Ojolhns 10 Issue II Dec 2016 Color

DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.
2
DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.2
ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)
VOLUME - X ISSUE II, JULY-DEC, 2016
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Prof Abhoya Kumar Kar Cell- 09437165625, 09437036411
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Journal of Phonosurgery & Laryngology, JIMA,
Associate Editor
World Articles in ENT, ORL Clinics International
Journal,Indian Journal of Clinical Medicine, Dr K. C. Mallik
Elsevier(India) Publications, IJLO & HNS. Associate Professor, Dept of ENT andHNS
PANACEA&OMJ. S.C.B. Medical College, Cuttack, Odisha,
Correspondence address: Cell- 09437092087
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Editor Dr. Subhalaxmi Rautray
Prof. R.N. Biswal Assistant Professor, Dept of ENT and HNS
Professor of ENT and Head and Neck Surgery, S.C.B. Medical College, Cuttack, Odisha,
Kalinga Institute of Medical Sciences (KIMS), Mob.82802165585
KIIT University, Bhubaneswar Email: drsubhalaxmirautray123@gmail.com
NATIONAL EDITORIAL ADVISORY BOARD

Prof. B. K. Dash Prof Sanjeev Mohanty
HiTech Medical College,Bhubaneswar, Odisha Prof and HOD, ENT. SRMC, PORUR
Prof. G. C. Sahoo, Professor and HOD, S33, I-Block, Jains Avantika Apartment
Dept of ENT and Head and Neck Surgery Manapakkam, Chennai-600116,
IQ City Medical College and Contact: 9840131091
Narayana Multispecialty Hospital, Durgapur, E mail: drsanjeevmohanty@gmail.com
Vol.-10, Issue-II, July-Dec - 2016
West Bengal Prof. Bachi T. Hathiram

Email.gcsent99@gmail.com Flat No.-2, Ground Floor;
Prof. Dipak Ranjan Nayak M. N. Banaji Building;
Department of ENT-Head & Neck Surgery, Forjett Street Cross Road; Opp.
Kasturba Medical College, Saibaba Temple;
Manipal, Mumbai- 400 036; Maharashtra, India.
KARNATAK bachi.hathiram@rediffmail.com
E-mail: drnent@gmail.com Prof. B.Viswanatha
Prof. S. K. Behera # 716, 10th Cross, 5th Main; MC Layout,
Department of ENT-Head & Neck Surgery, Vijayanagar; Bangalore 560030; Karnataka,
S.C.B.Medical College, Mobile: 09845942832.
Cuttack, Odisha. drbviswanatha@yahoo.co.in
2
Prof. K. K. Ramalingam Prof Vikash Sinha

K.K.R ENT Hospital & Research Institute, Dean, MP Shah Medical College,
274 Poonamalllee High Road, Kilpauk, Chennai- 600 010, Pt. Nehru Road, Jamnagar-361008, Gujerat.
Tamil Nadu. Phone 044-26411444. dr_sinhavikas@yahoo.co.in
kkramalingam@hotmail.com Prof P.S.N. Murthy
Dr Madan Kapre Head of Dept of E.N.T.,
Neeti Clinics & Nursing Home (ENT); P.S.I. Medical College, Chinoutpalli, At /P.O. Gannavaram,
NeetiGaurav Complex; 21, Central Bazar Road; Vijayawada, Andhra Pradesh.
Ramdaspeth; Nagpur 440010; Maharashtra. drmurtypsn@gmail.com
madankapre@gmail.com Prof Mohan Kameswaran
Prof R. Jayakumar Madras E.N.T. Research Foundation(P) Ltd; 1,
Senior Consultant, Dept of E.N.T., 1st Cross Street;
Kerala Institute of Medical Sciences(KIMS), Off. 2nd Main Road; Raja Annamalaipuram;
P.B. No. 1, P.O. Anayara, Chennai-600028; Tamil Nadu.
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Prof Ahin Saha Uma Krishna; 5-9-30-1/27 AB, Basheerbagh Palace;
FE-99, Sector-3, Salt Lake City, Kolkata-700106, Hyderabad-500053; Andhra Pradesh.
West Bengal.
ahinsaha@gmail.com drrao@mmdsofttech.com
Prof AchalGulati; Prof Krishna Kishore T.
Prof ENT, Mualana Azad Medical College Superintendent, and HOD,
A-72, SwasthyaVihar; Delhi-110092. Dept.of ENT & HNS,
achalgulati@rediffmail.com Govt ENT Hospital and Andhra
Prof T. S. Anand; Medical College,China Waltair,
4, Hemkunt Colony; Opp. Nehru Place, Visakhapatnam, 500017, A P India
New Delhi-110048, Email: drkktent@hotmail.com
doctoranand50@yahoo.com Mob.919849116868.
INTERNATIONAL EDITORIAL ADVISORY BOARD

Prof. Ashutosh Kacker M.D Dr. Sharat Mohan
Professor of Clinical Otorhinolaryngology ENT & Voice surgeon
Weill Cornell Medical College, National Health Services
NY, NY 10021USA Derby, United Kingdom
Personal address:- 1305 York Avenue, sharatmohan@hotmail.com
5th floor,NY, NY 10021 Prof. Ullas Raghavan
USAT: (646)962-5097F:646)962-0100 Department of ENT,
Ask9001@med.cornell.edu Doncaster Royal Infirmary,
Prof. Arun K. Gadre, MD, FACS Armthorpe Road,
Heuser Hearing Institute Doncaster DN2 5LT UK
Professor of Otology and Neurotology, ullasraghavanent@yahoo.com
Division of Otolaryngology Prof. Prepageran Narayanan
Head and Neck Surgery, Dept of Otolaryngology and
University of Louisville, 401 E Chestnut St Head & Neck Surgery.
Suite 710 , Louisville, KY 40202, USA University Malaya Medical Center, Malaysia.
arungadre@yahoo.com prepageran@yahoo.com
Prof. Ludwig Moser Prof. Peter Catalano, MD, FACS, FARS
University of Wuerzburg Chief of Otolaryngology
Department of Oto-Rhino-Laryngology, Plastic, St. Elizabeths Medical Center
Aesthetic, and Reconsructive Head and Neck Professor of Otolaryngology
Surgery, Wuerzburg, Bavaria, Germany Tufts University School of Medicine
l_u_moser@hotmail.com Medical Director of Research
Prof. Sylvester Fernandes Steward Health Care
22 Kelton St, Cardiff NSW, Australia
Sylvester.Fernandes@newcastle.edu.au Peter.Catalano@steward.org
3
Prof. Sady Selaimen da Costa Seattle Washington, USA

douglas.backous@swedish.org
Federal University of Rio Grande do Sul,
Faculty of Medicine, Department of Prof. Dan M. Fliss
Ophthalmology and Otorhinolaryngology Professor and Chairman Deprtment of
Rua Ramiro Barcelos, Otolaryngology Head and Neck Surgery
2350 Zone 19 Room 1922 Good End, Tel Aviv Sourasky Medical Center
Porto Alegre, RS. 6 WEIXMANN ST.TELAVIV-64239 ISRAEL,
Brazil - CEP 90035-003 TEL- 972-3-697-3573
selaimen@gmail.com Email - fliss@tlvmc.gov.il
Prof Douglas D. Backous, MD, FACS.
Medical Director
Center dor Hearing &
SSkull Base Surgery
Swedish Neurosciences Institute
STATISTICAL ADVISORY BOARD

Dr. Kaushik Mishra Dr. Sandeep Kumar Panigrahi
Associate Professor (RHTC) Assistant Professor,
Dept. of Community Medicine Dept. of Community Medicine
SCB Medical College, Cuttack IMS & SUM Hospital, Bhubaneswar
Mob: 9437228312 Mob: 9439369093
Email: kaushikmishra1965@gmail.com Email: dr.sandeepvss@gmail.com
INTERNATIONAL CO-ORDINATOR
PROF DEEPAK RANJAN NAYAK
Dept of ENT and Head and Neck Surgery Kasturba Medical College, Manipal, Karnata
E-mail: drnent@gmail.com
The views expressed in the articles are entirely of individual author. The Journal bears no responsibillity about
authenticity of the articles or otherwise any claim how-so-ever. This Journal does not guarantee directly or
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which is purely commercial in nature.
STATEMENT OF OWNERSHIP & OTHER PARTICULARS OF ODISHA JOURNAL OF

OTOLARYNGOLOGY AND HEAD & NECK SURGERY
1. Place of Publication : Cuttack, Odisha

2. Periodicity of Publication : Half yearly
3. Nationality of Publisher : Indian

4. Publishers name & Address : Dr. K.C. Mallik, Plot. No. 460 / C-03, Sector-8,
CDA, Cuttack, Odisha, India, 753014
5. Owner of the Journal : Association of Otolaryngologists of India, Odisha State Branch.
6. Printers Name and Address : Bani Press, Tulasipur, Cuttack - 8
I Dr K.C.Mallik hereby declare that, the particulars given above are true to the best of my knowledge &
belief.
Sign. of Publisher
Dr. K.C.Mallik
4
ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)
July-Dec 2016 Volume-X Issue-II
Contents
Sl.No Tittle and authors Pages
INVITED EDITORIAL
1. Balloon sinuplasty: an historical perspective.
Peter Catalano, MD, FACS, FARS : 7-11
MAIN ARTICLES
2. Comparative Outcome Of Temporal Fascia And Tragal Cartilage
Graft In Type 1 Tympanoplasty
Gurshinderpal Singh Shergill, Dipak Ranjan Nayak, Ankur Kaur Shergill : 12-17
3. Sleep disordered breathing due to adeno-tonsillar hypertrophy in children
Merin Bobby
G. M Puttamadaiah, B Viswanatha. : 18-25
4. Study of crushing and wedge resection technique for management of concha bullosa
Shrikrishna B H, Jyothi A C : 26-30
5. Effects of glossopharyngeal nerve block and peritonsillar infiltration on
post-tonsillectomy pain: A randomised controlled study
Uma Srivastava, Dharmendra K., Chakresh Jain, Nidhi Chauhan, Tapas K. Singh : 31-35
6. Endoscopic transnasal repair of cerebrospinal fluidrhinorrhea - analysis of 400 cases
G. Sundhar Krishnan,V. J. Vikram, Shruthi Satish : 36-41
7. Interlay myringoplasty: hearing gain and outcome in large central tympanic
membrane perforation.
Gaurav Kumar, Ritu Sharma, Mohammad Shakeel, Satveer Singh Jassal : 42-48
8. Role of bilateral coronoidectomy with buccal pad of fat reconstruction in
management of OSMF
Loknath Sahoo, Rajesh Kumar Padhy, M.S, Sandeep Kumar Samal, MDS ,
Ritesh Roy, M.D, Kshitish Chandra Mishra, MD : 49-52
9. Phonomicrosurgery for benign vocal fold lesions using medial-microflap

technique with cold instruments in a teaching hospital of India.
Dipak Ranjan Nayak, N Apoorva Reddy, Shipla Rudraraju, Gopi Krishnan,
Balakrishnan R, Ajay Bhandarkar. : 53-58
CASE REPORTS:
10. A rare case report:- intact eye ball in maxillary antrum follwing traumatic
injury to right orbit.
Souvagini Acharya, Debasis Jena, Utkal P Mishra. : 59-62
INSTRUCTIONS TO AUTHORS
5
INVITED EDITORIAL
BALLOON SINUPLASTY: AN HISTORICAL PERSPECTIVE

*Peter Catalano, MD, FACS, FARS
Date of receipt of article - 13.11.2016

Date of acceptance - 20.11.2016
DOI- https://doi.org/10.21176/ojolhns.2016.2.1
ABSTRACT
Balloon dilation technology (BDT), also knownas balloon sinuplasty, has been in clinical use since September,
2005. Prior to BDT, surgeons performed a procedure called FESS, or functional endoscopic sinus surgery, for
patients with chronic sinusitis. As is true with any newtechnology or procedure in medicine, a debate often
ensues between early adopters and mainstream practitioners. Over the past 7 years, much has been discussed,
debated, andlearned about BDT. What follows is a review of the originsof the BDT: the theory, technology,
indications and applications;and a review of the pertinent outcomes literature. Independent of how one feels
about BDT, the evidence strongly supports its safety, efficacy, and growing popularity among patients and
physicians alike.
Keywords: Balloon Sinuplasty.
INTRODUCTION There are well-known examplesof disruptive technolo-

Balloon Dilation Technology (BDT) was intro- gies in other areas of medicine. Today, cardiac cath-
duced in September, 2005 at the American Academy eterization is considered routine for patients with car-
of OtolaryngologyAnnual meeting in Los Angeles, CA, diac disease, arthroscopic knee surgery is the standard
USA. This technology isconsidered disruptive, not of care for orthopedists, and laparoscopic androbotic
because it interfered with conventional treatment or surgery has replaced the majority of open abdominal
patient care, but because it introduced a paradigm shift procedures performed by general surgeons, urologists,
for the treatment of patients with chronic rhinosinusitis and gynecologists. In fact, it took 15 years for
(CRS), and it required the otolaryngologist tolearn arthroscopic surgeryto be considered the standard of
catheter-based surgical techniques, a new skill set not care for most knee injuries !
previously taught. Over the past 25 years, there have In what follows, we will discuss the tools required
been 4 major technological advances in rhinology: the and the theory behind BDT, its application in the treat-
endoscope, the powered micro-debrider, image guid- ment of patients with CRS, including exciting data on
ance systems, and BDT. functional preservation, the role of the uncinate pro-
cess, and physiologic gas exchange principles within the
The minimally invasive concepts of Messerklinger,
which are founded on understanding the pathophysi- sinus. A review of the pertinent current literature as it
ology within the transition space, have been validated relates to BDT is then followed by a discussion of clini-
by BDT. Hence BDT isconsidered a transition space cal indications.
tool. The functional elegance of BDT, coupled with
its relative conceptual simplicity, earned BDT descrip- Affiliations:
tors such as innovative, revolutionary, and ingenious. *Chief of Otolaryngology

