Ojolhns Vol II Issue II 2008

Orissa Journal of Otolaryngology and Head & Neck Surgery
Volume-II
JanuaryJune,2008
The Official Publication of the Association of Otolaryngologists of India, Orissa State Branch
All rights owned by the Association of Otolaryngologists of India, Orissa State Branch (O.S.B.)
OSB
Editorial :
Chairman
Number-I
Prof. Abhoya Kumar Kar

Gandhinagar 3rd Line East, Berhampur(Gm.)-760 001, Orissa, India.
Phone : 916802225003 / 919937064983
Email : abhoya.kar@gmail.com / abhoya_kar@yahoo.co.in
Editorial Board
International Advisory Board
CHAIRMAN:
Dr. James P. Thomas, USA
Dr. Asutosh Kacker, USA
National Advisory Board

Prof. K.K. Ramalingam, Chennai
Prof. T.V.Krishna Rao, Hyderabad
Dr. Arun Gadre, USA

EDITOR:
Prof. M.Kameswaran, Chennai

Prof. N.Udaya Kiran, China
Prof. R.N. Samal

919437165625
Dr. Ludwig Moser, Germany
Prof. Gobind Ch. Sahoo,

Chidambaram
Dr. Sylvester Fernandes, Australia

MEMBERS:
Dr. Sharat Mohan, U.K.
Prof. R. N. Biswal, Cuttack
Dr. Ullas Raghavan, U.K.
Prof. D.R. Nayak, Manipal
Prof. R. Jaya Kumar, Trivandrum

Prof. Ahin Saha, Kolkata
Prof. Bachi Hathiram, Mumbai
Prof. G. C. Sahoo, Chidambaram

Prof. S. N. Panda, Burla
Prof. Achal Gulati, New Delhi

Prof. Vikas Sinha, Ahmedabad
Prof. P. S. N. Murthy, Vijayawada
Dr. Madan Kapre, Nagpur
The views expressed in the articles are entirely of individual author. The Journal bears no responsibility
about authenticity of the articles or otherwise any claim howsoever.
This Journal does not guarantee directly or indirectly for the quality or efficiency of any product or services
described in the advertisements in this issue which is purely commercial in nature.
ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY
From the desk of Editorial Chairman

The 2nd issue of Orissa Journal of Otolaryngology and Head & Neck
Surgery, at last could be published, through bit late, but atleast before
end of June, 08 for which I may kindly be excused.
This delay is because, I have to do single handedly everything alone
i.e. begging repeatedly to the advertisers for finance & articles from
contributors, scrutinising the articles, running to the press for proof reading,
keeping the account, etc. Even after printing, I have to run to the post
office to post the Journals. This again becomes too difficult when you
are retired, as you dont have official support.
But I didnt lose my patience to achieve my goal due to constant
encouragement of Prof. L. H. Hiranandani & Prof. S. K. Kacker. I am very
much indebted to Prof. G. C. Sahoo, Prof. M. Kameswaran & Prof. R. N. Samal for arranging
finance & contributing articles.
I request my junior AOI colleagues to help me to make this Journal at par with National /
International standard by arranging finances & standard articles, thus making my dream true.
I have corresponded with Grazyna Czapiewska, Deputy Manager for Journal Master list, Evaluation
Dept., Index Copernicus International S.A. to make the Journal indexed. Most probably it will be
done in Jan, 2009. Then I will succeed in fulfilling my goal by making it a Registered Indexed
Journal.
I am very much obliged to Contributors of articles, Advertisers and International & National
Advisory Board members for their help rendered for bringing out this issue of the Journal.
I expect the same cooperation in subsequent Issues.
Abhoya Kumar Kar

STATEMENT OF OWNERSHIP & OTHER PARTICULARS OF ORISSA
JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY
1.
2.
3.
4.
Place of Publication
Periodicity of Publication
Nationality of Publisher
Publisher & Editorial
Chairman, Name & Address
:
:
:
:
5.
Owner of the Journal
6.
Printers Name and Address
Berhampur (Gm.), Orissa.

Half Yearly.
Indian
Gandhi Nagar 3rd Line East,
Berhampur (Gm.) - 760 001, India.
Association of Otolaryngologists of India,
Orissa State Branch.
Sri Durga Off-set,
R.C. Church Road, Berhampur-1, Ganjam, Orissa.
I, Prof. Abhoya Kumar Kar hereby declare that, the particulars given above are true to the best
of my knowledge & belief.
Date : 10.6.2008
Sign. of Publisher
ORISSA JOURNAL OF OTOLARYNGOLOGY

AND HEAD & NECK SURGERY
Volume 2
Number 1
January - June, 2008
CONTENTS
EDITORIAL :
A reminiscence of Joseph Toynbee
(1815 - 1866) - The Philanthropic &
Humanitarian Otologist
Abhoya Kumar Kar, & G. C. Sahoo
MAIN ARTICLE :
Whats new in Obstructive Sleep Apnoea
Syndrome ?
Mohan Kameswaran
2-4
Semi-automated Digital Model Of Ciliary
Beat Analysis
Ashutosh Kacker & Vijay Anand
5-7
Facial Nerve Monitor - Our experience
K. K. Ramalingam, Ravi Ramalingam,
T. M. Sreenivasa Murthy, Uttam Agarwal,
Sriram Nathan, Chandrakala G R.
8-11
Endoscopic DCR for Chronic

Dacryocystitis a series of 50 cases
G. C. Sahoo, R. Vasudevan,
S. Balaji & N. M. Arun
25-27
Parathyroids in Thyroid Surgery

Madan Kapre
28-29
Current status and future trends of Post

Graduate Education in ORL & HNS
Govind Chandra Sahoo
30-32
Medicine on the information
superhighway: An introduction to the
internet
P Mishra, K Krishnaram, S Luke,
Deepak Nair & Anosh Agarwal
33-37
CASE REPORT :
National Program for Prevention & Control

of Deafness
T. V. Krishna Rao
12
Leiomyosarcoma of the Maxilla - Case

Report and Review of Literature
Moras Kuldeep, Swain Santosh Kumar
& Roy Priyankur
38-40
Role Of Fungus in Chronic Maxillary

Sinusitis
R. N. Samal, S. K. Misra & D. Dora 13-16
Brown Tumor of Nasal Bone :

A rare case report
Kumar Avanindra & Bhardwaj Chaitanya 41-42
Facial Nerve Needling as a curative

treatment for hemifacial spasm - Revisited
Ogale S. B. & Avanindra Kumar
17-20
Endoscopic Solutions to Headache
Jacinth
21-22
Quality Control in Audiometry
Ludwig M. Moser
23-24
Recurrent Rhinosporidiosis
N. K. Goyal, Viplav Dutta,
Varsha Mungutwar & Reema Nair
43-45
Otoplasty in TCS
S. N. Mishra & G.C. Sahoo
46-47
Fractured Tracheostomy Tube as a Foreign

Body in Bronchus
Kumar Avanindra & More Mukesh
48-49
A reminiscence of Joseph Toynbee (1815 - 1866)

The Philanthropic & Humanitarian Otologist
Prof. Abhoya Kumar Kar, Berhampur
Prof. G. C. Sahoo, Chidambaram
Joseph Toynbee had earned the unique reputation as the
first martyr who dedicated his life for the development of
medical science, a victim of his devotion to science, who
died suddenly while experimenting on himself the effect
of chloroform and hydrocyanic acid gas on tinnitus, using
valsalva manouver to squeeze gases out of the mouth into
the middle ear. Adam politzer, in his detailed biography of
Joseph Toynbee published in 1905, had recognised and
stressed the importance of Toynbee in the development
of otology. Politzer has started this biography with words
that, "Modern otological science may, with reason, write
Joseph Toynbee's name at the top of the list of its
representatives" and finished the biography with the words
that, "The most important fact that he established, thanks
to numerous anatomical observations, was that contrary
to previous opinions, that vaguely look at most ear ache
as being nervous, the major cause of hard of hearing was
a result of peripherial process of an inflammatory nature,
with the principal site being the tympanic cavity ".
Born in 1815, Joseph Toynbee published his first paper on
the pathology of ear in 1841 in the medico-chirurgical
transactions and was appointed a member of the Royal
society of London in the same year. Toynbee was the
founder of the pathological basis of modern otology, who
was the first person to realize in otology the therapeutic
progress depends on the knowledge of anatomy. He had
catalogued his anatomic research after examining &
dissecting a large number of patients with hard of hearing
to establish the cause of hearing difficulty which was
published in 1857, with the subsequent publication of a
clinical book in 1860, titled "The disease of the ear, their
Nature, Diagnosis and Treatment", which is considered as
a master piece in the history of otology & the first work
ever about ear diseases on a pathologic anatomical basis.
In addition to his scientific activity, Toynbee considered it
a sacred task to dedicate his spare time for the improvement
of the living and health conditions of poor people for which
he founded the "Samaritan federation" to get better food,
clothing and aired living spaces with his idea that, the
physicians would combat diseases more efficiently &
thoroughly by improving the living condition of the poor,
than through medicine. He became a recognised authority

in the field of ventilation & its importance of airing the
living spaces, for which he obtained an order of parliament
in 1847 to issue a report on the state of London's
apartments for the poor and to make suggestions for their
improvement.
He worked hard delivering lectuers for the intellectual
development of his countrymen in Wimbledon, near London,
at his country retreat and also fought for the foundation of
small countryside museums, where all the objects of
natural and cultural interests found within five miles of
surrounding area were meticulously collected and
displayed. This fine example was copied throughout
England for protection & preservation of nature and
cultural sensitivity, while dealing with the various problems
of poverty and social reform. He gave considerable
importance for closer contact between the classes to
reduce the gulf between the poor and wealthy, which
Toynbee considered as distinctly unhealthy. This
sophisticated humanitarian sense was also imbibed by his
son Arnold Toynbee as a valuable heritage for the service
of humanity. But unfortunately Arnold Toynbee died very
young, at the age of 31 only, after contracting meningitis.
Joseph toynbee also died tragically in July 10th 1866 during
a dangerous experiment on himself, a victim of his
occupation. One of the daughter of Joseph Toynbee,
Gertrude Toynbee wrote about the social qualities of her
father that, " Benevolence may be said to have been the
main spring of my father's life" and of her brother, "His
great sensitiveness to the suffering of others".
So, in conclusion the take home message of this historical
article for all the medical fraternity is that, life not only
have a professional aspect, but also have various other
dimensions like social, humanitarian & philanthropic
aspect, which is equally important to be nurtured for the
benefit of the humanity, the burning example of which, is
the life of the great Otologist, Joseph Toynbee.
P.S. This article is based on the manuscript published in
the Journal of Laryngology & Otology, March 2004, Vol.
118. pp. 179-184.
WHATS NEW IN OBSTRUCTIVE SLEEP APNOEA

SYNDROME ?
Dr. Mohan Kameswaran
MS, FRCS, FICS, FAMS, DLO
Madras ENT Research Foundation, Chennai
Obstructive sleep apnoea syndrome is a common disease
of adult & pediatric age groups with a myriad of
presentations. It affects 2 - 4% of middle aged adults
and 1 - 3 % of pediatric age groups. Guilleminault,
Eldridge and Dement described sleep apnoea syndrome
in 1973 & they established one of the first sleep clinics.1
Significant advances have been made since then in this
field and the otolaryngologist must be familiar with the
diagnosis and various methods of management of sleep
apnoea.
Factors that reduce upper airway size or predispose to
upper airway collapsibility, increase the susceptibility to
sleep apnoea. If untreated, the patient is likely to suffer
from deleterious effects on the cardiovascular system,
secondary to long standing oxygen deprivation.
A patient presenting to the outpatient department with
snoring may have
Primary snoring.
Upper airway resistance syndrome (upper airway
narrowing with frequent arousals without overt apnea/
hypopnea).
Obstructive sleep apnoea syndrome.
Sleep apnoea may be
Obstructive sleep apnoea - cessation of airflow in
the presence of continued respiratory effort.
Central sleep apnoea - no airflow at the nose or
mouth associated with a cessation of all respiratory
effort. This may be physiological or due to CVS or CNS
causes.
Mixed apnoea - begins initially as central apnoea,
then becomes obstructive.
It is crucial to differentiate primary snoring from obstructive
sleep apnoea in which recurrent episodes of upper airway
collapse and obstruction occur during sleep. These episodes
of obstruction are associated with recurrent oxyhemoglobin
desaturation causing increased sympathetic output &
peripheral vasoconstriction and high negative intrathoracic
pressures with arousal from sleep & termination of
obstructive episode. In OSAS, the patient suffers from 30
or more apnoeas (cessation of airflow at the nostrils and
mouth for at least 10 seconds) during a 7-hour period of
sleep. The apnoea index (number of apnoeas per hour of

sleep) is equal to or greater than 5 and Respiratory
Disturbance Index (RDI) or apnoea hypopnoea index
(number of apnoeas and hypopnoeas per hour of sleep) is
greater than 10.
Anatomic space occupying lesions in the nose, naso/oro/
hypopharynx and larynx, micro/retrognathia as well as
neuromuscular factors cause turbulent airflow with vibration
of the soft palate and uvula, faucial pillars, lateral
pharyngeal walls and sometimes, the tongue base. The
strongest risk factors are obesity and male gender. In
children the commonest etiology is adenotonsillar
hypertrophy, neuromuscular hypotonia and craniofacial and
neurologic syndromes.
Fujita described 3 major levels of upper airway
obstruction and collapse:
Retropalatal (Type 1).
Retropalatal and retrolingual (Type 2).
Exclusively retrolingual (Type 3).
Clinical features
The common clinical features of OSAS are snoring,
excessive daytime sleepiness and obstructive episodes
during sleep. Less common features include morning
headaches, personality change, intellectual deterioration,
depression, abnormal body movements, frequent waking,
nocturnal choking etc. In children, mouth breathing,
abnormal shyness, nocturnal enuresis, poor growth
problems, rebellious and aggressive behavior may be noted.
The common associations with OSAS include
gastroesophageal reflux, systemic & pulmonary
hypertension, cor pulmonale, coronary artery disease,
cardiac arrhythmias, myocardial infarction and depression.
Management of OSAS
Investigations are aimed at identifying if the patient has
simple snoring or OSAS. If he has OSAS, the site and
severity of obstruction must be determined. Evaluation for
OSAS starts with a proper history taking including h/o
alcohol, drugs, e.g. sedatives. Comprehensive ENT & head
and neck examination is done. The common findings noted
are short thick neck, enlarged floppy uvula, elongated soft
palate, tonsillar hypertrophy & enlarged tongue. The
presence of micrognathia / retrognathia is noted. Weight
and blood pressure are recorded. A general medical work

up must be done to identify patients at risk for
cardiopulmonary complications including FBC, ECG, chest
X-ray, thyroid evaluation and lung function tests.
Fig.4 : Continuous positive

airway pressure
Fig.1 : Obstructive sleep

apnoea syndrome
Polysomnography was first described in 1974 by Holland,

Dement and Raynall.2 Nocturnal Polysomnography is the
gold standard investigation for OSAS and involves overnight
monitoring of pulse oximetry, End tidal CO2, ECG, EEG,
anterior tibialis EMG, EOG, nasal & oral airflow, chest &
abdominal movements & sleeping position. It helps to
differentiate obstructive from central sleep apnoea and helps
evaluate the severity of the problem.
Sleep MRI, a dynamic imaging modality & fiberoptic
endoscopy help assess the site of obstruction retropalatal/
retrolingual / combined.
Surgical treatment consists of eliminating / controlling

the etiology of obstructive breathing. In children, surgical
removal of obstructing tissue (adenoids and tonsils) is the
most common method of treatment of OSAS.3 There are
many options for correcting the retropalatal and retrolingual
airway. A thorough evaluation is essential before decision
for a particular technique is made. No single procedure
works for all patients. The indications for surgical treatment
include:
Apnea Hypopnea Index > 15.
O2 desaturation < 90%.
AHI > 5 or < 14, with excessive daytime sleepiness.
Upper airway resistance syndrome.
Cardiac arrhythmias associated with obstruction4.
Enlargement of retropalatal airway can be done by:
Uvulopalatopharyngoplasty this is the most
common procedure for retropalatal obstruction in which
excessive redundant tissue in the oropharynx is removed
resulting in increased cross-sectional area. This procedure
has a 85-90% success rate in curing snoring and 23 - 77%
success rate in reducing apnoeic index. There are several
anesthetic considerations in surgery viz:
Fig.2 : Sleep MRI Type 1

obstruction
Fig 3: Sleep MRI

type 2 obstruction
Treatment depends on the severity and underlying cause

of the disorder. The treatment modalities may be medical/
appliances such as nasal splint, mandibular positioning
device, tongue retaining device/surgical. If anatomic
obstruction is present, corrective surgery should be done.
Medical management consists of advice on increased
physical activity and weight reduction, treatment of systemic
disorders and advice on alcohol abstinence. Mandibular
positioning device in nonobese patients with micrognathia/
retrognathia helps advance the mandible and increases
posterior airway space. It has a success rate of 50 % &
compliance rate of 25%.
Nasal Continuous Positive Airway Pressure (CPAP)
is a noninvasive and highly effective primary treatment
modality for OSAS and has a 50% success rate. It delivers
a continuous flow of air to stent the upper airway from
collapsing during sleep by increasing airway volume, area
and lateral dimensions in retropalatal and retroglossal
regions. Nasal BiPAP and Demand PAP (DPAP) are also
effective in treatment of OSAS.
- Avoidance of sedatives & narcotics.

- Possibility of difficult intubation (Fiberoptic intubation may
be required).
- Need for nasopharyngeal airway, pulse oximetry monitoring
and avoidance of narcotic analgesia after extubation,
monitoring for post obstructive pulmonary edema5.
This procedure is contraindicated in velopharyngeal
insufficiency, cleft palate and in patients with special voice
or swallowing considerations.
Laser assisted uvulopalatopharyngoplasty
(LAUP) is effective and has the advantage of a bloodless
field. The success rate for this procedure is 77 89 %.
Fig. 5 : Laser assisted
uvulopalatopharyngoplasty
Radiofrequency thermal ablation

uses low levels of RF energy to create
targeted tissue ablation resulting in
reduction of tissue volume. The procedure
is quick, painless and is associated with
minimal edema.
Coblation may also be used to improve the retropalatal

airway.
for the most severe cases of OSAS with RDI above 50,
lowest O2 saturation below 60% or cardiac arrhythmias.
Uvulopalatopharyngoglossoplasty (UPPGP)
combines UPPP with limited resection of the tongue base.
In the future, neuromuscular stimulation of the genioglossus

muscle and direct stimulation of the hypoglossal nerve may
be useful in the management of OSAS.6
Enlargement of retrolingual space can be done by :

Tongue base reduction procedures which include
- Midline Laser glossectomy - laser is used to extirpate a
rectangular strip (2.5 x 5 cms) of the posterior portion
of tongue. It is useful in Downs syndrome,
Mucopolysaccharidosis, etc.
- Lingualplasty - involves additional excision of lateral
tongue tissue.
- Radiofrequency tissue ablation of tongue base.
Mandibular osteotomy with genioglossal
advancement - This increases the tension placed on the
tongue and helps increase the retrolingual space.
CONCLUSION :
A detailed history, clinical examination & simple overnight
observation will usually help to clinch the diagnosis of
obstructive sleep apnoea syndrome. Polysomnography is
the gold standard investigation to help diagnose the type
and severity of sleep apnoea. Sleep MRI (dynamic MRI)
with F.O. nasoendoscopy has obviated the need for
cumbersome cephalometric measures to establish the site
of obstruction. CPAP & Tracheotomy form the gold standard
of management but are not accepted by a majority of
patients. In properly selected cases, UPPP, LAUP, RAUP and
procedures to enlarge the retrolingual airway have all
yielded gratifying results.
Repose tongue suspension intraoral approach tongue base is pulled forward and secured anteriorly by a
titanium screw placed at the lingual cortex of genial tubercle
of mandible.
REFERENCES :
1.
Charles B. Croft, Michael B. Pringle. Snoring and sleep

apnea. Scott-Browns Otolaryngology. 1997: 4/19/1
Hyoid Myotomy and suspension - The hyoid bone

is suspended upwards and anteriorly to the inferior aspect
of the mandible with permanent sutures, fascia lata or
stainless steel wires to advance the epiglottis and tongue
base. In a modified procedure, the hyoid bone is isolated
and advanced over the thyroid ala and secured.
2.
Jack Coleman. Sleep studies current techniques and

future trends. Otolaryngol Clin N A. 32 (1999), 195
3.
Charles M. Bower, Anil Gunyor. Pediatric OSAS.

Otolaryngol Clin N A. Update on the pediatric airway.
Feb 2000, 66
4.
Robert J. Troell, Daid J. Terris. Sleep apnea and sleepdisordered breathing. Cummings Otolaryngology &
Head and Neck Surgery. 2005: Vol. 2, 1707
5.
Regina Paloyan Walker. Snoring and OSA. Byron J.

