Patient was kept on
intravenous antibiotics and oral antihitaminics and analgesic
for two days in the ward. The mastoid dressing was changed
nd
after 48 hours. The patient was discharged on 2 day with oral
antibiotics, analgesic and antihistamines. The patient were
instructed to drape the operative ear while taking bath, Avoid
forceful blowing on the nose,abstinence from travelling high
and low altitude,not to carry heavy weight,avoid swimming
and water sport activity.All patient were ask to follow up on
th th
7th and 15 day and at 1st and 4th month. On 7 day the
sutured were removed and topical instillation of medicated
ear drop was advised. On every follow up visit otoscopic
th
examination was done. The PTA was done on 6 week of
postoperatively.
Results and analysis:
Following the study interval all the data required was
compiled. The objective assessment was done by means of
otoscopic examination and EUM. The operation was
considered to be successful after uptake of graft on 4th month
follow up by doing otoscopic examination and EUM. Of 150
patients, 70 (46.66%) were females and 80 (53.33%) were
males. The mean age of presentation was 28 years. All the
patients had otorrhoea as their chief complaints followed by
hearing loss. Out of 150 cases, 72(48%) had right ear
involvement and 78(52%) had left ear involvement. During
the intraoperative and immediate postoperative period and on
each follow up visit, we have checked for any surgical
th th
complication. All patients were followed up on 7 and 15
st th
postoperative day and 1 and 4 month with otoscopic
th
examination and EUM. On 7 day follow up only soaked gel
th
foam was seen in external ear canal, no graft was seen. On 15
postoperative day, all the patients had graft in place along with
soaked gel foam on EUM with 100% graft uptake. At 1st
month follow up success rate of patient who had undergone
tympanoplasty with mastoidectomy was 100%, whereas that
of patient who had undergone tympanoplasty without cortical
mastoidectomy was 97.33%. At 4 month follow up success
rate of Tympanoplasty with Cortical Mastoidectomy was
97.33% and that of tympanoplasty without cortical
mastoidectomy was 93.33%.the total failure rate was found to
be 9.33%.
Discussion:
Chronic suppurative otitis media is the result of acute
suppurative otitis media which has left permanent perforation
.None of the literature shows that, doing cortical
mastoidectomy in tubotympanic type of chronic suppurative
otitis media has better outcome than tympanoplasty without
cortical mastoidectomy. Tubotympanic disease is common in
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

oth children and in adults .There is no any sex preponderance
and no any side preponderance seen. Out of 150 patients, we
had 80(53.33%) male patients and 70(46.66%) female
patients .Our mean age of presentation was 28 years, and
nd rd
common in 2 and 3 decade.We did tympanoplasty with
mastoidectomy in 75 patients (Group A) and tympanoplasty
without mastoidectomy in remaining 75 patients (Group B).
th th
All the patients were followed up at 7 day, 15 day, 1st month
and 4th month postoperative day. Otoscopic examination
th
was carried out to see the status of graft. At 7 day follow up,
th
only soaked gel foam was seen. At 15 postoperative day
follow up, all the patients showed 100% graft uptake along
with soaked gel foam. As the days progressed, success rate of
tympanoplasty without cortical mastoidectomy has fallen
down which was 97.33% at one month follow up and 93.33%
th
at 4th month follow up. In group A success rate at 15 day and
1 month follow up was 100%and at four month follow up was
97.33%. Graft uptake was 100% in 25(33.33%) patients
having glue ear intraoperatively, in whom cortical
mastoidectomy was carried out.
At the end of the study the total graft failure rate was 9.33%
only which was really insignificant and that was because of
repeated upper respiratory tract infection .Graft failure was
the complication seen in patients with tympanoplatsy with
cortical mastoidectomy as well as in patients with
tympanoplatsy without mastoidectomy. Out of 75 patients in
whom tympanoplasty with cortical mastoidectomy was
carried out, 8(10.66%) patients complaining of giddiness
postoperatively were managed with labyrinthine sedatives.
Out of eight patients who received injection stemetil only one
had extrapyramidal symptoms (neck rigidity) and, relieved
with withdrawal of medication. One(1.33%) patient had
Grade II facial palsy due to excessive heat produced by burr
while drilling the densely sclerosed mastoid which recovered
nd
on 2 postoperative day, as patient was kept on steroids for
seven days. 14(18.66%) patients were had loss of taste
sensation due to secondary damage to chorda tympani nerve
.Our 25(33.33%) patients in whom tympanoplasty without
cortical mastoidectomy was carried out, showed good
improvement in hearing from severe to moderate conductive
hearing loss to mild to moderate hearing loss .No significant
hearing improvement was noticed in patients in whom
tympanoplasty with cortical mastoidectomy was done.
Conclusion:
There was no significant difference in graft uptake with
tympanoplasty with cortical mastoidectomy as compared to
tympanoplasty without mastoidectomy.Cortical
Mastoidectomy does not offer significant hearing
improvement .In the Group B 25(33.33%) cases who had
10
moderate to severe hearing loss preoperatively have mild to
moderate hearing loss postoperatively.Postoperative
complications in tubotympanic type of CSOM are more with
tymanoplasty with cortical mastoidectomy as compared with
tympanoplasty without cortical mastoidectomy.
Postoperative care should be taken to avoid upper respiratory
infection which is one of the most common cause of graft
rejection.For glue ear cortical mastoidectomy is preferred to
avoid lurking in middle ear cleft as there was 100% graft
uptake in 25(33.33%) patients with glue ear. Aerating the
sclerosed mastoid does not have significant importance in
uptake of graft as the results were almost same in both type of
study group.
References:
1. I. Simso Hall.BernardH.Colman.Disease of nose, throat,
ear.
2. AnitaKrishnan, E.K.Reddy, C.Chandrakiran,
K.M.Nalinesha and P.M.Jagganath.Indian Journal of
Otolaryngology and Head and Neck Surgery 2002
Volume 54,Number 3,195-198.
3. NylenCO.microscope in aural surgery,its first use and
development, ACTAOtolaryng,a suppet.1954;116:226-
240.
4. Wullstein H.(Technic and early results of
tympanoplasty)MonatsschrOhrenheilkdLarynorhinol
1953;87(4):308-311.
5. Wullstein H.Funktionelle operation in mittelohrmithilfe
des freionspaltlappen-transplantates.ArchOhren-Nasen-
U Kehlkophf 1952; 161:422.
6. Committee on Conservation of Hearing, American
A c a d e m y o f O p h t h a l m o l o g y a n d
Otolaryngology.Standard classification for surgery
chronic ear disease.ArchOtol 1965; 81:204.
7. Zollner F. (Surgical technics for the improvement of
sound conductin after radical operation ).Arch Ital
Otol.Rhinol Laringol 1953;64(4):455-468.
Address for correspondence
Dr. Shrinivas Shripatrao Chavan
Assistant Professo E.N.T. and Head and Neck Surgery
Govt. Medical College
Aurangabad ( M.S.)
E Mail : shrinivasc77@hotmail.com
Cell +91 9403151515
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

11
Main Article
A study of oto-acoustic emissions (OAE) in 130 cases: a screening tool for hearing loss in children.
1 2 3 4
Jaymin A. Contractor ,Piyush M. Vaghmashi ,Rahul B. Patel ,Ishwar M. Chaudhari , Dilavar
5 6
A. Barot ,Neepa Jariwala - Surat (Gujarat)
Abstract
Hearing loss is the most common birth anomaly, affecting approximately 3 per 1000 live births and of these 20% have a
profound loss. Aims of the study were to screen all newborn and children with age 5 years or less, for hearingloss & to find
congenital incidence of hearingloss of newborns & children in tertiary referral hospital. 39.23% (51) candidates presented with
st st
'REFER' on 1 test out of which 14.61% were unilateral & 24.61 % were bilateral. On doing 1 retest at 1 month on these 51
nd
candidates it was found that 9.23% (12) remain 'REFER' out of which 1.53% was unilateral & 7.69 % bilateral. On doing 2
nd
retest at 2 month on these 12 candidates it was found that 3.84% (5) remained 'REFER' which was bilateral. Out of these 5
candidates only 1 came for BERA, which was suggestive of bilateral SNHL (0.76%)
Key Words: OAE, hearing loss
Introduction
Hearing loss is the most common birth anomaly, affecting
approximately 3 per 1000 live births and of these 20% have a
profound loss. These children are unable to hear speech
sounds. Although hearing loss is one of the most common
birth anomalies, the concept of universal new born screening
has not been implemented in India. It's mandatory to get the
newborn screened at birth in most of the developed countries
and it's become standard of care. We still have high risk
newborn screening, which misses up to 50% of newborns till
school going age. This would mean they remain undiagnosed
up to 4-5 years of age. This period being critical as the central
auditory pathway gets developed by 5 years.
If the hearing loss is not diagnosed until the child is 2 to 3
years old, the emotional and social damage can be
longstanding. It can also impair language development. The
most critical stage of language development occurs before 6
months of age. This is sometimes referred to as a “critical
period” for speech and language development. How can we
go about having Universal Hearing Screening programme
implemented? We are such a big nation with so many
languages.We have a good National Immunization
Programme in place, so the health worker responsible for it
can be trained to look for hearing by performing a simple test
like the ball pen click test. It is done by introducing a sound of
a ball pen click an inch from the ears. When compare to
audiometry as the gold standard, the test has a good average
and an accuracy of 98.9% for 1,000 ears.Those kids who fail
this test can be sent for a detailed hearing evaluation with an
1 3 4 6
advised appropriate intervention in the form of hearing
aids.So, let's make a difference in the child hearing
impairment and prevent deafmutism.
Aims & Objectives:
1. To Screen all newborn and children with age 5 years or
less, for hearing loss.
2. To find incidence of congenital hearing loss of newborns
& children in tertiary referral Hospital.
Methods:
This is a prospective study of 130 patients carried out at
Department of ENT-HNS, Government Medical College,
New Civil Hospital, Surat. Total 130 newborns and children
aged 5 years or less seen in OPD or admitted in wards of New
Civil Hospital, Surat have been included in the study. Only
those candidates having intact tympanic membrane were
included in this study.
Our college has Human Research Ethics Committee which
approved our study. We clearly mentioned the following
ethical issues in the application for approval of this study by
the committee: After OAE children suspected of having
hearing loss will have to be further investigated (By BERA,
CT Scan etc.) for exact etiology, amount and management of
hearing loss. This may cause anxiety & stress in some parents
& guardians even though prior to OAE they have been
counseled regarding benefit of early detection of hearing loss.
Parents of all the candidates included in the study were
explained about the purpose & use of OAE, detail of
procedure & after their consent, they were included the study.
A detailed history was elicited from parents. This was
Professor & Head, Asst. Prof. Audiologist:, Ex sr. Resident Dept of ENT-HNS Government Medical College, Surat.
2 5
Asst. prof E.N.T. Govt. Medical; College Bhavnagar . Asst Prof in ENT, M.P. Shah Med College, Jamnagar.
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