St. Elizabeths Medical Center
Unfortunately, disruptive technologies are not easily Professor of Otolaryngology
or quickly embraced in medicine. There are many rea- Tufts University School of Medicine, USA
sons forthis, including the belief by many practitio- Address of Correspondence:
ners that they already deliver quality care to their pa- Peter Catalano
Medical Director of Research
tients and feel comfortable with their existing skill set. Steward Health Care.
7
INSTRUMENTATION: of a submillimeter guide-wire and plus-millimeter bal-

The basic BDT system is comprised of several dis- loon catheterinto the transition space can be challeng-
posable components including suction capable guide ing at times, yet still represents the least traumatic means
catheters, flexible kink-resistant guide-wires, balls on to access this anatomicarea. Once in place, the balloon
dilation catheters of various diameters (3.5, 5, 6, and 7 catheter is slowly inflated to10 atm, and during this
mm), and a manual pump mechanism to inflate and process the opposing walls of the transition space are
deflate the balloon catheters. separated an amount equal to the diameter of the cho-
sen balloon. This prying open of the transition space
Fiberoptic guide-wires, irrigation catheters, and
occurs via micro-green stick fractures of the immediate
drug elution balloon catheters have replaced first gen-
peripheral bone (i.e. uncinate process), which usually
eration tools. Flouroscopy, initially a requirement of
retainsits new position as the sub-structure heals. Thus,
the technology tohelp guide and confirm proper wire
no stent isrequired to maintain the enlarged lumen.
and balloon placement,is now optional due to the in-
troduction of sinus trans-illumination through a light BDT can be used alone as a sole intervention for
wire. Under endoscopic control,the balloon catheter one or more sinuses, or in combination with more con-
is then threaded over the guide-wire,positioned prop- ventional endoscopic sinus surgical techniques (ESS),
erly within the sinus transition space, inflated, and re- the so-called hybrid procedure. It is most important
moved. The balloons themselves are non conforming for the reader to understand that BDT surgery, like
and therefore can displace bone and tissue with in the ESS, only addresses the structural relationship between
sinus transition space and/or ostia. Balloons are inflated the sinus cavity and its communication or connection
tobetween 8 and 12 atmospheres to achieve a clinical to the nasal cavity. Neither intervention changes the
effect. patients biology, allergy status, or reactive airway. By
enlarging the sinus drainage pathway, the patients mu-
In 2008, new sinus balloons were introduced and
cosal reactivity will likely still occur, yet is less likely
provide an important benefit of shape retention be-
to cause sinus obstruction with its associated pain and/
tween dilations. These balloons deflate in 1/4 the time
or subsequent infection.
of the original balloons and resume their original com-
pressed, wrapped configuration to permit easier pas- PRESERVATION OF STRUCTURE AND FUNC-
sage through the sinus guides and transition spaces on TION:
subsequent applications in the same patient. In 2009, The natural Mechanical and Chemical Defense
soft bevel-tipped, flexible suction-ready sinus guides Mechanisms:
were introduced to permit atraumatic access to the tar- The role of the uncinate process remains in ques-
geted transition space with the option for suction at tion. However, research to evaluate sinus airflow may
the tip of the guide. provide some important clues. Several years ago,
The next generation of improvements, first intro- Nayak, an otolaryngologist in India, performed a few
duced by Entellus and then by Acclarent emphasize studies to try to determine the role of the uncinate
functional independence by permitting the surgeon to process. Nayak[3] first used simple inhalational dye stud-
hold the endoscope in one hand while placing the guide, ies with methylene blue comparing dye deposition
introducing the guidewire and advancing the balloon within the nose and sinuses in 2 groups of post opera-
catheter with the other. An assistant is only needed to tive patients, those with and without preservation of
inflate and deflate the balloon. the uncinate process. He found dye within the maxil-
THE THEORY: lary and ethmoid cavities when a maxillary antrostomy
(MMA) was performed; however, dye remained only
As previously mentioned, BDT is essentially a tran-
on the anterior middle turbinate and uncinate process
sition space tool, targeting primarily the ethmoidal in-
when the latter were preserved. A MMA is a man-made
fundibulum and frontal recess. The sphenoid sinus does
enlargement of the natural maxillary ostia that remove
not have atransition space and is rarely involved with
part of the medial wall of the maxilla.
inflammatory disease. These transition spaces, per Setliff
[1]
, or prechambers, per Messerklinger[2], are slit-like In 2008, Xiongs group[4] in China designed me-
in nature, having a maximum diameter of 1.52 mm, chanical airflow simulation models using actual human
and even lessin many symptomatic patients. Placement anatomic CT scan data. In their model, there is mini-
8
mal to no air entering any sinus cavity in the human eral position. Thus, under normal circumstances, a small
head during either phase of respiration! Airflow arched amount of NO flows out of the maxillary sinus and
through the nose with highest flow rates between the into the lung with each inspiration. Subsequently, NO
middle turbinate and lateral nasal wall. Xiong et al. then has a positive physiologic effect on oxygen uptake in
repeated their experiments using CT images from post- the lung[15]. Furthermore, NO levels ininspired or ex-
ESS patients who had a surgical Ethmoidectomy and haled air are undetectable after ESS in whicha MMA
MMA[5]. In these patients, there was a striking increase has been performed[5, 17]. Thus, the washout of maxil-
in maxillary and ethmoid sinus airflow. In a recent lary sinus NO, as predicted by Xiong, may have unto-
study Kirihene et al.[6] also measured intra-sinus air- ward physiologic consequences on sinus health.Can all
flow before and after various sized MMAs, and found these findings relative to sinus airflow and NO pro-
that measurable air flow occurred within the maxillary duction and function be purely coincidental ? Is the
sinus once the size of the middle meatal opening ex- lossof NO from the sinus after a MMA in any way
ceeded 20 mm. Coincidentally, the cross-sectional area related to thefact that the bacteriology of recurrent CRS
of the maxillary os after dilation with a 5-mm diameter after ESS includes virulent, atypical organisms (i.e.
sinus balloon is exactly 20 mm. Pseudomonus, E. coli, and Klebsiella) ? Is uncinate pres-
This natural mechanical defense mechanism of the ervation more important to the delicate balance of the
sinuses suggests that the uncinate process and anterior gaseous physiology of the sinuses than many are will-
middle turbinate help filter inspired air and prevent ing to acknowledge ? How else do we explain thehigh
exposure ofthe sinus mucosa to inhaled debris in the concentrations of NO within the normal maxillary si-
form of pollutants, allergens, carcinogens, etc. There is nus, its absence in CRS, and its vasodilatory effects on
a second natural defense mechanism that exists within the pulmonary vasculature when inhaled in minute
the para nasal sinuses, here termed the chemical defense concentrations ? One could argue that not all patients
mechanism. The latter consists of an interesting who have an MMA are disadvantaged, or are colonized
moleculecalled NO, or nitric oxide. The molecule is by virulent pathogens, orshow any measurable adverse
not the same as nitrous oxide (N2O), the general anes- pulmonary effects. While this may be true, the con-
thetic. NO is made within the maxillary sinus by the verse is as well, and thus knowingly creating a MMA
enzyme nitric oxide synthase[7]. Research has shown when a clinically valid and physiologically superior al-
that the natural concentration of NO within the nor- ternative exists, seems irresponsible. I submit that
mal maxillary sinus reaches toxic concentrations if in- amajority of patients given these facts would opt for
haled. However, at these higher concentrations, NO conservatism, tissue preservation, and a more functional
haslocal antiviral, antibiotic, and antifungal properties, procedure.
and will also increase ciliary beat frequency[814]. OUTCOMES DATA:
We have come to learn that NO comes in many Numerous articles have been published on many
forms. The free radical form is present within the vas- aspects of BDT.Of the more relevant are the CLEAR
cular system and has a very short half-life, where as the studies (I, II, and III) which followed patients treated
form active within the sinuses and airway is not a free with either BDT alone or a hybrid option, for 6
radical and can persist for up to 11 min[9]. It has also months, 1 year, and 2 years, respectively [1820]. The
been shown that small amounts of NO (approximately CLEAR study used validated outcome instruments
30 parts per billion), are inhaled into the lungs with (SNOT-20 and Lund-Mackay) to evaluate a patients
each breath. Inhaled NO has a vasodilatory effect on sinus health at the various time points after surgery.
the lung increasing oxygen absorption(16). Inhalation of The results show a statistically significant difference
NO is today used as a therapy for hypoxic infants with between pre- and post-operative SNOT-20 and Lund-
immature pulmonary systems[16]. Mackay scores at each of the three time points, which
NO is also heavier than air, thus the highest con- validates the durable results seen by practising surgeons.
centrations of NO occur at the floor of the maxillary The Lund Mackay score is assigned to each sinus based
pyramid depending upon the patients position. Note on the degree of mucosal inflammation or hypertro-
that the maxillary os is always at the apex of the pyra- phy within it.
mid when we are ineither the upright, supine, or lat- Complications from BDT were rare, and remain
9
rare to this day. In fact, in almost all cases where a CSF tients had surgery on other sinuses in addition to the
leak has been reported following the use of BDT tools, frontal, and the inability to correctly apportion ben-
the surgeon in questions has reported first using con- efit to the various parts of the procedure made subjec-
ventional tools to try and open the frontal sinus and tive metrics less appealing.
then reverted to BDT to try and salvage unsuccessful INDICATIONS:
traditional frontal sinus surgery (see MAUDE website).
The indications for BDT are no different than
The major complications associated from conventional
those for performing endoscopic sinus surgery, as BDT
ESS, such as blindness, meningitis, CSF leak, and
is a tool, not necessarily a procedure unto itself. That
hemorrhage,can be devastating and irreversible. How-
said, BDT is especially suited for patients with recur-
ever, these complication shave never been reported
rent acute sinusitis (RARS) or chronic sinusitis with-
when BDT has been performed alone. Thus, the safety
out nasal polyps (CRSw/oNP), as thesepatients tend
of BDTas a surgical tool is unmatched in rhinology.
to have a biology that is not progressive and rarely
Many other articles have been written about vari- requires aggressive topical medical management. These
ous aspects of BDT. One by Friedman et al.[21] looked groupsare currently being targeted for office applica-
at the cost of sinussurgery with and without the use of tions of BDT. Patients with advanced inflammatory
BDT. While disposable costs are higher when BDT is biology such as CRSwith polyps (CRSwP), Samters
used, the shorter procedure and elimination of the Triad, allergic fungal sinusitis,or hyperplastic sinusitis
need for serial post-operative sinus debridements in the usually require removal of tissueas opposed to reorien-
office setting make surgery with BDT more cost-effec- tation of tissue, and thus are not well suited for BDT
tive than surgery without. This economic advantage as a stand-alone intervention. BDT may beused in a
was realized without including the significant reduc- hybrid procedure in these patients with conventional
tion in postoperative morbidity permitting patients to surgery being performed on the maxillary and ethmoid
return to work within24 h of surgery, as opposed to sinusesand BDT being applied to the frontal and possi-
needing an average of 1014 days off work to recover bly sphenoid sinuses. Fortunately, the majority of pa-
from conventional sinus surgery. tients with inflammatory sinus disease fall into the
Another article by Catalano and Payne [22] evalu- RARS and CRSw/oNPgroups, making BDT an ap-
ated the efficacy of BDT for the frontal sinus in pa- pealing option for many sinus sufferers.
tients with advanced frontal sinus disease (i.e. Samters CONCLUSIONS:
Triad, hyperplastic sinusitis,or fungal sinusitis). All
Interventions to correct inflammatory sinus dis-
study patients had at least 1 frontal sinusthat was ei-
ease are trending toward less invasive procedures. From
ther completely or near-completely opacified preop-
a conceptual standpoint,BDT is a safe, effective, and
eratively. Using only a 5-mm-diameter balloon (larger
appropriate first choice forthe majority of sinus suf-
balloonswere not yet available), 50 % of patients had
ferers who require surgical intervention. In addition,
radiologicclearing of their frontal sinus post-procedure
the procedure is less morbid, less costly, andBDT fail-
that was durableover the 6-month follow-up period.
ures can be easily revised. Data have shown the posi-
Thus, 50% of patients with advanced frontal sinus dis-
tive results after BDT are durable for a minimum of 2
ease were spared from a more aggressive and more
years[20], which equals or exceeds those reported after
morbid surgical intervention. In an attempt to be purely