Bailey Head and Neck Surgery Otolaryngology. 2001:
Vol 1. 593
6.
David W. Eisele, Alan R. Schwartz. Tongue

neuromuscular and direct hypoglossal nerve
stimulation for obstructive sleep apnea. Otolaryngol
Clin N A. 36 (2003), 510
Genioglossal advancement and hyoid suspension

(GAHM) is a combined procedure of inferior mandibular
osteotomy with genioglossal advancement and hyoid
myotomy & suspension.
Fig. 6 : Genioglossal advancement
Maxillofacial techniques to advance the skeletal

support of soft tissues that collapse during sleep are used
in severe OSAS. Maxillomandibular osteotomy &
advancement (Riley & Powell) improves retropalatal and
retrolingual space and increases airway caliber in an
anteroposterior direction. This procedure has a success
rate of 95%.
Tracheostomy to bypass airway obstruction is reserved
Dear Members of Orissa State Branch of AOI,

Kindly inform your present Postal address, Phone & Cell Nos. and E-mail ID to the
undersigned and Dr. Sanjoy Panda, Hon. Secretary, Kesharpur, Cuttack-753001,
E-mail : drsanjoypanda@yahoo.com, Cell : 9861055677.

Editorial Chairman
SEMI-AUTOMATED DIGITAL MODEL OF CILIARY

BEAT ANALYSIS
Vijay Anand, MD
Ashutosh Kacker, MD
Department of Otolaryngology-Head and Neck Surgery

New York-Presbyterian, The University Hospitals of Columbia and Cornell
New York, New York 10021
ABSTRACT
Background: Traditional quantitative measurements of ciliary beat are often time-consuming and arduous. Herein,
we describe a novel, reliable and relatively simple method of measuring of ciliary beat.
Material and Methods: A phase-contrast microscope was coupled with a high resolution 3-chip color camera.
Images of beating cilia were obtained at a magnification of 100X and were then digitized using Image-Pro software.
The ciliary beat frequency was calculated using image analysis and a customized macro program. Specimen was
obtained from brushings of healthy human nasal epithelium and chicken tracheal epithelium.
Results: The described technique generated reproducible quantitative measurements of ciliary beat in both
normal human nasal epithelium as well as in a chicken trachea model.
Results of ciliary beat frequency in human nasal epithelium were consistent with those reported in prior studies
using other methods of ciliary beat analysis.
Conclusion: The semi-automated digital model of ciliary beat analysis provides a reliable and reproducible
qualitative and quantitative measure of ciliary beat frequency. This technique is relatively simple to perform
and can ultimately be applied to evaluate the effects of various chemical agents on the nasal mucosa.
Key words: Ciliary Beat Analysis, ciliary beat frequency, cilia, phase-contrast microscopy.
INTRODUCTION
Mucociliary transport plays an important role in the defense
of the upper and lower respiratory system including the
normal function of the paranasal sinuses. The mucociliary
system consists of ciliated respiratory epithelium, an
overlying mucous layer and mucous-producing glands. The
action of cilia propel mucociliary transport; in particular,
the beating of cilia within the nasal cavity direct the overlying
mucous layer towards the oropharynx. This activity of cilia
can be measured as ciliary beat frequency (CBF) and has
been shown to be the main regulator of mucociliary
clearance1.
Ciliary dysfunction disrupts normal mucociliary transport
which may ultimately yield mucous stasis and subsequent
rhinosinusitis. Ciliary pathology can be congenital or
acquired. Acquired dysfunction may be secondary to upper
respiratory infections, allergies and environmental or
iatrogenic causes (i.e., post-surgical or drug-induced
states). For example, CBF has been shown to be diminished
in patients with chronic sinusitis as well as in those
chronically exposed to cigarette smoke, decreased
temperature and pollution2,3. Indeed, the ability to easily
detect impaired CBF and to diagnose ciliary dysfunction
would help guide the management of these patients.
A variety of methods to measure CBF have been described.
Stoboscopy, auditory clicking devices synchronized with
ciliary action and photometric and cinematographic studies
were amongst the earlier described techniques but were

either tedious and time-consuming or subject to human 4,5.
More recently, studies have utilized photoelectric
measurement systems in conjunction with video image
analysis, computer assistance and/or photometry to assess
CBF in patients6,7. While such techniques are more reliable
than those previously described, the associated equipment
set-up is complex and expensive as multiple components
are required for data acquisition6. Herein, we describe a
novel, reliable, and relatively simple method for measuring
CBF using phase-contrast microscopy with image and
computer analysis. We test the reliability of this technique
by measuring the CBF in human nasal epithelium as well
as that of chicken trachea.
Materials and Methods :
Specimen collection was performed by using a 2-mm
microvasive cytology brush which was inserted gently
into the nasal cavity to obtain a biopsy from the middle
third of the inferior turbinate to evaluate human nasal
CBF. These nasal specimens were taken from ten
healthy human volunteers. Similarly, cytology brushings
of chicken trachea were performed for evaluation of CBF
in the respiratory epithelium of the trachea. Institutional
Review Board approval was obtained for collection of
human as well as chicken tracheal epithelium per
guidelines for human and animal studies. After
collection, each specimen was immediately suspended
in tissue culture medium 199 at room temperature. A

small sample of the suspended specimen was placed
onto a microscope slide for CBF analysis with
microscopy.
Fig.1 : Brush used to obtain ciliated

respiratory epithelium.
Fig.2 : Digital recording devise

to record CBF.
Fig.3 : Nikon Phase

contrast Microscope.
CBF analysis was performed using a phase-contrast inverted

microscope (C-1 confocal modular scope, Nikon, Melville,
NY) coupled with a high resolution 3-chip color camera
and DV-CAM (Sony, NY, NY) recorder and image analyzer.
Images of beating cilia were obtained at a magnification of
100X and were then digitized using Image-Pro software
previously installed on a Dell computer (Dell, Round Rock,
Texas). Image-Pro is a custom macro program, which
analyzes the change of color at the area of interest (AOI).
The custom macro program analyzes the same AOI in the
consecutive image frames (30 frames/sec for a period of 5
seconds =150 frames). The total number of frames in
which the color becomes dark is divided by 10 to give the
frequency in hertz (each cilia has a forward and recovery
beat).
Fig. 4 :
Digitized image of a ciliated
respiratory epithelial cell.
1. Area of interest for Ciliary
beat analysis
2. Cilia, 3. Cell body
RESULTS :
CBF analysis was performed in 10 healthy human
volunteers specifically those without a history of nasal/
sinus or lung pathology. CBF ranged from 7-10 Hz with
a mean of 8 Hz.
DISCUSSION :
Many techniques to measure ciliary beat frequency in
respiratory epithelium have been described since the
1930s4,5,8. Recently described methods include photometric,

high-speed cinematographic and photoelectric techniques.
Wilson et al used a pin-hole photometric technique to
demonstrate that CBF is diminished when compared to
controls in patients with bronchiectasis and mucopurulent
rhinosinusitis9. Photometry utilizes real-time recording but
is time-consuming and does not generate reliable
measurements with synchronized ciliary beats. Proetz
employed high-speed cinematography to record the
frequency of mucous waves10 and Sanderson et al used
this technique in concert with a photoelectric method to
analyze CBF6. Photographic techniques regardless of their
high-speed recordings can be slow and fail to provide realtime analysis of CBF. Moreover, high-speed cinematographic
studies in prior reports do not measure ciliary beat directly
but rather the image density changes which can be produced
by ciliary motion and/or mucous flow. Ohashi et al utilized
the photoelectric technique to corroborate that CBF in
patients with chronic rhinosinusitis is impaired when
compared to normal controls3; additionally, Sanderson et
al described a video- and computer-assisted photoelectric
technique to evaluate ciliary activity6. Other studies using
computerized imaging and photoelectric techniques include
Kurosawa et al and Braverman et al, who demonstrated a
linear relationship between CBF and temperature and an
increase in CBF with nasal polyposis, respectively12,13. In
the photoelectric technique, ciliary activity is measured by
the reflections of light off the mucous waves generated by
the cilia. These photoreflections are detected by a
photoelectric cell and recorded on an oscilloscope7. Thus,
direct measurement of ciliary action is not possible with
photoelectric principles alone; corroboration of photoelectric
signal changes corresponding to video recording must be
performed to precisely pinpoint ciliary beat. While such a
method may be reliable and reproducible, it becomes timeconsuming and expensive to gather all the unit components
required for data acquisition.
We describe a method using computer-assisted image
analysis of phase-contrast microscopy. Phase-contrast
microscopy allows for the detection of respiratory epithelial
cells and cilia based upon the difference of image density.
These changes in image density are recorded and
processed by the computer macro program. With this
method, reproducible and reliable data was obtained using
real-time and high-resolution recording. Moreover, the
macro software program calculated CBF using fast fourier
transform technique thereby obviating the errors associated
with observer perception and calculation.
To verify the reliability of our technique, we measured the
CBF in human nasal respiratory epithelium. CBF in this
population ranged from 7-10 Hz (mean 8 Hz) which is
consistent with prior studies 2,12,13. We place emphasis on
using proper hardware and software. A phase-contrast
microscope coupled with a high resolution 3-chip color
camera and a good video board with at least 2 gigabytes

of memory is recommended. This allows for high-resolution
of image capture and adequate recording storage capability.
With this relatively simple and reliable method of
investigating CBF, we intend to investigate further the effects
of medications on ciliary activity. Moreover, combining this
method of analysis of ciliary function with ultrastructural
studies would be powerful in terms of diagnosing and
managing disease processes associated with impaired cilia
and their function.
CONCLUSION :
6. Sanderson M, Dirksen ER. A versatile and quantitative

computer-assisted photoelectric technique used for the
analysis of ciliary beat cycles. Cell Motility 5: 267-292,
1985.
7.
Yager J, Chen T, Dulfano MJ. Measurement of frequency

of ciliary beats of human respiratory epithelium. Chest
73: 627-633.
8. Lucas AM. Direction of ciliary movement in the nasal

cavity of Macacus rhesus. Tran Am Laryngol Otol Rhinol
37: 172-176, 1931
The semi-automated digital model of ciliary beat analysis

provides a reliable and reproducible qualitative and
quantitative measure of ciliary beat frequency. This
technique is relatively simple to perform and can
ultimately be applied to evaluate the effects of various
chemical agents on the nasal mucosa.
9. Wilson R, Sykes DA, Currie D, Cole PJ.Beat frequency

of cilia from sites of purulent infection.Thorax
Jun;41(6):453-8, 1986
REFERENCES
11. Kurosawa H, Wang CG, Dandurand RJ, King M, Eidelman

DH. Mucociliary function in the mouse measured in
explanted lung tissue. J Appl Physiol Jul;79(1):41-6,
1995
1. Duchateau G, Graamans K, Zuidema J, et al. Correlation

between nasal ciliary beat frequency and mucus
transport rate in volunteers. Laryngoscope 95: 854,
1985
10. Proetz AW. Motion picture demonstration of ciliary

action and other factors of nasal physiology. Trans
Am Laryngol Assoc 54: 264-273, 1932.
2. Agius AM, Smallman LA, Pahor AL. Age, smoking and

nasal ciliary beat frequency. Clinical Otolaryngology
23: 227, 1998.
12. Braverman I, Wright ED, Wang CG, Eidelman D, Frenkiel

S. Human nasal ciliary-beat frequency in normal and
chronic sinusitis subjects. J Otolaryngol Jun;27(3):14552, 1998
3. Ohashi Y, Nakai Y. Reduced ciliary action in chronic

sinusitis. Acta Otolaryngolica Suppl (Stockholm) 397:
3, 1987.
13. Jorissen M, Willems T, Van der Schueren B. Nasal

ciliary beat frequency is age independent.
Laryngoscope 108: 1042, 1998.
4. Gray J. The mechanisms of ciliary movement: 6.

Photographic and stroboscopic analysis of cilia
movement. Proc Roy Soc 107: 313-322, 1930.
5. Bleeker JD, Hoeksema PE. A simple method to measure
the ciliary beat rate of respiratory epithelium. Acta
Otolaryngolica 71: 426-429, 1971
Address for Correspondence

Dr. Ashutosh Kacker, MD
445 E 77th street, Apt #3B
New York, NY 10021
Ask9001@med.cornell.edu
Phone: 212-746-1485
The 30th Sate Conference of AOI, Orissa State Branch with workshop on
Sinus Endoscopy, Head & Neck Surgery and Thyroplasty will be held on 8th & 9th
November, 2008 at Berhampur.
Kindly contact Prof. R. N. Samal, Organising Secretary, Dept. of E.N.T., M.K.C.G.
Medical College, Berhampur (Gm.)-760 004 or Prof. Abhoya Kumar Kar, Chairman
Organising Committee for registration & accomodation
Prof.
Abhoya Kumar Kar

Editorial Chairman
FACIAL NERVE MONITOR OUR EXPERIENCE

Prof. K. K. Ramalingam, Prof. Ravi Ramalingam, Dr.T. M. Sreenivasa Murthy,
Dr. Uttam Agarwal, Dr. Sriram Nathan, Dr. Chandrakala .G.R
KKR Ent Hospital And Research Institute, Chennai
The facial nerve has been described as the otologists friend
and servant by eminent otologists James Sheehy and John
Shea, respectively. These statements emphasize the need
for the surgeon to be familiar with the facial nerve course
and its various abnormalities. The surgeon should identify
the facial nerve and then only proceed with the rest of the
surgery. While identifying the facial nerve is not difficult for
any otologist in normal circumstances, it may be difficult if
it is a revision operation or the region is affected by diseased
process like tumour, cholesteatoma, tuberculosis, etc.
Intraoperative monitoring of facial nerve is an important
adjunct to identify the facial nerve and to avoid injury. Hence
the intraoperative facial nerve monitoring is being used
routinely in advanced otology centers in the following
conditions:
movement during surgery and only smaller amount of

electrical stimulation is required to assess facial nerve
function. Both a graphical signal which can be observed on
an oscilloscope screen and an acoustic signal which can be
heard through out the operation theatre are generated.If
the nerve is very thin [eg-mandibular branch of facial
nerve], the electrophysiological responses will demonstrate
whether or not the nerve is intact. An increase in the latency
of the evoked action potential or a decrease in its amplitude
will mean damage to the nerve by manipulation or stretching
during the surgery.
1.
Acoustic neuroma removal.
2.
Vestibular neurectomy.
2. To know the prognosis of facial nerve function

postoperatively.
3.
Micro vascular decompression of facial nerve in the

CP angle for hemifacial spasm.
4.
Surgery for congenital atresia, revision surgery for

chronic otitis media and in cochlear implantation.
5. Parotid surgeries.
As more and more surgeons realize the usefulness of
intraoperative monitoring of facial nerve, the indications
will broaden.
The facial nerve monitor can be used along the course of

dissection for the following purposes:
1. To identify the facial nerve and map its course.
3. To identify potential injurious stimuli.

4. Reducing trauma to the nerve during dissection.
Nevertheless, the instrument is only an adjunct in
identification and monitoring of motor nerve at risk during
surgery and not a replacement for sound anatomical
knowledge and surgical experience.
Technique:
No muscle relaxant should be used other than for
intubating the patient as even small dose may diminish
the ability to monitor small amplitude response.
Electrode placement
Nerve monitor
[Neurosign 100]
Electromyography[EMG] and electroneurography[EnoG]

techniques have been used for many years. In early 1980s
these mechanical monitoring techniques came into vogue
which relied on sensing actual facial movement, but later it
was disfavoured because actual movement requires a large
suprathreshold stimulus.
Delgado,in 1979 first demonstrated the electrophysiologic
monitoring of facial nerve. The same principle is now being
used to monitor nerve discharges and compound action
potential following electric stimulation of the facial
nerve.This avoids the need for observation of facial
Paired electrodes are placed in 2 facial muscle groups

(for acoustic neuroma and otosurgeries ). The portion
of the electrode not within the muscle itself should
be insulated. The orbicularis oris and orbicularis oculi
are usually selected because of its relatively large size
and easy identification. A pair of needle electrodes are
inserted subdermally into the above said muscles with
a reference electrode from each channel going to
nasolabial groove. The electrodes are inserted parallel
to and close to each other, but not making contact.
After securing the electrode, its correct position is
confirmed by using an impedence meter. The stimulus
is set at 30 Hz and the usual setting of current for
myelinated nerve is 0.2 mA to 0.5mA and for
unmyelinated nerve is 50uA. Once all the electrodes are

properly positioned and placed, tapping gently on the
face to determine whether a faint response can be
heard from the facial nerve monitor is useful. It
indicates that the system is functioning properly. For the
parotid gland surgeries the electrodes are placed in
different facial muscles so that the individual branch of
facial nerve can be monitored.
Electrode placement for parotid

gland surgery
Electrode placement for

acoustic neuroma and
otosurgery
Interpretation
There are four basic sounds from the instrument when
used correctly. These are :
Description Causes
Pulses
Electrical
stimulation
Regular clicks at the

stimulator frequency
when using the
stimulator probe; a
weak sound may
indicate that the
nerve lies away from
the stimulated tissue
Burst
Direct surgical
manipulation
Clicks synchronized
with surgical
manipulation of the
nerve or tissue
to which the nerve is
attached; often
sounds like the
rustling of tissue
paper.
Train
Stretching of the
nerve.
Compression of
the nerve.
Irrigation.
Heating [LASER
or
diathermy].
Continuous clicks
lasting several
seconds or even
minutes after the end
of surgical action.
Except for irrigation,
a train response is a
warning that the
nerve has been
irritated significantly
and the surgeon
should wait until the
response dies down.
Stimulation probes:
There are different types of probes available
1.
Bipolar probe -This allows current flow only from

one tip directly to the other, therefore facial nerve
is stimulated only if it lies directly between 2 tips
2.
Concentric probes - Two in number and they have

a diameter of only 1 mm.
These are especially useful to differentiate seventh
and eighth cranial nerve, to stimulate within internal
auditory canal or to stimulate fibres of extracranial
nerve without stimulating surrounding tissue.
3.
Monopolar probe - Current flows from stimulating

probe to all directions. The probe should be made
in contact with the tissue until the nerve is located.
A higher strength of current may be required for
this. It is used to stimulate the tumour mass or
when a large current spread is required.
Silence
BIPOLAR PROBE
Typical sound
Nerve not present.