tympanic membrane(TM) was seen clearly, candidates were
sent for OAE.
OAE was done in sound-treated room by full-time audiologist
of our department by Welch Allyn Audio Path Screener. If the
results were 'PASS' then no follow up OAE done. If results
were ''REFER'' then candidates were called after 1 month for
nd rd
2 OAE. If result still remain ''REFER'' then 3 OAE was
done after another 1 month. If result still remains same then
candidate were sent for BERA (Brainstem evoked
st
response audiometry). Further in the study, the 1 OAE tests
st nd st rd
will be referred as 1 test, 2 OAE as 1 retest and 3 OAE as
nd
2 retest.
Results & discussion:
1. In our study, maximum no of patients i.e. 64.61 %were in
the age group of 0-6 months. This is desirable but the goal
should be to screen 100% children by this age for possible
further investigations and interventions in selected cases.
2. In our study, 56.15 % were male child & 43.84 % were
female child which suggest male preponderance of 1.3:1.
Amongst them 'REFER' result was found in 43.83% &
33.33% respectively in male & female.
3.96.92 % of candidate's mothers took routine ANC visits.
This is quite an encouraging result as this suggests that
mothers from even low and middle socio-economic strata are
now aware of the importance and benefit of regular ANC
resulting in better chance of having a healthy mother & child.
4.76.75 % was Term delivery & 23.84 % were Pre-term
delivery.
5. In our study 52.30 % births were FTND, while 24.61%
were FT with LSCS. 64.70% pre-term and 39.70% FTND had
st
'REFER' results in 1 OAE. While amongst LSCS delivered
children, 23.08% pre-term & 45.16% full term babies showed
'REFER'.
6.83.84 % candidates cried immediately while 5 candidates'
history was not known to parents. 40.74 % of candidates who
cried immediately show 'REFER' while only 18.75 %
amongst those who did not cried after birth show 'REFER'.
This is paradoxical finding as a baby who cries immediately
after birth is likely to be healthier. The very small sample size
of our study may be responsible for this anomaly.
7.In our study, 80 % candidates had normal post-partum
period without any complications. Out of rest 20%, 12.30 %
candidates were having history of Jaundice in immediate
postpartum period, 3.84 % had LBW and 3.84 % had both
LBW and Jaundice.
In candidates with normal post-partum period, 38.46% had
'REFER' result.
'REFER' result had a peak incidence of 80% candidates
amongst those having h/o LBW & jaundice both, while
12
amongst those having h/o LBW & jaundice singly; 'REFER'
result was found in 40% and 31.25% respectively.
8.We found that 6.92% candidates had history of intravenous
Amikacin. Out of them 33.33% had OAE result 'REFER',
while amongst those having no such history (93.07%),
39.66% had OAE result 'REFER'. This is again a paradoxical
finding which may be due to small sample size of our study &
due to conditions of middle ear.
9. In our study 86.92% had no accompanied disease. 10
%having CNS disease & 3.07 % having other diseases.
Amongst candidates having CNS disease, 58.33% had OAE
result 'REFER', while those not having any accompanying
disease only 38.05% were 'REFER'.
10.63.46 % of TM was Normal & 36.15 % were retracted.
Candidates with normal TM showed 30.12% 'REFER', while
those with retracted drum had 55.31% 'REFER'. This is easy
to explain as middle ear conditions (eg. OME) give 'REFER'
st
result.The 39.23% candidates presented with 'REFER' on 1
test
Out of which 14.61% were unilateral & 24.61 % were
st
bilateral.On doing 1 retest at 1 month on these 51 candidates,
it was found that in 9.23% results still remained 'REFER' (out
of which 1.53% was unilateral & 7.69 % bilateral).On doing
nd nd
2 retest at 2 month on these 12 candidates, it was found that
3.84% remained 'REFER' which was bilateral. Out of these 5
candidates only in 1 BERA could be done which was
suggestive of bilateral SNHL (0.76%).
Comparison of our study with 2 other studies conducted at
Trieste and Ferrara WB (Well baby) nurseries, under
Universal Neonatal Hearing Screening (UNHS) programme,
Italy31
At 1st test in our study 39.23 % of the patients show 'REFER',
while studies of Trieste and Ferrara show 9 % and 24.9 %
st
respectively. The percentages of 'REFER' results at 1 retest in
our study, Trieste and Ferrara were 9.23 %, 0.06 %, 2.02 %
respectively.
Both of these results are higher in our study.
In our study the percentage of candidates having 'REFER' in
nd
2 retest reduced to 3.84 % which was not performed in two
other studies, instead BERA was performed.
After doing BERA the results in our study, Trieste and Ferrara
turned out to be SNHL in 0.76 %, 0 % and 0.70 % respectively.
Conclusion:
A screening programme can only be as strong as the weakest
link in the follow up chain. It should be remembered that the
incidence of persistent significant hearing loss increases with
age.
The Joint Committee on Infant Hearing (JCIH) millennium
position statement (2000) defines Universal Newborn
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Hearing Screening (UNHS) as a programme which use
physiological measures to screen for hearing loss, all infants
in Well Baby Nursery (WBN) and Neonatal Intensive Care
Unit (NICU) before discharge and infants from alternate
birthing before 1 month of age with objective of atleast 30 db
hearingloss in infants.UNHS promotes early identification of
hearing loss.Early detection of hearing impairment due to
implementation of the screening results in early intervention
and implantation of deaf children which has a major positive
impact on both auditory receptive skills and speech
intelligibility.
National Programme for Prevention & Control of Deafness
(NPPCD) - In India, the Central Government has started
National Programme for Prevention & Control of Deafness
(NPPCD). It was launched on a pilot basis in 25 districts
during 2006-2008. The programme is now integrated with
NRHM (National Rural Health Mission). It is now being
gradually expanded to other districts. It aims to cover over
200 districts by 2012.Currently in Gujarat State, 1 State Nodal
Officer and 26 District Nodal Officers are appointed in 26
districts for implementation of NPPCD. The Overall
objective of the National Programme: To prevent hearing loss
due to disease or injury, do early diagnosis, treatment, medical
rehabilitation, strengthening linkages, creation of database
and facilitation of need based research. The ultimate aim is to
ensure that no person remains needlessly deaf or suffers the
consequences thereof. Though we did not meet the first
benchmark of JCIH 2000, our study with 130 children (93
infants) suggests that even in a Government teaching hospital
having immense clinical & academic workload, when
Obstetricians and Pediatricians are sensitized and more paramedical
personnel are available in ENT department,
implementation of Universal Newborn Hearing Screening is
feasible. This is the first step which should be followed by
identifying the hearing impaired children and then treating
them.Ultimately, the ear should hear.
References:
1.Scott Brown: Diseases of ear, nose and throat 4th ed, edited
by John Ballantyne, John Groves: 55-65
2.Chaturvedi V. N: Hearing impairment and deafness:
'Magnitude of problem and strategy for prevention.' Indian
Journals of Otolaryngology and Head Neck Surgery (1999)
51(2):3-6 http: //www.mass.gov/dph/fch/unhsp/index.htm
3.Kemp, D.T., Ryan's., & Bray. et al(1990). 'A guide to the
effective use of otoacoustic emissions'. Ear and
Hearing,11,93-105
4.Kok M.R., VanZanten G.A, Brocaar M.P et al (1993).
Aspect of spontaneous otoacoustic emissions in Healthy
newborns.' Hearing Research, 69,115-123.
13
5.Gaskill S.A., Brown A.M. (1990): 'The behavior of acoustic
distortion product, 2f1-f2, from the human ear and its
relation to auditory sensitivity.' Journal of the Acoustic
society of America, 88,821-839
6.Keilson S.E., Khanna S.M., Ulfendahl M.N., Teich M.C. et
al (1993): 'Spontaneous cellular vibrations in guinea pig
cochlea.' Acta Oto-Laryngolocia, 113,591-597.
7.Hurley R.M. & Musiek F.E. (1994): 'Effectiveness of
transient-evoked otoacoustic emissions (TEOAE) in
predicting hearing level.' Ear and Hearing , 5,195-203
8. Scott Brown Otolaryngology, Head and Neck Surgery, 7th
edition, edited by Michael Gleeson. (3): 3108-3119
9. Scott Brown Otolaryngology. 6th ed, edited by Alae G
Kerr: 1/2/1-1/2/31
10.Timothy C, Hain M.D : 'OAE Testing' HTML Page
modified June 13,2003
Address for Correspondence:
Jaymin A. Contractor
52, Sugam society, Adajan Patia, Rander road, SURAT -
395009.
E Mail: dr_jcontractor@yahoo.co.in,
Cell +91 9824190210
35th Annual Conference of
Otolaryngologists of India
Gujarat State Branch
Rajpath Club Ahmedabad.
th th th
16 ,17 , 18 December 2011.
Organising Chairman
Dr. Atul Kansara
Organising Secretary
Dr. Navin Patel, Dr. Kalpesh Patel.
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Introduction:
Dacryocystorhinostomy (DCR) has been traditionally
performed for nasolacrimal duct obstruction via an external
approach, although the procedure is actually uniquely suited
for an endoscopic approach. The first dacryocystectomy,
dating back to 50 A.D. was performed by Celsus. Anel (1713)
introduced the concept of probing and syringing. Over a
period of time various techniques evolved and in 1904, Toti,
w a s t h e f i r s t p e r s o n t o p e r f o r m e x t e r n a l
dacryocystorhinostomy for obstruction of the nasolacrimal
duct. He made an incision through the skin and created a new
ostium between the nasolacrimal sac and the nose. By
removing this bone, drainage to the nose was allowed through
bypassing any obstruction distally. Kuhnt (1914) and Ohn
(1920) introduced the concept of suturing the flap of nasal
mucosa to periostium or to the sac. Summerskill (1952)
exposed the sac and a polythene tube was inserted
permanently in the nasolacrimal duct to maintain patency.
The introduction of nasal endoscopes and improvement of
optics brought about thereby improved the surgery and results
of endonasal endoscopic DCR In 1990 it was Rice who
reported his experience using endoscopic instruments to
create this neo-ostium and since then there has been quite a lot
1
of literature on the subject .Many modifications like LASER
assisted endoscopic DCR, use of silicon tube for stenting,
mitomycin C application etc. have been described, yet most of
the surgeons still follow the standard endoscopic DCR
procedure. Here we share our experience of this standard
endoscopic DCR done without mucosal flap preservation.
Objectives:
To study by prospective, non-randomized method with
14
Main Article
Endoscopic endonasal dacryocystorhinostomy: Outcome in 81 cases
1 2 3 4
Sharan kumar Shetty , Ajay George ,Sanjay Kumar ,Ranjan Kumar - Nalgonga (A.P.)
Abstract:
Endonasal dacryocystorhinostomy is an evolving procedure for the management of nasolacrimal duct obstruction. This is a case
series of 81 cases done to study the outcome of endonasal dacryocystorhinostomy in relation to aetiology and symptomatology,
and to study the efficacy of endonasal DCR without mucosal flap preservation. All cases were subjected to endoscopic
endonasal DCR without mucosal flap preservation. Success was defined by resolution of symptoms of epiphora and patency of
the canalicular system on lacrimal irrigation at 1 week and on follow up. Of the 81 cases, 73 cases had nasolacrimal duct
obstruction of inflammatory origin and 8 cases had traumatic aetiology. Amongst these cases, 5 required revision surgery, 6 had
to undergo external dacryocystorhinostomy for persistence of symptoms and the remaining 70 cases were free of epiphora.
Thus endonasal DCR is a viable surgical technique for those presenting with epiphora due to nasolacrimal duct obstruction.
Keywords: Endonasal dacryocystorhinostomy, chronic dacryocystitis, epiphora
relatively short postoperative follow up, the outcome of
endoscopic endonasal dacryocystorhinostomy in the
management of nasolacrimal duct obstruction in terms of
aetiology and symptomatology. Also to study the success rate
of endoscopic endonasal dacryocystorhinostomy when done
without mucosal flap preservation.
Materials and methods:
A total of 81 consecutive endonasal DCRs performed from
January 2008 to December 2009 were included in the study.
Patients included in the study had constant epiphora due to
nasolacrimal duct obstruction secondary to inflammation or
trauma. Patients with previous lacrimal surgery, noticeable
lower lid laxity, suspicion of malignancy and previous
radiation therapy and soft stop on lacrimal probing were
excluded from the study. A detailed history of the patients
presenting with constant, moderate to severe epiphora to our
out patient department was taken. They were subsequently
subjected to detailed ENT and ophthalmologic examination.
While examining the eyelid, any lower eye lid laxity was
noted. The punctum was thoroughly inspected to see if there
was any obstruction or inflammation. Evaluation of the
lacrimal canaliculi was done by probing. The Bowman probe
was passed through the puncta, and then swung horizontally
to cannulate the inferior lacrimal canaliculus. The difference
in feel between a hard stop versus a soft stop was noted. A hard
stop would be a stop created by bones, such as the lacrimal
bone. A soft stop felt could be because of an obstruction in the
soft tissue. The nasolacrimal duct was further evaluated by
thorough irrigation of the duct with a syringe. A nasal
examination was done to note any obstructive lesions on the
1,2 3,4
Associate Professor, Assistant professor, Kamineni Institute of Medical Sciences, Sreepuram
Narketpally, Nalgonda,A.P.
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