conventional FESS. Facility with BDT has allowed
objective, Lund-Mackay score was the onlyoutcome
many surgeons to treat sinus sufferers earlier than would
metric used, thus we cannot say how many additional
be recommended for conventional FESS due to its lower
patients had reduction or elimination of frontal sinus
morbidity, and the ability to perform BDT procedures
symptoms after BDT surgery, despite residual mucosal
in the office setting under a combination of local and
inflammation within the frontal sinus. It is well known
topical anesthesia.
that in sinuses with advanced biology (i.e.
Samterstriad), complete resolution of mucosal inflam- While BDTcan also have a role in patients with
mation is not expected, while sinus symptoms are mark- advanced mucosal disease, it is best used in these situa-
edly reduced with appropriate resolution of ostial ob- tions as a hybrid procedure. BDT technology contin-
struction. SNOT-20 scores were not used because pa- ues to evolvealong with our knowledge of sinus physi-
ology and pathophysiology,and the body of evidence
10
thus far suggests thatwhen it comes to sinus surgery, tion. J Allergy ClinImmunol. 2004; 113(4): 697
less is often better. 702.
DISCLOSURES 11. Jain B, Rubinstein I, Robbins RA, Leise KL, Sisson
(a) Competing interests/Interests of Conflict- None JH. Modulationof airway epithelial cell ciliary beat
(b) Sponsorships - None frequency by nitric oxide.BiochemBiophys Res
(c) Funding - None Commun. 1993;191(1):838.
(d) No financial disclosures 12. Lindberg S, Cervin A, Runer T. Low levels of
HOW TO CITE THIS ARTICLE nasal nitric oxide(NO) correlate to impaired
Peter Catalano, MD, FACS, FARS.- Balloon sinuplasty: mucociliary function in the upper airways. Acta
an historical perspective. Orissa J. Otolaryngology & Head & Neck Sur-
gery 2016 Dec ;10(2):7-11. Otolaryngol. 1997; 117(5):72834.
DOI : https://doi.org/10.21176/ojolhns.2016.2.1 13. Runer T, Cervin A, Lindberg S, Uddman R. Ni-
REFERENCES: tric oxide is a regulator of mucociliary activity in
1. Setliff RC. The small-hole technique in endoscopic the upper respiratory tract.Otolaryngol Head
sinus surgery.OtolaryngolClin North Amer. Neck Surg. 1998;119(3):27887.
1997;30(3):34154. 14. Austin AT. The chemistry of the higher oxides of
2. Messerklinger W. Endoscopy technique of the nitrogen asrelated to the manufacture, storage and
middle nasal meatus. ArchOtorhinolaryngol. administration of nitrousoxide. Br J Anaesth.
1978;221(4):297305. 1967; 39(5):34550.
3. Nayak DR, Balakrishnan R, Murty KD. Endo- 15. Griffiths MJ, Evans TW. Inhaled nitric oxide
scopic physiologicapproach to allergy-associated therapy in adults.NEngl J Med. 2005; 353(25):
chronic rhinosinusitis: a preliminary study. Ear 268395.
Nose Throat J. 2001;80(6):392403. 16. Finer N, Barrington KJ. Nitric oxide for respira-
tory failure ininfants born at or near term.2009.
4. Xiong GX, Zhan JM, Jiang HY, Li JF, Rong LW,
doi:10.1002/14651858. CD000399. pub2.
XuG.Computational fluid dynamics simulation of
airflow in the normal nasal cavity and paranasal 17. Lundberg JO, Weitzberg E, Lundberg JM, Alving
sinuses. Am J Rhinol2008;22(5):47782. K. Nitric oxidein exhaled air. EurRespir J.1996;
9(12):267180.18. Bolger W, et al. Safety and out-
5. Xiong G, Zhan J, Zuo K, Li J, Rong L, Xu G.
comes of balloon catheter sinusotomy: a multi-
Numerical flowsimulation in the post-endoscopic
center 24-week analysis of 115 patients. Oto H&N
sinus surgery nasal cavity. Med Biol Eng Comput.
Surg. 2007;137:1020.Curr Allergy Asthma Rep.
2008;46(11):11617.
19. Kuhn F, et al. Balloon Catheter Sinusotomy: one
6. Kirihene RK, Rees G, Wormald PJ. The influ- year follow-up outcomes and role in functional
ence of the size of the maxillary sinus ostium on endoscopic sinus surgery. OtoH&N Surg. 2008;
the nasal and sinus nitric oxide levels.Am J Rhinol. 139:52737.
2002;16(5):2614.
20. Weiss R, et al. Long-term outcome analysis of
7. Jorissen M, Lefevere L, Willems T. Nasal nitric balloon catheter sinusotomy: two year follow up.
oxide. Allergy.2001; 56:102633. Oto H & N Surg. 2008; 139:53845.
8. Mancinelli RL, McKay CP. Effects of nitric ox- 21. Friedman M, et al. Functional endoscopic dila-
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in the resolution of experimentalrhinovirus infec-
11
MAIN RESEARCH ARTICLE
COMPARATIVE OUTCOME OF TEMPORAL FASCIA AND TRAGAL

CARTILAGE GRAFT IN TYPE 1 TYMPANOPLASTY
*Gurshinderpal Singh Shergill, **Dipak Ranjan Nayak, ***
Ankur Kaur Shergill

ABSTRACT
Background: Tympanoplasty is the preferred treatment for chronic suppurative otitis media (CSOM) of
tubotympanic disease. Numerous varieties of grafts are employed to repair the tympanic membrane in such
cases. Our study compared the graft take up rate and conductive hearing gain after type 1 tympanoplasties using
temporalis fascia and tragal cartilage grafts.
Materials and method: One hundred and twenty patients who had undergone type 1 tympanoplasty using
temporal fascia and tragal cartilage were retrospectively reviewed. Eighty seven patients underwent tympanoplasty
using temporal fascia graft while in 33 patients, tragal cartilage with perichondrium was employed. Graft take up
was analyzed at 6 weeks post-operatively, in both the groups. Pre-operative mean of calculated averages of air
bone gap was compared with postoperative mean in both groups. Conductive hearing gain was also compared.
Results and conclusion: Although conductive hearing gain was noteworthy in both, but still there was no
statistically significant difference when the two groups were compared. Similarly, our study demonstrated no
significant difference in graft take up rate and conductive hearing gain in both the groups. Consequently, both
temporal fascia and cartilage can be used unconventionally as suitable graft materials in type 1 tympanoplasty
surgeries.
Keywords: Tympanoplasty, Tragal cartilage graft, temporal fascia graft, Graft take up rate, Air bone gap closure.
INTRODUCTION temporalis fascia graft and tragal cartilage graft were

Tympanoplasty is the main stay of treatment for employed independently.
chronic suppurative otitis media of tubotympanic MATERIALS AND METHOD:
disease. Various types of grafts are being used to repair Patient population: All the patients who
the tympanic membrane. The most widely used graft underwent type 1 tympanoplasty with underlay
in tympanoplasty is temporal fascia graft followed by
cartilage, skin, vein graft, fat, perichondria etc[1-4]. Affiliations:
*
Cartilage offers to be better graft option in graft take Assistant Professor, Department of ENT and Head and Neck Surgery,
Kasturba Medical College, Manipal. Manipal University.
up rates, especially in the ears where there is Eustachian **
Professor & Unit Head, Department of ENT and Head and Neck Surgery,
tube dysfunction, large perforations and ears with Kasturba Medical College, Manipal. Manipal University.
***
Assistant Professor, Department of Oral Pathology and Microbiology,
atelectasis. Meanwhile, temporal fascia graft is considered Manipal College of Dental Sciences, Manipal. Manipal University.
to be a better graft in terms of hearing outcome owing
Address of Correspondence:
to its thinness and more pliable texture[5-7]. Our study
Professor Deepak Ranjan Nayak
compared the graft take up rate and hearing Professor & Unit Head, Department of ENT and Head and Neck Surgery,
improvement in type 1 tympanoplasty cases where Kasturba Medical College, Manipal. Manipal University.
E-mail: drnent@gmail.com
12
method using temporal fascia graft or cartilage graft in type 1 tympanoplasty were retrospectively selected for
a span of one year (2012-2013) were retrospectively the study.The age of patients in the study ranged from
chosen for the study. The patients who had undergone 15 to 69 (mean age 35.7) years. The predominant
ossicular reconstruction, mastoid surgery along with population of patients were females with a male to
tympanoplasty or cases where graft materials other than female ratio of 0.87 (Fig.1). Out of a total of 120 cases,
temporal fascia or cartilage employed were excluded majority had left side CSOM, followed by bilateral
from the study. The total eligible patients for the study tube tympanic type (39) and right side (34) CSOM cases.
were 120. In our study, 71 patients had a large perforation (>
PROCEDURE: 50% area of pars tensa), 36 medium perforation (25-
50% area of pars tensa), 9 subtotal perforation (only
Both the graft materials had been employed
annulus present)and 4 patients had small perforation
independently for the surgeries. In one group of
patients, tragal cartilage with perichondrium was used
to repair the tympanic membrane. The tragal cartilage Table 1. Patient distribution and percentage of different types
of perforation
was harvested by keeping one side perichondrium intact
on the cartilage. A 2 mm slit was cut over the cartilage
graft (where the perichondrium was elevated) to
accommodate the handle of the malleus.
Tympanomeatal flap was then raised in the usual
manner. Thereafter, the cartilage graft was placed
medial to annulus and the perichondrium repositioned
over the cartilage and the handle of malleus. The
tympanomeatal flap was then repositioned back over
the cartilage graft. In the second group of cases, the
temporal fascia was harvested in the same operative field (< 25% area of pars tensa)(Table 1).
and used as graft material in the underlay tympanoplasty Eighty seven patients underwent tympanoplasty
in other group. using temporal fascia graft while 33 patients underwent
The perforation closure in all cases was analyzed tympanoplasty utilizing the tragal cartilage
postoperatively at 6 weeks. Hearing assessment was perichondrium composite graft. In temporal fascia
done by doing pre-operative and post-operative pure group, 48 patients were females followed by 39 males.
tone audiometry. Conductive hearing loss of individual In the tragal cartilage group, there were 17 male patients
patients was calculated (air bone gap) preoperatively and 16 female patients. The age of the patients in
and 3months postoperatively by taking the average of temporalis fascia group ranged from 15-63 (mean
air bone gap at 0.5, 1, 2, and 3 kHz pure tone 34.5)years. In tragal cartilage group, age of the patients
ranged from 19-69 (mean 40.27) years.
frequencies. Mean of air bone gap was calculated for
all the patients preoperatively and postoperatively. In temporal fascia group, out of 87 patients a
Preoperative mean air bone gap was compared with majority 54 (62%) had large perforation followed by
post-operative mean air bone gap in both graft materials. medium perforation cases 24(27%), 6 (6.9%) cases had
Patients with residual perforation postoperatively are subtotal perforation and 3 (3.4%) had small perforation.
not taken up for the hearing assessment. In tragal cartilage group, out of 33 patients, 17 (51%)
had large perforation followed by 12 (36%) cases of
Statistical analysis:The results were analyzed using
medium, 3 (9%) cases of subtotal and 1 (3%) case of
SPSS software version 16. We compared the graft take
small perforation[Table 2]. On comparison of the
up rate (primary outcome) and hearing improvement
parameters, both groups demonstrated homogenous
e.g. closure of air bone gap (secondary outcome)in both findings.
types of graft material used in tympanoplasty.
All patients underwent type 1 tympanoplasty with
OBSERVATIONS AND RESULTS underlay technique. Out of 120 cases, 102 had successful
A total of 120 eligible patients who underwent closure of the perforation postoperatively at 6 weeks.
13
Table 2. Clinical characteristics of patients in the temporal 3months in temporal fascia graft group was 20.84dB
fascia and tragal cartilage groups (standard deviation 8.9dB) and 18.64dB (standard
deviation9.1dB) for tragal cartilage group.
Paired t test was applied to compare the
preoperative means of air bone gap with the 3 months
postoperative air bone gap in temporal fascia and in
tragal cartilage graft cases. Mean air bone closure was
11.02dB (standard deviation 9.9dB) in temporal fascia
graft group and mean air bone gap closure was 10.14dB
(standard deviation 7.5dB) in tragal cartilage cases.
These results were statistically significant (P value <
0.05). However, when the air bone closure in both
The overall graft take up rate was 85%. In temporal
groups were also compared, the values were not
fascia graft group, 74 out of 87 (85%) patients had
successful closure of perforation at 6 weeks statistically significant (p value >0.05) (Table 4). There
(postoperative). In tragal cartilage cases, 28 out of 33
Table 4. Preoperative and postoperative average airbone gap
patients had successful closure at 6 weeks postoperative. (ABG) distribution in both graft materials (Paired sample t
The graft take up rate was 84.9% in the latter group. It test/ independent sample t test).
was statistically significant (p value <0.05) (Table 3).
Table 3. Perforation closure rate in temporal fascia and

cartilage graft (chi square test)
was statistically significant conductive hearing gain (air

bone gap closure) in both the groups. Nevertheless, on
comparision between the two groups the values did
We also calculated the pre-operative air bone gap not reach to a statistically significant level.
for each patient by taking the average of air bone gap DISCUSSION
at frequency 0.5, 1, 2 and 3 kHz. Mean of average air Chronic suppurative otitis media is a common
bone gap for all the patients was calculated. Mean value disease entity in India especially in the population with
of the air bone gap was 32.25db (standard deviation a lower socioeconomic background.Primary goal of
11.1dB) for the temporal fascia group and 29.87dB
(standard deviation 9.9dB) for tragal cartilage group.
Correspondingly, the post-operative mean air bone gap
at 3 months post-surgery was calculated by taking
average of air-bone gap at 0.5, 1, 2 and 3 kHz