Nerve not stimulated.
Incorrect stimulation
technique. Patient
paralysed. Nerve
damage prior to
surgery. Electrode in
wrong muscle group.
MONOPOLAR PROBE
Silence can often be

worrying until the
first positive response
is obtained. Normal
anatomic procedures
for locating the
nerve should be
followed.
2.
3.
4.
5.
6.
Facial nerve monitoring during cochlear implant

Submandibular gland surgery by monitoring marginal
mandibular branch of facial nerve.
Modified radical neck dissections by monitoring
accessory nerve.
Cervical, brachial and sacral plexus surgery.
Surgery involving the territory of the oculomotor nerve.
LARYNGEAL ELECTRODE
OUR EXPERIENCES
Assesment of neural integrity

After dissection is complete,the integrity of the nerve can
be assessed by stimulating it at an area proximal to site of
dissection. During acoustic neuroma excision,this stimulation
should be performed adjacent to pons at minimal current
setting, which may be just a fraction of usual current setting
during dissection. It is often helpful to compare the amplitude
obtained at the proximal nerve to a response obtained early
in the procedure, when the nerve distal to the site of
pathology has been stimulated.
We are using facial nerve monitor [Neurosign 100] for past

4 years and found it of immense help. The monitor, apart
from reducing the incidences of facial nerve injury, has
given us a lot of confidence and courage to tackle difficult
situations. Neurosurgeons operating on tumours such as
acoustic neuroma need to spend a long time in identifying
the 7th and 8th nerve. Use of monitor has reduced the
operating time.We also have used it successfully for a case
of microvascular decompression in idiopathic hemifacial
spasm.
We have used the monitor for below mentioned cases:
Special uses
The facial nerve monitor can be useful not only for acoustic
neuroma, mastoid or middle ear surgery, but also for
extratemporal course of facial nerve as in parotidectomy
and selective peripheral neurectomy.
The monitor can also be useful for :
1.
Thyroid and parathyroid surgery by monitoring

recurrent laryngeal nerve by the use of specially
designed laryngeal electrode which attaches to the
endotracheal tube and is surgically non invasive.
Frequently asked questions about facial nerve

monitoring :
Q. Can repetitive intraoperative stimulation injure the
nerve?
A. All available facial nerve monitor uses pulsed current
technology and it has been shown by studies [ Hughes
et al] that, pulsed current produces no evidence of
injury.
Burst response after direct
stimulation with bipolar probe
Branches of facial nerve after

parotidectomy
Parotid
sialography
showing
intraductal and intraparenchymal
sialolithiasis involving deep lobe of
gland
Q. Can frequently repeated stimulation produce metabolic

exhaustion?
A. It has been shown by Babin et al that, 3 stimulations
per second to the facial nerve at 1 mA for 1 hour had
no permanent changes in sensitivity, although a
transient decrease in sensitivity occurred for several
minutes after cessation of stimulation.
Moreover during last few decades thousands of patients
have been monitored using electrophysiologic techniques
including intraoperative stimulation. This has not produced
any evidence that, nerve monitoring can be harmful.
Parotid sialography
showing sialectesis
Surgeons need to be very careful while operating on

conditions requiring handling of the facial nerve to prevent
catastrophic eventuality, such as facial palsy. With the
availability of the nerve monitor, the present day surgeons
should avail of its uses, however confident one is of their
knowledge and expertise.
National Program for Prevention & Control of Deafness

Dr. T. V. Krishna Rao
Member Central Co-ordination Committee
In our country deafness by and large is not properly
diagnosed & most often unattended. In our country
6.8% of general population suffers from hearing loss.
Nearly 25,000 children are born deaf every year in our
country. 15% to 17% of school going children suffer
with hearing problems. Although these statistics are
very impressive, there is no systematic program for
prevention & control of deafness either at the state
level or at the central level.
In view of the above stated facts, as the President of
the Association of Otolaryngologists of India, I had
presented a memorandum regarding deafness to the
Union Government in the year 2004. Many times I have
personally met & represented to the Union Health
Minister, Union Health Secretary & also the Director
General of Health Services. The Government took the
matter very seriously & has discussed this subject with
a number of ENT Specialists & also Audiologists from
all over the country. After prolonged discussions the
Union Government has decided to start a pilot project
for prevention & control of deafness. This will cover
25 districts in various parts of the country. There will
be a Central co-ordination committee at New Delhi, a
State Health Society & Program Health Committee at
the state level & a District Health Society & program
Health Committee at the district level.
This pilot project will make use of the existing Health
infrastructure. The State Medical College in the
identified districts would be the centre of excellence.
They take care of the patients referred to them either
from the district hospital or from the primary health
centre. If necessary they will investigate the patient
thoroughly & also provide treatment by surgery and
provide rehabilitation by providing hearing aids &
Speech Therapy.
They will also help the ENT Specialists & Audiologists
from the districts to update their skills. The ENT
Surgeon & the Audiologist attached to the Medical
College/Hospital will be in charge of the program.
The district will be the nodal point for the actual
implementation of the program. The ENT Specialist &
Audiologist attached to the Hospital will be in charge
of the project. The facilities at the district hospital will
be strengthened to enable proper diagnosis &
rehabilitation (Hearing Aids). They will look after the
patient referred from the Primary Health Centre and
School Health Centers.
The Primary Health Centre & Community Health Centers

will be provided with basic equipment for screening of
patients with Hearing Problems. The Doctors, Nursing
staff & other Paramedical staff will be sensitized about
the deafness program & will be trained by relevant
people to enable them to do their job effectively.
The School Health System has an important role to play
in the program. The School Teachers of the primary
sections will conduct a survey based on a questionnaire
for the primary children. This record will be scrutinized
by the school doctors & where necessary, the identified
children with hearing problems will be referred to the
appropriate centers for investigations.
Doctors, Audiologists, Paramedical staff and School
Health Doctors will be sensitized about the program &
will also given suitable training to fulfill the work
expected of them.
Pediatricians & Obstetricians will be briefed about
deafness in all its aspects & its early recognition. The
importance of Newborn Hearing Screening will be
emphasized.
School Teachers at the village level & all Health
Workers will be briefed about deafness including the
causes, consequences & various types of treatments
available.
Screening Camps for deafness problems will be
periodically conducted at Primary Health Centers &
District Hospitals and the co-operation of voluntary
organizations will be taken.
IEC Activities : Information, Education & Community
Activities.
Innovative IEC strategies will be utilized for the purpose
of awareness regarding Hearing Impairment, it causes,
ill effects & treatment.
The strategies would focus on suitable advertisement
and messages over the Radio, T.V, Newspapers &
Magazines. It will also be done through posters &
lectures.
The pilot project started in January 2007 & lasted for
one year. It is expected that, the number of districts
will be increased every year in the next Five Year Plan.
ROLE OF FUNGUS IN CHRONIC MAXILLARY SINUSITIS

Prof. R. N. Samal1, Dr. S. K. Misra2 & Dr. D. Dora3.
ABSTRACT - Chronic sinusitis is a common disease affecting all age group. Though rare at present there is an
increasing tendency of fungal infection of the sinuses. This study is taken up to find out the role of fungus
infection in cases of chronic maxillary sinusitis
INTRODUCTION :
Chronic sinusitis is a common and often a debilitating
disease affecting both adults & children. Ranging from
mild nasal congestion to excruciating pain, the
symptoms of sinusitis are among the most common
complaints heard in doctor's clinics & emergency rooms.
Gliklich & Metson8 have shown that, the amount of
morbidity is more than that of heart diseases and
arthritis as the major causes of missed work, school
& social activities.
Mycological infection though a relatively rare entity, its
incidence is growing in this changing modern world due
to increase in incidence of diabetes rnellitus, AIDS,
cancers, other debilitating diseases and prolonged use
of local nasal steroids, trauma to face especially
compound faciomaxillary fractures. Fungal infections of
the sinuses have recently been blamed for causing a
number of cases of chronic rhinosinusitis. Most fungal
infections are benign or non-invasive, except when they
occur in individuals who are irnmunocomprised. The
number of reported cases of fungal infections of nose
& paranasal sinuses has been increasing due to increase
in number of immunodeficient patients due to HIV
infection . In the present series of chronic maxillary
sinusitis, careful attempt has been made to evaluate the
role of different fungi associated with chronic maxillary
sinusitis .
MATERIAL AND METHODS :
This study has been conducted jointly in the
Departments of ENT and Microbiology of M.K.C.G.
Medical College and Hospital, Berhampur during the
period from 10th February, 2004 to 9th February, 2006.
The cases selected for the present study were taken
from the patients attending the ENT out patients
department during the said period of tlme.The cases
for the present study were selected at random on the
basis of clinical and radiological evidence of chronic
maxillary sinusitis.
Recurrent attacks of headache or heaviness of head,
nasal / post nasal discharge, nasal obstruction, impaired
sense of smell, chronic hawking & cleaning of throat
and intermittent epistaxis, atleast for a period of 3

months were taken as definite symptoms while selecting
cases.
On examination, the nasal signs that were considered
to be strongly in favour of chronic maxillary sinusitis
were : discharge in the middle meatus, congestion and
hypertrophy of middle turbinate, tenderness over
maxillary sinus, nasal polyp and post nasal drip. X-ray
of the paranasal sinus & C.T. scan in some cases was
done to confirm the above diagnosis.
Basing on history, host characteristics, physical findings,
nasal smear study and radiological evidence, cases
were selected for antral washout. The washout was
sent for fungal study .
Method for fungal study :
A wet mount was prepared on a clean glass slide by
mixing a drop of specimen with one drop of 10%
potassium hydroxide. It was then examined under
microscope for hyphae, spores, yeast cells and
pseudohyphae.
Then the specimens were incubated in Sabourd's
dextrose agar medium (pH 5.4) at 370C for at least a
week. Identification of the fungus is done by :
1. Character of the colony.
2. Microscopic morphology.
OBSERVATION :
Out of 563 cases of chronic sinusitis, 381 cases
(67.67%) were diagnosed to be suffering from chronic
maxillary sinusitis .
In the present study, maximum number of cases
belonged to the age group of 21 - 30 years, which
constitutes 45% of the total cases. Next age group
involved was 31 - 40 years (23.33%). So 68.33% of
cases in this study were from age group of 21-40 years,
who form the bulk of working class and are exposed
to polluted atmosphere, dust, smoke, allergens and to
the odds and evens of weather. Male to female ratio
was found to be 1.24:1 .
1. Professor & Head of Dept., 2. Asst. Professor, 3. P.G. Student, Dept. of E.N.T.,
M.K.C.G. Medical College, Berhampur (Gm.) Pin-760004
TABLE
SHOWING FREQUENCY OF DIFFERENT SYMPTOMS (n=120).
Symptoms
No. of cases
Percentage
Headache
83
69.16
Nasal obstruction
57
47.50
Chronic hawking
51
42.52
Sneezing
42
35.00
Heaviness in head
31
25.83
Nasal discharge
26
21.66
Epistaxis
09
7.50
TABLE-3 : RADIOLOGICAL OBSERVATION OF CHRONIC

MAXILLARY SINUSITIS (n=240).
Type
Above table shows that, headache is the most common

presenting symptoms (69.16%) in chronic maxillary
sinusitis. Headache, nasal obstruction (47.50%) and
hawking (42.52%) taken together, constitute the major
nasal symptom complex in the present study.
TABLE -2. SHOWING DISTRIBUTION

POSITIVE SIGNS (n=120).
Signs
No. of cases
Percentage
Congestion of middle turbinate
66
55.00
Sinus tenderness
58
48.33
Pus in middle meatus.
23
19.16
Associated polyp
13
10.83
D.N.S. (Gross)
36
30.00
OF
Congestion of the middle turbinate is the most common

positive nasal finding in this study which is observed
in 55.00% of cases.
Sinus tenderness (48.33%) and pus in middle meatus
(19.16%) are also frequent positive findings.
RADIOLOGICAL INVESTIGATIONS :
Radiological evaluation of the pathological changes in the
maxillary antrum was done on the basis of the degree
of loss of normal translucency. Five different types of
findings were observed.
Type - 1 : Normal translucent air shadow.
Type - 2 : Loss of translucency limited to the
margins having a clear space at the
center (mucosal thickening).
Type - 3 : Opacity involves the whole antrum, but
the density is not bony hazy.
Type - 4 : Opacity involves the whole antrum and
the density is bony hazy.
Type - 5
: Sinus having a fluid level.
The radiological picture of both maxillary sinus in each

case varies. Hence each maxillary sinus was considered
to be an unit while the frequency was studied as given
below :
No. of Sinuses
Percentage
Type - 1
10
4.16
Type - 2
104
43.33
Type - 3
66
27.50
Type - 4
54
22.50
Type - 5
2.50
95.84% of sinuses had positive radiological findings in

cases of chronic maxillary sinusitis. Maximum number
of sinuses (43.33%) were found to have mucosal
thickening. 27.50% sinuses had antral haziness, 22.50%
had bony hazy antrum and only in 2.50% fluid level was
seen.
TABLE - 4 : C.T. SCAN FINDINGS (25 Cases)
C.T. Scan Finding
No. of cases
Percentage
Gross opacity
Bony erosion
Mucosal thickening
Bony thickening
12
1
11
1
48.00
4.00
44.00
4.00
Out of 120 cases, in 12 cases gross opacity was found.

11 cases had mucosal thickening. Bony erosion and
bony thickening was seen in 1 case each.
DIAGNOSTIC PROOF PUNCTURE :
Proof puncture and collection of specimens for culture
and sensitivity was done in 120 cases of radiologically
confirmed maxillary sinusitis, following which antrai wash
out was done in each case and the character of the
returning fluid was observed.
TABLE - 5 : SHOWING QUALITY OF ANTRAL

RETURNS (n=240)
Quality of antral return No. of Antral fluids
Percentage
Clear
37
15.42
Mucoid
48
20.00
Mucopurulent
118
49.16
Purulent
37
15.42
Total
240
100.00
In each case of antral washout, two returning fluids

were collected. So total Antrai wash out fluid was 240.
But in each case, the fluid having more pathology was
sent for study. Returning fluid was clear in 37 sinuses
(15.42%) out of 240 sinuses. But in the remaining 203
sinuses (84.58%), the returning fluid was pathognomic.
TABLE - 6 : SHOWING ORGANISMS (120 Specimens) :
Organism
No. of cases
Percentage
No growth
106
88.34
Isolated fungi
14
11.66
In the culture, fungus had grown in 11.66% of cases.

TABLE - 7 : SHOWING DISTRIBUTION OF ISOLATED
FUNGI (n=14) :
Fungi
No. of cases
Percentage
Aspergillus fumigatus
42.86
Aspergillus flavus
21.43
Aspergillus niger
7.14
All Aspergillus species
10
71.43
Candida albicans
14.29
Cladosporium
7.14
Penicillium
7.14
Out of 14 cases, Aspergillus specis was present in

10 cases (71.43%).
TABLE -8
SHOWING CLINICAL TYPES (n=14) :
Clinical variant
No. of Cases
Percentage
Non-invasive
13
92.85
Invasive
7.15
Out of 14 cases where fungus was isolated,

non-invasive clinical variants were 13 (92.85%) in
number and 1 (7.15%) case was of chronic invasive
granulamtous variety, in which causative agent was
Aspergillus niger.
DISCUSSION
The present work was based on study of 120 patients
of chronic maxillary sinusitis who were selected on the
basis of clinical and radiological findings. Diagnostic
proof puncture was done and the returning fluid was
sent for fungal study.
Sinusitis or more accurately rhinosinusitis is a common
disorder, affecting approximately 20% of the population
at some time of their lives. Whether fungi can exist in
sinus mucous without causing disease is unclear. Fungal

rhinosinusitis occurs in two distinct forms - the fulminant
invasive disease which is predominantly seen in patients
with some form of immunosuppression and chronic
fungal rhinosinusitis in apparently healthy hosts.
Though species of Aspergiilus is isolated from majority
of such cases, Dematiaceous hyphomycetes,
Pseudallescheria boydii, Candida species, Fusarium
species, Hyalohyphomycetcs and Zygomycetes are also
reported from some cases.
Based on histopathologic findings, five basic diagnostic
categories of fungal rhinosinusitis disorders are currently
recognized. The lesion can be broadly divided into two
categories, the invasive and non-invasive. Three types
of fungai rhinosinusitis are tissue-invasive infectious
diseases: 1) acute necrotizing (fulminant) fungal
rhinosinusitis, 2)chronic invasive fungal rhinosinusitis and
3) granulomatous invasive (indolent) fungal rhinosinusitis.
The two non-invasive fungal rhinosinusitis disorders are
1) fungal ball (sinus mycetoma) and 2) allergic fungal
sinusitis .
In the present study, maximum number of cases
belonged to the age group of 21 - 30 years, which
constitutes 45% of the total cases. McNeil1 found the
common age group affected by maxillary sinusitis was
to be 20 - 29 years and Mukherjee et al,9 also found
the common age group to be 20 -30 years. Male to
female ratio was found to be 1.24:1 in this study,
which is similar to the observations of Jee et al10
(1.7:1), but differs from the findings of Su et al3 and
Prabhakar et al7, where the male : female ratio was
found to be 5:1 and 3:2, respectively.
In this study fungi are isolated in 14 eases (11.66%)
out of 120 patients, which is more or less equal to the
observation of Grewal et al4 (10.7%) and Prabhakar et
al7 (9.3%), but differs from that of Evans et al2, who
found fungi in 94.2% of cases. Among the fungi
Aspergillus species constituted the most i.e. 10 cases
(71.43%), Candida albicans 2 cases (14.29%), 1 case
each of Penicillium & Cladosporium (7.14%). Among the
Aspergillus species, Aspergillus fumigatus was isolated
in 6 cases (42.86%), Aspergillus flavus in 3 (21.43%)
and Aspergillus niger in 1 (7.14%).
Out of 14 cases, one case was found to be having
chronic granulomatous invasive form. All other 13 cases
were of non-invasive variant. Chakrabati et al5 in their
study of 50 fungal sinusitis cases found, 31 (62%) to
be non-invasive and 19 (38%) to be invasive type. Dass
et al6 in their study of 14 cases observed, 12 (85.71%)
to be invasive variant and 2 (14.29%) to be of noninvasive type.
COMPARISON OF PRESENT STUDY WITH OTHERS

Aspergillus
Pencillium
Candida
albicans
Cladosponum
Mucor
Present study
71.43%
7.14%
14.29%
7.14%
__
Grigoriu et al
(1975)
66.60%
2.00%
8.30%
__
__
Laskownick et
25.20%
16.80%
41.10%
__
__
75.00%
12.50%
12.50%
__
__
4.00%
2.00%
__
__
66.00%
__
33.00%
__
__
67.47%
4.82%
26.51%
__
1.20%
al (1978)
Grewal et al
(1990)
Chakrabarti et 86.00%
al (1992)
Aher et al
(2000)
GPS Gill et al
(2004)
Infection by fungus in chronic maxillary sinusitis is not

so rare as previously thought. Prolonged use of steroid
nasal spray and diabetes may predispose to fungal
sinusitis. Aspergillus is the most common fungus isolated
from cases of fungal sinusitis. All cases of chronic
rhinosinusitis not responding to standard therapy should
be investigated for fungal rhinosinusitis. The most
important issue in treating a case of fungal rhinosinusitis
is to determine whether the disease is invasive or noninvasive.
REFERENCES :
1. McNeill RA (1963) : Comparison of the findings of
transiiiumination, X-ray and lavage of the maxillary
sinuses. J Laryng 77, 1009.
2. Evans FO, Sydnor JB, Moore WEC : Sinusitis of the

maxillary antrum. New Eng J Med, 1975; 293 :
735-39.
3. Su WY, Liu C, Hung SY, Tsai WF : Bacteriological
study in chronic maxillary sinusitis. Laryngoscope,
1983 Jul, 93 (7): p.931 - 34.
4. Grewal RS, Khurana S, Aujla KS and Goyal SC :
Incidence of fungal infections in chronic maxillary
sinusitis. Ind J Path and Microbiol, 1990; 33 :
p. 339 - 43.
5. Chakrabarti A, Sharma SC, Chander J :
Epidemiology and Pathogenesis of paranasal sinus
mycoses. Indian Journal of Otolaryngology and Head
& Neck Surg, 1992; 107 : p. 745 - 50.
6. Dass A, Ahlawat S, Bahadur S and Ghosh P :
Paranasal sinus Aspergillosis. Ind J Otolaryngology
and Head & Neck Surg, 1992 December; 1(4) :
p. 211 -15.
7. Prabhakar S, Mehra YN, Talwar P, Mann SBS and
Mehta SK : Fungal infections in maxillary sinusitis.
Ind J Ototaryngol Head Neck Surg, 1992; 1 (2) :
p. 54 - 58.
8. Gliklich RE, Metson R: Health impact of chronic
sinusitis in patients seeking otolaryngologic care,
Otolaryngology and head and neck surgery 1995;
113: 104 -104.
9. Mukherjee SK, Figuerora RE, Ginsberg LE, Jeifer BA,
Marple BF, Alley JG. Allergic fungal sinusitis. CT
findings. Radiology 1998; 207 : p. 417 - 22 .
10. Jee BH, Lee SW and Lee BJ: Isolated bacteria and
their susceptibility to antibiotics in chronic sinusitis
: Results of endoscopically guided cultures of
maxillary sinus secretions. J Rhinol, 1999; 6 (1) :
p. 66 - 69.
Dear Members of Orissa State Branch of AOI,

Kindly contribute articles and arrange advertisers for next issue (JulyDec., 2008) of
Orissa Journal of Otolaryngology & HNS.
Without your kind help it is not possible to publish the next issue

Editorial Chairman
FACIAL NERVE NEEDLING AS A CURATIVE TREATMENT

FOR HEMIFACIAL SPASM - REVISITED
Dr. Ogale S. B.
MS, DORL, FCPS, MNAMS, FAMS
Dr. Avanindra Kumar

MS, DNB
Abstract : 40 Patients with idiopathic hemifacial spasms were subjected to transtympanic needling of the horizontal
segment of the affected facial nerve. Out of which 35 patients showed complete relief of symptoms in the immediate
post operative period. This treatment modality is advocated as a curative treatment of hemifacial spasms.
Key words: Hemifacial spasms, Facial nerve, Transtympanic needling
INTRODUCTION :
Hemifacial spasm is a disease of unknown etiology
characterized by spontaneous, involuntary & repetitive
twitching of facial musculature of one side. Though
supposedly benign, its a cause of much disability (cosmetic
than functional) & embarrassment for the affected. After
its description by Wartenberg for the first time in 1952,
many hypotheses have been put forth as regards its etiology.
Understandably, medical as well as surgical managements
depend to a large extent on the etiological hypothesis
followed.
Clinically, the disorder presents with repetitive, involuntary
twitching of the facial muscles of one side. There is no
weakness of the affected muscles. The twitchings appear
suddenly in the absence of any precipitating factor & are
present even during sleep. The twitching cant be
suppressed voluntarily. Its invariably unilateral with a
gradual increase in the number & severity of attacks.
Here, we are presenting a large series of 40 patients over
a period of 20 years, its a continuation of a previous series
of 19 patients reported by the main author in 1997.
Material & Methods
This is a prospective study of 40 patients who presented to
us with idiopathic hemifacial spasm over a period of 20
years (1986 2006) & were treated with transtympanic
needling of facial nerve. Twenty three of the patients were
males & seventeen were females. The age distribution was
between 30 to 65 years with the mean age of 42 years.
Table 1.
Sex of the patients
Number
Male
23
Females
17
Total
40
The patients presented with history of gradually increasing,

spontaneous, spasmodic hemifacial movements for 1 -3
years with no known precipitating factors, being present
even during sleep. There was no past history of facial
trauma, facial nerve paralysis or ear surgery. There were
no symptoms suggestive of CP angle tumor. None of the
patients had any contributory systemic disorder like diabetes
mellitus or syphilis. Family history was not contributory.
Otolaryngolgical examination showed no abnormality except
for the presence of spasms. All the patients underwent
MRI as part of a routine work up, it didnt show vascular
loop or tumor at the CP angle in any of the patients, thus
confirming the diagnosis of idiopathic hemifacial spasms.
Pure tone audiometry showed mild sensorineural hearing
loss in 8 patients & moderate sensorineural hearing loss in
1 patient, while the remaining had hearing within normal
limits. Brain stem evoked potentials were normal in all the
patients. Caloric tests & ENG were normal. Other routine
investigations failed to show any abnormality. EMG studies
showed hyperkinetic responses.
PROCEDURE :
In all the patients, the Ludmans procedure of facial nerve
needling of the horizontal part was performed under local
anaesthesia viz. preoperative medication of 0.6 mg
atropine followed by I.V. sedation with 30 mg Petazocine &
10 mg Diazepam and local infiltration with 2% lignocaine &
1:100000 adrenaline, as in stapes surgery.
With the patient in supine position, the affected ear being
placed uppermost, the parts were painted & draped in a
sterile fashion. Using Rosens endomeatal approach, the
tympanomeatal flap was raised & the middle ear entered.
The overhang was curetted till the incudostapedial joint
was exposed. The bone was removed posterosuperiorly
as needed for stapedectomy. On inspection, in all cases,
the ossicular chain & facial nerve was normal. In only
one case a dehiscence of horizontal segment of the fallopian
canal was noted. The mucosa over the bony fallopian canal
was removed using a needle. Using a small diamond burr
& a right angled hook, the entire bony shell was removed
exposing the sheathed horizontal segment of the VII nerve.
In all 40 cases studied, none of the nerve showed any
evidence of neuroma, hematoma, oedema or areas of
demyelination. Using a straight fine microsurgical pick,
taking care not to displace incus or stapes, four to six
punctures were made in the horizontal segment of the facial
nerve by pushing it medially through the thickness of the
nerve to hit the medial wall of fallopian canal. The puncture
site was covered with a small gelfoam. The tympanomeatal
flap was reposited and antibiotic impregnated pack was
placed in the external canal. Postoperatively, the patients
were given amoxycilline-clavulinic acid combination,
analgesics & multivitamin capsules for 5 days, following
which the patients were discharged from hospital. No ear
drops or steroid (systemic or local) was prescribed. None
of the complications (as reported elsewhere) viz.
L
L
L
L
L
L
L
dislocation of the IS joint.

injury to the stapes suprastructure.
perforation of the tympanic membrane.
postoperative vertigo.
dead ear.
facial nerve paralysis.
worsening of spasms.
was noted in our series.