nose. This is a very important part of the examination protocol
to diagnose hidden etiological factors. Obstruction of the
nasolacrimal system distal to the lacrimal sac was diagnosed
with nasolacrimal syringing. Radiographic imaging was not
part of the routine preoperative evaluation as it does not add
much to the clinical examination and outcome in a majority of
the cases. Otorhinolaryngological preoperative assessment
including full endoscopic examination of nasal cavities was
done to look for evidence of mucosal disease including polyps
particularly in the middle meatus, not accessible on clinical
examination. Each patient with primary nasolacrimal duct
obstruction was counselled as to the advantages,
disadvantages and estimated success rates of the procedure.
Patients were considered for surgery either under
general or local anaesthesia. Nasal cavity was packed with
ribbon gauze soaked in 4% lignocaine with 1:100000
0
adrenaline. Under 0 rigid nasal endoscopic guidance, the
lateral wall of the nose anterior to middle turbinate was
infiltrated with lignocaine, 2% with 1:200000 adrenaline.
Using anterior portion of the middle turbinate as a landmark, a
'C' shaped mucosal flap was elevated, exposing the lacrimal
fossa. The lacrimal fossa is made up of the frontal process of
the maxillary bone, anteriorly and by the thin lacrimal bone
posteriorly. This bone was punched out using a Kerrison's
bone punch, exposing the lacrimal sac. In cases where the
bone was hard it was drilled out using a micromotor drill. The
sac was tented using a probe and incised to create a neoostium
so that tears could drain from the canaliculus directly
into the nose through the middle meatus and thus bypassing
any obstruction in the nasolacrimal duct. Medial wall of the
sac was excised using Blakesley forceps. The 'C' shaped
mucosal flap elevated earlier was excised completely. No
stents were used in any of the cases. Nasal pack was done as
and when required for haemostasis.
Post-operatively, nose was cleared of clots and
crusts. Lacrimal syringing was done twice for the first two
post-operative days and then the patient was discharged. A
course of topical ciprofloxacin eye drops was given for 1
week. Patients were followed up at 1 week, 3 weeks
postoperatively and as and when required. Mean follow up
period was 1 month. During follow up, nasal endoscopy was
performed to remove any crusts, to confirm the patency of
neo-ostium and to look for complications of the procedure.
The success is assessed, subjectively based on the patient's
symptoms and objectively (anatomical success) based on (i)
patency on syringing and (ii) presence of a functioning
rhinostomy.
Observations:
A total of 81 cases were studied during the period of
15
study. Maximum cases were females accounting to 57 cases
(70.4%) and males being 24 (29.6%).. Out of the 81 cases,
maximum cases were in the age range of 31-40 years (34.6%),
and least in the range of 61-70 years (1.2%) with youngest
being 12 years of old and oldest being 65 years. The mean age
of patients in the series was 30.3 years. The symptom was left
sided in 48 cases (59.3%) and right sided in 33 cases
(40.7%),.On history, all the cases had constant epiphora, 18
cases had swelling over the medial canthus of eye, 9 cases had
scar due to previous abscess and 15 cases had concomitant
nasal obstruction secondary to deviated nasal septum. 73
cases had a history of repeated infection of nasolacrimal
system, and 8 cases had previous history of trauma
unattended, of which one case developed epiphora following
reduction of nasal bone fracture.Out of the total of 81 cases,
75 cases were operated under general anaesthesia and the
remaining 6 cases were operated under local anaesthesia.
Patients who appeared to be cooperative on assessment and
those patients who were unfit for general anaesthesia were
considered under local anaesthesia. All cases underwent
endonasal DCR, with 15 cases requiring additional septal
surgery to provide adequate space for the instrumentation and
to relieve associated nasal obstruction. Of the 73 cases of
inflammatory aetiology who underwent surgery, 68 cases
were relieved of epiphora. 5 cases developed epiphora on
follow up, indicating obstruction of the neo-ostium. A
majority of the cases (6 cases - 75%) of traumatic aetiology
had persistent epiphora secondary to development of fibrosis
and resultant restenosis. These cases were subjected either to
revision DCR or external DCR. This gives an overall success
rate of 86.4%. Of the 81 patients operated, the commonest
complication (15 cases -18.52%) noted on follow up was
synechia and granulations in the nasal cavity. 11 cases
(13.58%) suffered from residual epiphora and no passage
upon irrigation. Intraoperative bleeding was minor in 48
cases, moderate in 26 cases, and severe in 7 cases (8.64%),
requiring anterior nasal packing. Other complications like
periorbital ecchymosis and transient maxillary pain were
noted in 6 cases (7.41%) and 5 cases (6.17%) respectively.
Discussion:
Out of the total of 81 cases majority (70.4%). This female
predominance has been noted in all case series like Tsirbas
2 3
and Wormald (65.1%) and Ressiniotis T. et al (75.9%). The
patients operated in our series were in the age range of 12
years to 65 years with a meaN age of 30.3 years. This is
somewhat lesser as compared to the age range of 3 years to 89
years, with a mean of 59 years in the study by Tsirbas and
2
Wormald and mean age of 75 years in the study by
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

3
Ressiniotis T. et al . In our series majority of the cases had left
sided disease (59.3%). This finding is similar to that reported
3
by Ressiniotis T. et al (53.6%) . However there is no
explanation for this type of side preponderance of the disease.
The commonest symptom in our case series was epiphora
which was found in all cases and swelling over the medial
canthus of eye which was note in 18 (22.2%) cases. This
symptom profile is also noted by other authors like Tsirbas
2 3
and Wormald and Ressiniotis T. et al . 15 (18.5%) of our cases
needed septoplasty to correct the deviation of nasal septum
and to create enough space to introduce the instruments
2
required for the procedure. Tsirbas and Wormald have also
reported need for nasal septal surgery as an adjunct to DCR in
46% of their cases. In 15 (18.5%) of the 81 case there were
granulations and synechia in the nasal cavity on follow up.
Similar rate (14.9%) of post operative granulation and
4
synechia formation was also noted by Kansua L. et al . We
could achieve a success rate of 86.4%. There is almost similar
success rate reported by other authors, ranging from 100% by
5 7 2
Rice D. , Sprekelson 96%, Tsirbas & Wormald 89% ,
8 6
Whidenbecher 86% to 83% by Whittet HB et al .
Conclusion:
In line with contemporary literature, we conclude
that endoscopic endonasal DCR is a simple and minimally
invasive procedure which is highly effective in the successful
management of nasolacrimal duct obstruction. It has the
added advantage of being able to address any intranasal
pathology which could be the basic cause of the disease.
Avoidance of external scar and preservation of the lacrimal
pump system are significant plus points to the procedure.
References
1. Gupta N. History of Lacrimal Sac Surgery.In:Gupta N.
Endoscopic Dacryocystorhinostomy A Revolution. New
Delhi: Paragon International Publishers; 2006; p. 1-8.
2. A Tsirbas, P J Wormald. Mechanical endonasal
dacryocystorhinostomy with mucosal flaps, Br J
Ophthalmol 2003; 87: 43-47.
3. Ressiniotis T., Gerasimos MV, Vasilios TK, Sean C. and
Christopher N. Dacryocystorhinostomy. A report of 200
cases.BMC Ophthalmology 2005, 5:2.
4. Leyla Kansua, Erdinc Aydina, Suat Avcia, Ali Kalb,
Sansal Gedikb. Comparison of surgical outcomes of
endonasal dacryocystorhinostomy with or without
mucosal flaps. Auris Nasus Larynx International journal
of ORL & HNS October 2009; 36(5): 555-559.
5. Rice D. Endoscopic intranasal dacryocystorhinostomy
results in four patients. ArchOtolaryngol Head Neck Surg
1990; 116: 1061.
16
6. Whittet HB, Shun-Shin GA, Awdry P. Functional
endoscopic transnasal dacryocystorhinostomy. Eye 1993;
7: 545-549.
7. Sprekelsen MB, Barberan MT: Endoscopic
dacryocystorhinostomy: surgical technique and results.
Laryngoscope 1996; 106:187-189.
8. Weidenbecher M, Hosemann W, Buhr W: Endoscopic
endonasal dacryocystorhinostomy: results in 56 patients.
Annals of Otology Rhinology Laryngology 1994;
103:363-367
Address for correspondence
Sharan kumar Shetty
Department of ENT,
Kamineni Institute of Medical Sciences, Sreepuram,
Narketpally, Nalgonda,Andhra Pradesh – 508254.
E mail : drsharanshetty@in.com
Cell+91 9287522325
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

17
Main Article
A study of the corelation of the clinical features, radiological evaluation and operative findings in
chronic suppurative otitis media with cholesteatoma
1 2, 3 4 5
Santosh U.P , Dr. S.M Siddalingappa Sheeba Mathew , Vinay Bhat , Deepak Janardhan - Davangere
( Karnataka)
Introduction
The middle ear cholesteatoma, most often acquired than
congenital, is the main complication of COM, from the
ingrowth of keratinising squamous epithelium from external
auditory canal skin to middle ear, through the tympanic
membrane. It is a very common disease in India and also other
developing countries where conditions like poverty, over
crowding, illiteracy and poor hygiene are very common. With
the availability of antibiotics, operative microscope and the
microsurgical operating instruments it has become easier to
s u c c e s s f u l l y t r e a t m i d d l e e a r i n f e c t i o n a n d
cholesteatoma.Otoscopic examination with the use of
binocular microscope is imperative. The characteristic of
cholesteatoma is the lumen of the perforation containing
varying amount of epithelial debris. To minimize the
interpretative errors of the mild bone erosions, particularly the
tegmen, the lateral semicircular canal and horizontal potion of
the facial nerve canal, familiarity with the radiographic
variations and comparisons with the normal side are
1
valuable . Prior to the availability of high resolution C.T., the
mainstay of roentgenographic diagnosis of cholesteatoma
was conventional filming and complex motion tomography.
The radiographic appearances do not generally affect the
surgical approach or the course of the operation which must
be exploratory. Tomographic investigation is needed when
the diagnosis is in doubt, as when the ear drum is obscured or
when complications develop, but should not cause delay in
instituting necessary surgery. A C.T scan may be valuable in
early diagnosis of cholesteatoma, when the disease is
confined to
attic or posterior tympanum, beyond otoscopic view. On
occasion, a decision to operate may hinge on the detection of
cholesteatoma presence by C.T scan alone. This article is for
the budding ENT surgeons to appreciate the importance of
correlating the clinico radiological findings to anticipate,
associate and finally to go about during surgery.
Materials and methods
This study group includes 30 patients who underwent
surgical exploration of middle ear and or mastoid, for the
removal of cholesteatoma. All patients had preoperative
evaluation by otoscopy or EUM (examination under
microscopy) and by plain X ray mastoid / CT scanning. These
cases included only those suspected of chronic suppurative
otitis media with cholesteatoma; and those cases that have no
findings suggestive of cholesteatoma in the middle ear on
examination and those diagnosed with congenital
cholesteatoma were excluded from the study. The cases were
taken from the otorhinolaryngology department of Bapuji
Hospital and Chigateri Hospital, Teaching Hospitals attached
to J.J.M.Medical College, Davangere, in a period of two years
from December 2007 to October 2009.A detailed clinical
history, with otoscopic examination was performed for all
these cases. Some of the cases required EUM, to know the
extent of the cholesteatoma or the bony erosion. Radiological
investigation consisted of both conventional plain
radiography and computerized tomography. Conventional
plain radiography was in the form of a lateral oblique view
(Law's) of both ears. In computerized tomography, high
resolution serial 3 mm thick sections were obtained in both
axial and coronal planes. Taking into consideration the cost of
both the radiological methods of evaluation, X-ray was more
affordable and convenient for the patients. Most of these 30
patients came from a low socio economic status. Following
mastoid exploration, for about 18 patients CWU procedure
was performed, while the rest of the cases required CWD
procedure. Out of the 12 cases of CWD techniques, 4 required
radical mastoidectomy and two cases underwent facial nerve
decompression.
Results
Cholesteatoma with granulation was the commonest feature
seen in the patients, followed by 6 (20%) patients who showed
only cholesteatoma flakes. 6 (20%) patients presented with
polypoidal mass in the external auditory canal obscuring the
view of the tympanic membrane, of which 4 were with foul
smelling cholesteatoma flakes. 2 (6.6%) patients had
posterior canal wall sagging with cholesteatoma. In our study,
in 13 patients ossicular involvement of the disease could be
visualized, mostly through microscopic examination, out of
which 9 patients showed absence of incus and 8 cases showed
malleus erosion. However, stapes involvement could not be
1,2 3,4,5
Professor, Resident Dept of Otolaryngology,JJM Medical College Davangere (Karnataka)
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