frequencies. Similarly post-operative mean air bone gap
was calculated for both the groups. Out of 120 patients,
(postoperatively at 3 months) 7 patients were lost to
follow up and 18 patients had residual perforation.
Patients with residual perforation were not taken for
post-operative hearing assessment. Consequently, the
eligible patients for hearing assessment were 68 and 27
for temporal fascia group and tragal cartilage group
respectively. Post-operative mean air-bone gap at Fig. 1. Gender distribution among the patient population.
14
Fig. 2. Kaplan-Meier survival estimate. Fig. 3. Kaplan-Meier survival estimate.
treatment for CSOM is elimination of the chronic with 15-63 years range in temporal fascia graft cases
inflammatory process. The secondary goal aims at and 19-69 years in the cartilage graft group.
reconstruction of sound conducting mechanism[8]. There are very few reported studies in literature
Tympanoplasty forms the mainstay of treatment for to compare the outcome of myringoplasty using
CSOM of tubotympanic disease. To reconstruct the temporal fascia and cartilage. Most of these studies
tympanic membrane,several graft materials are used like conducted in the past were retrospective. Literature
temporal fascia, cartilage, tensor fascia lata and vein depicts 3 randomized clinical trials which compared
graft. Temporal fascia is the most widely used graft the outcome of cartilage myringoplasty to temporalis
because it can be harvested from a local operative site. fascia myringoplasty. Mauri et al compared results of
Temporal fascia has additional advantages over the other inlay cartilage butterfly grafts and underlay temporal
grafts owing to its light, mouldable structure which fascia grafts. They investigated the graft take up rates
mimics tympanic membrane. Success rate with temporal and hearing outcomes at 1 month and 2 months
fascia in a well aerated middle ear ranges up to 90% in respectively. They included only those perforations
different studies[9]. Nonetheless, success rate decreases where the size of perforation was less than 50% of the
markedly in cases with Eustachian tube dysfunction or size of the tympanic membrane. They did not detect
presence of an adhesive process[10-12]. On the other hand, any significant difference in either the graft take rates
since cartilage is rigid and possesses a thick structure, it or hearing improvement[13]. Cabra et al examined the
is resistant to resorption and atrophy and can be placed patients with perforation size more than 25 % of
precisely into a perforation. Cartilage graft is preferred tympanic membrane to compare the cartilage palisade
in cases with large perforations, revision surgery, graft with the temporal fascia graft. They found higher
tympanosclerosis, tympanic membrane atelectasis, and morphological (absence of retraction, atrophy,
Eustachian tube dysfunctions. Being a thick and rigid lateralization, anterior blunting, and otorrhea) success
structure, cartilage can affect the pliability of the rates in cartilage (82.3%) than fascia (64.4%) but with
tympanic membrane and result in inferior hearing no significant difference in hearing improvement[14].
outcome as compared to temporal fascia graft which is Young et al conducted a clinical trial to compare the
thinner and more pliable[5-7]. cartilage and fascia graft. They considered tympanic
Chronic suppurative otitis media is more perforations involving more than 50% of the tympanic
commonly reported in females than males. Our study membrane [15] . This study showed no statistical
also indicated a female predilection with male to female significance difference between perforation closure and
ratio of 0.88. Chronic suppurative otitis media affects hearing improvement in both types of graft materials.
all age groups ranging from childhood to elderly In the present study, we took all the sizes of perforations
people. A wide age range was also observed in our study ranging from small to medium to large.
15
Onal et al in their study demonstrated a better population group. Although the healing rate of
outcome with cartilage graft in both perforation closure tympanic membrane was similar in both temporal fascia
rate and hearing improvement rate[16]. Demirpehlivan and cartilage groups, there was no statistically significant
et al compared the outcome of cartilage with difference in the hearing improvement in both types
perichondrial graft, cartilage graft and fascia graft. They of graft materials. Consequently, both cartilage and
presented higher graft take up rates in perichondrium temporal fascia can be utilized as graft materials
cartilage (97.6%) compared to cartilage only (78.95%) independently with good success rates in tympanoplasty
and fascia (80.6%). No difference in hearing surgeries.
improvement was noted among the 3 groups[17]. Few DISCLOSURES
other retrospective studies have established a better graft a) Competing interests/Interests of Conflict- None
take up rate with cartilage graft when compared to
b) Sponsorships None
fascia graft with follow up period ranging from 6 to 24
c) Funding - None
months. However, no difference was noted in the
d) Written consent of patient- taken
hearing improvement in both types of graft
materials[18-20]. Al lackany and Sarkis investigated the e) Animal rights- Not applicable
HOW TO CITE THIS ARTICLE
graft take-up rates and hearing improvement utilizing Gurshinderpal Singh Shergill Dipak Ranjan Nayak Ankur Kaur Shergill.-
cartilage, perichondrium,, composite graft, Comparative Outcome Of Temporal Fascia And Tragal Cartilage Graft In
Type 1 Tympanoplasty.Orissa J Otolaryngology & Head & Neck Surgery
perichondrial graft and fascia graft in central, subtotal 2016 Dec ;10(2):12-17.
and total perforations. A better graft take up rate was DOI : https://doi.org/10.21176/ojolhns.2016.2.2
established in cartilage perichondrium composite graft REFERENCES:
(92.3%) when compared to perichondrium (88%) and
fascia graft (80%), nevertheless a statistically significant 1. Wullstein HL. (1952) Funktionelle Operationenim
value was achieved only for total perforation cases. Also Mettelohrmit Hilfe des Freien Spaltlappen-
a better air bone gap closure was proven with composite transplantates. Arch Otorhinolaryngol161:422-35.
graft by Yetiser S et al[21] . Cartilage perichondrial graft 2. Zllner F. (1955)The principles of plastic surgery
gave better result in comparison to fascia graft in of the sound-conducting apparatus. J
subtotal and total perforations while air bone closure LaryngolOtol 69:637-52.
was superior in fascia graft in central perforations. Kadir 3. Heermann J. (1962)Experiences with free
zdamar et al also studied the hearing improvement transplantation of fascia-connective tissue of the
(air bone gap closure) in cartilage tymanoplasty group temporalis muscle in tympanoplasty and reduction
and temporal muscle fascia group. They also compared of the size of the radical cavity. Cartilage bridge
the middle ear pressure, air volume and compliance of from the stapes to the lower border of the
tympanic membrane in both groups. They concluded tympanic membrane. Z LaryngolRhinolOtol
that no statistical differences were observed in air 41:141-55.
volume, pressure or compliance values at any frequency 4. Buckingham RA. (1992) Fascia and
perichondrium atrophy in tympanoplasty and
in audiometry and tympanometry in the cartilage and

fascia groups[22]. In our study, the graft take up rate in recurrent middle ear atelectasis. Ann
cartilage perichondria composite graft and temporalis OtolRhinolLaryngol 101:755-8.
fascia graft was 84.85% and 85% (statistically significant) 5. Adkins WY. (1990) Composite autograft for
respectively. Hearing improvement (air one gap closure) tympanoplasty and tympanomastoid surgery.
was also significant in both the groups. Laryngoscope 100:244-7.
CONCLUSION: 6. Poe DS, Gadre AK.(1993) Cartilage tympanoplasty
for management of retraction pockets and
Our study attempted to recognize better graft
cholesteatomas. Laryngoscope 103:614-8.
options in tympanoplasty surgeries. Various parameters
7. Glasscock ME, House WF. Homograft
such as healing, hearing improvement and graft take
reconstruction of the ear. A preliminary report.
up rates were comprehensively studied in a large
16
Laryngoscope 1968;78:1219-25. 17. Demirpehlivan IA, Onal, K, Aslanoglu S,

8. Caye-Thomasen P, Andersen J, Uzun C, Hansen etal.(2011) Comparison of different tympanic
S, Tos M.(2009) Ten-year results of cartilage membrane reconstruction techniques in Type 1
palisades versus fascia in eardrum reconstruction tympanoplasty. Eur Arch Otorhinolaryngol
after surgery for sinus or tensa retraction 268:471Y4.
cholesteatoma in children. Laryngoscope 2009; 18. Albirmawy OA.(2010) Comparison between
119(5): 944-952. cartilage-perichondrium composite ring graft and
9. Boedts D. (1995) Tympanic grafting materials. temporalis fascia in type one tympanoplasty in
Acta Otorhinolaryngol Belg 49(2):193-199. children. J LaryngolOtol 124:967Y74.
10. Onal K et al.(2005) A multivariate analysis of 19. Ozbek C et al.(2008) A comparison of cartilage
otological, surgical and patient related factors in palisades and fascia in Type 1 tympanoplasty in
determining success in myringoplasty. Clin children: anatomic and functional results.
Otolaryngol 2013 30:115-120. OtolNeurotol 29:679Y83.
11. Uguz MZ, Onal K, Kazikdas KC, Onal A. (2008)the 20. Kazikdas KC, Onal K, Boyraz I, et al. (2007)
influence of smoking on success of tympanoplasty Palisade cartilage tympanoplasty for management
measured by serum nicotinine analysis. Eur Arch of subtotal perforations: a comparison with the
Otorhinolaryngol 265(5):513-516. temporalis fascia technique. Eur Arch
12. Murbe D, Zahnert T, Bornitz M, Huttenbrink Otorhinolaryngol 264:985Y9.
KB.(2002)Acoustic properties of different cartilage 21. Yetiser S, Hidir Y.(2009) Temporalis fascia and
reconstruction techniques of the tympanic cartilage-perichondrium composite shield grafts for
membrane. Laryngoscope 112(10):1769-1776. reconstruction of the tympanic membrane.Ann
13. Mauri M, Neto JFL, Fuchs SC.(2001) Evaluation OtolRhinolLaryngol 118:570Y4.
of inlay butterfly cartilage tympanoplasty: a 22. zdamar K et al.(2014) Long-Term, High-
randomised clinical trial. Laryngoscope Frequency Tympanometry and Audiometry
111:1479Y8. Results after Cartilage and Fascia Tympanoplasty.
14. Cabra J, Monoux A. (2010) Efficacy of cartilage Turk Arch Otolaryngol 52:43-6.
palisade tympanoplasty: randomized controlled
trial. OtolNeurotol 31:589Y95.
15. Yung M, Vivekanandan S, Smith P.(2011)
Randomized study comparing fascia and Cartilage
grafts in myringoplasty. Ann OtolRhinol-
Laryngol 120:535Y41.
16. Onal K, Arslanoglu S, Oncel S, et al.(2011)
Perichondrium/cartilage island flap and emporalis
muscle fascia in Type I tympanoplasty J
Otolaryngol Head Neck Surg. 40:295Y9.
17
SLEEP DISORDERED BREATHING DUE TO ADENO-TONSILLAR

HYPERTROPHY IN CHILDREN
*Merin Bobby , **G. M. Puttamadaiah, ***B Viswanatha

ABSTRACT
Adeno-tonsillar hypertrophy is one of the main causes of upper airway obstruction and Obstructive Sleep
Apnoea Syndrome (OSAS) in children. Studies have shown that adeno-tonsillectomy significantly improved
oxygen saturation in children with sleep-disordered breathing. This study was undertaken to evaluate the effect
of adeno-tonsillectomy on quality of life in children with sleep-disordered breathing and on oxygen saturation
measured through nocturnal pulse oximetry in children.
Methods: Sixty children suspected of having sleep-disordered breathing and who subsequently underwent adeno-
tonsillectomy were randomly selected for this study. Quality of life was evaluated pre- and post-operatively by
questionnaire and the symptoms were scored depending on its frequency of occurrence. Pre-and post-intervention
nocturnal oxygen saturation was monitored and recorded. Oxygen desaturation index (ODI) as well as desaturation
events were recorded. The data was analysed using paired student t-test and Wilcoxons Signed Rank Test.
Results: Out of the 60 study population, 36 (60%) were males and 24 (40%) were females. Age distribution of the
population ranged from 6 to 12 years with a mean age of 8.2 years. There was a significant improvement in the
quality of life of these children after the surgery. The study showed a positive correlation between grade of
adeno-tonsillar hypertrophy and ODI(r-0.25). The pulse oximetric parameters improved after adeno-tonsillectomy
(p<0.05). There was also significant improvement in the quality of life of these children after the surgery.
Conclusion: Adeno-tonsillectomy was found to be effective in children with sleep disordered breathing. It can
be recommended as the primary surgery as it substantially reduced the morbidity and health care utilisation by
these children.
Keywords: Sleep-disordered breathing; obstructive sleep apnoea, adeno-tonsillectomy; pulse oximetry.
INTRODUCTION Primary snoring (PS).

Sleep medicine has undergone a revolution since Upper airway resistance syndrome (UARS).
the first description of abnormal airway during sleep Obstructive sleep apnoea (OSA).
in patients with Pickwickian syndrome in1965[1]. Sleep
In the general population, OSAS is one of the most
disordered breathing (SDB) refers to a spectrum of

prevalent SDB conditions, affecting adults as well as
disorders that ranges in severity from primary or simple
children. Prevalence of OSA in childhood is around 2-
snoring, through upper airway resistance syndrome
(UARS) and, in its most severe form, obstructive sleep Affiliations:
apnoea syndrome (OSAS)[2]. OSAS was first reported *,**,*** - Department of Otorhinolaryngology, Bangalore Medical College
& Research Institute, Bangalore, India
in children by Guilleminault et al. (1976) following
which recognition of abnormal breathing has Address of Correspondence:
progressed[7]. Prof. B.Viswanatha,MS, PhD, FACS (USA)