The patients experienced relief from spasms within a mean
time interval of 48 hours to 15 days post-operatively.
Results
Assessment of results was based mainly on the patients
subjective experience and partly from the examiners
assessment. Out of the 40 patients, 35 patients were totally
relieved of spasms in the immediate post-operative period.
The mean interval of relief from spasm was 48 hours postoperatively.
While 3 patients had partial relief, 2 patients had no relief
at all. All these 3 patients with partial relief subsequently
underwent a transmastoid needling of the mastoid segment
of the facial nerve. They had complete relief from spasm
within the next 24 hours of surgery. The other two patients
refused any further exploration. The results are tabulated
below:
Table 2.
Relief from spasm
No. of patients
Complete
35
Partial
None
The only significant complication that we encountered was

facial paresis (not paralysis) in 5 patients, which resolved
spontaneously within the next 2 to three weeks.
Table 3.
Complications
No. of cases
Facial paresis
Conductive deafness
Temporary conductive deafness was also seen in 3 patients.

In this study spanned over 20 years (1986 to 2006), the
average time of follow up has been 3 months to 7 years.
During this period, 3 patients reported a recurrence of
symptoms. While 2 patients lent themselves to a second
operation & were successfully treated, the 3rd patient with
recurrence refused treatment.
Advantages of the procedure
Has a sound etiological basis.
Can be performed under local anaeasthesia.
Simple & short procedure.
Cosmetically accepted incision with no external scar.
Easy yet adequate exposure.
Normal anatomic architecture & landmarks are
maintained, therefore relook surgery becomes easier.
L Minimum intraoperative & post operative complication
L Short duration of in patient management required (day
care procedure).
L Immediate relief of spasms.
L There is no need for follow up, hence useful even in
geographically inaccessible patients.
L Less morbidity & mortality as compared to other
procedures, especially posterior fossa approach.
DISCUSSION :
L
L
L
L
L
L
Hypotheses regarding etiology of hemifacial spasms fall

into 2 groups. The first set believes that, it is a central
disorder, originating in the facial nerve nucleus in the pons.
As originally proposed by Ferguson & Kruetzberg in 1973,
finding its supporters in Ludman, et al this theory states
that, secondary to a peripheral nerve injury, deafferentation
of central pontine nucleus of facial occurs, which results in
abnormal discharges eventually leading to chronic facial
spasms. A variant of this theory, as proposed by McCabe,
supported by Karnik & Jain- states that, the motor fibres
that supply the facial musculature originate in the 4s area
of the motor cortex of the brain (also known as the
suppressor strip), any damage to this area leads to
uncontrollable overactivity of the facial nerve, thus leading
to clonic, facial hemispasm. Our technique was based on
cutting down the number of innervated motor units in the
peripheral musculature by including lesions in the peripheral
course of the facial nerve. Here minimal facial weakness

was traded for relief of spasm. Various sites have been
proposed for this purpose, namely, horizontal segment,
mastoid segment, stylomastoid foramen & peripheral
parotid branches. Ludman has reported a series of 62
patients. He performed transtympanic needling of the
horizontal segment in 54 patients & has reported successful
relief in 3 cases. 23 patients needed a second surgery of
which 16 patients were totally relieved of spasm. Another
modality based on this theory includes partial neurectomy
hemisection of the parent nerve, in the mastoid segment
(Karnik, Jain) or longitudinal splitting in the cerebellopontine
angle (Fan). Fan has successfully treated 33 cases with
this procedure. 20 patients followed up for one year none
showed a recurrence. One case required a second surgery
& was resolved completely. He has reported a 10% failure
rate.
The second set believes that, the disorder is of peripheral
origin, following compression injury to the nerve trunk. This
results in the establishment of the transaxonal links between
fibers, called Ephapses. This compression injury could also
be due to an aberrant vascular loop commonly at the root
entry zone in the cerebellopontine angle or Porus internus
acoustico facialis as proposed by Janetta, Gardener,
Magnan, Sava. Based on this theory the other surgical option
of management of hemifacial spasms mentioned in the
literature include:
Its obvious disadvantage is temporary effect & the need

for frequent injections. The treatment is non etiological,
provides short term relief, costly & requires repeated follow
ups.
Medical treatment :
Drug therapy for hemifacial spasm is difficult &
unpredictable. There is no fixed or best drug regimen. The
following drugs have been tried carbamazepine,
clonazepam, diazepam, levodopa, bromocriptine &
amantadine. Though, the list is by no means complete.
CONCLUSION :
There are as many therapeutic surgical options available
for idiopathic hemifacial spasms as there are aetiologies.
The treatment of this disabling & socially unacceptable
condition is by no means easy. Based on the above study,
the authors in no way claim that transtympanic facial nerve
needling is the perfect solution or that it always gives 100%
cure. However, it has proved to be treatment option to
reckon with.
REFERENCES :
1.
Ludman H, Choa D L, Hemifacial spasms operative

treatment. JLO 1985: 99: 239 45.
2.
Ferguson J. Hemifacial spasm & the facial nucleus.

Ann Neurol 1978: 4: 97.
3.
McCabe BF, Boles R. Surgical treatment of essential

blepharospasm. Arch Otolaryngol 1972; 81: 611 8.
4.
Karnik PP, Jain JC. Hemifacial spasms. Ind J Otol 1973;

2531 4.
5.
Total decompression of the intratemporal facial nerve

(Pulec). This procedure does not have good results.
Fan Zhong. Intracranial longitudinal splitting of the facial

nerve- a new approach for hemifacial spasm. Ann
Otorhinolaryngol 1993; 102(2): 108 9.
6.
Faciohypoglossal (Andrew) or Facioaccessory (Ehning)

anastomoses: apart from the fact that this method
includes a double deficit, though temporary, its a non
etiological procedure.
Janetta PJ, Abbasy J, Maroon JC, Ramos FM, Albin

MS. Aetiology & definitive microsurgical treatment of
hemifacial spasm. J Neurosurg 1977; 47: 321 28.
7.
Gardener WJ, Sava GA. Hemifacial spasm a reversible

pathophysiologic state. Neurosurgery 1962; 19: 240.
8.
Pulec JL. Idiopathic facial spasm: pathogenesis of

segmental oedema successfully treated by total facial
nerve decompression. Presented to the American
Otological Society on April 24, 1972 in Palm Beach ,
Florida.
9.
Andrew J. Surgery for involuntary movement. Br J Hosp

Med 1981: 26: 522 8.
Posterior fossa neurosurgical approach with

decompression of the aberrant vascular loop (Janetta,
Magnan) this procedure has the obvious disadvantage
of being a major procedure, under general anaesthesia
with a higher risk of complications. Also there are a
large number of anatomical variations in the
vasculature at the cerebellopontine angle.
NON- SURGICAL MODALITIES

Botulinum toxin injection :
Botulinum toxin is an approved treatment for hemifacial
spasms & blepharospasm in United States & Canada. This
is a toxin produced by Clostridium botulinum bacteria, it
weakens the muscles by blocking the nerve impulses
transmitted from the nerve endings of the muscles. The
sites of injection vary from patient to patient & according
to physician preference. Benefits begin after 1 to 14 days
after the treatment & last for an average of 3 to 4 months.
10. Ehni G, Woltman HW. Hemifacial spasm: review of one

hundred & six cases. Arch Neurol Psychiat 1945; 53:
204 11.
11. Ogale SB, Chopra S, Thakur S. Transtympanic Facial

nerve needling: A curative surgical option for
hemifacial spasms. Acta Otolaryngol (Stockh) 1995 :
115: 405 407.
17. Ogale SB, Sandu KB. Facial nerve needling An option
for hemifacial spasms. Indian Journal of Otology 1997:
vol. 3, no 3. 119 122.
Address correspondence & reprint requestsDr. S. B. Ogale, MS, DORL, FCPS, MNAMS
B 523, Dhanwantari CHS,
Deonar Municipal Colony, Sector II
Mumbai, India-400043
Phone-*919820542962
Fax-*9122-24143435
Email: dr_sbogale@yahoo.com
Prof. Abhoya Kumar Kar has been appointed as Honorary Visiting faculty of Annamalai
University for the year 2007-08.
Prof. G. C. Sahoo has been appointed as Hon. Editor of International Profiles
Accomplished Leaders published by American Biographical Institute, Inc.
of
ENDOSCOPIC SOLUTIONS TO HEADACHE

Prof. Jacinth
Abstract : Headaches of rhino-sinusogenic origin have been mostly deemed to be due to sinusitis. The aim of this
study is to detect the rhinologic headaches that arise from contact areas consequent to synapse of sensory innervations
and cutaneous neurons. Endoscopic decompression of such contact areas resulted in great relief. The incidence of
coexisting migraines also drastically reduced following such surgeries.
Key words : Headache; contact area; neuropeptides; patch & probe test; Endoscopic decompression.
INTRODUCTION :
Headache is not a disease, but a symptom reflecting the
presence of myriad disease spectrum. When it is recurrent,
it becomes a source of misery to the sufferers as well as to
those who venture to treat it. Research has reported about
300 causes of secondary headaches. About 20% of the
headache cases get referred to ENT department from
various other disciplines of medical science to rule out rhinosinusogenic headaches. CT scans & diagnostic endoscopy
resolve most of the puzzles in rhinosinusogenic headaches
& offer solutions.
METHODS :
This study includes referred patients from Medical, Neuro,
Ophthalmic, Dental or other departments for opinion
regarding headache. All the cases were subjected to
diagnostic endoscopy & CT scans to detect the cause.
Neoplastic lesions of nose & PNS were excluded from the
study. Frank sinusitis cases were identified and treated
appropriately. For the rest of those who walked in with
headache, patch test was done. 4% xylocaine nasal packs
were applied as patches over the contact nasal mucosal
area of the meati, turbinates and septum. Disappearance
of headache & reappearance after the lapse of action of
local anaesthetic identified headaches due to contact areas
from this patch test. Probe test by probing the suspected
areas of contact triggered and aggravated the headache1.
Application of a local anaesthetic patch over that area
relieved headache & confirmed the cause of headache.
Such of those patients with rhinologic headaches due to
contact areas were treated with FESS beneficially. We
reviewed those, who were accessible for 6 months to 2
years follow up in treatment. Total of such number of
compliant patients were 128 in this study of past 5years.
Middle turbinate causing headache due to contact:

Paradoxical 9%, Concha bullosa 27%, Contact area
between accesory ostium & adjoining middle turbinate-1%.
Medialised or pnuematised uncinate causing headache due
to contact 21%
Septal deviations / Spurs2 causing headache due to contact
- 22%
Hyper pneumatised agger nasi cells causing vacuum frontal
headache 2%
Rare C.T. revelations towards Headache unseen in
diagnostic endoscopy.
Onodi cell infection causing

headache (CT)
Septal Spur causing

rhinologic headache
(Endoscopic View)
CT picture of Hallers cell

blocking maxillary sinus
ostium caused cheek pain
Medialised uncinate causing

rhinologic headache
(Endoscopic View)
RESULTS :
Contact areas within nasal cavity that is responsible for
headache as confirmed during diagnostic nasal endoscopy
by the patch and probe test revealed the following sites.
Large Ethmoidal bulla with contact area & headache 18%
Aggernasi causing
rhinologic headache
(Endoscopic View)
Bulla causing rhinologic headache
(Endoscopic View)
(CT View)
Concha bullosa causing rhinologic headache
(Endoscopic View)
(CT View)
Endoscopic decompression or routine FESS offered near

total or total relief of headache in about 92% cases of our
study. The remaining 8% were those who had coexisting
migraines. However the follow up studies revealed that
the attacks of migraine drastically dropped down by 50 to
60%. This suggests that, the contact areas may even trigger
a migrainous attack.
Another case of neuralgic pain with Onodis cell disease
was relieved of the neuralgia after clearance of disease,
which probably irritated maxillary nerve & caused neuralgia.
Similarly another patient who presented with facial pain
had an antral cyst. Antral endoscopy revealed anterosuperior
alveolar nerve stretched over the retention cyst.
Marsupilisation of the cyst relieved the facial pain by
decompressing the superior alveolar nerve. Another
interesting case was that of a Hallers cell causing facial
pain in the absence of antral purulence or any other
pathology. Endoscopic decompression offered complete
relief of pain.
DISCUSSION :
Headache cases referred to ENT, present with constellation
of symptoms such as nasal block, discharge and fullness
or pressure probably due to sinonasal origin. Coexistence
of tension headaches, migraine, neuralgias, cervical spine
disorders, temperomandibular joint disorders, vascular
anomalies, ophthalmic disorders and intracranial
pathologies may also feature and need to be borne in mind.
When a good history rules out the above-mentioned causes,
headache of rhinosinusogenic origin alone remains to be
excluded. In a study of 100 consecutive patients elsewhere
with a diagnosis of acute or chronic sinusitis, headache
was the 4th commonly occurring symptom 3. Nasal
congestion, secretion and fullness or pressure were more
common symptoms. In another study elsewhere of 400
consecutive patients undergoing FESS, 63% suffered from
headaches as 3rd common symptom. However FESS

offered universal relief for all the symptoms. Another
category of patients with headache as major symptoms is
detected to be of non-sinus origin with disease free sinuses.
When a headache presents as a major symptom, a
rhinologic cause has to be evaluated to find the contact
areas, which has been understood to cause referred pain.
Sensory innervations of nose and sinuses synapse with
cutaneous sensory neurons. Irritation of such contact areas
released neuropeptides and orthodromic pulse to cause
referred pain in face and head 4.
Medical treatment inclusive of nasal spray is helpful in initial
stages of relieving this headache by decongestion. When it
becomes recurrent, surgery needs to be considered.
Headache due to rhinologic contact areas were treatable
by FESS. Uncinectomy, Agger nasi & Bulla clearance opens
to two important pre chambers, infundibulum & frontal
recess, to ventilate the sinuses by exposing the respective
ostia to drain and facilitate mucocilary transport in FESS.
In the process, contact between two mucosal surfaces was
also eliminated, thus obliviating irritation, that might arise
out of the contact to release neuropeptide and cause pain.
Middle turbinate is the important landmark of this surgery.
Concha bullosa might warrant a lateral lamellectomy to
release contact areas. Occasionally, attention may be
required at sphenoethmoidal recesses for posterior group
of sinuses. This procedure in essence, decompressed the
OMC and relieved the contact areas by either eliminating
or reducing the pressure over the contact areas.
CONCLUSION :
Headaches always occurred in combinations. Diagnostic
Endoscopy offers excellent idea about decision of treatment.
FESS offers 90% relief in headaches due to rhinosinusogenic cause and reduces the attacks of coexisting
migraines by about 50%. The other advantages are reduced
morbidity, minimal blood loss, minimal nasal packing &
shorter hospitalization.
REFERENCE :
1)
2)
3)
4)
McAuliffe GW, Goodell H, Wolff HG. Experimental studies

on headache pain from the nasal and paranasal
structures
Gerbe RW, Fry TL, FischerND. Headache of nasal spur
origin: an easily diagnosed and surgically correctable
cause of facial pain. Headache.1984: 24:329 -330
James A. Stankiewicz, Advanced endoscopic sinus
surgery: Evaluation of rhinologic headache. 1995;
121 126
Stammberger H, Wolf G Headaches and sinus diseases:
Endoscopic approach. Ann ORL 1988; 97 (suppl 134);
3-23
Address for contact: Prof. Jacinth

Head Department of ENT,
Stanley Medical College & Hospital,
Chennai 600001.
Quality Control in Audiometry