assessed. All the X-rays of involved ears showed sclerotic
mastoid. 26 (86.6%) of these patients showed cavity lesions in
the X-rays, among which attic, aditus and antrum were
involved in 13 (43.3%) cases. In 9 (30%) out of the 26
patients, mastoid was also involved. Computed tomography
was done in 10 patients. Preoperative computed tomography
diagnosis of cholesteatoma was made in all these cases. The
hall mark of cholesteatoma was non-dependent soft tissue
mass alone and/or bony erosion or smooth bony expansion
was present in all these cases. On HRCT, epitympanum and
antrum were the commonest sites of cholesteatoma, 90%
each. 6 (60%) of the cases showed involvement of
mesotympanum. Perilabyrinthine cells were involved in only
one case. Destruction of malleus could be identified in 8
(80%) cases. Incus was eroded in 9 (90%) cases. However,
stapes involvement could be seen in only one the cases.
Preoperative HRCT diagnosed dehiscence of horizontal
segment of facial canal in 2 (20%) cases. Lateral semicircular
canal erosion, sinus plate dehiscence, mastoid cortex
dehiscence was seen in 3 patients each. Postauricular abscess
and brain abscess was seen in (20%) each.In our study
27(90%) patients showed cholesteatoma on surgical
exploration and the remaining 3(10%) patients showed
pathologies like granulation tissue and mucosal hypertrophy.
Among these 27 patients only 20(66.6%) patients correlated
well with the otoscopic findings of cholesteatoma with or
without granulation tissue or polyp. All 3(10%) patients in
whom only polypoidal mass was seen on otoscopic
examination, there was associated cholesteatoma sac or
debris seen on surgical exploration. Mucosal hypertrophy
observed in surgical exploration was missed out in one case in
which otoscopic findings showed foul smelling discharge
with granulation tissue. Ossicular erosion could be
appreciated by otoscopy or EUM in only 13 cases and all these
cases showed malleolar or incus erosion which were in
agreement with the corresponding surgical findings. There
was correlation of 26 cases between the conventional mastoid
X-ray findings and surgical findings for the diagnosis of
cholesteatoma. Comparing the extent of cholesteatoma there
was an agreement of 13 (43.3%) cases seen between
preoperative radiological and surgical findings in the attic,
aditus and antrum. The 10 patients, in whom computed
tomography was done, HRCT found to be very sensitive in
diagnosing cholesteatoma accurately,(ie), the true positive
were seen in 90% of the cases. However HRCT could not
differentiate cholesteatoma from granulations in one case. In
case of conventional radiography, there was an agreement of
26(86.6%) cases with the surgical findings but the one of the
cases could not be diagnosed with the plain X-ray. There were
18
Discussion
Cholesteatoma as defined by Schuknecht, is the accumulation
of exfoliated keratin in the middle ear or any pneumatised area
of the temporal bone, rising from the keratinized squamous
epithelium. Histologically, it comprises of perimatrix of
subepithelial connective tissue with collagen fibres, elastic
fibres, fibroblasts and inflammatory cells, together with
matrix and cystic content.
Otoscopic examination- Based on the observations of
Bluestone et al, the diagnosis of cholesteatoma is most
effectively made with an otoscopic or, more accurately, with
2
the otomicroscope . In this study there were 20 (66.6%) cases
which showed characteristic cholesteatoma flakes on
examination, with or without granulation tissue or polyp. All
these were in agreement with the surgical findings. 5(16.6%)
cases showed granulation tissue on examination, but 4 cases
among this also showed scant cholesteatoma flakes confined
to the attic or both attic and antrum on surgical exploration.
3
This was in accordance to the results of Proctor Bruce which
suggested the association of granulation tissue in 93-95% of
the cases of cholesteatoma. Polyp was seen in 2(6.6%) and
4(13.3%) patients presented with polyp in association with
cholesteatoma on otoscopic examination. In very inflamed
20(66.6%) of true positive cases whereas 7 false negative
cases, that is, those cases in which there was no evidence of
cholesteatoma on otoscopic examination. ears, a
cholesteatoma may not be visible at the first presentation.
Sometimes there is an aural polyp obscuring the attic or
posterior pars tensa; such a case should be assumed to be a
4
cholesteatoma until proved otherwise . In this study all these 6
cases correlated well with surgical findings and showed
cholesteatoma on surgical exploration.
Radiological examination- A conventional plain X ray or a
CT scan provides information about congenital anatomic
variations that may be encountered during surgery, as well as
5
the complications of cholesteatoma. HRCT provides a more
precise definition of the anatomic extent of the disease of the
middle ear and the relationship of these cholesteatoma masses
to the contiguous structures. The hallmarks of cholesteatoma
are the presence of soft tissue density in the middle ear cavity,
ossicular erosions, smooth erosions of the middle ear borders
and adjacent structures.In this study of the 30 patients
reviewed, 26 (86.6%) patients were accurately diagnosed
with cholesteatoma and correlated well with the surgical
findings. Earlier series have given rates of detection of
surgically confirmed cholesteatomas of about 45% - 75%.
7
Mac Millian detected cholesteatomas in 45% of cases with
8,9
law projection and Brunner et al. detected cholesteatoma in
58% of cases with multiple plain films. The plain films
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

demonstrated the extent of the disease in all these cases. The
bony erosion could be appreciated including attic, antrum and
mastoid, but however, the ossicular erosions were not well
visualized. Out of the 26 patients majority of the cavity lesion,
13(43.3%), was seen in the atticoantral region, with widening
of the aditus. Preoperative CT scan could diagnose soft tissue
density mass in all the 10 patients, with one false positive
5 10
interpretation. Mafee had similar results, whereas Jackler
11
and Garber found it to be less sensitive and specific.
However, CT scan is less sensitive in differentiating
cholesteatoma from granulations. Most authors are in
10
agreement with this finding. In this study, homogenous and
soft tissue densities were present in the mastoid antrum and
middle ear cavity. About 30% of the cases had both
granulation tissue and cholesteatoma which could not be
radiographically distinguished. Cholesteatoma sac,
associated with granulation tissue, mucosal oedema and
10
effusion may be indistinguishable on CT scanning.
Although cholesteatoma is said to show a lower attenuation
than granulation tissue the difference is subtleand only
5
magnetic resonance imaging can differentiate the two.
Bony erosion, an additional sign for the presence of
cholesteatoma was identified in 9 of the 10 cases. This is
10
comparable to the reports by Jackler et a1 who found
cholesteatoma to be present in 80% of the cases with bony
erosion who were explored.In this study, CT was found to be
most accurate in identifying ossicular destruction, which is in
5 10
consonance with studies by Mafee et al , and Jackler et al . CT
detected ossicular destruction in 9 of 10 the patients who had
5
such lesion on surgery. Mafee et a1 were able to define the
state of the ossicular chain in 89% of cases scanned and
10
Jackler et a1 were able to predict the state of the ossicular
chain in 83.3% of their cases. In this study incus was most
commonly involved and CT could identify involvement of the
incus in 9 of the 10 cases, with destruction found during
surgery. Dehiscence of the horizontal part of the facial canal
was accurately diagnosed in 2 cases. In the studies performed
10
by Jackler
Conclusion
The diagnosis of cholesteatoma can be made with both
otoscopic examination and radiological evaluation. In this
study, 66.6% patients, on otoscopic examination revealed
cholesteatoma, and were in agreement with the surgical
findings, while 86.6% patients, showed true positive cases on
radiological examination. Thus there was good correlation
between the radiological evaluation and the surgical
diagnosis of cholesteatoma compared to the otoscopic
diagnosis. CT scan is valuable in cases suspected of
intracranial complications and in those cases in which
19
diagnosis is not obvious. Cholesteatoma in hidden areas and
ossicular destruction can be revealed with CT scan, which
cannot be assessed on otoscopic examination. CT scan was
found to be specific in the diagnosis of cholesteatoma and also
in cases of lateral semicircular erosion, facial nerve canal
dehiscence, sinus plate and mastoid cortex destruction.
References
1. Jackler RK, Witham P. Dillon, Schindler RA. Computed
tomography in suppurative ear disease: a correlation of
surgical and radiographic findings. Laryngoscope 1984;
94: p. 746-752.
2. Bluestone Charles D, Klein JO. Intracranial complications
and sequelae of Otitis media. In : Bluestone CD eds.
Paediatric Otolaryngology. WB Saunders, Philadelphia,
nd
1990.2 ed: Vol 1. p. 738-740.
3. Proctor B. Chronic otitis media and mastoiditis. In:
Paparella MM, Shumrick DA eds Otolaryngology (Otology
rd
and Neurotology). WB Saunders, Philadelphia 1991. 3 ed;
Vol2: p. 1366.
4. Scott-Brown's. Chronic otitis media. In :
Otorhinolaryngology, Head and Neck surgery. Gleeson M,
Browning GG, Burton MJ, Clarke R, Hibbert J, Jones NS,
th
et al, edts. Chapter 237, 7 edn. Vol. 3. Edward Arnold
(Publishers) Ltd, Great Britain; 2008. P. 3395-3397.
5. Mafee MF, Levin BL, Applebaum EL, Campos CF.
Cholesteatoma of the middle ear and mastoid. Otolaryngol
Clin North Am. 1988; 21:p. 265-268.
6. Lin DPC, Bergeron RT. Contemporary radiological
imaging in the evaluation of the middle ear – attic – antral
complex cholesteatoma. Otolaryngol Clin North Am 1989;
22: p. 897-909.
7. Mac Millian AS: radiologic diagnosis of Neuro-otologic
problems by conventional radiology. Arch Otolaryngol
1969; 89: p. 78-82.
8. Brunner S, Peterson O, Sandberg LE. Tomography in
cholesteatoma of the temporal bone. Correlation between
the standard roentgenographic examinations and
tomography. AJR 1966; 97: p. 588-596.
9. Coel MN, Godwin D. Simplified plain film screening
examination for erosive otitis media. AJR 1979; 133.
10. Jackler RK, Witham P. Dillon, Schindler RA. Computed
tomography in suppurative ear disease: a correlation of
surgical and radiographic findings. Laryngoscope 1984;
94:p.746-752.
Address for correspondence
Santosh U.P.
Prof. Dept of Otolaryngology,
JJM Medical College, Davangere (Karnataka)
E Mail: drsantoshup@gmail.com Cell +91 9845155223
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

20
Main Article
Tumours of maxilla
1 2 3
Darshan V Doshi , J. A. Contractor , I. K. Aditya - Ahmedabad, Surat ( Gujarat)
Abstract: Background. The aim of the study was to calculate the incidence of maxillary tomour, to study the clinical
presentation, to evaluate the investigation measures and their usefulness, to apply and study the various mode of treatment and
their outcomes and to determine the prognosis and factors affecting the prognosis of maxillary tumors.
Methods. This prospective and retrospective study had included 35 patients of tumours of maxilla who presented to New Civil
Hospital, Surat from Jan. 2001 to Dec. 2004 . They were regularly followed up till Dec. 2006.
Results. There is an average 6 months of delay in presentation with the range of 2-18 months. Two year survival rate was
80%. Five year survival rate was 70 %.Neck metastasis was an ominous sign with 3 year survival rate was 50%. Postoperative
RT improves survival.
Conclusion. Unsatisfactory results could be duo to rarity of tumour, delay in diagnosis, complex anatomy of the region with
proximity to vital structures which makes the surgeons and radiotherapist reluctant to treat the tumour aggressively, histology of
tumour and preference and compliance of patient. The prognosis of cancer of maxilla has been improved over the last thirty
years, due to improved investigative measures, surgical techniques and newer radiotherapy techniques.
Keywords: clinical study, maxillary tumour, reviews of literature, outcomes, and prognostic factors.candidates only 1 came for
BERA, which was suggestive of bilateral SNHL (0.76%)
Key Words: OAE, hearing loss
Introduction:
The neoplasm of sinonasal tract are rare representing only 3%
of all upper aero digestive tract and about 0.3-0.8% of all
1
human malignancies. Cancer of the nose and paranasal
sinuses has been reported to be more frequent in workers
exposed to nickel, Chromium, leather, and wood dust. Leather
and wood dusts were associated more with adenocarcinoma
than with squamous cell carcinoma. Both primary and
secondary tobacco smoke also appear to be related to an
increased incidence of sinonasal cancer, particularly
2
squamous cell carcinoma. The benign or malignant nature of
the tumours can only be determined after a correct
histopathological diagnosis, as the clinical presentation of
both are often similar. The neoplasm of maxillary sinus is
most common sino- nasal neoplasm. By the time maxillary
tumours presented to a consultant, they are in an advanced
stage with 6-12 months of symptoms duo to their rarity and
3
clinical symptoms simulating chronic sinusitis. The
lymphatic drainage of posterior part goes primarily to
retropharyngeal and lateral pharyngeal nodes at base skull,
and then to the upper jugular lymph nodes. Cancer of the
anterior part spreads to the submandibular and upper jugular
lymph nodes. Lymphatic spread is evident on initial
presentation in approximately 10% of patients; an additional
15% of patients will develop lymph node metastasis at some
point after treatment. For squamous cell carcinoma, the rate of
distal metastasis is approximately 10%, it rarely occurs in the
2
absence of local recurrence. Availabilities of nasal telescope,
CT scan and MRI help to arrive at early diagnosis and proper
assessment of tumour. The treatment protocol for benign
tumour is surgery while malignant tumours are treated by
surgery, radiotherapy, and chemotherapy alone or in various
4
combinations. The surgerical incision for maxillectomy are
Lateral rhinotomy, Weber-Ferguson incision, Weber-
Ferguson incision with Lynch extension, Weber-Ferguson
incision with lateral subcilliary extension and Weber-
Ferguson incision with subcilliary and supracilliary
extension. Surgery for maxillary tumour includes medial
maxillectomy, peroral partial maxillectomy, sub total
maxillectomy, total maxillectomy, radical maxillectomy with
5
orbital exenteration. If benign tumour are completely
6
excised, they rarely recure. Resent advances in the diagnosis
and treatment of patients with maxillary sinus cancer have had
a clear impact on our ability to control the disease and improve
survival. Survival rates have improved from 25% to 40% in
2
the 1960s, to 65% to 75% in most recently reported series.
Material and Method:
The Study was conducted in the Dept. of ENT-HNS, New
Civil Hospital, Surat, over the duration of 6 years from Jan,
1 2
Consultant Head and Neck Cancer Surgeon, Ahmedabad, Gujarat., J. A. Contractor Professor, and Head ,
3
Associate Professor of Department of ENT & HNS Govt. Medical College and New Civil Hospital, Surat
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