Professor of ENT,
Sleep disordered breathing Bangalore medical college & research institute
Bangalore, INDIA
Sleep-disordered breathing is a spectrum of airway E-mail: drbviswanatha@yahoo.co.in
obstruction during sleep which encompasses [2]. Mobile : 91984594283
18
3% affecting all ages; and peaks between 2-8 years [3]. or more[6]. The degree of hypoxia is influenced by the
Frequent snoring is reported by parents in 3-15% duration of the apnoeic event, the condition of the
children, while prevalence of reported apnoeic events cardiopulmonary system and whether a coexisting
is 0.2-4%. neuromuscular disorder is present. Apnoea hypopnoea
(a) Primary Snoring: index (AHI) indicates the severity of OSA. It is the
number of apnoea and hypopnoea per hour of sleep. It
Primary snoring has been defined as snoring
is agreed that an apnoea-hypopnoea index greater than
during sleep without associated apnoea, gas exchange
1 is abnormal in a child[6].
abnormalities, or excessive arousals[4].Approximately
10% of children snore during sleep on most or all nights, Sleep-related upper airway obstruction can lead
and the majority of these children have primary snoring to a variety of night-time and daytime symptoms in
(PS)[5]. The prevalence of primary snoring is estimated children. It causes significant sleep disruption. This can
to be 3-12%. Major risk factors for snoring in lead to daytime neurobehavioural problems such as an
otherwise healthy children are obesity, decreased nasal increase in total sleep time, hyperactivity, irritability,
patency (rhinitis, septal deviation, nasal obstruction), bed-wetting and morning headaches. If diagnosis and
and adeno-tonsillar hypertrophy[5]. treatment of OSAS are delayed, sequelae like
corpulmonale, failure to thrive and long-lasting neuro-
(b) Upper Airway Resistance Syndrome
behavioural consequences may occur.
Upper airways resistance syndrome is a more subtle
The diagnosis of obstructive sleep-disordered
form of sleep-disordered breathing than OSA. Children
breathing is reached by sleep based history and physical
with UARS snore and have partial upper airway
examination. The clinical history and examination will
obstruction that leads to repetitive episodes of increased
identify most children with sleep disordered breathing.
respiratory effort ending in arousals and sleep
Specific questionnaires are designed to complement the
fragmentation. This disorder is more common than
clinical history for screening and identifying severe cases.
OSA but is often underdiagnosed. Children with
UARS have no evidence of apnoea, hypopnoea, or gas The gold standard investigation for sleep disorders
exchange abnormalities on polysomnography. is full polysomnography. Pulse oximetry is another
screening tool. [8] It relies on indirect measurement of
(c) Obstructive Sleep Apnoea Syndrome
the arterial oxygen saturation using a probe (pulse
OSA is defined by the American Thoracic Society oximeter), usually applied to the finger. It is minimally
(ATS) as a disorder of breathing during sleep invasive, and can be undertaken even at home. Pulse
characterized by prolonged partial upper airway oximetry has a high positive predictive value of
obstruction and/or intermittent complete obstruction approximately 97 percent. It is not effective in mild-to-
(obstructive apnoea) that disrupts normal ventilation moderate OSA, with a low negative predictive value of
during sleep and normal sleep patterns [17] . approximately 47 percent. Therefore, children with
Approximately 1% to 3% of all children will have OSAS, negative results on screening studies should undergo a
and as many as 40% of snoring children referred to a more comprehensive evaluation. Since the most
sleep clinic or otolaryngologist may have OSA. OSAS common cause of OSAS in children is adeno-tonsillar
is characterized by recurrent episodes of upper airway hypertrophy, adeno-tonsillectomy is accepted to be the
collapse during sleep. first line of treatment [5] .
The International Classification of Sleep Disorders The correlation of adeno-tonsillar hypertrophy
2nd edition (ICSD II) by the American Academy of and impact on the quality of life in children is intended
Sleep Medicine (AASM) defines apnoea as the cessation to be studied. The overall efficacy of adeno-
of airflow for at least 10 seconds over two or more tonsillectomy (AT) in treatment of obstructive sleep
respiratory cycles[4]. Sleep apnoea syndrome is diagnosed apnoea syndrome (OSAS) in children is unknown.
when 30 or more episodes occur during a 7-hour sleep Although success rates are likely lower than previously
period. Hypopnea is defined as a recognizable transient estimated, factors that promote incomplete resolution
reduction (but not complete cessation) of breathing for of OSAS after adeno-tonsillectomy remain undefined.
10 seconds associated with oxygen desaturation of 4%
19
Aims and Objectives of the study were addition to a review of audiotaped breathing of the
1. To study the impact of adeno-tonsillectomy on children during sleep.
the quality of life in children with sleep disordered Mitchell and co-workers assessed behavioural
breathing(SDB) abnormalities in children with OSAS using the
2. To correlate the effect of adeno-tonsillar Behavioural Assessment System for Children before
hypertrophy assessed clinically and radiologically adeno-tonsillectomy, and again within 6 months after
on overnight oxygen saturation. surgery and 9 to 18 months after surgery [10]. These
investigators found improvements in behavioural
3. To determine whether adeno-tonsillectomy is
measures after adeno-tonsillectomy that seemed to
effective in improving SDB in children.
persist during long-term follow-up, although to a lesser
REVIEW OF LITERATURE degree than seen shortly after surgery. It is not clear,
Since the first report of obstructive sleep apnoea however, if the cognitive and behavioural complications
syndrome (OSAS) in children by Guilleminault et al. of OSAS are completely reversible.
in 1976, recognition of abnormal breathing during sleep De Serres and colleagues reported the results of a
has progressed.Guilleminault et al reported that in their multicentre study of quality of life changes after adeno-
sample of eight children with excessive daytime tonsillectomy in children who had adeno-tonsillectomy
sleepiness and learning difficulties at school improved for treatment of obstructive sleep disorders [11]. Large
behaviour 3-months post adeno-tonsillectomy and by changes in quality of life were documented in almost
6 months improved hyperactivity symptoms[7]. 75% of children, with the most improved domains being
Methods to help identify SRBDs without the sleep disturbance, caregiver concerns, and physical
expense of polysomnography could greatly facilitate suffering.
clinical and epidemiological research. There are several Brietzke and co-workers in a systematic review of
clinical assessment scores to evaluate the quality of life the literature and meta-analysis on the effectiveness of
in OSAS in children. tonsillectomy and adenoidectomy in the treatment of
Chervin et al developed and validated a Paediatric Paediatric Obstructive Sleep Apnoea Syndrome found
sleep questionnaire that can be used to investigate the adeno-tonsillectomy to be effective in the treatment of
presence of childhood SRBD[8]. It is a 22-item score OSA. They found that 11 of 12 articles in the literature
with sensitivity of 0.85 and a specificity of 0.87. They concluded that clinical assessment is inaccurate in the
diagnosis of childhood OSAS [12]. Although the clinical
concluded that scales for snoring, sleepiness, and
history may not be diagnostic, a thorough evaluation
behaviour are valid and reliable instruments that can
of daytime and night-time symptoms is helpful in
be used to identify SRBDs or associated symptom in
planning subsequent studies and interpreting the
clinical research when polysomnography is not feasible.
findings. They found a post-surgery reduction in AHI
Using the OSA-18 quality of life survey, Goldstein by approximately 14 events per hour. The summary
and associates found similar improvements in quality success rate was 83%.
of life, again with the most significant improvements
Gozal and Kheirandish reported a cure rate of

seen in the domains of sleep disturbance, caregiver
77% in a recent review but noted residual OSAS in up
concerns and physical discomfort, with concomitant
to 45% of children after adeno-tonsillectomy in their
improvements in behaviour after adeno-
own prospective study [13]. More snoring and increased
tonsillectomy.[9] In their study they found children with inspiratory effort during sleep were noted in teenagers
a positive clinical assessment of OSA but negative studied 12 years after adeno-tonsillectomy. This finding
polysomnography(PSG) have significant improvement emphasizes the need for long-term study of both the
after adeno-tonsillectomy, thus validating the clinicians natural history of and treatment outcomes for OSAS
role in the diagnosis. They evaluated 30 snoring in children.
children referred to a paediatric otolaryngology clinic
Several studies show behavioural and
using a focused history and physical examination in
neurocognitive improvement following adeno-
20
tonsillectomy in children with sleep disordered Total number of desaturations of > 4%,
breathing. Oxygen desaturation index (ODI)
Chervin and co-workers in their study found that Mean saturation and
children undergoing adeno-tonsillectomy for any
Minimum saturation.
clinical indication with suspected sleep-disordered
breathing had increased hyperactivity, inattention, and ODI is defined as the total number of desaturation
daytime sleepiness were more likely to be diagnosed events divided by the total duration of sleep in hours.
with attention deficit-hyperactivity disorder than A desaturation event was considered when the
control children undergoing other surgical procedures haemoglobin saturation level (SaO2) fell below 4% from
[14]
. Avior et al assessed attention in 19 children with baseline saturation. Falls in oxygen saturation to >4%
SDB before and 2 months after adeno-tonsillectomy, in the interval 90100% of saturation was also
demonstrating that neurocognitive changes occur within considered as desaturations. ODI was obtained for each
the first 2 months after treatment[15]. patient with three cut off points;>5: (ODI-5),>10:
(ODI-10), >15: (ODI-15).The data collected were
Sohn H and co-workers in their study on Quality
analysed in oximetric and heart rate distribution tables.
of life of children with obstructive sleep apnoea after
Validity of the test was approved if the duration of
adeno-tonsillectomy found that the relationship
oximetric monitoring was 6 hours or more and if
between the OSA-18 summary score and respiratory
oxygen saturation data was reliable and compatible with
distress index remained significant[16].
pulse rate according to the pulse rate variable recorded
Gottelib DJ et al assessed the prevalence of SDB in the memory of pulse oximeter.After obtaining fitness
symptoms in 5 year old children and found it to be for surgery patients were taken up for adeno-
associated with an increased risk of problem behaviours, tonsillectomy under general anaesthesia. All surgical
attention-deficit hyperactivity disorder[17] . procedures were performed under general anaesthesia
METHODOLOGY with orotracheal intubation. After surgery, the children
This study was undertaken in the department of were closely monitored for any probable bleeding and
ENT, Bangalore Medical College & Research Institute, complications for atleast 24 hours. Thereafter, they
Bangalore from August 2014 to July 2016. Sixty (60) were re-evaluated in 3 months period.
children aged 6-12 years with symptoms and signs Assessment tools: Treatment response was
suggestive of adeno-tonsillar hypertrophy and SDB , assessed by
who met the inclusion criteria were randomly enrolled OSA-18 survey on quality of life improvement
for the study.Demographic data, medical history, before and after the surgery.
concomitant medications, clinical examination including
Pulseoximetric evaluation of the subjects pre- and
recording of vital signs, lab investigations and details
postoperatively to assess the improvement in oxygen
were recorded in the study proforma.The study was
saturation.
conducted prior to adeno-tonsillectomy until three
months (12 week) after the surgery. Patients physical Statistical analysis: Pre- and post-operative
oximetric variables were analysed using paired student
parameters like weight and height,BMI were recorded.
Radiological study of Nasopharynx was done to know t-test or Wilcoxonssigned rank test depending on the
nasopharyngeal air-way. Measurement of oxygen variables. Correlation between variables was considered
saturationwas done by nocturnal pulse oximetry. The using Pearson correlation test.
children were programmed for evaluation by pulse RESULTS
oximetry 1-2 days before and 3 months after the Out of the 60 study population, 36 were males
surgery, by keeping the child in observation room. (60%) and 24 were females (40%). Age distribution of
Pulse oximeter, which has a memory upto72 hours, the population ranged from 6 to 12 years with a mean
was used for this study. Oximetric monitoring both age of 8.2 years.
pre- and post-operatively was carried out. The Most of the patients were between 6-8 years of
following variables were studied: age. Majority of study population (58.3%) had grade
21
III tonsils (enlarged tonsils that come in contact with

uvula).
Majority of study population (50%) had Grade
III adenoids (enlarged adenoids filling from 2/3rd of
vertical portion of choanae to nearly complete
obstruction). The correlation between grades of
adenotonsillar hypertrophy and ODI scorewas assessed
using Pearson correlation test.The test showed
correlation co-efficient r 0.25 indicating a positive
correlation.
ODI grade: The Oxygen Desaturation Index
(ODI) was graded as shown below and thepre-operative
and post-operative values were compared.
Table2: Showing preoperative and postoperative

snoring among study population
Restlessness at night:
Table1: showing Oxygen Desaturation Index
Pre-operatively most of the patients had ODI

grade >15 (43.33%) while post-operativelymajority
have ODI grade <5 (80%). Paired-t test was used to
analyse whether the postoperative ODI had
significantly reduced compared to preoperative
ODI.Average ODI score preoperatively was 15.115.4
and that postoperatively was 3.482.3. p value was
significant (p< 0.05).
Evaluating the Quality of life pre-and post-
operatively among study population.

To evaluate the continuous scores of quality of
life questionnaire non-parametric Wilcoxons Signed
Table 3: Showing preoperative and postoperative
Rank Test was used. The following observations were
restlessness at nights among studypopulation
made: -
Snoring:
Preoperatively most of the patients (61.66%) often
Preoperatively most of the patients (45%) had
had restlessness at nights and postoperatively majority
snoring very often and postoperatively majority
(88.33%) almost never had restlessness at nights. The p
(58.3%) had snoring sometimes. The p-value was
value was significant p<0.05.
significant (p<0.05)
22
Mouth breathing: Irritability on waking up:
Table 6: Showing preoperative and postoperative

irritability on waking-up among studypopulation.
Preoperatively most of the patients (48.33%) had