Ludwig M. Moser, Prof. ret.
ENT-Clinic, Julius-Maximilians-Universitt
Josef-Schneider-Str. 11, D 97080 Wrzburg, Germany
An audiometer is a medical instrument and an electronic
instrument, that is regulated by many international and
national standards (ISO 389). Those standards name
different classes of audiometers, like screening or clinical
audiometers. Each has to comply with different limits for
accuracy and function. Those parameters are to be checked
at least once a year by a certified service (ISO 8253). The
daily operation of the audiometer has to be checked by
the operator of the instrument. The procedure for doing
that is stated in an international standard, ISO 8253. This
standard at the moment has three parts 8253-1, 8253-2,
and 8253-3. In part 1 this standard is asking for a daily
check, a quick check to make sure the instrument is working
properly. A second test is required at least once a week.
The operator of the audiometer has to test a normal
hearing person, with no known hearing impairment. This
person ideally should be less than 25 years old. The test
should include writing air and bone PTTs. For a clinical
audiometer that uses insert ear-phones, they should be
included in the weekly checking procedure.
It is good lab practice to check your instruments on a known

test item and it has been practised for a long time. Today
it is very often neglected, assuming the microprocessor,
that is the heart of most modern instruments, is doing
that at start up, no human testing is required. The standard
ISO 8253 just tells you to do it once a week, it stops at
that point. You can do as the standard says, do the test,
write or print the audiogram and then file it. This is correct,
but it is not good lab practice. The calibration testing of
the audiometer is done once a year. Within a year it is
possible that, some specifications of the instrument
gradually drifts outside of limits. Good lab practice is to
compare the normal audiograms, to the other normal
audiograms that are filed. This comparison could be done
by eye or by calculation and by statistics.
It is much easier to store the audiograms into a worksheet
file and do the calculation and statistics on a computer.
Since the days of AppleII and C64, those computers have
spreadsheet programs. Today those programs, either MS
Excel or Open Office Calc will most of the time be used.
Table 1 is a very simple example of a useful table listed.
Date
Audiometer
Ident
Age of
Tested
Side
left/right
Transuducer
Air/Bone
PT0250
PT0500
PT1000
PT2000
PT4000
PT8000
13.12.07
25
Blue
Air
-5
10
Table 1: Example of a worksheet to store audiometer control checks
Modern audiometers are connected to a computer and

are storing the audiometric data in internal files. At the
University ENT-Clinic in Wrzburg we have 6 audiometric
test rooms. All test results are stored in a central server in
an audiometric database. A little programming is needed
to extract the control audiograms into a worksheet table
as seen in Tab.: 1. The six audiometers were connected
to a central computer server in the fall of 1994. Since that
beginning more than 60 000 patients have been tested
and their audiograms have been written into that server.
In the spring of 2007 we had the first serious crash of that
system but the standby server could take over and the
crashed hard disk was replaced and the system lost no
data. The control audiograms are taken every Monday
morning, in short Monday control-audiograms. The age
limit of the tested head is not enforced strictly. It is seen in
our analysis for the pure tone 8000 Hz data. In Table 2 are
the results of all Mondays since 1994.
Frequency
cases
mean
Stderr
Air
500
2388
1.9
0.2
1000
2580
3.0
0.2
2000
2364
5.1
0.2
4000
2371
2.7
0.2
8000
2640
11.0
0.2
500
1104
-1.7
0.5
1000
1218
-0.3
0.4
2000
1099
0.4
0.4
4000
1060
0.2
0.5
8000
946
2.2
0.8
Bone
Table 2 : Results of the stastical analysis of control

audiograms.
In table 2, in the first column the test frequency and the

transducer are marked. In column 2 are stated the number
of cases recorded, in column 3 the mean of all recorded
PTT and in column 4 finally the standard error of all
recorded PTT. The value of 11 dB for the mean at 8000 Hz
air is different and in value twice the next bigger difference
of 5.1 dB at 2000 Hz. For bone conduction the 8000 Hz
mean is also the largest deviation at 2.2 dB. Here the
standard error is 0.8 dB the largest recorded standard
error (stderr) value in Table 2. The test results at 8000 Hz
for air and bone may be due to different influences. At
8000 Hz air the head phones should be centered over the
entrance of the external ear canal, the phones should not
be placed over hair. Both hints in the ISO 8253 standard
probably are taken lightly when the audiometric technicians
are testing colleagues. It might be the same at 8000 Hz
bone, the bone transducer should be placed at the most
sensitive spot, but this takes time and this might also be
taken lightly at the Monday controls. It is easy to spot those
deviations in table 2, but it is nearly impossible to see
them in paper form directly in the Monday audiograms.
Deviations are seen in the test audiograms only when the
differences are larger than 15 dB. As an anecdotal
reference, one Monday, an audiometer was called defect
at 8000 Hz, the PTT was 60 dB. It turned out not the
audiometer, but the tested person had a problem, she spent
the weekend in a very loud environment, in a disco.
To see the difference between the Monday control
audiograms and clinical audiograms, the age group of 18
to 25 year old patients is plotted with AIR and BONE
audiograms together with the Monday controls at 1000
Hz.
The mean values of table 1 are slightly higher than the
median values of diagram 1. The distribution of the PTT
values is not normally distributed. This is more extreme
for the PTT values of patients age 18 to 25 years of age.
The standard ISO 8253 as well as ANSI S3.21 is asking
for a quality, that the marked PTT is within of 3 dB. To
make sure that, this limit is not exceeded, it suggests that,
the PTT value should be recorded in 2 out of 3 trials. This
is a quality statement, that is not seen in a final printed
audiogram. Even in the most modern audiometers, no hint
is given that the PTT value is within that limit. In Wrzburg,

the data server is taking care for that. When the PTT at a
certain frequency with a certain transducer, air or bone, is
measured, every response is recorded by pushing a button.
The data server records the event like in table 1, but in
addition there is an additional column in the table marked
last. The flag recorded in this column is 0, only when
the test frequency is changed, the flag is changed into 1.
For each PTT the table should have at least 2 lines for
each frequency and transducer. The 2 lines should have
the same values in each field, but the last one. If there are
only two lines and the PTT values are different, then it is
obvious that, the 2 out of 3 rule is broken and the audiogram
does not give a reliable PTT value. On the other side ISO
8253 takes into account that, there are rare cases where
it is impossible to comply with the 2 out of 3 rule. In cases,
when there are more than 5 attempts to find the PTT and
there is no 3 out of 5 equal valued PTT responses, the PTT
at that frequency with that transducer should be marked
unreliable. It is not easy to grade a printed audiogram as
being in compliance with ISO 8253. So far the most modern
audiometers to the author's knowledge do address
reliability of measurement, it is left to the people operating
the instrument. For all audiometers that do have a port to
send data to a computer, it is possible to take care of that
recommendations by a special computer program.
Unfortunately there are no commercial ones available.
There are some audiometric training programs for PTT,
that include reliability of measurement (Otis).
At the ENT department of the Wrzburg ENT-University
clinic, we have followed the above mentioned standard
recommendations since 1994. During that interval more
than 60,000 patients had their pure tone audiograms
measured. The data base has been very valuable in
providing insight into many audiological questions.
Literature
ANSI S3.21-2004; Methods for Manual Pure-Tone
Threshold Audiometry.
ISO 8253-1:1989; Acoustics-audiometric test methodsPart 1: Basic pure tone air and bone conduction threshold
audiometry.
ISO 389-3:1994; Acoustics - Reference zero for the
calibration of audiometric equipment Part 3:
Reference equivalent threshold force levels for pure tones
and bone vibrators.
Otis der virtuelle patient; www.audiometrie.com
Diagram 1: Distribution of PTT at 1000 Hz for Monday control

measurements and for patients age 18 to 25 years old.
ENDOSCOPIC DCR FOR CHRONIC DACRYOCYSTITIS

A SERIES OF 50 CASES
Dr. G. C. Sahoo, Professor and Head of Department of ENT
Dr. R. Vasudevan, Professor and Head of Department of Ophthalmology
Dr. S. Balaji, Lecturer, Department of ENT
Dr. N. M. Arun, Post Graduate
Abstract:
A study has been performed in 50 cases of chronic dacryocystitis to know the success of endoscopic DCR in
Rajah Muthiah Medical College & Hospital from September, 2005 to 2007. The study recorded age, sex distribution,
intra operative, post operative complications & success rate. After 6 months of follow-up success rate of endoscopic
DCR was 90%.
Key words: Dacryocystitis, Endoscopy, DCR
INTRODUCTION :
Chronic dacryocystitis is a very common condition
prevalent in all age group. Epiphora secondary to lacrimal
obstruction is a common ophthalmologic problem. It usually
causes discomfort & pain. It is a frequent irritation to the
patient. The study was done to know the result of
endoscopic DCR.
MATERIAL & METHODS :
50 cases of dacryocystitis were included in the study
over a period of 2 years, i.e from Sept., 2005 to Sept.,
2007. They were subjected to endoscopic DCR in the
department of ENT in Rajah Muthiah Medical College &
Hospital. All patients were subjected to complete ENT &
ophthalmic examinations. Patients were selected on the
basis of clinical history. On lacrimal duct canalaisation &
irrigation on applying pressure over lacrimal sac, there
was regurgitation of fluid, mucous or pus, which was
confirmed by syringing.
OPERATIVE TECHNIQUE :
Nasal cavity was packed with 4% xylocaine with 1:40,000
adrenaline prior to surgery. Infiltration was given with
2% xylocaine with adrenaline just anterior to the
attachment of middle turbinate.
1x1 cm incision was given just anterior to the uncinate
process & excised. The lacrimal bone overlying the
lacrimal sac area was removed by Kerrisons punch
forceps. Lacrimal sac was visualized & medial wall of sac
was exposed.
Excessive bleeding was controlled by applying gauze dipped
in 4% xylocaine with 1:2,00, 000 adrenaline.
Lacrimal sac was confirmed endoscopically by applying
pressure over the medial canthus. Mucosa of the sac was
incised by sickle knife, mucopurulent discharge came out
of the sac. Medial wall of the sac was removed with
Blakesley's forceps.
Lacrimal sac syringing was done with normal saline & free
flow of fluid was observed endoscopicaly. Nose was
packed with ribbon gauze smeared with neosporin
ointment. Patient was put on prophylactic antibiotics and
anti inflammatory drugs. Saline irrigation and nasal
douching was done.
Patient was asked to come for review weekly once for Ist
month and then monthly once.
OBSERVATION AND RESULT :
In our study, patients of age from 20 years to 70 years
were taken.
It was found that majority of patients were in 3rd and 4th
decades of life (34% in 3rd decade and 30% in 4th
decade).
A female preponderance was noticed, 30% were males
compared to 70% females.
In intra operative complications 30% i.e. (15 cases) had
moderate bleeding and in 8% i.e. (4 cases), there was
difficulty in doing bony window.
Post -operative complications include synechiae and
granulation. Synechiae was found is 6% i.e. (3 cases)
and granulation in 10% i.e (5 cases).
Success rate was defined as no complaint of epiphora and
presence of patency of duct on syringing. Success rate of
endoscopic DCR was 90% i.e. (Lacrimal drainage system
was patent in 45 cases).
DISCUSSION :
The present study was conducted from Sept., 2005 to Sept.,
2007, during which 50 cases were studied & they under
went endoscopic endonasal dacryocystorhinostomy.
Chronic dacryocystitis was more common in adults &
highest incidence was seen in 3rd & 4th decades. In
present study patients were aged between 20 to 70 years

of age.
HB Whittet et al (1993)1 observed the age of the patients,
which ranged from 14-80 years. In a study conducted by
Cookeser et al (2000)2, age range was from 4 to 76 years.
Female preponderance was noticed in 35 patients (70%),
only 15 were males (30%).
According to Sprekelsen et al (1996)3, 80% patients were
females & 20% were males.
The striking predilection may be due to narrow lumen of
bony lacrimal canal endocrine factors. Gossel S. A. et al4
in their study of axial maxillo facial CT scans showed,
women of having a smaller bony diameter at the level of
lower fossa & middle nasolacrimal duct compared to men.
CONCLUSION
Endoscopic DCR is simple & safe. The surgical duration
is short. Intranasal pathologies like grossly deviated nasal
septum can be corrected in same sitting.
Endoscopic DCR avoids scar formation & injury to
adjacent structures like medial palpebral ligament and
angular vessels. The lacrimal pump mechanism is not
disturbed as the orbicularis muscle is not incised. The
procedure is cost effective & patient friendly.
Thus endoscopic DCR is a better procedure for treatment
of chronic dacryocystitis. With wide spread use of nasal
endoscopic techniques, this surgery is gaining popularity
all over.
Our study showed 15 cases (30%) had moderate bleeding,

haemostasis was attained with gauze soaked in 4%
xylocaine with adrenaline.
In a study conducted by Jounko et al5, 1 patient required
anterior nasal tamponade after resection of anterior end
of middle turbinate.
Infiltration
Nasal cavity packed with merocel
In 8% (4 cases), there was difficulty in doing bony window.

In our study the post-operative complications we came
across were synechiae, granulations & rhinostomy
obstruction.
3 patients (6%) developed synechiae between middle
turbinate & sac area. They were released a week later
under endoscopic guidance.
According to Sperkelsen3 synechiae occurred in 22% of
cases & most of them were minor & did not interfere with
final results. Granulation at the site of rhinostomy was
seen in 10% i.e (5 cases). Sperkelsen3 reported granulation
tissue formation in 6.6% of cases.
Crusting was found at the site of rhinostomy in 5 patients.
It was cleared in 1st week endoscopically & did not
interfere with final result.
According to Hartikainen et al6 , seven patients had
obstruction at rhinostomy site.
Lacrimal sac through bone window
Incision and elevation of mucoperiosteal flap
Bone Nibbling
Sac Incision
FOLLOW UP PHOTOGRAPHS
Success of the procedure was defined as a patent lacrimal

drainage system at the end of 6 months. In our study we
had success in 90% (45 cases) & failure in 20% (10 cases).
The success rate of endoscopic DCR has been reported
between 82% to 86% (Jokinen et al, 1974; Rice DH et al,
1990; Shunshin et al 1998)7.
Our success rate in endoscopic DCR is better. The choice
of case selection must have had bearing on success rate.
1 st Week
1 st Month
6. Shun shin GA, Thunrairajan G. 1998. "External DCRan end of an era?". British journal of Ophthamology,
south Asia. 1: 11-12.
7. Seppa, Grenman R. 1994. "Endonasal CO2 - Nd: YAG
laser dacryocystorhinotomy". Acta ophthalmologic. 72:
703-706.
6 th Month
1 Year
REFERENCES :
1. Whittet et al. 1993. "Functional endoscopic transnasal
dacryocystorhinotomy" Eye, 7: 545-549.
2. Cokkeser Y. evereklioglu C. Er. H comparative external
versus endosopic dacryocystorhinostomy: results in 115
patients (130 eyes). Otolaryngol head neck surg. 2000;
123(4): 488-91.
3. Sprekelsen
MB
1996
"Endoscopic
dacryocystorhinostomy: Surgical techniques and
results". Laryngoscope 106: 187-189.
4. Hartikainin, Jounko et al. 1998. "Prospective
randomized comparison of endonasal endosopic
dacryocystohinostomy
&
external
dacryocystohinotomy". Larynogoscope 108: 18611866.
5. Rice DH. 1990.
"Endoscopic intranasal
dacryocystorhinostomy: Results in 4 patients".
Achieves of oto laryngology 116: 1061.
8. Susan MH. 1986. "The history of lacrimal surgery".

Adv opthal plastic reconstruct surg 5: 139-168.
9. Tarbet KJ. "External dacryocystorhinostomy",
ophthalmology. 102, 1065-70.
10. Wormald PJ. Powered endonasal dacryocystorhinostomy.
Laryngoscope 2002: 112: 69-71.
ACKNOWLEDGEMENTS :
We would like to place on record, our sincere thanks to
our Vice Chancellor Professor Dr. M. RAMANATHAN for
encouraging us, our Dean Professor Dr. N. CHIDAMBARAM
and our medical superintendent Professor Dr. S.
VISWANATHAN for allowing us to use the hospital facilities
and perform the surgery.
Address for correspondence:

Dr. G.C. Sahoo
Professor and Head of Department of ENT
RMMC&H, Annamalai University
Mobile: 9994645192.
PARATHYROIDS IN THYROID SURGERY

Dr. Madan Kapre
Director, Neeti Clinics, Nagpur
As we are growing of age and learning curves are plateauing, the myths of thyroid surgery are slowly unraveling.
When one looks back upon the misadventures and lessons learnt, it is common knowledge now that the injuries to
either external branch of superior laryngeal or recurrent laryngeal nerve take quite a second seat to shutting down
of parathyroid glands. No matter how dramatic the effects of nerve injuries either unilateral or bilateral following
thyroid surgeries, they are hardly life threatening and rarely if ever fatal. Author sadly admits to losing one patient in
his tribal thyroid surgical work due to parathyroid shut down 11 months after surgery and is prompted to share his
views on this surgical complication. The parathyroid dysfunction may be evident within 24 hours due to perennially
undernourished and relatively low calcium reserve status of tribal population. The present article addresses the issue
of avoiding this complication.
Medial to lateral dissections: (Fig. 1, 2, 3 )
NORMAL ANATOMY :
The parathyroids vary in numbers and various authors
report varying numbers and their incidences could be as
follows.
Number
1-12
Normally
87%
Fig. 1
2 Superior
Fig. 2
2 Inferior
3 glands
6%
5 glands
0.2%
6 glands
0.6%
The average weight of parathyroid gland is 35 mg and four

of them, two superior and two inferior, put together weigh
approximately 135 mg. Anatomically the superior
parathyroids are most consistent in location as they develop
from 4th arch, which is same as thyroid. They are found
within l cm of the cricoaretenoid joint on the posterior
surface of the upper pole of the thyroid gland. The inferior
parathyroids are very variable in their location as they
develop from 3rd arch, same as thymus and can be dragged
down for a variable distance in the superior mediastinum.
A consistent finding impresses author that, the main blood
supply of both the parathyroids is inferior thyroid artery
and there is a definite fascial compartment, if respected
and identified would save these vessels. In most cases the
inferior thyroid artery contribute minimally to thyroid gland
and is mostly spent on parathyroids vide fig.
Avoiding surgical insult through handling or devascularising
the gland is the key move in thyroid surgeries and following
technique is recommended.
Fig. 3
The dissection of parathyroids

begin after ligating the superior
thyroid artery, preferably after the
delivery of the posterior branch of
the superior thyroid artery as it
often communicates with
ascending branch of the inferior thyroid artery. Staying in
the subcapsular plane very close on the posterior surface
of the upper pole, the superior parathyroids are identified
as deep yellow ovoid mass, which soon turn into purple,
should you handle it roughly. The plane thus found is
pursued inferiorly and medially on to the cricothyroid joint.
The RLN would be identified here entering the larynx. The
RLN is just demonstrated still in its fascial covering and
separation carried medially to identify the twigs of the
inferior thyroid artery. Now the dissection proceeds laterally
staying in front of and anterior to the inferior thyroid artery.
Only those branches of the inferior thyroid artery which
are seen to enter the gland are ligated and the dissection
proceeds laterally until the lowermost limit of inferior
parathyroid gland tissue is pushed out laterally into its fascial
/ vascular plane.
Author finds this the simplest and surest way of not only
identifying and preserving the parathyroid but also
protecting its vasculature, which is safe in its fascial
Case study from 1994 - 2002
compartment.
Our experience of parathyroid dysfunction:
Duration
1. Total Thyroidectomies - 55
2. Onset of Hypocalcemia
Day 1
8
2
12
3. Calcium Support required

for 6 weeks longer
6 wks
5
Longer
15
4. Metabolic deaths
3
--
CHANGING DICTUMS IN THYROID SURGERY:

From the early days of my training in thyroid surgery, there
was a simple dictum to address the blood supply of thyroid.
Ligate superior thyroid artery close to the gland and inferior
thyroid artery away from the gland, was the order. However,
more years of work in tribal area has taught a lesson that
such ligature would completely deprive the parathyroid
blood supply more so if you would to do a bilateral
dissection. Hence the dictum needs to change. The new
order should be to ligate the superior thyroid artery after
identifying and saving its anastomotic vessel to inferior
thyroid artery and ligate the inferior thyroid artery close on
gland if at all required. This saves the dissection in the
vascular plane and protects not only the external branch of
the superior laryngeal nerve and the recurrent laryngeal
nerve with all its branches, but it also more importantly
protects the parathyroid glands of its blood supply.
CONCLUSION :
We have realized over a decade of thyroid surgical work in
tribal set up that, the real issue in surgery for thyroid is not
the recurrent or the external branch of superior laryngeal
nerve, but parathyroid function. Author has not touched
the issue of reimplantation deliberately as it would mean a
separate disciplined discussion. We strongly recommend
subcapsular medial / lateral dissection to prevent physical
as well as vascular insult to parathyroid glands in total
thyroidectomies.
Current status and future trends of Post Graduate