2001 to Dec, 2006.All patients with clinical diagnosis of
maxillary tumor were included. Non-neoplastic and
inflammatory conditions were excluded. All such patients
were subjected to detailed history & Clinical examination
which included general examination, ENT examination, oral
cavity examination, local examination of cheek swelling,
ophthalmic examination, neck node examination and
systemic examination. Routine investigations for major
surgery and Contrast Enhanced CT scan paranasalsinus were
done in all the patients. Material for histopathological
diagnosis was obtained from cheek swelling by FNAC or
biopsy from nasal mass, oral cavity or maxillary sinus via
Caldwell luc approach. AJCC classification (2002) was used
7
to stage the malignancy. Preoperative dental impressions
were taken in all patients for post operative rehabilitation.
Patients were treated according to the disease stage. All the
patients were regularly followed up with strict vigilance on
residual or recurrence of the tumour. The follow up period
ranged from 5 years to 2 years and stander protocol for follow
4
up were used.
Results:
After a detailed study of 35 patients of tumours of maxilla, I
found malignant tumours were 6 times more common than
benign tumours. The incidence of maxillary malignancy was
3.4% of all head and neck cancers. Benign tumours were more
nd rd
common in male of 2 and 3 decade. Maximum age
th
incidence of malignancy was in the 6 decade with median
age of 51.5 years. Only 9 patients were exposed to tobacco in
some other ways. In my study the most common symptom
was facial (75%) in both benign and malignant tumours.
Nasal symptoms coming to next i.e. 75% in benign tumors
and 40% in malignant tumour and orodental symptoms
occurring in 25% and 35% of cases of benign and malignant
tumours respectively. The range of the duration of symptoms
was 2-18 months with the median duration of 6 months. In my
study, 6 out of 30 had lymphatic metastasis. All the patients
with neck metastasis had squamous cell carcinoma (SCC).
Benign tumours found in our study were heamangioma in 2
patients, fibrous dysplasia in 2 patients and cementoosifying
fibroma in 1 patients and in case of malignant tumours we
found 24 patients of SCC, 3 patients of sarcomas, 2 patients of
salivary gland malignancies and 1 patient of malignant
melanoma. Regarding the AJCC staging 8, 12 and 10 patients
were in stage 2, stage 3 and stage 4 respectively, while none of
the patient was in stage 1. Outof 8 patients of stage 2, 6 were
treated by total maxillectomy and 2 had taken curative
radiotherapy. After total maxillectomy, 2 patients had
recurrence and 2 year and 5 year survival rate were 83.3% and
66.7% respectively. After radiotherapy, both the patient had
21
recurrence in one year follow. All 12 patients of stage 3 were
treated by either total or extended maxillectomy and post
operative radiotherapy. After maxillectomy and post
operative radiotherapy, 1 patient had residual disease and 2
year and 5 year survival rate were 91 % and 66% respectively.
Out 10 patients of stage 4, 5 were treated by total
maxillectomy with neck dissection and post operative
radiotherapy and 5 had taken palliative radiotherapy. After
total maxillectomy with neck dissection and post operative
radiotherapy, 1 patient had residual disease and 1 had
recurrence and 2 year and 5 year survival rate were 60% and
40% respectively. After radiotherapy, 4 patients had residual
disease and one had recurrence in one year follow.
All the benign tumors were treated by surgery either subtotal
maxillectomy with preservation of orbital floor (4 patients) or
partial medial maxillectomy (1 patient). At end of 3 years
follow-up, none of the patient had residual disease or
recurrence.
24 patients had taken radiotherapy. Out of them 4 patients had
mucositis(In Bush & Bugshav series 4 patients), 1 patient had
serous otitis media(None in Bush & Bugshav series), 1 had
osteoredionecrosis(In Bush & Bugshav series 2 patients), 2
had neck fibrosis(None in Bush & Bugshav series) and 1 had
trismus(None in Bush & Bugshav series). In Bush & Bugshav
series 2 patients had blindness while in our series none of the
patient had blindness after radiotherapy. After surgery 2 had
ectropion, 1 had wound gapping and 1 had maggots in
operated cavity.
Discussion:
Compared with the malignant tumour, benign tumours of
maxilla are rare and present in early age with male
predominance. Surgery is the treatment of choice for benign
tumors and if completely excised they rarely recur. In my
study one case was heamangioma of maxillary sinus, which
was previously operated outside civil hospital, Surat and
came to us with recurrence and was completely excised. In
three years of follow up none of the patient with benign
tumour had residual tumour or recurrence.
Unlike to other study, in the present study, I found that there
was no significant male predominance (M: F was 1.2:1) in
1
malignant maxillary tumour. There is an average 5-6 months
of delay in the presentation which contributes the poor
9
prognosis. The symptoms of maxillary sinus malignancy
depend upon extent and direction of spread and site of
1
tumors. two patient of stage 3 who refused for surgery and
received radiotherapy had not obtained cure and died within 2
years. Two patients of stage 3 disease, who were advised for
postoperative radiotherapy but had refused for the same due
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

to fear of eye complication of radiotherapy, had developed
recurrence and died within 3 years. So patient's compliance
contributes the poor prognosis. All the patients who had
residual disease received chemotherapy, so chemotherapy is
only for palliative treatment. Two patients received curative
RT but they had recurrence and when they came for follow up
the tumors were too advanced to treat and died within 3 years
Due to newer technique of RT, the chances of grave
complications likes osteoradionecrosis and blindness were
rare.
Survival rate
After RT , My series - 40% 1 year survival and all died before
2
3 years. Badib et al - 33% 4 year survival , Bush &Bugshaw -
13
33% 5 year survival
After Surgery- My series – 83% 2 year survival, 66% 5
13
year survival, Bush & Budshaw - 75% 5 year survival
After Surgery followed by RT, My series – 84% 2 year
survival,2% 5 year survival, Bush & Budshaw - 50% 5
2
year survival, 65% to 75% in most recently reported series.
One patient had lost for follow up and not included in
survival rate. Crude 2 year and 5 year survival rates were 80%
and 44% respectively.
Conclusion:
Delay in presentation, TNM Stage, Histology of the tumour,
Patient's preference and compliance for the treatment,
Combined modalities of treatment in stage II and IV, are the
key factors to determine the outcome of the maxillary tumors.
No significant improvement in crude 5 year survival rate and
it remains same as in the past. But 5 year survival rate has
improved significantly after curative treatment which is
comparable to the most resent reported series.
References:
1. J.C.Watkinson, M.N.Gage, J.N.Wilson: Stell & Maran's:
th
Head & Neck Surgery, 4 edition, Chap. 19, 377-96
2. Ehab Y.N. Hanna, Christopher T. Westfall; Cancer of the
Nasal Cavity, Paranasal Sinuses, and Orbit; In Eugene N.
Myers, James Y. Sune, Jeffrey N. Myers, Enab Y.N.
Hanna Editors; CANCER OF THE HEAD AND NECK;
th
4 edition; Chapter 9, 155-2o6.
3. Badib A.O. et al: Treatment of cancer of the Para nasal
sinus. Cancer, Vol.2; 533-537.
4. Jatin P. Shah, Snehal G. Patet; Nasal Cavity and
Paranasal Sinuses; In Jatin Shah; HEAD & NECK
rd
SURGERY & ONCOLOGY; 3 Edition; Chapter 3;
Page 57-93.
5. J.C.Watkinson, M.N.Gage, J.N.Wilson: Steii & Maran's:
th
Head & Neck Surgery, 4 edition, Chap. 2, 22-23
22
6. S. K. Das, Somnath Saha, L. M. Ghosh, A.
Bhowmick.haemangioma of maxillary sinus, Indian
Journal of Otolaryngology and Head & Neck Surgery,
Vol. 53, No. 1, 65-67.
th
7. AJCC cancer staging manual; 6 addition,59-67
8. Guo GF, Yang AK, Xie RH et al; Prognostic analysis of
151 patients with maxillary sinus malignant neoplasm.
Ai Zheng. 2004 Nov. 23(11 suppl.); 1456-50.
9. AL-Jhani AS et al: Maxillary sinus carcinoma, Natural
History and outcome. Sudi med J. 2004 Jul: 929-33.
10. Kingdom TT, Kalpan MJ: Mucosal melanoma of the
nasal cavity and paranasal sinuses. Head Neck 17 : 1995;
184-9
11. Sercarz JA, Mark RJ, Tran L, et al: Sarcoma of the nasal
cavity and Para nasal sinuses. Ann Rhinol Laryngol
1994 Sep; 103(9); 699-704.
12. Le QT, Fu KK, Kaplan et al; Treatment of maxillary
sinus carcinoma: A comparison of the 1997 and 1977
American Joint Committee on Cancer staging systems.
Cancer, 1999 Nov.1; 86(9): 1700-11
13. Malcom A. Bagshaw. Carcinoma of Para nasal
Sinuses.Cancer.Vol.50 154-158.July 1982
Address for correspondence
Dr. Darshan Doshi
5, Madhuvan apartment. Pragna soc.
B/H; Samved Hospital, Stadium 5 road
Navarangpura, Ahmedabad-380009
E-mail drdvdosho@yahoo.com
Cell +91 9825634964
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Introduction
The symptom of hoarseness is one with many causes and
several treatments. Whether the patient notices vocal fatigue
or says that it's harder to go with a worsening voice as the day
progresses, the underlying cause of hoarseness must be found.
Aims and objectives
The study was aimed to study the etiology of hoarseness of
voice in 100 cases.
Material and Method
The present study was conducted on 100 patients of
hoarseness of voice attending ENT OPD and Indoor in ENT
ward. A thorough clinical history, clinical and ENT
examination were done,
Observations
In the present series, the peak incidence of laryngeal diseases
was in the 4th decade (31%) of life though the age range was
from 10 years to 86 years .66% were males and 34% were
females thereby showing male preponderance in the present
study. Labourers (24%) formed the predominant group
followed by housewives (20%), farmers (14%) and students
(8%). Out of all intralaryngeal causes (88%), vocal
nodule(18%) formed the most common etiology followed by
carcinoma larynx(15%), chronic hyperemic laryngitis
(14%),chronic hyperplastic laryngitis(12%), acute
laryngitis(10%), vocal polyp(8%), tubercular laryngitis(5%)
,benign tumours (3%), radiotherapy induced (2%) and
external trauma in 1 % case only. While out of extralaryngeal
cases (12%), neurological (10%) and functional (2%) were
responsible for etiology of hoarseness.
Discussion
In the present study, the maximum cases were found in the
fourth decade accounting for 31%. The findings are in
consistence with study of Ghosh et al (2001). In the present
study, the main bulk of patients who complained of
hoarseness consisted of labourers (24%) followed by
housewives (20%), The findings of above study are in
consistence with study of Baitha et al (2002) where labourers
(36.36%) constituted the single largest group followed by
housewives(21.81%). In the present study, majority of cases
of hoarseness (88%) had pathology in larynx while only 12%
had extralaryngeal pathology which included vocal cord
23
Main Article
Aetiological study of 100 cases of hoarseness of voice
1 2 3
Harvinder Kumar , Sonia Seth , Deep Kishore -Hisar ( Haryana)
palsy (10%) and functional dysphonia (2%). The majority of
the patients of hoarseness (95%) had intralaryngeal pathology
and only 5% had extralaryngeal cause which included vocal
cord palsy (3%) and functional dysphonia (2%).
In the present study, vocal nodules (18%) formed the most
common etiology. Chopra and Kapoor (1997) also reported
the incidence of vocal nodules (33%) as highest in their study
In the present study, the incidence of carcinoma larynx was
15% cases. It was consistent with the findings of Parikh
(1991) who reported incidence of carcinoma larynx to be 12%
.In the present study, extralaryngeal causes formed 12% of
total causes of hoarseness. Baitha et al (2002) reported
extralaryngeal causes to be 9.09% of total causes of
hoarseness. All the cases (100%) were of neurological (vocal
cord palsy).
Summary and Conclusion
The peak incidence was in the 4th decade of life. Male
preponderance was seen. Labourers formed the predominant
group. Amongst intralaryngeal etiologies, vocal nodules
formed the most common cause while out of extralaryngeal
causes, neurological cause was predominant etiology.
References
1. Baitha S, Raizada RM, Singh AK et al (2002): Clinical
profile of hoarseness of voice. Indian Journal of
Otolaryngology and Head and Neck Surgery 54: 14-18.
2. Chopra and Kapoor (1997): Study of benign glottic
lesions undergoing microlaryngeal surgery. Indian
Journal of Otolaryngology and Head and Neck Surgery
49: 276-279.
3. Ghosh SK, Chattopadhyay S, Bora H et al (2001):
Microlaryngoscopic study of 100 cases of hoarseness of
voice. Indian Journal of Otolaryngology and Head and
Neck Surgery 53: 270-272.
Address for correspondence
Dr. Harvinder Kaur
Assoc Prof & Head
Maharaja Agrasen Medical College,
Agroha.Hisar ( Haryana)
E mail: drharvinderent@gmail.com
Cell +91 9416345395
1 2 3
Associate Professor & Head, Associate Professor, Senior Resident Maharaja Agrasen Medical College,
Agroha.Hisar ( Haryana)
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Introduction-
Malignant external otitis (MEO) is a severe infection of the
external auditory canal, generally due to pseudomonas, most
commonly affecting elderly diabetics. The condition is
characterized by deep seated, excruciating, continuous ear
pain, resistant to analgesics and worse at night; persistent pus
discharge from the ear and granulations at the junction of the
osseous and cartilaginous portions of the external auditory
canal. The pathogenesis of MEO most probably depends on
some underlying alterations in the immune system and the
peculiar microbiological characteristics of the bacteria. Once
the organism is established in the susceptible external canal, it
can spread in three directions: (1) anteriorly through the
fissures of Santorini to involve the infratemporal fossa,
parotid gland and facial nerve at the stylomastoid foramen;
(2) posteriorly to invade the mastoid process and the vertical
portion of the facial nerve; (3) medially as an osteomyelitis
affecting the jugular foramen, thereby involving the cranial
nerves IX, X, XI and XII and possibly causing jugular venous
thrombosis, brain abscess or death. Though granulations in
the external auditory canal is usually a characteristic feature
of MEO, the patient can sometimes present with a normal
external auditory canal, as was the case in the patient who
presented to us.There is no single imaging modality to
accurately evaluate the extent of the disease and the response
to treatment. Computerised Tomography (CT) with the ability
to delineate normal fat planes and the bony cortices has been
the preferred imaging modality for evaluation of MEO. Ismail
et al proposed that MRI should be used as the primary
imaging modality in MEO and to monitor disease
24
Case report
Malignant external otitis – an atypical presentation and management dilemma
1 2
George A. Mathew , Kamal Kishore - Ludhiana (Punjab)
Abstract
Malignant external otitis is a disease predominantly of elderly diabetics caused most often by Pseudomonas. Classical features
include severe ear pain, otorrhoea and granulations in the floor of the external auditory canal. Advanced infections can cause
skull base osteomyelitis, multiple cranial nerve palsies and temporomandibular joint involvement. Though high resolution CT
scan of the temporal bone has been the primary imaging modality of choice, MRI of the skullbase is emerging as a very useful
tool to diagnosis and to monitor the response to treatment. Treatment consists of prolonged systemic antibiotics combined with
aural toilet, removal of granulations in the external auditory canal and control of diabetes. Although systemic ciprofloxacin is
the drug of choice, ceftazidime is increasingly being used due to the development of resistance to fluroquinolones. Surgical
debridement is to be used judiciously and sparingly because of the risk of spreading the infection into uninvolved tissues.
Key Words: Malignant external otitis (MEO), MRI skull base, Prolonged medical management
progression. Both morbidity and mortality can be reduced
significantly, if MEO is diagnosed early and treated
aggressively, the mainstay of treatment being a suitable and
sufficiently protracted course of antibiotics. Treatment
strategies have changed significantly over time. Surgical
debridement, once the mainstay of treatment has been
superseded by systemic antibiotic therapy. In particular, oral
quinolones such as ciprofloxacin are highly effective against
pseudomonas. This provides good bone bioavailability and
can be taken orally. This drug given in combination with a
third or fourth generation cephalosporin may provide optimal
antibiotic therapy. Topical antibiotics have no role in
treatment. Grandis et al assert that there is no role for surgical
management in MEO other than diagnostic biopsies. Total
surgical eradication is impractical because of deep
penetration into the skull base as well as lack of demarcation
lines in this diffuse pathological process; furthermore, a noninvolved
middle ear or mastoid cavity may become infected
after extensive surgery.
Case report-
A 65 year old diabetic lady was referred to ENT from the
Neurology department with complaints of severe right sided
headache and ear pain of two weeks duration, not controlled
with analgesics, and facial palsy. On examination, she was
found to have a right sided grade 3 facial weakness. The
external auditory canal was normal and there was no tragal
tenderness. She had a large central perforation of the
tympanic membrane, but normal middle ear mucosa. The CT
scan of the temporal bone was reported to be normal. A
provisional diagnosis of malignant otitis externa was made
1 2
Assistant Professor, Senior Resident, Dept of ENT, Christian Medical College, Ludhiana ( Punjab)
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