irritability on waking-up sometimes and
postoperatively majority (60%) almost never had
irritability on waking-up. The p-value was significant
(p<0.001).
Table 4: Showing preoperative and postoperative mouth
breathing among study population DISCUSSION
Paediatric sleep-disordered breathing is a relatively
Preoperatively most of the patients (58.33%) had new field, and a number of questions remain
mouth breathing very often and postoperatively unanswered. One of the most important questions in
majority (60%) had mouth breathing sometimes. The paediatric sleep-disordered breathing is the outcome of
patientswith OSAS. We do not know the clinical
p-value was significant p<0.05
correlates of mild obstructive apnoea, or what degree
of OSAS warrants treatment. The long-term
relationship between primary snoring, UARS, and
OSAS has not been studied. Although
polysomnography is widely used, it is not known which
polysomnography parameters predict morbidity. We
used Quality of life questionnaire and Pulse oximetry
to assess the improvement of symptoms following
adeno-tonsillectomy in the children in our study.
The correlation was assessed using Pearson
correlation test. The test showed a positive correlation
between grade of adeno-tonsillar hypertrophy and
ODI. This indicates that the size of adenoids and tonsils
aids in assessing the severity of sleep disordered
Table 5: Showing preoperative and postoperative day breathing and the same can be used to select children
time somnolence among studypopulation. for surgical intervention.
These findings were in par with similar studies
Preoperatively most of the patients (46.66%) had such as those conducted by Li AM et al. [18]
day time somnolence sometimes and postoperatively MitsuhikoTagaya et al[19].
majority (63.33%) had noday time somnolence. The p- Li AM, Wong E, Kew J, Hui S, Fok TF conducted
value was significant ( p<0.05) a study in 35 children referred consecutively for
23
suspected OSA secondary to tonsillar hypertrophy. [18] internal consistency, and validity.Survey domains
Their results showed that in children with OSA, included sleep disturbance, physical suffering,
tonsillar hypertrophy as assessed by lateral neck emotional distress, daytime problems, and caregiver
radiograph correlates positively with the severity of concerns. All the symptoms of SDB and chronic adeno-
obstructive sleep apnoea. tonsillar hypertrophy improved significantly among
MitsuhikoTagaya, et al in their study of 58 the study population post-operatively. From this we
children with SDB found that adenoid grade and apnoea can conclude that adeno-tonsillectomy has a significant
index correlated significantly in preschool children impact on the quality of life of these children. Also,
(r=0.45, p<0.01).[19] that the OSA-18 is a reliable, and responsive QOL
measure.
Comparing pre-and post-operative pulse oximetric
parameters among study population. CONCLUSION
All the pulse oximetric parameters improved There is a positive correlation between grade of
significantly after the intervention. The mean ODI pre- adeno-tonsillar hypertrophy and ODI..This indicates
operatively was 15.11and that post-operatively was 3.48. that the size of adenoids and tonsils aids in assessing
The p value was <0.001. Since p value is < 0.05, we the severity of sleep disordered breathing and the same
conclude that ODI have significantly improved can be used in selecting children for surgical
postoperatively. intervention.
The mean SPO2 preoperatively was 90.83 and that There is significant improvement after adeno-
postoperatively was 95.02 Standard deviation of pre- tonsillectomy in all the pulse oximetric parameters
operative mean SPO2 and post-operative mean SPO2 namely ODI, mean SPO2, minimum SPO2 in children
was 1.54 and 1.66 respectively. The p value <0.001. with SDB and chronic adeno-tonsillar hypertrophy.
Hence we can say that mean SPO2 significantly This indicates that thereis also an objective evidence of
improved postoperatively. improvement in the nocturnal arterial oxygensaturation
of children with SDB. The results of the previous
These all indicates that there is an objective evidence
studies strongly support our study and emphasize the
of post-surgical improvement in the nocturnal arterial
effectiveness of adeno-tonsillectomy as a first line
oxygen saturation of children with SDB. These findings
management of children with SDB.
were in par with similar studies such as those conducted
by Arrarte JL et al, Kargoshaie A and colleagues. There is significant improvement in the quality
of life of children with SDB after adeno-tonsillectomy.
Arrarte JL et al conducted a pre- and post-
Adeno-tonsillectomy can be recommended as the
intervention study using nocturnal pulse oximetry.
primary surgical modality for children with sleep
Atotal of 27 children completed the study. Out of
disordered breathing as it substantially reduced the
these, 23 children (85.2%) presented class III or class IV
morbidity and health care utilisation by thechildren..
hyperplasia of the palatine tonsils. There was significant
Despite more than 20 years of treating children with
improvement in the post-operative period over the pre-
this condition, we have limited information on the long-
operative period in terms of the oxygen desaturation
term consequences of paediatric OSAS.It is a frequent
rate [20]
but under diagnosed problem in children. The
Kargoshaie A and colleagues carried out a similar immediate consequences of OSAS in children include
study. The study revealed a significant improvement behavioural disturbance and learning difficulties,
in the postoperative oxygen desaturation index (1.60 pulmonary hypertension, and compromised somatic
3.22) compared with the preoperative oxygen growth. However, if nottreated promptly and early in
desaturation index (3.98 4.93; (p < 0.01).[21] the course of the disease, OSASmay also impose long-
Evaluating the Quality of life pre-and post- term adverse effectson neurocognitive and
operatively among study population. cardiovascular functions of the children, providinga
Quality of life questionnaire was assessed using strong rationale for effective treatment.
Wilcoxons Signed Rank test. The p-value was DISCLOSURES:
significant (<0.001) for all the symptom scores except a) Competing interests/Interests of Conflict- None
that of discipline problems. We used the OSA-18, an
18-item QOLsurvey with known test-retest reliability,
c) Funding - None
24
d) Written consent of patient- taken 11. De Serres LM, Derkay C, Sie K, et al: Impact
e) Animal rights-Not applicable of adenotonsillectomy on quality of life in
HOW TO CITE THIS ARTICLE children with obstructive sleep disorders.
Merin Bobby, G.MPuttamadaiah, B Viswanatha.-Sleep disordered Arch Otolaryngol Head Neck Surg 2002;
breathing due to adeno-tonsillar hypertrophy in children. Orissa J 128(5):489-496.
Otolaryngology & Head & Neck Surgery 2016 Dec; 10(2):18-25.
DOI : https://doi.org/10.21176/ojolhns.2016.2.3 12. Brietzke SE, Gallagher D: The effectiveness of
tonsillectomy and adenoidectomy in the treatment
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25

STUDY OF CRUSHING AND WEDGE RESECTION TECHNIQUE
FOR MANAGEMENT OF CONCHABULLOSA
*Shrikrishna B H, **Jyothi A C
Date of receipt of article -26.07.2016

Date of acceptance - 22-09-2016
ABSTRACT
Background and objective: Concha bullosa is associated with obstruction of the osteomeatal complex which can
manifest in acute or chronic sinusitis. The presently popular techniques of managing the concha bullosa have
their own disadvantages. Hence this study was undertaken to find the usefulness of crushing and wedge resection
technique to manage concha bullosa.
Materials and methods: Thirty cases of concha bullosa in 18 patients were operated using crushing and wedge
resection technique over a period of 1 year. All the cases were followed up for a minimum of 1 year. After 1 year
duration a pre- and post-operative comparison was done using endoscopic imaging and CT scans.
Results: After one year follow up, there has been reduction in the size of the concha bullosa and no evidence of
mucosal edema within the concha bullosa.
Conclusion: Crushing and wedge resection technique is an easy, minimally invasive technique for the management
of concha bullosa.
Keywards: concha bullosa, crushing, endoscopy, computed tomography.
INTRODUCTION have their own advantages and disadvantages. In the

Concha bullosa (CB) is the pneumatisation of the present study we have done a year of follow up of
concha (turbinate) and is most commonly encountered patients who have undergone crushing and wedge
in the middle concha. It is rarely found in the superior resection of the concha bullosa at our centre. An
and inferior conchae[1]. According to Bolger et al., there endoscopic and tomographic comparison was done to
are 3 types of concha bullosa, namely- lamellar type find out any relapse in the pneumatisation of the middle
with pneumatisation of the vertical lamella of the turbinate after 1 year.
concha; bulbous type with pneumatisation of the MATERIALS AND METHODS:
bulbous segment; extensive type with pneumatisation
This prospective study was conducted at the
of both the lamellar and bulbous parts [2] . The
department of oto-rhino-laryngology of Navodaya

osteomeatal unit as defined by Stammberger& Kennedy
Medical College Hospital, Raichur (Karnataka) during
is a functional unit of the anterior ethmoid complex
representing the final common pathway for drainage
Affiliations:
and ventilation of the frontal, maxillary and anterior
*Professor, Department of ENT and Head-Neck Surgery, Navodaya Medical
ethmoid cells[3]. Although the role of the concha bullosa College Hospital and Research Centre, Raichur, Karnataka (India) - 584103
in rhinosinusitis is still debatable, a large concha bullosa **, Professor, Department of ENT and Head-Neck Surgery, Navodaya
may narrow the middle meatus from the medial side Medical College Hospital and Research Centre, Raichur, Karnataka (India)-
584103.
and thus may block the osteomeatal unit[4].
Different surgical techniques have been described
Dr. Shrikrishna B H
for treating CB, including partial or complete resection, Professor, Department of ENT and Head-Neck Surgery, Navodaya Medical
turbinoplasty, and crushing [2, 5-8] . All these techniques College Hospital and Research Centre, Raichur, Karnataka (India)- 584103
26
1st June 2013 to 31st May 2015. Thirty cases of concha operatively nasal pack was kept for 24 hours and
bullosa in 18 patients were operated as part of sinonasal patients were discharged on the second day after
surgery by crushing and wedge resection technique. surgery.
Patients who presented to our outpatient department All the patients were followed up for a minimum
with symptoms of chronic nasal obstruction, sinusitis, duration of 1 year. A comparison data was collected
and headache were evaluated by computed tomography by pooling information in endoscopic and tomographic
(CT) and diagnostic nasal endoscopy (DNE). Patients evaluation pre and post-operatively at the end of one
with concha bullosa were included in the study. The year of their follow-up (Figs 3 & 4). Endoscopic analysis
CB surgery was performed alone or in combination of the concha bullosa was done using the classification
with functional endoscopic sinus surgery (FESS) or method done by Tanyeri et al.[9]. The volume of the
septoplasty. CB was calculated on a Leonardo workstation (Siemens
All the patients were pre-operatively prepared
with nasal packing of 4% lignocaine with 1 in 100,000
adrenaline. Under general anaesthesia, endoscopic sinus
surgery was performed. The concha bullosa area was
packed with gauze dipped in plain adrenaline for 3
minutes. After removing the adrenaline gauze, the CB
was crushed from its superior attachment to the inferior
portion and then posteriorly with Blakesley forceps to
prevent mucosal injury (Fig 1). After adequate crushing
of the concha bullosa, the inferior portion of the CB
was wedge-resected using a tru-cut forceps (Fig 2). Post
Figure 3. Pre-operative ct image showing bilateral

concha bullosa.
Figure 1: Concha bullosa being crushed with straight

blakesley forceps .
Figure 4: CT scan image at the end of 1 year in a patient

who had undergone crushing of concha bullosa on both
sides. Reduction in size is more prominant on left side.
Medical Systems), which generated a volume from a

stack of two-dimensional images of computed
tomography. The data thus collected was statistically
analysed using the paired t test.
Figure 2: Wedge resection of inferior Portion of concha Institutional ethical clearance committee
bullosa being done by tru-cut forceps. permission was taken before the commencement of the
27
study. Also a written informed consent was taken from Some authors have reported that concha bullosa
all the patients who participated in this study. plays a role in recurrent sinusitis by compressing the
RESULTS: uncinate process and obstructing or narrowing the
Thirty cases of concha bullosa in 18 patients (8 infundibulum and the middle meatus [1, 2, 14, and 15]. Lloyd
male and 10 female patients) were included in our study. et al. have stated that when concha bullosa fills the space
The mean age of the patients was 31 years. All the between the septum and the lateral nasal wall, there
patients underwent crushing of the concha bullosa with may be total obstruction of the middle meatus
wedge resection of the inferior portion. This was done orifice [14, 15] . Comparative studies involving
along with septoplasty or functional endoscopic sinus asymptomatic patients and sinusitis patients have
surgery as indicated by the diagnosis. The patients were reported that concha bullosa is more frequently
followed up for a minimum of one year and an encountered in patients with sinusitis[14, 15, and 16]. It is
endoscopic and tomographic evaluation of the concha significant to note that the comparative studies which
bullosa was done at the end of first year of follow-up. failed to show a significant association between the sinus
The tomographic CB volume was also significantly disease and concha bullosa were performed only on
(P<.01) smaller postoperatively (mean, 0.62 cm3; the symptomatic groups[8, 17]. There are studies pointing
SD=0.3) than preoperatively (mean, 1.53 cm3; SD= out that the size of concha bullosa is important for the
0.7). Endoscopically, the middle turbinates were presence of symptoms[18,19]. Yousem et al. have advocated
significantly (P<.01) smaller postoperatively (mean that concha bullosa is not one of the causes of sinusitis
grade, 1.43; SD=0.62) than preoperatively (mean grade, yet the size has implications[17]. In the most extensive
2.56; SD=0.89). study on this topic by nl et al., no significant relation
DISCUSSION was demonstrated between concha bullosa and
Stallman defined concha bullosa as being present osteomeatal unit blockage; however, when the bulbous-
when more than 50% of the vertical height (measured extensive type was compared with the lamellar type, a
from superior to inferior in the coronal plane) of the significant correlation was found regarding osteomeatal
middle turbinate is pneumatised while Smith et al unit blockage. They thus concluded that pneumatisation
defined concha bullosa as the presence of of the inferior portion of the middle concha has a role
pneumatisation of any size within the superior, middle in osteomeatal unit blockage[8].
or inferior conchae[10,11]. However, Hatipolu et al The different surgical modalities used for
classified pneumatisation of the middle concha
management of concha bullosa include partial
depending on the location of the pneumatisation as
turbinectomy (resection of anterior portion of the
lamellar, bulbous and extensive[12].
concha bullosa), lateral turbinectomy (resection of the
Although the exact mechanism of concha bullosa lateral half of the turbinate) and conchoplasty
formation has been unclear, it is considered that the (submucosal resection of the lateral plate of the concha
airflow pattern of the nasal cavity plays an important bullosa)[20]. All these turbinate surgeries carry risks viz.
role. This theory is named as e vacue. As the airflow bleeding, synechia, and olfactory dysfunction[21]. Since
is markedly reduced in the nasal cavity with convexity

the damage to the nasal mucosa is minimal in crushing
of the deviation, pneumatisation of the middle
technique, the incidence of above complications is very
turbinate is augmented in the contralateral site [13]. This
much reduced in our technique. Though there was
theory can explain the association between contralateral
minimal bleeding during crushing of CB, it was very
concha bullosa and nasal septal deviation. However,
much less compared to that during turbinate surgeries.
nasal septum is away from the dominant concha for
Also, none of our patients developed synechia or
preserving adjacent air channels, and therefore nasal
olfactory dysfunction during the follow-up period.
septal deviation can be occurred. Stalman at al. reported
contralateral nasal septal deviation in 69.5% of patients HasanTanyeri et al stated in their study that concha
with unilateral concha bullosa or dominant concha bullosa does not appear to reform after crushing[9].
bullosa[10]. However, their follow-up period was only for 4
28
months. On the other hand, the study by Kieff and REFERENCES:

Busaba states that concha bullosa does recur after the 1. Zinreich S, Albayram S, Benson M, Oliverio P.
crushing technique of surgery[5]. Penttila has stated that The osteomeatal complex and functional
no published study has compared the surgical treatment endoscopic surgery. In: Som P, ed. Head and Neck
of CB using the crushing technique with other surgical Imaging. 4th ed. St Louis: Mosby, 2003; 149-173.
treatments of CB[22]. Thus, the true incidence of CB 2. Bolger WE, Butzin CA, Parsons DS. Paranasal
reformation following the crushing technique remains sinus bony anatomic variations and mucosal
unknown. In our study, the concha bullosa a significant abnormalities: CT analysis for endoscopic sinus
reduction in size after 1 year follow up. However, a surgery. Laryngoscope 1991; 101:56-64.
more long-term study with larger study group and a 3. Stammberger HR, Kennedy DW. Paranasal
longer duration endoscopic and tomographic follow- sinuses: anatomic terminology and nomenclature.
up is required to get more conclusive results. The Anatomic Terminology Group. Ann
OtolRhinolLaryngol Suppl. 1995; 167:716.
Penttila has stated that crushing may damage the
mucosa lining the air cell lumen or air cell ostia, leading 4. Shrikrishna B H et al. Relationship of concha
to mucocele formation in the involved air cell[22]. bullosa with osteomeatal unit blockage-
tomographic study in 200 patients. Journal of
Keeping this in mind, in our study, we have done
Evolution of Medical and Dental Sciences, 2013;
wedging of the inferior portion of the concha bullosa
2(22):3906-3914.
besides crushing. This was done to help drainage of
5. Kieff DA, Busaba NY. Reformation of concha
secretions or mucocele from the concha bullosa if ever
bullosa following treatment by crushing surgical
it happens. However, during our 1 year follow-up,
technique: implication for balloon sinuplasty.
there was no report of mucocele or infection in concha
Laryngoscope 2009; 119:24542456.
bullosa. This suggests that crushing and wedge resection
6. Dogru H, Tuz M, Uygur K, Cetin M. A new
of concha bullosa is an easy and minimally invasive
turbinoplasty technique for the management of
technique for management of concha bullosa.
concha bullosa: our short-term outcomes.
CONCLUSION: Laryngoscope 2001; 111:172174.
Crushing and wedge resection of concha bullosa 7. Pochon N, Lacroix JS. Incidence and surgery of
is an easy and minimally invasive technique for concha bullosa in chronic rhinosinusitis.
management of concha bullosa. Our study shows that Rhinology 1994; 32:1114.
there is a significant reduction of size of concha bullosa 8. Unlu HH, Akyar S, Caylan R, et al. Concha
even after one year after surgery. However, a long- bullosa. J Otolaryngol 1994; 23:2327.
term follow-up is required to get more conclusive 9. HasanTanyeri et al. Will a Crushed Concha
results. Bullosa Form Again? Laryngoscope, 2012;
DISCLOSURES: 122:956960.
a) Competing interests/Interests of Conflict- None 10. J. S. Stallman, J. N. Lobo, and P. M. Som, The
incidence of concha bullosa and its relationship to
nasal septal deviation and paranasal sinus disease,
c) Funding - None American Journal of Neuroradiology 2004;
d) Written consent of patient- taken 25(9):16131618.
e) Animal rights-Not applicable. 11 Smith KD, Edwards PC, Saini TS, et al. The
HOW TO CITE THIS ARTICLE Prevalence of Concha Bullosa and Nasal Septal
Shrikrishna B H, Jyothi A C .- Study of crushing and wedge resection Deviation and Their Relationship to Maxillary
technique for management of conchabullosa. Orissa J Otolaryngology & Sinusitis by Volumetric Tomography. Int J Dent
Head & Neck Surgery 2016 Dec; 10(2): 26-30.
DOI : https://doi.org/10.21176/ojolhns.2016.2.4 2010; 2010: 404982.
29
12. Hatipolu HG, Cetin MA, Yksel E. Concha 17. Yousem DM. Imaging of the sinonasal
Bullosa Types: Their Relationship with Sinusitis, inflammatory disease. Radiology 1993; 188: 303-
Osteomeatal and Frontal Recess Disease. 314.
DiagIntervRadiol 2005; 11(3): 145-9. 18. Uygur K, Tz M, Doru H. The correlation
13. Aktas D, Kalcioglu MT, Kutlu R, et al. The between septal deviation and concha bullosa.
relationship between the concha bullosa, nasal Otolaryngol Head Neck Surg 2003; 129:33-36.
septal deviation and sinusitis. Rhinology 2003; 19. Zinreich JS, Mattox DE, Kennedy DW, Chisholm
41:103-6. HL, Diffley DM, Rosenbaum AE. Concha
14. Lloyd GAS. CT of the paranasal sinuses: study of bullosa: CT evaluation. J Comput Assist Tomogr
a control series in relation to endoscopic sinus 1988; 12:778-784.
surgery. J LaryngolOtol 1990; 104:477-481. 20. AyalWillner et al. Endoscopic treatment of concha
15. Lloyd GAS, Lund VJ, Scadding GK. CT of the bullosa in children. Operative Techniques in
paranasal sinuses and functional endoscopic Otolaryngology. 1996; 7(3): 289292.
surgery: a critical analysis of 100 symptomatic 21. HasanTanyeri et al. Will a Crushed Concha
patients. J LaryngolOtol 1991; 105:181-185. Bullosa Form Again? The Laryngoscope. 2012;
16. Calhoun KH, Waggenspack GA, Simpson CB, 122:956960.
Hokanson JA, Bailey BJ. CT evaluation of the 22. Penttila M. In reference to reformation of concha
paranasal sinuses in symptomatic and bullosa following treatment by crushing surgical
asymptomatic populations. Otolaryngol Head technique: implication for balloon sinuplasty.
Neck Surg 1991; 104:480-483. Laryngoscope 2010; 120:1491.
30

EFFECTS OF GLOSSOPHARYNGEAL NERVE BLOCK AND
PERITONSILLAR INFILTRATION ON POST-TONSILLECTOMY
PAIN: A RANDOMISED CONTROLLED STUDY.
*Uma Srivastava, **Dharmendra Kumar, ***Chakresh Jain, ****NidhiChauhan, *****Tapas Kumar

Date of acceptance - 22-09.2016
ABSTRACT
Peritonsillar infiltration and glossopharyngeal nerve block, both methods have been used to treat immediate
pain after tonsillectomy. However, two techniques have not been compared.
Method: 50 patients aged between 10-20 years were randomized to receive glossopharyngeal nerve block (Group
GN) or Peritonsillar infiltration (Group PT) at completion of tonsillectomy to compare the efficacy of two
techniques. Postoperative pain at rest and swallowing was assessed using Verbal Analog Score at 30 minutes and
1, 4, 8 and 12 hours after surgery. In addition, the success of glossopharyngeal nerve block was evaluated by
observing obtundation of gag reflex and correlated with pain relief.
Results: Pain scores at rest and on swallowing were significantly lower in group GN than in group PT up to 8
hours after surgery (p< 0.001). Gag reflex was absent or only mild in majority of the patients receiving GNB.
More patients in group PT needed rescue analgesia within one hour of surgery (12% v/s 44% in groups GN and
PT respectively). Upper airway obstruction was observed in one patient in GN group.
Conclusion:Glossopharyngeal nerve block seems to be better than Peritonsillar infiltration for relieving pain
immediately after surgery. Obtunded gag reflex is a clinical indicator of successful blockade of glossopharyngeal
nerve and post-tonsillectomy analgesia.
INTRODUCTION reflex. Obtunded gag reflex is a good clinical indicator

Pain and discomfort after tonsillectomy is often of successful block.
stated to be of significant degree [1,2]. Inadequate Present study was done to determine the efficacy
treatment of pain may delay oral intake as well as of two techniques (Peritonsillar infiltration of tonsillar
return to regular activity and may also reduce overall Affiliations:
satisfaction with surgery. Difficulty in swallowing may *Professor , Department of Anesthesia, S.N. Medical College
lead to increased risk of bleeding and secondary Agra,(282002) Mobile-+91-9837246746,
Email: drumasrivastava@rediffmail.com
infection[3]. Several studies have shown that preincisional ** Professor and HOD, Department of ENT, S.N. Medical College
peritonsillar infiltration[4,5] and glossopharyngeal nerve Agra,(282002) Mobile-+91-9412157647,
Email : dharmendra_snmc@yahoo.co.in
block (GNB)[6] when combined with general anesthesia ***Resident , Department of Anesthesia, S.N. Medical College
improve operative condition and also provide Agra,(282002) Email : drumasrivastava2@rediffmail.com
postoperative analgesia. But these results were not **** Resident, Department of Anesthesia, S.N. Medical College
Agra,(282002) Email : drumasrivastava1@rediffmail.com
confirmed by other studies[7,8,9]. The reason for the *****Resident , Department of Anesthesia, S.N. Medical College Agra,
controversial results after GNB could be unsuccessful (282002) Email : singh.tapas1@gmail.com
block of the nerve as none of the studies provided a Address of Correspondence:
method to assess successful performance of GNB. *Professor, Department of Anesthesia, S.N. Medical College
Agra,(282002) Mobile-+91-9837246746,
Success of block can be evaluated by observing gag Email: drumasrivastava@rediffmail.com
31
bed and GNB) in relieving early postoperative pain after directed behind the posterior tonsillar pillar as laterally
tonsillectomy. In addition we also aimed to evaluate as possible and inserted through pharyngeal wall about
the success of GNB by examining gag reflex and find 0.5 1 cm in depth. After careful aspiration 1.5 ml of
correlation between obtunded gag reflex and post- bupivacaine solution was injected slowly. The technique
operative pain relief. was repeated on other side. The patients of group PT
METHOD received 3 ml of bupivacaine solution injected
The study was conducted after approval by the submucously into the upper and lateral parts of
institutional review board and informed written peritonsillar space bilaterally using a straight 23 G
consent from patients or parents. Fifty patients of both needle.
sexes aged 10-20 years, of ASA grade I and II requiring Each patient was assessed in PACU by an
tonsillectomy with or without adenoidectomy were investigator who was blind to group allocation. On
recruited for this prospective, randomized trial. The arrival in PACU, pain score and time to awaken (from
indications for surgery were either recurrent tonsillitis the end of anaesthesia until the patient opened the eyes
or hypertrophy with obstructive symptoms. Patients on command) were recorded. One hour after arrival
were excluded if they had any systemic disease, sensitive in PACU, pain at rest and on swallowing was assessed
to local anesthetic or had signs of acute pharyngeal using verbal analogue scale (VAS) of 0 10 (0 = no
infection. All patients had six hours of fasting and pain and 10 = unbearable pain). If pain score was more
received standard pre-medication and general than 5 at rest, diclofenac 1mg/kg was given IV/ IM, to
anaesthesia. Anaesthesia was induced by Pentothal reduce pain score to d3. Gag reflex was assessed by
sodium and fentanyl, intubated under atracurium and lightly touching posterior oropharynx with a tongue
maintained on O2, N2O and isoflurane. Fentanyl and depressor and the response was noted objectively on
atracurium were repeated when required. Tonsils were an arbitrary scale (None no response, Mild grimace
removed via monopolar electro-cautery by an but tolerable, Moderate facial flushing and Severe
experienced otolaryngologist (standard dissection facial flushing with cough, restlessness).
method). Adenoids were removed using a curette.
On transfer to ward, all patients were offered fluid
Hemostasis was done with suction, suturing and packs
two hours after surgery and VAS at drinking fluid was
as needed.
noted. Pain score at rest and swallowing were also
The patients were randomly divided into two recorded 1, 4, 8 and 12 hours after surgery. Oral
equal groups using random number table. At the
analgesic (paracetamol) was started 8 hours after surgery.
conclusion of surgery but before extubation, group GN
Time of 1st analgesic after surgery and adverse effects
patients (n=25) received bilateral glossopharyngeal
like nausea, vomiting, foreign body sensation and upper
nerve block (GNB) under direct vision using Mclvor
airway obstruction were noted and managed
gag by 1.5 ml of 0.5% bupivacaine with 1:200,000
accordingly.
adrenaline on each side. Group PT patients (n=25)
received bilateral peritosillar infiltration with 3 ml of The sample size of minimum 50 patients (25 per
0.5% bupivacaine with 1: 200,000 adrenaline each side. group) was calculated on the basis of VAS during
After giving the block, the patients were extubated after swallowing. A difference of two between the groups
checking bleeders and were shifted to post anaesthesia were considered significant to have a power of 80% at
care unit (PACU) in left lateral position after observing = 0.05 (two tailed). Pain scores were compared by
for 10 minutes in the operation room. repeated measures analysis of variable ANOVA. Other
Glossopharyngeal nerve was blocked intraorally data were analyzed using X2 test when appropriate.
using the technique as described by Park et al (2007)[10]. Fisher exact test was used to analyze gas reflex test,
A 25 gauge spinal needle was angled to 450 at 1 cm from values were considered significant if p< 0.05. Patient
the tip. The needle was inserted at the middle point of characteristic, operative time and time delay between
posterior tonsillar pillar (Palato-pharyngeal fold), block/infiltration and need of supplementary analgesic
piercing the retropharyngeal mucosa. The needle was was analyzed using two tailed paired t test.
32
Table I :Patient demography and other data. Table III: Analgesia requirement, response to gag
reflex and adverse effects.
Table II: Verbal analogue score (VAS) at rest and on