Education in ORL & HNS
Govind Chandra Sahoo, Professor & Head, E.N.T. & H.N.S.
Rajah Murhiah Medical College & Hospital, Annamalai
Abstract :
Inspite of the vast knowledge explosion in the field of ORL & HNS in the last few decades, it is not equally reflected on
the post graduate teaching and training in India. There is not only a paucity of motivated faculty due to mushrooming
of medical college, but also a lack of training facilities in various subspecialties like Neurootology & Audiolgy, Head &
Neck Surgery, Pediatrics Otorhinolaryngology, etc. One of the very neglected area is basic research and thesis writing
which is evident from a study in 1990, which observed that, 4,000 odd thesis from the Indian Medical Colleges were
not only substandard, but also the majority of them were outcome of fraudulence and professional misconduct with
deep rooted academic mal-practice, adopting unfair method. Updating the syllabus, better research and training
facility, faculty development programmes and strict implementation of MCI guidelines, etc are the key factors to
improve the standard for postgraduate training to cope up with the rapidly changing pattern of the speciality extending
from dura to plura.
Keywords : Teaching, Training, ORL & HNS, Postgraduate
With the changing pattern of the modern speciality of
Otorhinolarynology, it is no longer confined to the diseases
of the Ear, Nose and Throat only, but the discipline has
made a rapid stride from dura to plura within a short span
of time during the last two decades or so, which has
expanded to various subspecialities like Otology,
Neurootology, Paediatric Otolaryngology, Head and Neck
Surgery/Oncology, Skull base surgery, etc. However it is
noteworthy to mention that, this vast amount of knowledge
explosion is not equally reflected on the postgraduate
training in the Indian Medical Colleges & Hospitals in spite
of the establishment of various Health Science /Medical
Universities in many states and National Board of
Examinations at the Centre, under the Ministry of Health
exclusively. An unique project on The Status of P.G. Training
Programme in ORL & HNS in India & recommendation to
improve the same sponsored by the AOI was undertaken
10 years back, in which senior faculty members from
PGIMER, Chandigarh, AIIMS, New Delhi & other reputed
institutions were included to evaluate the report based on
the questionnaire (proforma) sent to 133 Medical Colleges
having P.G. training programme in ENT. Based on this
recommendations, respective action was planned to
improve the P.G. training programme in ENT-HNS. Some of
the important recommendations & plan of action to be taken
at different levels by various agencies like M.C.I., UGC,
Professional/Academic bodies, both at National and State
level, Medical Colleges / Institutions, etc. are still not fulfilled
or followed even after a decade. It is worth to highlight
some of these recommendations here like :
3. There must be 2 tables per day & 5 operative days per

week at the minimum.
1. The student : guide ratio should be 1 : 1 & should not

be more than 2 : 1 in any situation.
13. Participation in at least one national level conference

with presentation of paper based upon the thesis work.
2. Department must have 35 beds at the minimum per

each unit.
14. Maintainence of logbook.
4. Two posts of Audiologists cum Speech therapist is a

must for each department.
5. Core journals and books must be available.
6. There shoud be definite guidelines on the availability
of equipments.
7. Curriculum committee should prepare, design and
implement regular training programme.
8. Weightage of 20% of total mark should be given for
Internal Assessment.
9. Thesis should be a time bound programme & all P.G.
students should be given printed guidelines on thesis
writing with proper format.
10. Not more than 4 candidates should examined in a day.
11. There should be uniformity in the items to be kept in
the practical exam along with one long case & three
short cases, where candidates should be evaluated &
credit given accordingly as in OSCE/OSPE, to make
exam more objective.
12. To conduct workshop every year for the new P.G.
students highlighting the aim and objectives, planning,
collection of materials, protocol writing, use of library
services and literature searching, proper documentation
technique and applied aspects of bio-statistics to
imporve the quality of thesis work.
15. AOI National Body and State branch to approach central

and state governments to emphasize the need for
porviding adequate financial assistance to upgrade and
improve the facilities for standardizing P.G. training
programme in the country.
16. AOI should nominate two members to monitor the above
activities for the proper implementation along with M.C.I.
17. M.S. (ENT) qualification should be accepted for
registration in Mch, Neurosurgery and Plastic Surgery.
18. Department Seminar, Journal Club, Temporal Bone
dissection and Case presentation should be done atleast
twice weekly.
3 to 6 months of admission and progress of the thesis

should be reviewed periodically by the Guide/Co-guide.
6. Cadaveric dissection lab must be arranged either in
the department or in Anatomy department to learn the
surgical anatomy for different surgical procedures.
7. Other than bedside round, the P.G. student should also
attend integrated lecture, participate in the surgicopathological meetings, community health camps for
rural exposure and health care review meetings to
discuss death case records to take corrective measures,
as well as to maintain accountibility on the patient
management.
Guidelines for Competency based P.G. training :
8. Should attend emergency duties at least twice a week

for 12 hrs duration each.
At the end of the P.G. training programme the following

objective should be achieved by the student :
9. Should know the use of Medical literature search

including through Internet use in library.
1. Practice his speciality ethically and scientifically.
10. Should be able to write an abstrct/short paper/case

report and present in the state, regional and national
conferences.
2. Demonstrate sufficient understnding of basic sciences

related to the speciality.
3. Diagnose and manage majority of conditions clinically
and /or with the help of investigations.
4. Plan and advise measures for the prevention and
rehabilitation of patients.
5. Take part in the implementation of National health
programmes.
6. Aquire good teaching skill.
7. Competence in basic concepts of research methodology.
8. Aware of recent advance pertaining to the speciality.
9. Should have hand-on training in performing various
surgical procedures.
10. Knowledge of latest diagnostics and therapeutics.
Specific learning Objectives are :
1. Theoritical knowledge, Reserarch, Training and Clinical/
Practical skills.
2. Six months posting in the interdisciplinary departments
like Neurosurgery, Plastic Surgery, Oral and Maxillofacial
Srugery, Radiotherapy, etc should be mandatory.
3. Other than the routine Clinical teaching, there should
be special clinics like Tumour Clinic/Head and Neck
Cancer Clinic, Vertigo Clinic, Rhinology Clinic, Voice
Disorder Clinic and Deafness Clinic in the afternoon,
alternatively.
4. Clinical interaction with Audiologists and Speech
Therapist is essential pertaining the management.
5. Protocol for the thesis should be presented within first
11. A P.G. student at the end of postgraduation should be

capable of planning and carrying out an independent
research project and able to make a critical analysis of
Medical Literature.
12. At least 25% of the total mark should be awarded to
the thesis work in the final exam.
It is high time, we, as members of professional body
should pause and think of how to improve the P.G. training
by innovative teaching Learning (T-L) methods. The AOI at
state, regional and national level, in collaboration with
Universities and M.C.I. should initate for improving the
standard by starting superspeciality training programme/
course like Mch in Otology / Neurootology, Head and Neck
Surgery, Onocology, Peadiatric Otolaryngology and other
areas in the field of ORL & HNS. The course of medical
education in the excessive number of medical schools as
mentioned in the Flexners report, way back in 1910,
regarding the state of medical education in U.S.A., is very
much apropriate in India today, where medical colleges
are mushrooming without proper teaching facility and other
infrastructure. The problem of medical education is that,
doctors of tomorrow are taght by teachers of today, using
curriculam of yesterday. Hence there should be curriculam
and faculty development programme as promoted by the
Foundation of Advancement of International Medical
Education and Research (FAIMER), U.S.A.
The famous Nobel Prize winner Gurudev Rabindranath
Tagore has told that, A teacher who does not read is not a
good teacher, which is very true especially for mdical
teachers. To keep in touch with the rapidly advancing
medical science, it should be mandatory for all faculty
members to undergo National Teachers training programme

for health professionals and establishment of Medical
Education Units to train the faculty in every institutions as
per the recommendations of M.C.I. Over and above, the
Institutions should sign MOU with organization like FAIMER,
a sister organization of ECFMG in Philadelphia, which has
been successfully runining faculty develoment fellowship
since yr 2000. Last but not the least, a positive attitude
towards teaching and learning is required to develop and
improve the present standard of postgraduate training and
make learning relevant to the health needs of the
community.
Acknowldgements :
I am extremely thankful to Prof. (Dr.) Ramanathan,
Dean, Faculty of Medicine and Prof. (Dr.) N. Chidambaram,
Medical Seperintenant, RMMCH for their kind permission
to publish this article.
Address for Correspondence :
B-4, R.S.A. Housing Complex, Annamalai Nagar 608002,
Chidambaram, Tamil Nadu.
Prof. Abhoya Kumar Kar was felicitated as Eminent Otolaryngologist of National Stature
by the Organising Committee of Diamond Jubilee AOICON, Agra, 2008.
MEDICINE ON THE INFORMATION SUPERHIGHWAY:

AN INTRODUCTION TO THE INTERNET
Prof P Mishra, MS(Ophth),FRF,FSVH(Germany)
Dr K Krishnaram, MS DO
Dr S Luke, MD
Dr Deepak Nair, MBBS
Dr Anosh Agarwal, MBBS
Computers are already in widespread use in medical
practice throughout the world and their utility and
popularity is increasing day by day. While future
generations of medical professionals will be cent
percentage computer literate with a corresponding
increase in use of computers in medical practice, the
current generation finds itself in a dilemma of how best
to adapt to the fast-evolving world of information
technology. Telemedicine represents a combination of
expertise and technology that delivers medical services
and information across distances. Telecommunication
technology or tele-technology, delivers this information in
the form of voice, data or video imagery. Ever-increasing
varieties and bandwidths are becoming available, from
telephone lines to local area computer networks, from
fibre optic television cable to low-altitude earth-orbiting
satellites.
IMAGINE A WORLD WHERE YOU COULD:
Get opinions from experts and colleagues from all over
the world about a clinical problem almost instantly.
Liase with a co-author half a world away, many times
a day.
Read dozens of journals, as your fancy dictates,
without paying a single subscription charge.
Hold real-time discussions with researchers from Asia,
America, Europe or Australia.
Consult a colleague anywhere in the world and transfer
information regarding difficult cases, even transmit
photos or videos for grand round type discussions.
Browse through a bookshops catalogue, then order
and pay for your favourite textbook, all from your
desk.
Get a daily summary of a continuing medical
discussion, with opinions from all over the world at
your desk, free of cost.
Communicate with colleagues any where in the world
as often as you like, for the cost of a local phone
call.
Obtain illustrations and references for a presentation

at the click of a mouse.
Receive meeting announcements and register for
various meetings and conferences instantaneously.
Easily obtain information regarding various
fellowships, research facilities and opportunities.
ALSO, IMAGINE A WORLD WHERE:
Patients are able to communicate with doctors all
over the world and seek a second opinion.
Doctors can have their own home pages and let
patients and colleagues have access to their expertise
in various fields at the press of a button.
All this is already possible, the technology and facilities
are already in place - it is called the Internet. The Internet
is a sprawling collection of computer networks that spans
the globe, connecting government, military, educational
and commercial institutions, as well as private citizens to
a wide range of computer services, resources and
information linked often by regular phone lines and also
by microwave and satellite links. There were an estimated
20 million computers linked to the Internet. The links are
through different means, satellite links, optical fibres, ISDN
(integrated services digital network) and most commonly
ordinary phone lines. All of these exchange information
using the same set of protocols, TCP/IP (Transmission
Control Protocol/ Internet Protocol).
HOW TO CONNECT INTERNET
To connect to the Internet you need access to a computer
to visualise and store the incoming and outgoing data, a
modem - the instrument which is used to dial up and
connect (usually via your phone line) to your local server
- an agency which acts as a middleman for the transfer
of information. The middle man, the local internet service
providers (ISPs) are BSNL/Tata/MTNL/Sify/Reliance or
Airtel. One should have an account with one of these
service providers. On the other end is also a similar
assortment of modem and a local server connected via
the national/international telephone lines . More powerful
computers and faster modems (Broadband 2Mbps) are

useful to enable quicker transfer of information including
video images. It is always best to start internet browsing in
your own machine, but feel free to use e-mail first until
you get familiar with the use of equipment involved.
Internet and World Wide Web (WWW)
This is the graphic, user friendly face of the Internet,
presenting interlacing text and pictures in an attractive way.
The web is made up of tens of thousands of home pages
maintained by universities, medical departments, publishers,
researchers, industrial firms, government agencies and
individuals amongst others, the addresses are recorded as
uniform resource locators (URLs), transmitted by hypertext
transfer protocol (HTTP) and written in hypertext mark up
language (HTML).These are connected to each other by
links, clicking on one of these, takes you to a different
page. You can explore (browse) the WWW in this way.
Another way to access information is to use one of the
search engines. Among the better ones are Yahoo {http:/
/www.yahoo.com}, google and Webcrawler {http://
webcrawler.com}. The seeker types in one or more topics,
as wide as ophthalmology or more specific such as
trabeculectomy. Once the search is initiated, the search
engine comes up with a list of related sites each with its
own links to many more sources of information on the
subject. In following a series of the webs hypertext links,
you trace a path through information space. A click of
your mouse on a web link in India might take you to a
page in Asia, Africa, the Americas or Australia. Hypertext
encourages you to follow paths through information;
metaphorically you explore a web, also termed as netsurfing.
URLs (address) are the identifying tags of each page. It
stands for Uniform Resource Locator. It is a draft standard
for specifying an object on the internet, such as a file or
news group. URLs look like this: http://www.bmj.com( the
URL address of British Medical Journal). The first part of
the URL before colon, specify the access method. The part
of the URL after colon is interpreted specific to the access
method. In general, two slashes after the colon indicate a
machine name or location of the Web site. The 3rd part
after the dot refers to the type of web site; .com for
commerce, .edu for education, .org for organization, etc.
The software used to interpret and display the incoming
web pages from servers are called browsers. In other
words, to access the web one has to run a browser
programme. The browser reads documents and can fetch
documents from other sources, the three most common
browsers are Netscape Navigator, Microsoft Internet
Explorer and Mozilla Fire Fox. Browsers are available for
all platforms and vary in complexity and ease of use. A
server on the Web contains many sites, which in turn are
composed of pages. Websites offer text, pictures, graphics,
sound and the movies. The web servers use the internet
expressways to deliver data through a process called the

packet switching. Each file is broken into small packages,
tagged with its origin and the destination and sent through
routers, the computers which function like mail handlers,
sending each package it receives through various routes.
The client browser program on the other end re-constitutes
the pieces. You can easily revisit interesting sites, on the
web by using your history list or bookmark list. The history
list is a temporary log of all the sites that you have visited
since you opened the program; you can choose to revisit
any of the sites listed or go back to the most recent site
with a go back command. The bookmark list is similar to
this, but it contains only those sites where you have
previously placed a bookmark and it is maintained through
different sessions till you alter it. You can even have your
own private home page to include information about your
practice, educational information for patients, etc. Internet
providers that will design this page for you and place your
web site on their computers for a fee are now available in
India.
There are number of websites, explained below, dedicated
to medical subjects; quite a few even offers uploading of
articles from your local computer eg. http:// www.
indmedica.com/ophthal .The author (PM) has got few
electronic publications in the above mentioned website by
uploading files from the personal computer. Uploading
means, to copy data from a local computer to a remote
computer; the opposite of download. The information on
these websites has not undergone peer review. These sites
are maintained by learned organisations, well-established
societies, faculties or colleges, which provide reliable
information. On the other hand, there are sites maintained
by hospitals, departments, individual practitioners or even
interested patients. Most international meetings now have
online sites that contain useful information regarding
program details, registration, abstract preparation and
acceptance, travel and accomodation related information.
This allows the busy professional to plan and organise the
trip comfortably and well in advance. Information is usually
accessible online before the paper version reaches the
attendee.
Top Medical Websites
The following web sites have been chosen for their indepth coverage of medicine online and ease of use. Because
most of the sites listed are gateways to thousands of other
medical web pages, book marking just any one of them
should ensure that, you are kept informed and up-to-date.
Medical Database and Index Sites
BioMedNet (http://biomednet.com)
BioMedNet is an award winning site with over 1,00,000
members that offers free access to hundreds of full text
publications in biology and medicine. Some articles and
all the abstracts are free and the full-text articles can be
purchased online. The site offers an evaluated Medline
Service with full-text links, expert annotations and
connections to over 1000 libraries.
Cliniweb (http://www.ohsu.edu)
The Cliniweb site is an index and table of contents of clinical
information on the world-wide web. It has recently been
expanded to include nearly 10,000 URLs indexed by terms
from the Medical Subject Headings (MeSH) Anatomy and
Disease trees.
Doctors Guide to the Internet
www.pslgroup.com/docquide.html)
(http://
Doctors Guide to the Internet is a clear and simple to use

website that collates global medical news and information
services with a view to promote informed and appropriate
use of medicines by doctors and their patients. The medical
resources for doctors and information for patients are
divided by type, ranging from lists of all available online
journals to medical site directories covering almost every
medical issue.
Global Health Network (http://www.pitt.edu/HOME/
GHNet/GHNet.html)
Global Health Network (GHNet) is an alliance of experts in
health and telecommunications, who are developing a
health-information structure for the prevention of disease
in the 21st century. The GHNet team has experts from the
World Bank, NASA, AT&T, IBM, the Pan American Health
Organization and WHO. The site contains links to
international and national medical governmental and nongovernmental organisations and a vast list of global public
health resources from around the world.
Journal Club on the Web (http://www.webcom.com/
mjljweb/jrnlclb/index.html)
This web site is an interactive medical journal club. Every
two weeks, the site author, comments on articles from
recent medical publications. Feedback from readers is
appended to the article summaries. The articles are
primarily in the field of adult internal medicine and mainly
from the New England Journal of Medicine and Annals of
Internal Medicine.
and Internet search engines to explore subjects as diverse

as air travel and farming.
Medscape (http://www.medscape.com./) :
Medscape is a top rated medical site. Its membership is
free, one can access medline abstract, standard treatment
guidelines, full articles, specially prepared CME lessons and
get weekly abstracts of latest articles pertaining topic of
your choice.
Medsurf (http://www.medsurf.com/)
MedSurf is an Internet health guide for physicians and their
patients. Sections of the site such as Medicine Bag are for
doctors only and contain up-to-date information on time
saving technologies, advanced treatment alternatives, aging
research and upcoming educational forums. Medsurf also
offers doctors risk-assessment software and data such as
Remaining Lifetime Fracture Probability (RLFP) package,
which allows assessment of a patients susceptibility to
osteoporosis.
PubMed (http://www.ncbi.nlm.nih.gov/PubMed)
PubMed is a project developed by the National Centre for
Biotechnology Information, located at the US National
Institutes of Health. PubMed has been created in conjunction
with bio-medical publishers as a search tool for accessing
citations and linking to full text of the journals. It is expected
that, access to additional National Library of Medicine
databases will be added in the future
Reuters Health (http://www.reuterhealth.com)
Reuters Health information produces global health and
medical news services daily, to keep both professionals
and consumers abreast of breaking news stories in
healthcare. Alongside medical news stories the site offers
a searchable news archive and drug database.
Webdoctor (http://www.gretmar.com/webdoctor/)
Webdoctor is a comprehensive library of over 10,000
documents and websites, designed by physicians for
physicians. The resources are divided into specialities and
diseases. From there the user is able to link to online
journals, discussion and news groups, image databases,
case studies and mailing lists.
Literature Search :
Mednets (http://www.internets.com/mednets/)
Mednets sets out to provide a complete informationgathering service for the patient, physician and healthcare
providers. The site offers several search engines including
Medline and links to resources on over 40 specialist
subjects. For patients, the site offers pages of links covering
medical information and advice. For general interest, Mednet
has included links to most of the major online news services
A growing list of peer-reviewed journals, (Table 1) are

now available on the World Wide Web (WWW). Most freely
accessible sites offer a table of contents with abstracts;
however, they may also provide the full text of some articles.
In some cases full text is available to paying subscribers on
entering their subscription details. A major advantage of
this has been the early and simultaneous worldwide access
to the journal, transcending international barriers and
avoiding postal delays. Another very useful feature is the
provision of the current instructions for authors on most of

these sites
Table 1, Journal websites
increasing number of websites providing free access.

The URL (address) of PubMed which provides databases
on medline stands as http:// www.ncbi.nlm.nih.gov.
PubMed is a service of the U.S. National Library of
Medicine, that includes over 17 million citations from
MEDLINE and other life science journals for biomedical
articles back to the 1950s. PubMed includes links to full
text articles and other related resources. MeSH
(medical subject heading) is the U.S. National Library
of Medicines controlled vocabulary used for indexing
articles for MEDLINE/PubMed. MeSH terminology
provides a consistent way to retrieve information, that
may use different terminology for the same concepts.
How do I find what is new on Web
If the websites described do not have the information

required, then the next step is to use one of the search
engines shown in Table 2. Sometimes it is more useful to
key an inquiry into a search engine to open up all possible
avenues, rather than trawl around your favourite websites.
Table 2, Search Engines
There are excellent sites that offer you regular updates.