and she was started on intravenous ceftazidime 6 gm daily,
and was continued for one week. The pain and facial palsy
recovered completely after one week, and the patient was
discharged on oral ciprofloxacin 750 mg twice daily. After
one month, she presented in OPD with complaints of severe
ear pain, dysphagia, and change in voice, cough and
aspiration. On examination, the external auditory canal was
normal and the facial nerve was intact. There was a reduced
gag reflex, deviation of tongue to the right and right vocal
cord paralysis indicative of a right sided IX, X and XII nerve
palsy. In view of the strong clinical suspicion of skull base
osteomyelitis, an MRI was done (fig 1), the T2W images
showed hyper intense lesion of the skull base extending to the
nasopharynx, and clival erosion. She was restarted on
intravenous ceftazidime 6 gm daily which was continued for
six weeks. The patient showed excellent clinical recovery
over six weeks with resolution of the pain, aspiration and
cough and her hypoglossal palsy recovered, though her vocal
cord palsy persisted. She was discharged on oral
ciprofloxacin 750 mg twice daily for six months, and has
remained pain free and recovery of cranial nerve deficits at six
months of follow up except for the right vocal cord palsy. An
MRI scan 6 months later (Fig 2) showed significantly less
enhancement than on the previous MRI.(Fig 1)
Discussion As the number of diabetics increase, the
complications of diabetes like MEO is likely to increase
significantly in the coming years. Though malignant external
otitis is a relatively uncommon disease, the protracted and
invasive nature of the disease with significant morbidity and
mortality in an untreated patient calls for an aggressive
management strategy. Lack of a strong clinical suspicion can
result in the condition being underdiagnosed, as may be the
situation in our country today. Also, general practitioners
need to be made aware of this clinical entity and the
availability of effective treatment. In the case which is
mentioned above, there were no granulations in the external
auditory canal. Inadequate antibiotic treatment given
elsewhere could be the reason why granulations were absent
in the external auditory canal with disease persisting in the
skull base. A prevalent trend of extensive surgical
debridement for MEO is seen in India. Clinicians need to be
made aware of the pitfalls of venturing into surgery without
appropriate long term medical management. Among the five
patients of MEO with skull base osteomyelitis seen in our
institution from Jan 2007 to November 2009 which
comprised four women and one man, all were elderly
diabetics over sixty years of age, three of them having
underwent surgical debridement elsewhere and continued to
have severe ear pain and granulations in the external auditory
25
canal, all could be managed medically with high dose
intravenous ceftazidime given for one to eight weeks with
oral ciprofloxacin given for a further six weeks to six months,
depending on the resolution of symptoms. At the end of
treatment, all the patients were pain free with complete
resolution of granulations in the external auditory canal and
the MRI confirmed significant reduction in the inflammation
at the skull base. The key to successful treatment is to
continue the antibiotic therapy for a sufficiently long period of
time, sometimes even for up to one year. Recurrences can
occur as long as one year later and therefore a patient should
not be considered cured until at least a year after the treatment
is initiated. A reasonable protocol to follow would be
intravenous ceftizidime 3-6 gm per day for one week with
local ear cleaning and removal of granulations in the external
auditory canal. If the condition improves and the bacteria is
sensitive to ciprofloxacin, the patient can be sent home on oral
ciprofloxacin 750 mg twice daily for six weeks to six months.
Conclusions
Malignant external otitis should be suspected in a diabetic
patient with deep seated ear pain and granulations in the floor
of the external auditory canal with or without cranial nerve
involvement. A strong clinical suspicion is required to rule out
skull base osteomyelitis in the absence of granulations in the
external auditory canal. MRI may be used as the primary
imaging modality and to monitor disease progression.
Malignant external otitis with or without skull base
osteomyelitis can be cured with a long-term, high-dose,
appropriate antibiotic treatment.
References
1. Amorosa.L, Modugno.G.C, Pirodda. A - Malignant
external otitis: Review of personal experience. Acta
Otolaryngologica (Stockh) 1994; 521: 1-14
2. Ismail H., Hellier W.P., Batty V. ; Use of magnetic
resonance imaging as the primary imaging modality in the
diagnosis and follow-up of malignant external otitis: The
Journal of Laryngology and Otology; 2004, 118, 7 Pg 576
3. Levenson MJ, Parisier FC, Dolitsky J, Bindra G.
Ciprofloxacin: drug of choice in the treatment of malignant
external otitis Laryngoscope 1991; 101: 821-824
4. Grandis RJ, Branstetter BF, Yu VL. The changing face of
malignant (necrotizing) external otitis: clinical, radiologic
& anatomical correlations. Lancet Infect Dis. 2004; 4:34-39
Address for correspondence:
Dr George A. Mathew,
Assistant Professor, Dept of ENT,
Christian Medical College, Vellore, Tamilnadu- 632004
E mail: georgemathew70@gmail.com
Cell +91 9486860490
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

27
Case report
Gingival granular cell tumour of newborn
1 2 3 4
Trupti R.Chopade M.V.Jagade , Ashish R.Gandhe , Dhyaneshwar Ahire -Mumbai
Abstract:
Gingival granular cell tumour of newborn, or congenital epulis, is an uncommon benign soft tissue lesion that usually arises
from the alveolar mucosa of neonates. We report a case of a 10 days-old female newborn, who presented with an intraoral
gingival mass .The lesion, was completely removed surgically and the patient had an uneventful postoperative course.
Clinical features and treatment approach are presented and discussed, emphasizing the necessity of a multidisciplinary
approach in such cases.
Introduction
The term gingival granular cell tumour of the newborn refers
to a rare gingival tumour that most commonly occurs along
the alveolar ridge of the maxilla in newborn girls, usually
without associated abnormalities of the teeth or additional
congenital malformations.It is also known as congenital
1
epulis or Neumann's tumor . Usually, it is presented as a single
2
lesion, however multiples cases have been reported . As
spontaneous regression is rare and larger tumors may cause
difficulty in feeding and respiration,surgical excision is the
treatment of choice.There are no reports in the literature about
2
the malignant transformation of the lesion .We have reported
one such case of a 10 days newborn came from the remote
place .The aim of such presentation is to create the awareness
among the otorhinolaryngologist regarding such congenital
gingival pathologies and its benign nature as well as surgical
saftey.It is a multidisciplinary approach which makes the
accurate diagnosis and plans the management .
Case report:
10 days old female newborn from a remote place visited to
ENT OPD with soft tissue mass along the maxillary alveolar
ridge.The parents gave history of this intraoral mass existing
since the birth of the baby.The baby was delivered full term
by vaginal delivery . The newborn was asymptomatic till the
date.She had no evidence of local trauma or respiratory
distress during the birth. The newborn was not having any
difficulty in feeding. No history of any bleeding from the
lesion.There was no significant change in the size of lesion
since birth.
On local examination there was a rubbery, pinkish polypoidal
,non tender mass of 1.5x1x0.5 cm was present with small
pedunculated stalk along the alveolar ridge.There was no
other abnormality noted on physical and systemic
examination.After all routine investigations were
done,patient underwent the excision of lesion from its
alveolar base using bipolar cautery under general
anaesthesia.Histological examination revealed abundant
polygonal cells with a coarse granular cytoplasm.The
diagnosis was gingival granular cell tumour of the newborn.
Discussion:
Gingival granular cell tumour is a rare benign tumour that
most often presents on the maxillary or mandibular alveolar
ridges.It is also known as congenital epulis which is
1
nonspecific term denoting the masses of gingiva . Congenital
1
granular cell tumor , first described by Neumann in
1871,hence also known as Neumann's tumour.The lesion is
more common in females than males(10 time more common
3
in female children) The GGCTN usually presents as single,
soft tissue mass ,smooth,firm but can occur as multiple
1
lesions in 5-16% of cases .It arise from maxillary alveolar
ridges thrice as often as from the mandibular ridges,especially
2
from the anterior portion . It is usually found in the region of
2
lateral incisors or canine region .Underlying bone is usually
spared. The histogenesis is uncertain, and proposed cells of
origin include odontogenic epithelium,undifferentiated
mesenchymal cells pericytes, fibroblasts, smooth muscle
5
cells,nerve related cells, and histiocytes .Histologically ,the
GGCTN is lined by squamous epithelium with central aspect
of the tumour contains polygonal cells with course granular
cytoplasm.scanty collagenous stroma surrounds these
cells.The reason for the female predominance is peculiar.An
10
endogenous hormonal stimulus has been proposed but this
theory is not proved,since detectable estrogen and
4
progesterone receptors within the lesions are lacking . Small
7
lesions may regress and larger lesions must be resected, as
they often interfere with airway patency and cause feeding
difficulties.Complete surgical excision is curative,usually
done under general anaesthesia but in case of difficult
intubation in large size tumours it can be done under local
2 1,3,4
Prof & Head, Resident Department of Otorhinolaryngology & Head and Neck Surgery
Grant Medical College and Sir J.J.group of Hospitals, Mumbai
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