You can become a member of the electronic BMJ at
www.bmj.com and get weekly news letter on latest
articles in the medical topics of your choice. Medscape
at www.medscape.com is currently rated as the no. 1
medical sites. Its membership is free, one can access
medline abstract, standard treatment guidelines, full
articles, specially prepared CME lessons and get weekly
abstracts of latest articles pertaining topic of your choice
Information technology has had a tremendous impact on
the outlook of our professional lives. The Internet has
revolutionised the speed of access to information with touch
of a button. Such vast resources, when available and
accessible to all, even in rural India, will necessitate all
medical professionals to take a few corrective steps, so
that we should not let it overrun us but learn to ride the
tide and to master the use of internet in our profession.
REFERENCES :
It is essential for the modern physician/medicos to

develop skills in tracking down the best available current
literature, especially with the current emphasis on
evidence-based medicine. Literature searches are no
longer just a research tool, but have become an
indispensable part of clinical practice. Widespread
availability of computing resources including CD-ROMs
and the Internet has led to a dramatic increase in the
number of end-user searches. MEDLINE is by far the
most popular and useful computerised database for the
medical fraternity. The National Library of Medicine of
the United States compiles this. MEDLINE and other
databases are available on the Internet, with an
1.
LaPorte RE, Marler E, Akazawa S, Sauer F, Gamboa C,

Shenton C. The death of biomedical journals. Br Med
J 1995;310:1387-89.
2.
Prasad S, McCormack P. Accessing it (the internet) is

easy. Br Med J 1996;312:978.
3.
Sellu D. Clinical encounters in cyberspace. Br Med J

1996;312:49.
4.
Prasad S, Nagpal M, Nagpal PN. Ophthalmology on

the information superhighway: An introduction to the
Internet. Indian J Ophthalmol 1997;45:181-87.
5.
Crossan L, Delamothe T. The new order - Please

respond to articles using website, email, or disk but
not paper (letter). BMJ 1998;316:1406-10.
6.
Mezrich RS, DeMarco IK, Negin S, Keller I, Schonfeld

S, Safer I. Radiology on the information superhighway.
Radiology on the information superhighway. Radiology
1995;195:73-81.
7.
Fact Sheet NLM. Online Databases and Databanks:

National Library of Medicine, http:/ / www.nlm.nih.gov/
pubs/factsheets/online_databases. Html#nedkubel
(accessed 05 September 1999).
8.
Greenhalgh T. How to read a paper: The Medline

database. BMJ 1997;315:180-83.
9.
Kassirer JP. Posting presentations at medical meetings

on the Internet. New England Journal of Medicine
1999;340:803.
For Correspondence
Dr P Mishra,
Prof of Ophthalmology
RMMCH
Annamalai University
Tamilnadu, PIN- 608002
e mail: dr_pmishra@dataone.in
The book MCQs in ENT written by Prof. G. C. Sahoo, published by Jaypee Brothers
came to market in Jan/Feb, 2008. It is an excellent book.
Prof. Abhoya Kumar Kar delivered Guest Lecture on Laryngeal Cancer on the eve of
Inauguration of Cuddalore & Pondicherry Chapter of AOI on 18.11.07.
LEIOMYOSARCOMA OF THE MAXILLA CASE REPORT

AND REVIEW OF LITERATURE
Dr. Moras Kuldeep1, Dr. Swain Santosh Kumar2 & Dr. Roy Priyankur3
Department of Otorhinolaryngology, C.M.C., Vellore
Abstract : Leiomyosarcoma is a malignant smooth-muscle tumour. These tumors are very aggressive and the
prognosis is poor. Its diagnosis consists of histopathology, immunocytochemistry and radiology. In this article
we report a case of a patient with recurrent tumour of the right maxilla, which was diagnosed as
Leiomyosarcoma. The diagnosis and management of this tumour are discussed and the literature is reviewed.
Key words : Leiomyosarcoma, maxilla.
INTRODUCTION :
Sarcomas of the nasal cavity and paranasal sinuses are
rare. They are more common among the Asian
population. Men are affected 1.5 times more often than
women and 80% of these tumours occur in people
aged 45-85 years.
Sarcomas are commonly classified according to their
site of origin: soft tissues or bone 1. Soft tissue
sarcomas include the following:
Angiosarcoma.
Hemangiopericytoma.
Malignant fibrous histiocytoma.
Synovial sarcoma.
Chondrosarcoma.
Rhabdomyosarcoma.
Malignant schwannoma.
Liposarcoma.
Leiomyosarcoma.
Fibrosarcoma.
Alveolar soft part sarcoma (ASPS).
Kaposi sarcoma (KS).
excision of nasopharyngeal mass for these complaints

elsewhere. No details of the surgical findings or
histopathological reports were available with the patient.
He was symptom-free for 2 years after which the same
complaints recurred for which he underwent lateral
rhinotomy at another hospital. The histopathology report
stated spindle cell tumour - benign / low-grade
malignant.
He now presented in Christian Medical College and
Hospital with the complaints of swelling in the right
maxillofacial region, which was progressively increasing
in size, continuous nasal obstruction on the right side
and occasionally on the left for the past six months.
He also gave history of right-sided epistaxis, watery
nasal discharge, difficulty in breathing and anosmia.
History of blurred vision in the right eye and headache
were also present.
Bone sarcomas include the following :

Fig. 1 : Picture of the patient
showing swelling in the right
maxillo-facial region
Osteosarcoma.
Ewing sarcoma.
Smooth-muscle tumors are rare in the head and neck.
Leiomyosarcoma is a malignant smooth-muscle (soft
tissue) tumor, that has a predilection for the
gastrointestinal tract and the female genital tract,
perhaps because of the preponderance of smooth
muscles at these sites. Leiomyosarcomas of the head
and neck are believed to originate in the tunica media
of the blood vessels or in pluripotential mesenchymal
cells. Clinically, these tumors are very aggressive and
the prognosis is poor.
Case Report :
A 38-years-old male patient from the North-east India
gave history of right-sided nasal obstruction and
epistaxis in 2004. He had undergone a sub-labial
On examination, there was a swelling in the right

maxillofacial region of approximately 7 cms x 6 cms in
size. A large pinkish polypoidal mass was seen through
the right nostril. The nasal septum was pushed to the
left side abutting the inferior turbinate. A boggy swelling
was palpable in the right side of the hard palate. There
were no palpable lymph nodes.
1. Lecturer, 2.Tutor & 3. C.R.R.I. Intern.

Fig. 4 & 5 : CT
PNS, (axial and
coronal views) of
the mass filling the
right maxillary sinus
and nasal cavity
involving the floor
and medial wall of
the right orbit and
eroding the nasal
septum and the
antero-lateral wall of the maxilla.
CT-scan of the para-nasal sinuses showed mass filling

the right maxillary sinus and nasal cavity involving
bilateral ethmoids, floor of the right sphenoid, cribriform
plate, floor and medial wall of right orbit. The mass
was also eroding the nasal septum and the anterolateral wall of the maxilla. Posteriorly, the mass
extended to the infra-temporal fossa, pterygo-maxillary
fissure and the infra-orbital fissure.
A repeat histopathological examination from the mass
along with immunohistochemistry was done which
confirmed intermediate grade spindle cell sarcoma
consistent with Leiomyosarcoma.
A final diagnosis of Leiomyosarcoma of the right maxilla
- T4N0M0 was made and the patient was planned for
right total maxillectomy with orbital excenteration and
cranio-facial resection under general anesthesia.
Fig. 2 :
The dissected specimen
As the tumour was easily

peeled-off from the anterior
skull base leaving the dura
intact, a cranio-facial resection
was avoided.
Fig. 3 : Photograph of the patient
after the surgery
The patient underwent postoperative radiotherapy and is

on regular follow-up with
disease-free status for the past
six months.
Clinical features
Sinonasal leiomyosarcoma is a highly aggressive tumour.
On gross examination, leiomyosarcomas appear smooth
and well circumscribed5. They are unencapsulated and
are greyish or pink in colour. They may be polypoid or
sessile. Regional lymph node involvement is rare, but
cervical node metastasis has been reported in a few
cases6.
Histopathology
On histologic examination, the tumor is made up of
interlacing fascicles of spindle-shaped cells that have
elongated, blunt-ended nuclei and eosinophilic cytoplasm.
Numerous mitotic figures are seen. The cytoplasm of
the tumor cells stains red in Masson's trichrome
medium7.
Radiology
On CT scan, leiomyosarcomas appear as bulky masses
associated with extensive necrotic and cystic changes
with surrounding bony destruction. On MRI,
leiomyosarcomas show intermediate enhancement with
contrast and intermediate to high signal intensity on T2weighted imaging.
Differential diagnosis
Differential diagnosis consists of malignant schwannoma,
malignant fibrous histiocytoma, fibrosarcoma, amelanotic
melanoma, malignant lymphoma, squamous cell
carcinoma, extramedullary plasmacytoma, metastatic
tumor, glandular tumor, chondroma, chondrosarcoma,
osteogenic sarcoma and inverted papilloma.
Treatment
Surgical resection of the tumor with wide margins is
the treatment of choice. Neck dissection is needed if
nodes are involved 8 . Recent studies show that,
combination therapy with mesna, doxorubicin, ifosfamide
and dacarbazine or combination therapy with
cyclophosphamide, doxorubicin, vincristine and
dacarbazine is effective against soft-tissue sarcomas to
a certain extent. Combination chemotherapy and
radiation therapy are used as adjuncts for residual and
recurrent disease.
Conclusions
Discussion
The first case of maxillary leiomyosarcoma was
reported in 19582. Since then, only about 65 cases have
been reported throughout the world3. Leiomyosarcomas
account for 6.5% of all soft-tissue sarcomas and only
3% of them arise in the head and neck4. The most
common sites are the nasal cavity, the maxillary sinus
and the ethmoids.
Leiomyosarcoma is a malignant smooth-muscle (soft

tissue) tumor. Clinically, these tumors are very
aggressive and the prognosis is poor. Significant
advances in the radiotherapeutic and chemotherapeutic
regimens, as well as improved facilities in diagnosing
these tumors through histopathology, radiological studies
and immunohistochemical analysis have improved longterm disease-free survival.
REFERENCES :
1. Sercarz JA, Mark RJ, Tran L, et al: Sarcomas of
the nasal cavity and paranasal sinuses. Ann Otol
Rhinol Laryngol 1994 Sep; 103(9): 699-704.
2. Konrad HR. Nasal neoplasms. In: English GM, ed.
Otolaryngology. Philadelphia: J.B. Lippincott,
1993:1-11.
3. Ortega JM, Gomez-Angulo JC, Aragones P, et al.
Leiomyosarcoma of the paranasal sinuses with
intracranial involvement: Report of a clinical case
and review of the literature. Neurocirugia (Astur)
2001;12:331-7.
4. Tanaka H, Westesson PL, Wilbur DC.
Leiomyosarcoma of the maxillary sinus: CT and MRI
findings. Br J Radiol 1998;71: 221-4.
5. Josephson RL, Blair RL, Bedard YC. Leiomyosarcoma

of the nose and paranasal sinuses. Otolaryngol Head
Neck Surg. Apr 1985;93(2):270-4.
6. Sumida T, Hamakawa H, Otsuka K, Tanioka H.
Leiomyosarcoma of the maxillary sinus with cervical
lymph node metastasis. J Oral Maxillofac Surg
2001;59:568-71.
7. Izumi K, Maeda T, Cheng J, Saku T. Primary
leiomyosarcoma of the maxilla with regional lymph
node metastasis. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod 1995;80:310-19.
8. Rice DH, Stanley RB. Surgical therapy of tumors of
the nasal cavity, ethmoid sinus and maxillary sinus.
In: Thawley SE, Panje WR, eds. Comprehensive
Management of Head and Neck Tumors. 2nd ed. Vol.
1. Philadelphia: W.B. Saunders, 1999:571.
Dr. Kuldeep Moras,
Lecturer, Department of Otorhinolaryngology,
Christian Medical College & Hospital,
Vellore - 632 004,
Tamil Nadu, India.
E-mail: kuldeepmoras@gmail.com
Mobile No.: +91 98437 66770
BROWN TUMOR OF NASAL BONE: A RARE CASE REPORT

Dr. Kumar Avanindra, MS, DNB
Ex - Senior registrar
Dr. Bhardwaj Chaitanya,
MS
Ex - Registrar
Dept. of Otorhinolaryngology & Head & Neck surgery
King Edward VII Memorial Hospital & Seth G. S. Medical College, Mumbai, India
Abstract : Brown tumor is an uncommon focal giant cell lesion, which arises as a direct result of parathyroid hormone
on bone tissue in patients with hyperparathyroidism. Any of the skeletal bone can be affected including maxillo facial
bones. Initial treatment is to correct hyperparathyroidism. This is the case report of a Brown tumor of nasal bone in
22 year old female, who presented with nasal bone mass and femoral fracture. Laboratory values confirmed the
diagnosis. Partial parathyroidectomy was done. Patient has been kept under observation for the regression of tumor.
Key words: Brown tumor, hyperparathyroidism, parathyroid adenoma.
INTRODUCTION :
The Brown tumor is localized form of fibrocystic osteitis,
which occurs as a result of hyperparathyroidism. Brown
tumor can affect any bone, but most commonly affects
mandible, maxilla, clavicle, ribs and pelvis. Histologically,
tumor is made up of cell mass consisting of mononuclear
stromal cells along with multinucleate giant cells, in which
recent hemorrhagic infiltrates and hemosiderin deposits
are often found. That is why it is called as Brown tumor.1
Radiographic and histological features of this tumor are
very much similar to other tumors of face, but whenever
round, radiolucent, bone expanding tumor is found in facial
region along with hyperparathyroidism, one has to think
about Brown tumor as most likely diagnosis.
We report a rare case of brown tumor of nasal bone
in a young woman and discuss the clinical history,
differential diagnosis, diagnosis and treatment of this
type of lesion.
Case Report
A 21 yr old female, presented with right sided external
swelling of the nose since last 8 months, which was
increasing progressively. There was mild pain, but no
complaints of nasal blockage,
epistaxis or orbital problems. She
also had a fracture of right femur,
sustained due to fall 8 months ago,
which was not healing in spite of
adequate treatment.
Fig. 1: Profile showing the
bulge of nasal bone tumor
Otorhinolaryngologic examination
revealed the external nasal mass,
measuring 2 x 3 cm which was
hard in consistansy, nontender ,
nonmobile & not fixed to the
overlying skin. There was no
abnormality found on anterior
rhinoscopy. Oral & Neck examination didnt reveal any abnormality.
Fig. 2: Frontal view

showing brown tumor of
nasal bone
Laboratory investigations showed, raised serum Ca 14.7mg/

dl (normal: 8.8 to 11.0), alkaline phosphatase 1806 IU/L
(normal: 32 to 104) & high parathyroid hormone level,
more than 1000pg/mL (normal: 12 to 72). Patient had
normal renal function tests & normal blood sugar levels.
CT neck showed right sided inferior parathyroid adenoma,
CT skull showed lytic lesions in the skull and nasal bones
and CT pelvis showed lytic lesion in left iliac wing.
USG neck showed right sided inferior parathyroid adenoma
near the lower pole of right thyroid lobe, measuring 3.5 x
1.5 x 1.8 cm. USG abdomen showed nephrocalcinosis,
bilateral ureteric calculi & cystitis.
Whole-body bone scintigraphy using Tc-99 MDP showed
lytic lesions in skull, nasal bone and iliac wing.
This tumour was treated by right parathyroidectomy at
the Department of Surgery in our hospital. The lesion
was histopathologically diagnosed as a parathyroid
adenoma. Since then pt. is under periodic follow up for
monitoring the nasal bone tumor.
DISCUSSION :
Brown tumor is uncommon sequelae of
hyperparathyroidism. The lesion localizes in areas of
intense bone resorption and the bone defect becomes
filled with fibroblastic tissue, that can deform the bone
and simulate a neoplastic process.2 These tumors have

a brown or yellow hue3.
Different anatomic pathological entities, both benign and
malignant, can appear as a lytic lesion in the facial
bones. In facial bones, it mainly affects mandible and
rarely nasal bones. Giant cell lesions that can arise in
the facial-bones include giant cell tumour, giant cell
reparative granuloma, cherubism and brown tumor. The
clinical diagnosis is made based on the association with
HPT, as it is difficult to distinguish histologically or
radiologically, brown tumor from other giant cell lesions.
Brown tumors arise secondary to both primary and
secondary hyperparathyroidism. They have been
reported to occur in 4.5 % of patients with primary
hyperparathyroidism and 1.5 to 1.7% of those with
secondary disease. 1, 4. The main reason for
hyperparathyroidism is development of a parathyroid
adenoma rather than hyperplasia or a carcinoma.
Sometimes these are familial (5% of cases) and others
are part of multiple type I, IIa and IIb endocrine
neoplasias. The size of adenoma is correlated with the
level of parathyroid hormone in blood.
Anatomicorpathologic study of the parathyroid in our
patient revealed the presence of an adenoma.
The reported prevalence of brown tumor is 0.1%.2. The
disease can manifest at any age, but it is more
common among persons older than 50 years2. It is
three times more common in women than in men. In
our study patient was 22 years old female at the
diagnosis of the Brown tumor.
Most patients are asymptomatic and the abnormality is
detected incidentally. But sometimes it is detected
because secondary hormonal effects over bone as in
our case, as patient was presented with nasal swelling
and fracture of femur.
Parathyroid glands are not usually palpable in neck.
Patients present with the disease clinically in two ways,
either with urological manifestation or with skeletal
changes. In first case, patient will present with deranged
renal function tests mainly blood urea levels and serum
creatinine levels. Patient may also have renal stones.
Skeletal changes are loss of cortical bones and increse
in trabecular bones. He can have bone pain and
pathological fractures. Radiologically, parathyroid
adenomas may or may not exhibit well-defined margins;
they may also cause cortical expansions associated with
lytic lesions 5 . Finally, patients may exhibit
hyperparathyroidism-induced bone changes, such as
medullary bone demineralization of the mandible.
Histologically, they show rounded mononucleate
elements, mixed with a certain number of
multinucleated giant cells. In the brown tumour, there
is a combination of osteoblastic and osteoclastic activity,
often associated with cyst formation, clusters of

hemosiderin-laden macrophages and proliferating
fibroblasts. Examination will reveal a dense fibroblastic
stroma, areas of cystic degeneration, osteoid,
microfractures, hemorrhage, macrophages with
hemosiderin and multinucleated osteoclastic giant cells.
Similar changes may occur in fibrous dysplasia, true
giant-cell tumors and reparative granulomas.
The initial treatment of brown tumor involves control
of hyperparathyroidism, regardless of whether it is
primary or secondary. Treatment of primary
hyperparathyroidism requires a parathyroidectomy. Brown
tumor regression and healing are expected after the
correction of hyperparathyroidism. Although in some
cases surgical removal is necessary, especially for
patients who have large, symptomatic tumors. However,
several cases of brown tumor, that grew even after
parathyroidectomy
or
normalization
of
hyperparathyroidism level have been reported.
Our patient was a case of primary hyperparathyroidism,
she had an inferior parthyroid adenoma of the right
side. After correction of the metabolic profile of the pt.,
a decision regarding surgical treatment of parathyroid
adenoma was taken & pt underwent right sided inferior
parathyroidectomy. Intraoperatively rest of the
parathyroid glands were found to be normal, hence they
were preserved. Final histopathology report confirmed
the diagnosis of parathyroid adenoma.
Since brown tumors are known to reslove after
treatment of hyperparathyroidism & this nasal brown
tumor was not very symptomatic, we decided to follow
a policy of wait & watch.
REFERENCES :
1.
2.
3.
4.
5.
Bedard CH, Nichols RD. Osteitis fibrosa (brown

tumor) of the maxilla. Laryngoscope 1974; 84:20932100.
Keyser JS, Postma GN. Brown tumor of the
mandible. Am J Otolaryngol 1996; 17:407-10.
Friedman WH, Pervez N, Schwartz AE. Brown tumor
of the maxilla in secondary hyperparathyroidism.
Arch Otolaryngol 1974; 100: 157-9.
Kanaan I, Ahmed M, Rifai A, Alwatban J. Sphenoid
sinus
brown
tumor
of
secondary
hyperparathyroidism: Case report. Neurosurgery
1998; 42:1374-7.
Som PM, Lawson W, Cohen BA. Giant cell lesions
of the facial bones. Radiology 1983; 147:129-32.
Address correspondence & reprint requestsDr. Avanindra Kumar, MS, DNB

G-34, Hyderabad estate, Napean sea road
Phone: 919820349033, Fax : 9122-24143435
Email: dr.avanindra@gmail.com
RECURRENT RHINOSPORIDIOSIS
Dr. N. K. Goyal
Dr.Viplav Dutta
Professor & HOD, ENT
CMO, Dr. B.R.A.M.Hospital
Dr.Varsha Mungutwar
Dr. Reema Nair
Assistant Professor
Resident
Department of ENT, Pt. J.N.M.Medical College & Dr.B.R.A.M.Hospital , Raipur ( C.G.)
Abstract: Rhinosporidiosis is caused by Rhinosporidium Seeberi which is regarded as fungus. It mostly

affects mucosa of nose and nasopharynx and sometimes that of oral cavity, eyes, larynx, pharynx,
parotids, bones, genital & urinary tracts. It has a tendency to recur and spread to surrounding tissue and
rarely disseminate to other parts. It manifests as granulomatous polyp which bleeds on touch.
Present case, Recurrent Rhinosporidiosis is a rare disseminated case of rhinosporidiosis, where patient
was in constant follow up since 32 years and in spite of medical & repeated surgical excision, dissemination
of disease could not be controlled.
Key words: Rhinosporidiosis , Bone , Skin.
INTRODUCTION :
Rhinosporidiosis is a chronic infection of mucous membrane,
caused by Rhinosporidium Seeberi . It is endemic in
Chhattisgarh state. The common sites of predilection are
the nose, nasopharynx, conjunctiva and urethra and may
affect the peripheral bones rarely. Visceral and systemic
rhinosporidiosis was also reported (Rajam et. al. 1955,
Agrawal et.al 1959). Medical treatment of rhinsporidiosis
is not effective and till date surgery is only effective
treatment for this infective granuloma (O.P.Billore et.al.).
Recurrence of the growth is common due to multiplication
of the lesion by implantation of spores in fresh abrasions
made at operation. Here is a case of widely spread recurrent
rhinosporidiosis with failed medical and surgical treatment.
Case Report :
Mr. R, 42 years old farmer from low socioeconomic status,
a known case of recurrent rhinosporidiosis of nose and
pharynx, who was chronic alcoholic and smoker, attended
OPD with complains of mass in the nose & oral cavity,
abdominal distension, chronic fungating mass in the dorsum
of left foot and anterolateral aspect of left lower limb.
Patient had past history of recurrent nasal and pharyngeal
rhinosporidiosis for which he had been operated 59times
( as per hospital record) since the age of 10.With the help
of records it was found that, excision and wide base
cauterization of mass by diathermy or by cryocoagulation
was done several times. Histology report showed granulation
tissue with multiple sporangia of rhinosporidiosis. Patient
had also received Dapsone from 1985 to 1990 for five
years, but in 1992 again he presented with same extensive
nasal and pharyngeal mass, which was excised through
lateral rhinotomy and transpalatal approach and external
carotid ligation was done, followed by wide base diathermy

coagulation.
In 1993 he again came and at this time besides bilateral
nasal mass and bilateral ear discharge, a fungating ulcer
with red cauliflower like growth over left foot was present,
which was excised with excision of shaft of 1st metatarsal
bone. Histology reports confirmed the diagnosis of
rhinosporidiosis. In 1994 he had a palatal perforation with
extensive rhinosporidiosis mass of nose and nasopharynx,
the mass was excised and wide based cauterization was
done. Palatal perforation was not repaired, in order to avoid
more injury to surrounding area. In between 1994 to 2005
he was operated several times for recurring nasal and
pharyngeal masses and also for mass over the margins of
palatal perforation.
In his last attendence patient came with the complaints of
mass in the nasopharynx , oral cavity , abdominal distension
and fungating red mass over left foot ( at previous site of
operation) and anterolateral aspect of left lower limb and
nodular swelling over upper lip, neck, trunk and thigh. There
was history of trauma to the left foot six month back .On
examination rhinosporidiosis mass was
present in the nasopharynx over the
margins of palatal perforation, nose was
found clear at this time with posterior
septal perforation. General examination
of the patient showed mild anaemia only.
Per abdomen revealed free fluid and no
organomegaly. The left foot showed a
large 8 X 7 cm. fungating mass involving
1st and 2nd toe and dorsum of foot. The
anterolateral aspect of lower limb
revealed a 7 X 9 cm. large, tender,
Fig -1
ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK
SURGERY
Fig -2 : Rhinosporidiosis of
bones
Fig -3
fungating cauliflower like mass, fixed to underlying bone

with everted margins . Routine haemogram and X ray chest
were found normal, USG abdomen showed cirrhosis of liver
with decompensation and free fluid in the peritoneal cavity.
Xray of left foot and left leg upper 3/4th with knee showed
destruction of remaining part of 1st metatarsal , terminal
phalanx of 2nd metatarsal and fibular head.
Fig -4
Rhinosporidiosis of bones
Fig 5
mould related fungus belonging to the class Phycomycetes.