6
anaesthesia as well .The differential diagnosis of GGCTN
includes haemangioma, fibroma, rhabdomyosarcoma,
teratoma, leiomyoma, congenital dermoid cyst. In the
literature, congenital epulis is reported to be an isolated
finding without associated congenital abnormalities, with the
exception of an occasional report of a hypoplastic or absent
5
underlying tooth . (A) Histopathological slide showing an
overlaying parakeratinized stratified squamous epithelium.
The vascularized stroma shows a benign proliferation of
round cells, with abundant eosinophilic granular cytoplasm
and small nuclei. A connective fibrous tissue layer is
separating the epithelium from the granular cells. (B) slide
showing the round granular cells with eosinophilic
cytoplasm, with small basophilic nuclei, occasionally placed
in an eccentric position
Although the congenital epulis is composed of granular cells
and is similar to the true granular cell tumor (granular cell
myoblastoma), the histology and epidemiology of these two
lesions differ. Granular cell tumors are less vascular, often
have a component of pseudoepitheliomatous hyperplasia,and
contain more conspicuous nerve bundles than do congenital
epulides. Congenital epulis only occur in the gum pads of
infants, whereas granular cell tumors usually occur in adults
7
(between 20 and 60 years of age) and may involve multiple
organs.Most importantly ,granule cell tumour can
recur,whereas ,there have been no reports of recurrence after
2
excision .The GGCTN is most oftenly detected soon after the
birth .Depending upon size of the lesion ,prenatal Ultra
sound,usually done during the last few weeks of pregnancy
8
may detect its presence in utero .Also ,fetal MRI and Doppler
6
helps to exclude the differential diagnosis .It also has
important implication in the planning the type of delivery
especially in the cases with large size lesions.The GGCTN
diagnosis and management is of interest for the oral and
maxillofacial surgeon, the radiologist, the anaesthetist, the
otorhinolaryngologist, the pediatrician and the obstetrician.
Although several professionals are involved with prenatal
and delivery care, sometimes a lesion such as the one reported
may cause surprise and concern to the medical team. The
interaction between professionals involved with the prenatal
care and those involved in the treatment of oral and
maxillofacial lesions and syndromes, would certainly
optimize the diagnosis and treatment approaches in such
cases.
References
1. Neumann E. Ein fall vin congenitale epulis. Arch Heilkd
1871; 12:189–190
2. Loyola AM, Gatti AF, Pinto DS Jr, Mesquita RA. Alveolar
and extra-alveolargranular cell lesions of the newborn: report
28
of case and review of literature. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 1997 Dec; 84(6):668-71.
3. Fuhr AH, Krogh PHJ. Congenital epulis of the newborn:
centennialview of the literature. J Oral Surg 1972; 30:30–35
4. Lack EE, Perez-Atayde AR, McGill TJ, Vawter GF.
Gingival granular cell tumor of the newborn (congenital
“epulis”): ultrastructural observations relating to
histogenesis. Hum Pathol 1982; 13: 686–689
5. Zarbo RJ, Lloyd RV, Beals TF, McClatchey KD.
Congenital gingival granular cell tumor with smooth muscle
cytodifferentiation.Oral Surg Oral Med Oral Pathol 1983;
56:512–520
6. Batsakis JG. Tumors of the peripheral nervous system. In:
Tumors of the Head and Neck, Clinical and Pathological
nd
Correlations. 2 ed. Baltimore, Md: Williams & Wilkins;
1979:313–333
7. Jenkins HR, Hill CM. Spontaneous regression of
congenital epulis of the newborn. Arch Dis Child 1989;
64:145–147
8. Nakata M, Anno K, Matsumori LT, Sumie M, Sase M,
Nakano T, et al.Prenatal diagnosis of congenital epulis: a case
report. Ultrasound Obstet Gynecol.2002 Dec; 20(6):627-9.
1.Photograph showing soft tissue mass over alveolar ridge
Address of correspondence:
Trupti R. Chopade
Department of otorhinolaryngology & head and neck
surgery
Grant medical college and sir j j group of hospitals,
Mumbai
E mail: trupti.chopade@yahoo.in
Cell+91 9890300596
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

29
Case report
Extranasopharyngeal angiofibroma in female
1 2 3 4
Shrinivas Shripatrao Chavan ,Sunil D. Deshmukh ,Vasant G. Pawar , Vaibhav G. Kirpan , Smita W.
5 6 7
Khobragade ,Kaustubh V. Sarvade , Rajan S. Bindu - Aurangabad ( Maharashtra).
Abstract: The Nasopharyngeal angiofibroma originating from the sphenopalatine foramen in an adolescent male is a typical
entity and is considered to be the rule of thumb. Hereby we highlight a case which challenges the long held dogma with atypical
patient profile in terms of age, sex and origin. We illustrate an interesting case of extranasopharyngeal angiofibroma in Female
in her twenties. Despite Maxillary sinus being the most common site of origin for extra nasopharygeal angiofibroma, this case
stands apart in showing extra nasopharyngeal angiofibroma arising from nasal septum, the rarest site encountered in clinical
scenario.
Keywords: Extranasopharyngeal Angiofibroma; Female; Nasal Septum; Endonasal approach.
Introduction:
The nasopharyngeal angiofibroma [NPA] is a widely
discussed Head and Neck tumour condition which is highly
vascular, noncapsulated, locally invasive, histologically
benign. It's propensity to bleed torrentially is regarded as a
bane for surgeon. It typically arises from the sphenopalatine
foramen in an adolescent male under the influence of
testosterone and is also known as juvenile nasopharyngeal
angiofibroma [JNA]. The hallmark histological feature is
vascular channels lined by endothelial cells devoid of muscle
layer interspersed in network of collagen fibres of varying
maturity. The fibrous vascular nodule of similar histological
appearance when found outside the nasopharynx and or
involves female sex and or involves different age group is
termed as Extranasophayngeal angiofibroma or Atypical
[ 1 , 2 , 3 ]
a n g i o f i r o m a . T h e r a r i t y o f
Extranasopharygealangiofibroma is evident by the study
conducted by De Vincintelis and Pineeli in 1980 where they
reported only 13 cases of Extranasopharygeal angiofibrma
.[4]
amongst 704 cases of Angiofiroma. As per literature
Maxillary sinus is the most common site for
Extarnasopharyngeal angiofibroma and Nasal septum
represents the rarest site with only 7 cases reported so far
[2, 5]
worldwide. The Extranasopharygeal angiofibroma has
been the topic of intense debate and speculation in terms of its
etiology and pathogenesis; hereby we put forward an
interesting case of extranasopharyngeal angiofibroma in a
female.
Case report:
A 24 year old female came to Otorhinolaryngology
department of our institute with chief complaints of right side
nasal obstruction since 1 year and history of sudden onset of
epistaxis since 10 days. There was no significant past medical
1 2 3 4, 5, 6
and surgical illness. On Nasal endoscopy the mass was
pinkish red in color, smooth in appearance, soft in consistency
and sensitive to touch. The probe could easily be passed on
lateral aspect but not on medial aspect. All routine
investigations were within normal limits. The CT- Scan of
PNS predicted a well defined enhancing mass measuring 1.5 x
1 cm in size occupying the right nasal cavity
Procedure: 1] On nasal endoscopy there was pinkish red mass
attached to the nasal septum with broad base pedicle.2] the
nasal mass was removed by cauterizing the pedicle and was
sent for Histopatholog.
CT scan showing nasal mass Removed nasal mass
Histopathology report of hematoxylene and eosin slides:
shows dilated vascular channels of varying size lined by
endothelial cells devoid of muscle layer surrounded by
fibrotic spindle shape stroma, nuclei are plump and elongated,
focal areas of haemorrhages seen. Features suggestive of
Angiofibroma. Considering the rarity of such lesion to be
labelled as angiofibroma it was imperative to also rule out
other vascular tumors encountered in nasal cavity.
Assistant Prof., Prof. & Head, Sr. Resident, Resident, Dept. Of ENT & Head and Neck Surgery,
7
Prof & Head Dept of Pathology, Govt. Medical College, Aurangabad (Maharashtra).
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

CD31 marking the blood vessels CD 34 marking the blood
separated by fibrous stroma vessels separated by fibrous stroma
The differential diagnoses which were considered were
hemangiopericytoma, capillary hemangioma, solitary fibrous
tumor and schwannoma.The marker study of CD 31 and CD
34 ruled out hemangiopericytoma and solitary fibrous tumour
from the equation.The preponderance of multiple vascular
channels of varying sizes characteristic of capillary
hemangioma was not observed on histology, negating the
possibility of capillary hemangioma.After ruling out all the
possible differentials of vascular tumours encountered in
th
nasal cavity we were able to report the world's 8 case of
Extranasopharyngeal angiofibroma attached to nasal septum.
Discussion:
The term juvenile nasopharyngeal angiofibroma is self
explanatory attributed to exclusive occurrence of the lesion in
nasopharyngeal area of adolescent male in their second and
[6, 7]
early third decade. The nasopharyngeal angiofibroma
originates from sphenopalatine foramen and extends to
adjacent areas namely nose, paranasal sinus, infratemporal
.[7]
fossa and cranium. According to Celik et al when a fibrous
vascular nodule occurs outside the nasopharynx and or
involves female sex and or involves other age group is termed
as Extranasopharyngeal angiofibroma or Atypical
.[3]
angiofibroma. The ENA is extremely rare compared to NPA
with minuscule number of cases reported in female. The ENA
produces quicker symptom and inherently can be less
vascular in nature.
The etiopathogenesis of JNPA is till date a debatable issue as
various theories has been put forward regarding its origin.
According to hormonal theory it is believed that
hamartomatous nidus of vascular tissue in nasopharynx gets
.[7,8]
activated in adolescent under influence of Testosterone. As
st
per vascular atavism theory 1 branchial arch artery [
nd th
Normally appears between 22 and 24 gestational age and
recedes completely by the delivery ] fails to regress
completely leaving behind the persistent remnant of plexus
close to the sphenopalatine foramen which forms the vascular
component of angiofibroma due to growth stimulus at the
.[9]
adolescent phase. Despite the plethora of theories no single
theory is in a state to define the origin of JNPA, so the origin of
30
ENPA still remains in the dark. The only possible theory
which is close in explaining the origin of ENPA in our case
report is the migration of Fascia Basils through the
.[5,10]
perpendicular plate of ethmoid to nasal septum. As per
literature Maxillary sinus is the most common site for origin
for ENPA but our case study stand apart showing attachment
to nasal septum the rare site encountered in clinical practice
.[2, 5]
as have been only seven cases reported so far worldwide.
As per theory, in any NPA as the age advances the fibrous
tissue surpasses the angiomatous tissue to be called as
Fibroangioma.
References:
1. Nomura K, Shimomura A, Awataguchi T, Murakami K,
Kobayashi T. A case of angiofibroma originating from the
inferior nasal turbinate .AurisNasus Larynx 2005; 33:
191 – 193.
2. ITasca and G CeroniCompadretti .Extranasopahryngeal
angiofibroma of nasal septum .a controversial entity.
ACTA Otorhinolaryngologica Italica .2008; 28: 312 –
314
3. Celik B, ErisenL,Saraydaroglu O, CoskunH.Atypical
angiofibromas:a report of four cases. Int J Pediatric
Otorhinolaryngology 2005; 69:415-421.
4. DeVincentiis G, Pinelli V. Rhinopharyngeal
angiofibroma in the pediatric age group. Clinical
– s t a t i s t i c a l c o n t r i b u t i o n . I n t J P e d i a t r i c
Otorhinolaryngology 1980; 2:99-122.
5. Handa K.K, Kumar A, Singh M.K, Chhabra A H.
Extranasopharyngeal angiofibroma arising from the
nasal septum. Int J Peadiatric Otorhinolaryngology2001;
58: 163- 166.
6. Akbas Y, AnadoluY .Extranasopharyngeal angiofibroma
of the head and neck in Women. Am J Otolaryngology
2003; 24; 413 – 416.
7. A n n a S z y m a n s k a , E l z b i e t a K o r o b o w i c z ,
WieslawGolabek . A rare case of nasopharyngeal
angiofibroma in an elderly female. Eur Arch
Otorhinolaryngol .2006; 263: 657 – 660.
8. W i n d f u h r J P a n d R e m m e r t S .
Extranasopharyngealangiofibroma : Etiology,
incidence and management. Acta Otolaryngology 2004;
124: 880 – 889.
9. SchickB,Plinkert P K,PrescherA.Aetiology of
Angiofibroma:Reflection on their specific vascular
component .Laryngorhinootology.2002;81:280-284.
Address for correspondence
Dr. Shrinivas Shripatrao Chavan
Assistant Professor, Dept of E.N.T. and Head and Neck
Surgery,
Govt. Medical College
Aurangabad (M.S.)
E Mail: shrinivasc77@hotmail.com
Cell +91 9403151515
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