Recently its 18S r RNA gene analysis revealed that it is
closer to a fish parasite in the kingdom Protoctista and is
probably an aquatic parasite4.
Most persons with rhinosporidiosis have a history of bathing
or work exposure to stagnant water8. A breach in the
continuity of the epithelium seems to be necessary for
successful inoculation of the agent6. Spread to neighbouring
areas and cutaneous sites have been explained on the basis
of autoinoculation by fingers and nails contaminated from
primary sites2,12. Haematogenous spread has also been
observed in cases of generalized cutaneous lesions and in
cases of involvement of bones3,8.
Rhinosporidiosis shows both long duration and tendency
for recurrence2,6. Recurrent seeding of circulation with
spores from nose and nasopharynx may have lead to
involvement of nonmucosal sites after prolonged period of
infection8 . Transepithelial infection is also important for
recurrence in sites and extension to nearby sites8. It cannot
be doubted that trauma plays an important role in facilitating
infection and recurrence6.
Recurrence after surgical treatment is not uncommon.
Failure to remove all infected tissues at the time of operation
and implantation of spores in fresh areas of abrasions may
cause recurrence5. Treatment has been essentially surgical
on accessible sites. Removal of the growth by a snare
without cauterization was considered to result in
dissemination and recurrence. Good result obtained with
diathermy was explained on the basis that, it avoids
implantation of spores and destruction is deep7,9.
Excision and diathermy cauterization of the nasopharyngeal

mass was done. Ascites tapping was done and fluid was
examined for spores of rhinosporidiosis, but it was found
negative. For ulcerative mass on leg patient was advised
excision of mass with excision of 1st and 2nd toe and excision
of fibular head, but he did not follow the advise and left.
Dapsone therapy was found effective in inhibiting division

of the organism10, but we could not find same result. Failure
of dapsone therapy was also observed, attributed to
impenetrability of sporangial wall11. Complications of the
rhinosporidiosis include extremely rare life threatening
dissemination, local bacterial infection and recurrence8.
REFERENCES :
1.
DISCUSSION :
Rhinosporidiosis is the disease caused by Rhinosporidium
Seeberi in humans and animals. In humans, it manifests
as chronic granulomatous polyp predominantly in the nose
and nasopharynx. Extranasal sites are conjunctiva , lacrymal
sac , skin , parotid gland , bones , lip , vulva , palate ,
epiglottis , trachea , bronchi , urethra , vagina and rectum.
Extranasal manifestations of rhinosporidiosis are uncommon
and may not be diagnosed easily, especially in sporadic
cases occurring in non endemic areas.
Rhinosporidium Seeberi has never been successfully
propagated in vitro. Initially it was thought to be a parasite,
but for the past 25 years it has been regarded as a water
2.
3.
4.
5.
Agrawal S. (1960): Rhinosporidiosis. J. Indian Med.

Ass. 46:442-447
Allen S. and Dave M.L.(1936) : Treatment of
rhinosporidiosis in man based on study of cases. Indian
Med. Gaz. 71 , 376-393.
Billore O. P.: Rhinosporidiosis 1987.
Chatterjee P.K. Khatua C.R., Chatterjee S. N. & Dastidar
(1977): Multiple rhinosporidiosis with osteolytic lesion
in hand and foot. J. of laryng. Oto1.19; 729.
David N. et al, Fredricks (2000): rhinosporidiosis
Seeberi A human pathogen from a novel group
aquatic protistan parasite. Emerging infectious disease
6 (3); 273- 82.
6.
7.
8.
9.
Khan A., Khaleque K. A. and Huda M. N. (1969):

Rhinosporidiosis of the nose. JLO 83; 461
Karunaratne W. A. (1964): Rhinosporidiosis in man.
London, The athelone press.
Ravi R., Mallikarjuna V. S., Chaturvadi H. K. (1992):
Rhinosporidiosis mimicking penile malignancy.
Rajam R. V. , Viswanthan G. S. , Rao A. R. et al
(1995):Rhinosporidiosis with report of a fatal case of
systemic dissemination . Ind. J. Surg. 17 , 269
10. Samaddar R. R. , Sen M. K. ( 1990) : Rhinosporidiosis

in Bankura Indian J. Pathol Microbiol 33 ; 129-36
11. Venkateswaran S. et al (1997): Light and Electron
microscopy findings in Rhinosporidiosis after dapson
therapy. Tropical Medicine and International Health 12;
1128-32.
12. Woodard B.H., Hudson J. (1984): Rhinosporidiosis
ultrastuctural study of an infection in South California.
South Med. J. 77; 1587-8
Prof. Abhoya Kumar Kar has been elected as Vice-President, IMA, Orissa for
2008-09.
Prof. Abhoya Kumar Kar was felicitated as Otolaryngologist of National Stature by
GSL Educational Trust, Andhra Pradesh.
OBITUARY
Two members of Orissa State Branch of AOI, Dr. Banka Bihari Negi &
Dr. Ajit Kumar Das passed away in recent past.
Let their souls remain in peace.
OTOPLASTY IN TCS
Dr. S. N. Mishra, Professor and Head of Department of Plastic Surgery.
Dr. G.C. Sahoo, Professor and Head of Department of ENT.
Raja Muthiah Medical College & Hospital, Annamalai University.
Abstract
Treacher Collin's syndrome (TCS) or mandibulofacial dystosia is also otherwise known as Franceschettic Zwahlen - Klein syndrome or Berry syndrome, having an autosomal dominant trait with high penetration and marked
variability in expression. A 20 year old female patient with typical facial, otological, oral and ophthalmological features
of TCS reported here for whom otoplasty was performed to treat the cosmetic deformity of the pinna and a hearing
aid was provided which improved her hearing.
Key words : TCS, Otoplasty, Pinna, Flap
Introduction :
Operative procedure:
TCS is a congenital anomalty of the 1st arch, more commonly

known as mandibulofacial dystocia, the management of
which is always multidisciplinary including orthodontic
correction, plastic surgery for cosmetic reconstruction &
ENT care, which poses a challenging problem not only to
the otologists, but also to the orthodontitist, audiologist,
speech therapists & plastic surgeon.
The patient was operated under GA through the surgical

technique described below. For the right ear, a superiorly
based postaricular flap was raised from the sulcus area.
The pinna was released through a preauricular incision
and was rotated medially. The preauricular defect was
covered by the post auricular flap. The conchal cartilage
was fixed to the mastoid periosteum by 4/0 proline sutures
and the post auricular wound was directly closed with a
drain in the wound. For the left ear, a post auricular flap
was raised. The pinna was released through a preauricular
incision also. But, as the prearicular defect was too large
to be covered by the post auricular flap, a residual defect
remained with exposed cartilage, which was covered by a
superiorly based rotation flap from preauricular region.
Fixation of conchal cartilage to mastoid periosteum was
also done.
Case report :
A 20 years old female, presented with H/O inadequacy of
hearing and cosmetic deformity of both the ears to the
division ENT, RMMCH, Annamalai University & on examination
the patient had microtia with meatal atresia, bird like face
with prominent parrot beak nose, macrostomia and
hypoplasia of the maxilla. On investigation PTA showed
moderate to severe mixed hearing loss and 'X' ray mastoid
- Laws view showed sclerosis of the air cells. The patient
The post operative period was uneventful . The rotation of

pinna and opening up of the lobule was satisfactory on the
right side. On the left side, the lobule was incompletely
rotated and needed further rotation subsequently. The
patient was happy with the present outcome of the surgery
and started wearing ornament and using the hearing aids.
Fig 4 : Diagram of operative procedure.
(a) Right ear :
Fig 1 : Pre operative

front view of face.

lateral view of the
mircotic right ear.

lateral view showing
the left microtic ear
was referred to the division of Plastic Surgery for otoplasty

and subsequent rhinoplasty. Both the ears were microtic
and the right ear was constricted. The lobule was constricted
but normally oriented on the right side. It was malrotated
on the left side.
i.
Post auricular flap (F) and the pre auricular incision (I) marked.
ii.
Pre auricular defect (D) and the raised post auricular flap (F)
are seen in the field. The ear (E) is rotated medially.
iii. The post auricular flap (F) transposed to the pre auricular
defect.
(b) Left ear :
i.
Post auricular flap (F), release incision (I) and pre auricular
rotation flap (RF) marked.
ii.
The pre auricular defect (D), the raised post auricular flap (F)
and the medially rotated ear (E) are seen.
iii. The pre auricular defect is covered combinedly by the post

auricular flap (F) and the pre auricular rotation flap (RF).
She does not want any further surgery like rhinoplasty or

mentoplasty for which she has been advised.
DISCUSSION :
The present case needed extensive correction of the face
& jaws and correction of microtia.
Morphologic, anatomic and genetic interrelationships have
been shown to exist between microtia, constricted ear and
prominent ears5. In the present case both the ears were
microtic, constricted and forwardly rotated.
The microtia, ideally, needed a total external ear
reconstruction with costal cartilage framework as described
by Tanzer6. The ideal method of reconstruction is not always
acceptable to the patient. On many occasions the patient
demands a less extensive procedure which happened in
the present case. Surgery was restricted to correction of
Palate craniofac J.2000 Sep;37(%);434,Review.

PubMedcitation
4. Teber OA, Gillessen-Kaesback G, Fischer S, Albrecht
B, Albert A, Arslan-Kirchner M, Haan E, HagedornGreiwe M, Hammans C, Henn W, Hinkel GK< Koning R,
Kunstmann E, Kunze J, Neumann LM, Prott EC, Rauch
A, Rott HD, Seidel H, Spranger S, Sprengel M, Zoll B,
Lohmann DR, Wieczorek D. Genotyping in 46 patients
with tentative diagnosis of Treacher Collins syndrome
revealed unexpected phenotypic variation. Eur J Hum
Genet.2004 Nov;12(11);879-90.PubMed citation
5. Rogers B. Microtia, lop, cup and protruding ears; four
directly inherited deformities Plastic reconstructive
surgery 41:208,1968.
6. Tanzer RC, Total reconstruction of the external ear,
plastic Reconstruction Surgery;23:1,1959.
7. Cosman B, Repair of moderate cup ear deoformities.
In Tanzer RC, and Edgerton MT(Eds) Symposium on
reconstruction of the auricle. St Louis,MO,CV.Mosby
company,1974, p118.
ACKNOWLEDGEMENTS :
Fig 5 : Post operative

front view of the face.
Fig 6 : Post operative Fig 7 : Post operative
anterolateral view of anterolateral view of
the right ear.
the left ear.
We would like to place on record, our sincere thanks to

our Vice Chancellor Professor Dr. M. RAMANATHAN for
encouraging us, our Dean Professor Dr. N. CHIDAMBARAM
and our medical superintendent Professor Dr. S.
VISWANATHAN for allowing us to use the hospital facilities
and perform the surgery.
the constriction and rotation of the ears backwards.
Use of a preauricular flap helped in releasing the ear on

both sides. On the right side, it was adequate alone and
on the left side, it had to be supplemented by a preauricular
rotation flap. Since the lobule was malrotated on the left
side, it needed correction at a later stage. However the
patient is happy with the present result & does not want
any further surgery.
Dr. S. N. Mishra
Professor and Head of Department of Plastic Surgery
RMMC&H, Annamalai Nagar-608002, T.N.
Mobile : 9894857960.
The present procedure is simple and can be applied to

correct congenital constricted ears also.
The present method of correcting the micro and constricted
ear differs from the other methods in that, no cartilaginous
modification7 or additions were done. Also, a postauricular
flap was used, which is a simple procedure.
References :
1. Gene Review: Treacher Collins Syndrome
2. Marszalek B, Wojcicki P, Kobus K, Trzeciak WH. Clinical
features, treatment and genetic background of Treacher
Collins syndrome.J Appl Genet. 2002;43(2):22333.Review.PubMed citation
3. Posnick JC, Ruiz RL.Treacher Collins syndrome:current
evaluation, treatment, and future directions. Cleft
FRACTURED TRACHEOSTOMY TUBE AS A FOREIGN BODY

IN BRONCHUS
Dr. Kumar Avanindra, MS, DNB
Dr. More Mukesh, MS
Ex - Senior registrar
Ex - Registrar
Dept. of Otorhinolaryngology & Head & Neck surgery

King Edward VII Memorial Hospital & Seth G. S. Medical College, Mumbai, India
Abstract : Foreign body aspiration is a not so uncommon emergency in pediatric age group involving peanut, coin &
beads. Aspiration of a metallic tracheostomy tube is of rare occurrence. We hereby discuss the etiology, clinical
presentation, its prevention along with the relevant literature, of such a case.
Key words : Tracheostomy tube, Tracheostomy tube as foreign body
CASE REPORT :
DISCUSSION :
A 13 years old boy came to the out patient department of

nearby municipal hospital with complaints of mild respiratory
discomfort & breathlessness since morning, he also had
dry, hacking cough. He was on metal tracheostomy tube
since past 7 years.
Foreign body aspiration is a not so uncommon emergency

in the pediatric age group involving peanuts, beads, seeds
& coins in our setup, but cryptic foreign body in the form of
metallic tracheostomy tube is rare.
On examination, the outer tube of the tracheostomy tube

was missing & only the shield of the tube with the flange
was hanging around his neck. The boy was on no.5 Jackson
metal tracheostomy tube since past 7 years for recurrent
respiratory papillomatosis. Laser excision for the same had
been done in five sittings in a different hospital after which
the patient was lost to follow up for last 4 years.
His vital parameters were stable. A chest x-ray was done,
which showed the detached part of the outer tracheostomy
tube lodged in the left main bronchus. He was referred to
our institute in view of inadequate facilities.
Fig.1: X-ray chest- PA view.

Showing fractured outer tube in
the left bronchus
An emergency bronchoscopy was performed under general

anesthesia and fractured part of the tracheostomy tube
was removed from the left main bronchus. Post operative
period was uneventful.
Fig. 2 : Fractured outer

tube after removal
Amongst the many complications associated with a metallic

tracheostomy tube, fracture of the tube at the junction of
flange and outer tube is a rare one. Amongst the published
series of fractured tracheotomy tube as a foreign body in
the tracheobronchial tree, the largest series is probably by
S.C.Gupta et al, a total of 9 cases.1,3
Early breakages are actually detachments at the shield,
tube junctions due to manufacturing defects, an ill fitting
pilot, which then slips down & presents as foreign body in
the tracheobroncheal tree.2
Fractures after prolonged use are due to mechanical
(repeated removal & reinsertions, repeated cleaning &
boiling) or due to chemical reactions (corrosive cleaning
fluids, alkaline bronchial secretions). Atmospheric moisture
& alkaline bronchial secretions react with copper present
in the copper-zinc alloy tubes to form basic bicarbonates
called verdigris.2 The cause of such breakage of tube has
been described as season cracking (Bassoc & Boe et al,
1960).
There are a few cases which present quite late after
fracture of the tube, this is because the tube hardly interferes
with air passage due to its patency and may remain
quiescent for a long period.6
In a developing country like ours, people who require long
term tracheostomy care, are managed on metal
tracheostomy tube. Since Portex & Silicone tracheostomy
tubes require more intensive care in the form of repeated
suction, which is not easily affordable to majority of the
people. Lack of emergency Otolaryngological services in
the interiors of the country, further complicates the matter.
RECOMMENDATIONS :
Certain aspects of domiciliary tracheotomy tube care needs
review & emphasis in order to prevent such mishaps from
occurring. Besides checking for manufacturing defects,
regular inspection of tube for signs of wear & tear & its
periodic replacements should be carried out.
4.
Bowdler D.A.,Eving P.J.,Tracheostomy tube fatigue. An

unusual case of inhaled foreign body (J.L.O. 1985)
5.
Maru Y.N.,Puri N.D.,Majid A. Unusual foreign body in

tracheobronchial tree (J.L.O.1978)
REFERENCES :
6.
Kumar K.S.,Das K.,DCruz A.S. Aspiration of cryptic

foreign body. ( I.A.P.2004)
1.
Gupta S.C. Fractured tracheotomy tube in

tracheobronchial tree ( J.L.O. 1987)
2.
Kakkar P.P., Saharia P.S.,An unusual foreign body in

tracheobronchial tree (J.L.O. 1972)
3.
Bhargava S.K.,Bhargava K.B.Bhat N, Broken

tracheostomy introducer , an unusual tracheobronchial
foreign body (J.L.O. 1993)
Address correspondence & reprint requestsDr. Avanindra kumar, MS, DNB

G-34, Hyderabad estate, Napean sea road
Phone-*919820349033
Fax-*9122-24143435
Email: dr.avanindra@gmail.com
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issue.
Abhoya Kumar Kar

Editorial Chairman

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Orissa Journal of Otolaryngology and Head & Neck Surgery

Prof. Abhoya Kumar Kar

International Advisory Board

Dr. James P. Thomas, USA

Prof. Abhoya Kumar Kar

Dr. Asutosh Kacker, USA

National Advisory Board

Dr. Arun Gadre, USA

Prof. M.Kameswaran, Chennai

Prof. R.N. Samal

Dr. Ludwig Moser, Germany

Prof. Gobind Ch. Sahoo,

Dr. Sylvester Fernandes, Australia

Dr. Sharat Mohan, U.K.

Prof. R. N. Biswal, Cuttack

Dr. Ullas Raghavan, U.K.

Prof. D.R. Nayak, Manipal

Prof. R. Jaya Kumar, Trivandrum

Prof. G. C. Sahoo, Chidambaram

Prof. Achal Gulati, New Delhi

From the desk of Editorial Chairman

Abhoya Kumar Kar

Owner of the Journal

Printers Name and Address

Berhampur (Gm.), Orissa.

ORISSA JOURNAL OF OTOLARYNGOLOGY

January - June, 2008

Endoscopic DCR for Chronic

Parathyroids in Thyroid Surgery

Current status and future trends of Post

National Program for Prevention & Control

Leiomyosarcoma of the Maxilla - Case

Role Of Fungus in Chronic Maxillary

Brown Tumor of Nasal Bone :

Facial Nerve Needling as a curative

Fractured Tracheostomy Tube as a Foreign

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

A reminiscence of Joseph Toynbee (1815 - 1866)

than through medicine. He became a recognised authority

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

WHATS NEW IN OBSTRUCTIVE SLEEP APNOEA

sleep. The apnoea index (number of apnoeas per hour of

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

and blood pressure are recorded. A general medical work

Fig.4 : Continuous positive

Fig.1 : Obstructive sleep

Polysomnography was first described in 1974 by Holland,

Surgical treatment consists of eliminating / controlling

Fig.2 : Sleep MRI Type 1

Fig 3: Sleep MRI

Treatment depends on the severity and underlying cause

- Avoidance of sedatives & narcotics.

Radiofrequency thermal ablation

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

Coblation may also be used to improve the retropalatal

In the future, neuromuscular stimulation of the genioglossus

Enlargement of retrolingual space can be done by :

Charles B. Croft, Michael B. Pringle. Snoring and sleep

Hyoid Myotomy and suspension - The hyoid bone

Jack Coleman. Sleep studies current techniques and

Charles M. Bower, Anil Gunyor. Pediatric OSAS.

Regina Paloyan Walker. Snoring and OSA. Byron J.

David W. Eisele, Alan R. Schwartz. Tongue

Genioglossal advancement and hyoid suspension