Case report
Hairy polyp of nasopharynx in adult
1 2 3 4 5
Ajit Daharwal ,Hansa Banjara ,B. R. Singh ,Digvijay Singh ,Sutanu Sarkar -Raipur (Chattisgarh)
Abstract
Hairy polyps are rare benign congenital malformations occurring in the nasopharynx or oropharynx. They arise during early
embryogenesis and are invariably benign. They usually present at or soon after birth with signs of airway obstruction or feeding
difficulties. Hairy polyps rarely present in older patients and only few cases have been reported in adults. We report a case of
Hairy polyp of nasopharynx in a 22 year old female.
Key words: Hairy polyp, Nasopharynx, Adult.
Introduction
Hairy polyp of the nasopharynx is an unusual but well
recognised entity. To date approximately 137 cases have been
[1]
recorded . The hairy polyps are rare developmental
malformations usually presenting as pedunculated mass in the
nasopharynx or oropharynx. They usually present at, or soon
after birth with signs of upper aerodigestive tract obstruction.
I n t r a n a s a l g l i o m a s , R h a b d o m y o s a r c o m a ,
Meningoencephalocele, Rathke pouch cyst, Pharyngeal
hypophysis, Craniopharyngioma are the differential
diagnosis of this uncommon lesion. Very few cases of hairy
polyps are reported in adults. We report a case of hairy polyp
in a 22 year old female.
Case Report
A 22 years old female attended the Dr. B. R. A. M. Hospital
with symptoms of nasal obstruction for last two months.
There was no history of rhinorrhoea, rhinosinusitis, epistaxis
or headache. On nasal endoscopy a solid and solitary mass
was seen attached to the left lateral wall of nasopharynx. The
pedunculated mass was hanging in the oropharynx [Fig. 1],
grey-white in colour, firm in consistency and did not bleed to
touch. Rest of the otolaryngological examination was normal.
Clinically all other systemic examination showed no
abnormality. Puretone and impedance audiometry was
normal. X-ray paranasal sinuses showed mild haziness of left
maxillary sinus. X-ray chest was found normal.
Ultrasonography abdomen showed no abnormality. The
routine laboratory investigations were within normal limits.
Computed tomography or magnetic resonance imaging were
not considered for this particular case as clinical examination
did not reveal any intracranial involvement, and the mass
which was well circumscribed did not involve surrounding
tissue.
The mass was removed trans-nasally using an endoscope
under general anaesthesia. The base attachment was
1,2 4 5
31
cauterised using bipolar diathermy. The excised mass was
submitted for histopathology. There were no intraoperative or
postoperative complications and one year follow-up did not
reveal any recurrence. Otological examinations were found
normal on follow up.
On gross examination the excised mass was 4cm. x 1.5 cm. x
1.5 cm, cylindrical, with grey-white appearance. The cut
surface was also greyish white.
On histopathological examination, the mass was covered with
mature stratified squamous epithelium with presence of
appendages like sebaceous and sweat glands below the
epithelium [Fig. 2]. The central portion consisted of mature
fat cells and muscle [Fig. 3]. Based on these features a
diagnosis of hairy polyp of nasopharynx was made.
Discussion
Hairy polyps of nasopharynx are rare lesions with an
incidence of less than 1: 40,000 live births and till date only
[1]
137 cases are reported. In 1918, Brown Kelly was credited
[2]
for the first report of hairy polyp. Although hairy polyps are
the most common type of head and neck teratoma, they are
nevertheless rare; about 60% originate in the nasopharynx,
with most of the remainder occurring in the oropharynx. The
hairy polyps have been labelled in the earlier literature as
[2]
dermoid, teratoid, complex hamartoma and even teratoma.
Unlike the more differentiated types of teratoma which
contains all three germinal layers, hairy polyps derived from
only two germinal layers namely, the ectoderm and
mesoderm while, dermoid is due to implantation of epidermal
[3]
elements or incomplete break of epithelium. Hairy polyps
are not true neoplasm but represent a developmental
[4]
malformation. They arise during early embryogenesis. A
hairy polyp arises from either the segregation of epithelial and
mesodermal elements during the fusion of the lateral palatine
process or from the incomplete reabsorption of the buccal
[5]
nasopharyngeal membrane. They are invariably benign
Associate Professor, SeniorResident, Resident,Department of ENT and Head & Neck Surgery,
3
Pt. Jawaharlal Nehru Memorial Medical College, Raipur, Assistant Professor, , Chhattisgarh
Institute of Medical Sciences, Bilaspur ,Chhattisgarh
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

[6]
with very little growth potential. Their size varies from 0.5
[1]
to 6 cm. and may present as sessile or pedunculated mass.
Hairy polyps most frequently present in the neonatal period
but occasionally be discovered in childhood and rarely in
older age. Half of the cases are presented in the first year of
[5]
life. Our case was a 22 year old female who presented with
symptoms of nasal obstruction for the past 2 months. Hairy
polyps are more common in females as compared to males in a
[7]
ratio of 6:1.
Depending on the location, size and mobility, different
symptoms and findings may present. Mild respiratory
difficulty, nasal obstruction and drainage are the most
common complaints whereas feeding difficulty, vomiting,
coughing, earache and drainage, epistaxis and protruding
[7, 8]
mass in the oropharynx may also be seen. Chronic middle
ear effusion and sleep apnoea are rarely attributable to
[4]
tumours of the nasopharynx.
Differential diagnosis of nasopharyngeal mass in children
includes a long list. Hamartoma, teratoma, dermoid,
haemangioma, neuroblastoma, rhabdomyosarcoma, glioma,
meningocele and a foregut thymic, thyroglossal or lingual
[9]
cyst should be considered. These must also be ruled out in
adults. Radiological examination has an important role to
play in ruling out these entities. Computed tomography (C.T.)
and magnetic resonance imaging (MRI) can differentiate
between their tissue characteristics, localise the origin of the
tumour, rule out any intracranial or pharyngeal extension of
lesion and evaluate Eustachian tube and middle ear
involvement, however in this case we did not considered for
[9]
CT or MRI evaluation. The mass was successfully removed
by transoral surgery under endoscopic visualization. The
endoscope-guided surgery may help avoid undesirable
complications as well as completely excise the lesions
32
Fig. 1
Hairy polyp hanging
in oropharynx
Fig. 2
Fig. 3
Case report
[10]
attached close to the eustachian tube openings. Surgical
removal of this benign lesion is curative and there is no
recurrence.
This case was reported due to unusual presentation of hairy
polyp in nasopharynx and rarity of this lesion in adult patient
without any systemic involvement. Hairy polyps rarely
present in older patients and only few cases have been
reported in world literature.
References:
1. Luke Franklyn, R. Ashok,C. Daniel Nasopharyngeal
hairy polyp in an infant with apnoeic spells.
SheffieldChildren's Hospital, NHS Trust, Wester
Bank,Sheffield, South Yorkshire, S10 2TH [online].
2. Chaudhry AP, Loré JM, Fisher JE, et al. So-called
Hairy Polyps or Teratoid Tumours of the Nasopharynx.
Arch Otolaryngol 1978; 104(9): 517 525.
3. McShane D, El Sherif, Doyle-Kelly W, et al. Dermoids
('hairy polyps') of the oro nasopharynx. J. Laryngol
Otol 1989; 103(6): 612-615 [abstr].
4. Phansalkar M, Sulhyan K, Muley P, et al. Hairy polyp
of Nasopharynx- A Case Report. Indian J Pathol
Microbiol 2000; 43(3): 355-6.
5. Gleeson Michael, Browning GG, Burton MJ, et al,
editors. Scott-Brown's Otolaryngology, Head and
Neck Surgery, vol 2, 7th Ed. Great Britain: Hodder
Arnold; 2008. p. 2119.
6. Chakravarti A, Vishwakarma SK, Arora VK, et al.
Dermoid (Hairy Polyp) of the Nasopharynx. Indian J
Pediatr 1998; 65: 473-476.
7. Singh Ishwar, Gathwala Geeta , Saxena Sanjay, et al.
Dermoid of the Nasopharynx. Indian Pediatrics
September 1994; 31: 1142-1143.
8. Jarvis SJ, Bull PD. Hairy polyps of the nasopharynx.
Journal of Laryngol & Otology 2002; 116: 467- 469.
9. Uygur Kemal , Dursun Engin, Korkmaz Hakan, et al.
Hairy Polyp of the Nasopharynx. Gazi Medical
Journal 2000; 11: 43-46.
10.Jong-Lyel Roh. Transoral endoscopic resection of a
nasopharyngeal hairy polyp. International Journal of
Pediatric Otorhinolaryngology 2004;68(8):1087-1090
Photomicrograph Photomicrograph Address for Correspondence:
showing mature showing mature Dr. Ajit Daharwal
stratified squamous fat cells and muscle Associate Professor ENT
epithelium with (H and E x 400) C – 127/6, Ballabh Nagar, Across Ring Road No. 1,
sebaceous glands
Raipur, Chhattisgarh.
(H and E x 100)
E-mail daharwal50@yahoo.co.in
Mobile No. +91- 9981299959
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011

33
NEWS LETTER
1. Dr. Viral A.Chhaya Prof. & Head ENT M.P.Shah Medical College Jamnagar
th
(a) won S.D. Parikh senior consultant award paper at 34 Gujarat state annual ENT conference
Surat
rd
(b) was invited to deliver lecture on UPP at 63 annual conference of AOI Chennai
2. Dr. Vikas Sinha Dean and Prof. E.N.T. M.P.Shah Medical College Jamnagar
rd
(a) was judge at junior consultant award paper at 63 Annual Conference of A.O.I. Chennai
th
(b) invited as faculty for 7 SAARC ENT Congress at Kathmandu Nepal
3. The following faculty had fellowship at M.P.Shah Medical College Jamnagar under Dr. Vikas
Sinha and Dr. Viral A. Chhaya
4.
(a) Dr. Orjeta Tonuzi of Albania Europe - one month fellowship
(b) Dr. Alexendrosis Fasolis of Greece Europe – one week fellowship
(c) Dr. Chandrashekhar ENT surgeon of Belgaon Karnataka - one month fellowship
The ENT department M.P.Shah Medical College Jamnagar signed MOU (Memorandum of
understanding) with ENT department of Asan Medical Centre Seoul Korea , ENT department
CAWT Ireland (Dr. Kaluskar) and Madras Research Centre (Dr. Mohan Kameshwaran)for
exchange programme of faculty and resident for their training programme
5. Dr. Rajesh Vishwakarma Prof & Head ENT B.J.Medical College Ahmedabad delivered lecture at
(a) Bihar on “Early diagnosis and Hearing Management”
(b) NIOH Ahmedabad to doctors of Coal India Limited
rd
(c) Chaired session at Ballon sinuplasty and Cochlear Omplant at 63 annual conference AOI
Chennai
6. Dr. Girish Mishra Prof. & Head ENT P.S.Medical College Karamsad
rd
(a) Chairman on “Current Status and Future development of Cochlear Implant” on at 63 annual
conference of AOI at Chennai
th
(b) Hosted 4 Annual Conference of Gujarat Society of Head & Neck Oncology. Dr. Sidharth
Shah was the organizing secretary. A preconference workshop was conducted wherein
cadaveric dissection to demonstrate various Head & Neck surgeries.
(c) Principal Investigator of WHO supported tobacco cessation centre at P.S.Medical College,
Karamsad is now given the status of regional training centre.
7. Dr. Mukesh Ramani Assistant Professor ENT at B.J.Medical College Ahmedabad delivered
lecture at Asia Oceana congress Newzealand.
8. Dr Ajay Shah, Associate Professor E.N.T. N.H.L. Medical College, Ahmedabad was invited for
laser workshop at Akola M.S. and organized a live surgical workshop on FESS V.S.Hospital
Ahmedabad
9. Dr. Atul Kansara,Professsor & Head E.N.T.,L.G.Medical College, Ahmedabad became
President of AOI- GSB, Dr. K. N. Pansara Vice President of AOI- GSB
rd
10. Dr. Farida Wadia of Surat delivered lecture on CA larynx at 63 AOI conference Chennai
11. Dr Vinod Shah, E.N.T. Surgeon, Surat moderated “management of paediatric airway disorder”at
rd
63 AOI conference Chennai
12. Dr Saumitra Shah, E.N.T. Surgeon,Surat was awarded “Dr R.A.F. Cooper”award on Cochlear
rd
Implant at 63 AOI conference Chennai
13. Dr. Ajay George joined SBKS medical college Waghodia (Baroda) as Professor ENT
Otorhinolaryngology and Head & Neck Surgery, Vol. 8 No. 1, April 2011