swallowing after surgery
swallowing are depicted in Table II. The pain scores at

rest were similar in both groups at 30 minutes after
surgery but lower at 1, 4 and 8 hours after surgery in
group GN compared to group PT (p < 0.001). The
scores were comparable among the groups 12 hours
after surgery.
Pain scores on swallowing increased in both groups
at all-time points but increase was significantly more in
group PT than in group GN (p < 0.001). At 12 hrs.
although VAS was higher in group PT than in group
GN, the difference did not attain statistical significance.
Table III shows that 11 out of 25 patients needed
supplementary analgesia within one hour of end of
surgery in PT group compared to 3/25 patients in GN
group. Overall more patients needed analgesia in group
PT. Response to Gag reflex was none or mild in more
number of patients in group GN (18 vs. 6 in groups
GN and PT respectively). Similarly VAS at first liquid
intake was higher in group PT (7.21 3.2 vs. 3.86
2.10 in groups PT and GN respectively, p < 0.001).
Upper airway obstruction after surgery was seen in
one patient in group GN (Table III). Other side effects
were minimal and were similar in both groups.
DISCUSSION
Pain after tonsillectomy is due to multiple reasons.
Fig.1: Verbal Analogue score. It could be due to thermal damage to surrounding tissues
RESULTS leading to acute inflammation and edema or due to
retractor or due to open pharyngeal wound[11]. The
The patients were evenly distributed among two
pain is more severe immediately after surgery and
groups regarding age, weight, gender, duration of
gradually reduces over days. The observations obtained
anaesthesia, intro-operative fentanyl usage and time of
in this study showed that at rest and during swallowing,
awakening after surgery (Table I). VAS at rest and on
33
pain scores were lower in group GN compared to relieving pain on rest, swallowing and on first liquid
group PT between one and eight hours after surgery. ingestion.
The results of this study are consistent with those who Common complications related to GNB are upper
performed GNB for management of post-tonsillectomy airway obstruction (UAO), dyspnoea and foreign body
pain[6,10,12]. Glossopharyngeal nerve supplies most of the sensation in mouth. Peritonsillar infiltration also has
sensations responsible for pain transmission following some risks including bilateral vocal cord paralysis for
tonsillectomy[6]. Therefore glossopharyngeal nerve itself few hours and upper airway obstruction etc8 .We found
should be blocked to have effective pain control. To UAO in one patient who was an eleven years old boy
determine success of GNB, we evaluated response to with history of obstructive symptoms. He became
gag reflex which decreases after successful block[10]. The agitated just after he was extubated, had respiratory
degree of obtunded gag reflex indicates how successfully distress and oxygen saturation started falling. He was
glossopharyngeal nerve is blocked. Our observations managed with jaw thrust, 100% O2, oropharyngeal
demonstrated that the pain relief was better in patients airway and positive pressure ventilation. The patient
where gag reflex was absent or only mild. improved after a few minutes. He was shifted to PACU
In contrast to our results some authors have after keeping under observation for 10 minutes. UAO
reported that GNB was not effective for pain is a serious complication of GNB. It is presumed to be
management often tonsillectomy[9,13,14]. This could due to use of high volume and concentration of local
possibly be due to the fact that local anaesthetics did anaesthetic in the confined space ie lateral pharyngeal
not reach nerve terminals corresponding to the tonsillar space[19]. This may lead to blockade of vagus nerve
area. As none of these reports assessed success of block proximal to origin of recurrent laryngeal nerve or
by observing obtundation of gag reflex[10]. blockade of hypoglossal nerve. Both these nerves lie in
Previous studies regarding analgesic efficacy of peri- close proximity to glossopharyngeal nerve in lateral
tonsillar infiltration of local anaesthetic have reported pharyngeal space[13,19].
conflicting results. A systemic review concluded that In summary this study demonstrated the
there is no evidence that use of peritonsillar infiltration superiority of GNB in relieving post tonsillectomy pain
improves analgesia after tonsillectomy[15]. El -hakim over peritonsillar infiltration. Also, extent of obtunded
etal[14] demonstrated that infiltration of lignocaine along response to gag reflex strongly correlated with post-
with pethidine provided considerable pain relief after operative pain. GNB is easy to perform, but a note of
tonsillectomy. Other studies also reported similar caution is necessary before arguing for recommending
findings with other local anaesthetic bupivacaine[16]. On this block for post-tonsillectomy pain as some
the contrary several workers[7,8,17,18] failed to find any complications like UAO may be life threatening[13].
beneficial effect of peritonsillar infiltration. The results Therefore it necessitates careful selection of patient and
of our study are not very encouraging for patients who volume and dose of local anaesthetic and close
received peritonsillar infiltration for postoperative pain observation in the immediate post anaesthetic period.
relief. We found that 11 /25 patients in infiltration DISCLOSURES:
group needed rescue analgesic within one hour after
a) Competing interests/Interests of Conflict- None

surgery and subsequently also more patients demanded b) Sponsorships None
analgesics. The reasons for the conflicting reports of
c) Funding - None
infiltration could be several including surgical method
used for tonsillectomy, dose and volume of local d) Written consent of patient- taken
anaesthetic, timing (pre or post-incisional) & method e) Animal rights-Not applicable
of injection[8]. HOW TO CITE THIS ARTICLE
To best of our knowledge, no previous study has Uma Srivastava, Dharmendra Kumar, Chakresh Jain, NidhiChauhan,Tapas
compared GNB with peritonsillar infiltration for Kumar Singh. - Effects of glossopharyngeal nerve block and peritonsillar
infiltration on post-tonsillectomy pain: A randomised controlled study.
tonsillectomy pain. In general our results showed Orissa J Otolaryngology & Head & Neck Surgery 2016 Dec; 10(2):31-35
superiority of GNB over peritonsillar infiltration in DOI : https://doi.org/10.21176/ojolhns.2016.2.5
34
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1. Toma AG, Blanshard J, Eynon-Lewis N, Bridge indicator. Anesth Analg.2007;105: 267 71.
MW. Post-Tonsillectomy pain: The first ten days. 11. Sutters KA, Isaacson G. Post tonsillectomy pain
J LaryngolOtol 1995; 109: 963 4. in children. Am J Nursing 2014; 114: 36 42.
2. Kishikova L, Smith MD, Fleming JC, OConnell 12. Jeon YT, Park HP, Kim JH et al. The effect of
M. Analgesic regimen and readmission following glossopharyngeal nerve block with ropivacaine on
tonsillectomy25. Int J Otolaryngol& Head Neck immediate postoperative pain relief after
Surg 2013; 2: 121-. tonsillectomy in adult patients: A-390 Eur
JAnaesth. 2005; 22: 103.
3. Kaygusuz R, Suraman N. The effects of
13. Bean-Lijewski JD. Glossopharyngeal nerve block
dexamethasone, bupivacaine and topical lidocaine
for pain relief after pediatric tonsilectomy:
spray on pain after tonsillectomy Int J
retrospective analysis and two cases of life-
PediatrOtolaryngol 2003; 67: 737 42.
threatening upper airway obstruction from an
4. Jebelis JA, Reilly JS, Gutierrez JF et al. The effect interrupted trial. AnesthAnalg 1997; 84: 1232 6.
of preincisional infiltration of tonsils with
14. El-Hakim H, Nunez DA, Saleh HA. et al. A
bupivacaine on the pain following tonsillectomy randomized controlled trial of the effect of
under general anaesthesia. Pain 1991; 47: 305 8. regional nerve blocks on immediate post-
5. Naja MZ, El-Rajab M, Sidani H et al. Modified tonsillectomy pain in adult patients.
infiltration technique in tonsillectomy: expanded ClinOtolaryngol 2000; 25: 413 17.
case report of 25 children. Int J 15. Hollis LJ, Burton MJ, Millar JM. Perioperative
PediatrOtorhinolaryngol 2005; 69: 35 41. local anaesthesiafor reducing pain following
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tonsillectomy or uvulopalatopharyngoplasty. Can review 2000;2, CD001874
J Anesth 1994; 41: 1236. 16. Sharifian HA, Fathololooms MR, Bafghi AF,
7. Shoem SR, Watkins GL, Kuhn JJ et al. Control Naini SAI. Effect of local bupivacaine infiltration
of early postoperative pain with bupivacaine in on post-tonsilllectomy pain. Tanaffos 2006; 5: 45
pediatric tonsillectomy, Ear Nose and Throat 49.
Journal 1993; 728: 560 3. 17. Park AH, Pappas AL, Fluder E. et al. Effect of
8. Nikandish R. Maghsoodi B, Khademi S. et al. peri-operative administration of ropivacaine with
epinephrine on post operative pediatric adeno
Peritonsillar infiltration with bupivacaine and
tonsillectomy recovery. Arch Otolaryngol Head
pethidine for relief of post- tonsillectomy pain: a
Neck Surg 2004; 130: 459 64.
randomized double-blind study. Anaesthesia 2008;
63: 20 25. 18. Unal Y, Pampal K, Korkmaz S, et al. Comparison
of bupivacaine and ropivacaine on postoperative
9. Bell KR, Cyna AM, Lawler KM et al. The effect
pain after tonsillectomy in pediatric patients. Inter
of glossopharyngeal nerve block on pain after J PediatrOtolaryngol 2007;71;83-7.
elective adult tonsillectomy and uvulopalotoplasty.
19. Sher MH, Laing DI, Brands E. Life threatening
Anaesthesia 1997; 52: 597 602.
upper airway obstruction after glossopharyngeal
10. Park HP, Hwang JW, Park SH et al. The effects nerve block: possibly due to an inappropriately
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pain relief after tonsillectomy: The importance of 1998;86:678.
35

ENDOSCOPIC TRANSNASAL REPAIR OF CEREBROSPINAL FLUID
RHINORRHEA - ANALYSIS OF 400 CASES
*G. Sundhar Krishnan, **V.J.Vikram, ***Shruthi Satish

ABSTRACT
Objective: To describe our experience and outcome of transnasal endoscopic CSF leak repair in 400 patients.
Materials and methods: It was a retrospective study of 400 cases operated over a period of 19 years.
Results: 400 patients were reviewed. Of this, 62 % had spontaneous leaks and the rest of patients were found to
have leak secondary to trauma. 6 cases were congenital. Age of the patients was between 30-50 years except
congenital cases where majority were less than 10 years. CT Cisternography was our choice of radiological
imaging, which had a success rate of 95% in detecting the defect. Most common CSF leak in our study was
cribriform plate and the least was lateral recess or Sternbergs canal (1.5%). Our success rate in defect closure was
98% in the first attempt and 100% during the second attempt. Mean hospital stay was found to be 0.75 days. No
major complications were encountered following the surgery.
Conclusion: Our experience of endoscopic transnasal repair of CSF leaks is very good. Multi-layered closure is
advocated. Hadad Bassagasteguy flap has been observed to be a good graft material. We urge the use of endoscopic
repair due to better outcome and less morbidity.
Keywords: Endoscopic repair. Transnasal. Cerebrospinal fluid rhinorrhoea.
INTRODUCTION craniotomy for placement of a fascia lata graft.

Cerebrospinal fluid rhinorrhoea is the leakage of Endoscopic approaches were introduced in the 1980s
CSF from the subarachnoid space into the nasal cavity and early 1990s. Both Wigand[6] and Stankiewicz[7]
due to a defect in the dura, bone and mucosa[1]. Nearly described closure of incidental CSF leaks during
80% of CSF leaks occur as a result of accidental trauma, endoscopic sinus surgery. In 1989, Papay and
16% are iatrogenic and only 4 % due spontaneous leaks. colleagues[8] introduced rigid transnasal endoscopy for
The defects may be located in cribriform plate fovea the endonasal repair of CSF rhinorrhoea. Since then,
ethmoidalis, sphenoid bone or posterior table of frontal numerous series have been published, and endoscopic
sinus[2]. repair has emerged as a mainstay of surgical
management.
The majority of patients will present with
intermittent or continuous rhinorrhoea. This is usually The diagnosis of CSF rhinorrhoea is typically a
unilateral, but may be bilateral with change in head two-step process: First, the presence of a CSF leak must
position. There is often a history of previous surgery
or a head injury. Rarely, recurrent meningitis may be Affiliations:
*,**,*** Krishna Eye & ENT Hospitals, 39, Burkit Road,
the only indication.Up to 40 per cent of patients Chennai-600 017, Tamil Nadu, India
complain of headache[3]. Address of correspondence:
Dr G. Sundhar Krishnan, MS., DLO, Ph.D.
CSF rhinorrhoea was first reported in the 17th Krishna Eye & ENT Hospitals, 39, Burkit Road, Chennai-600 017
century[4]. In the early 20th century, Dandy[5] reported Tamil Nadu, India, Fax: 91-44-2435 5242
Email: dr.vjvikram@gmail.com
the first successful repair, which used a bifrontal
36
be confirmed through the documentation of objective

evidence of extra cranial CSF. Second, the position of
the skull base defect or defects through which the CSF
is draining must be determined. Nasoendoscopic
examination should be performed in the outpatient
clinic. This alone may identify the site of the leak in 36
per cent [9] or may identify the cause, such as an
encephalocele. The only test used to determine if a
sample is CSF or not is immunofixation of beta-2
transferrin. The sensitivity of this test is 100 per cent
with a specificity of 95 per cent[10]. Some authors favour
computerized tomography (CT) Cisternography. High
resolution coronal CT scans (l-2-mm slices) can offer
detection in up to 84 per cent of cases in a large series[11]. Fig.-1 Cribriform Plate Defect
A T 2-weighted MRI is the preferred imaging modality
of some authors and rates of detection of 100 per cent
are claimed[12].
Over the past two decades, the optimal treatment
strategy has undergone significant evolution as
minimally invasive, endoscopic techniques have gained
acceptance and supplanted more traditional techniques
requiring external incisions or craniotomy. There were
studies of large series of endoscopically treated patients
where high success rates were reported, approaching
95% at the first closure attempt[13].
The aim of our study is to share our experiences
Fig.-2 Fovea Ethmoidalis Defect
and outcome of Endoscopic transnasal CSF leak repair
in 400 patients over a period of 19 years.
PATIENTS AND METHODS
The study consists of 400 patients who were
operated from 1997 till March 2016. The case files
were reviewed and the investigations, procedure,
outcome and postoperative period noted.
PREOPERATIVE WORK-UP
The patients were first clinically assessed and Fig.-3 Sternbergs Canal Defect
checked for a positive reservoir sign. The collected fluid
was sent for CSF analysis mainly glucose.
Endoscopic examination was done to identify the
site of the leak. CT/ Cisternography was done as
radiological investigation (Pictures 1-5). Intrathecal
fluorescein dye was never used in our case series due to
risk of complications.
Traumatic cases which did not respond to the
initial conservative management of bed rest, head end
elevation, avoidance of strenuous activities are taken
Fig.-4 Posterior Table Frontal Sinus Defect
for surgery after a waiting period of 15 days.
37
Fig.-5 Iatrogenic Trauma Defect

Fig.-7: Closure with Septal Cartilage Middle
SURGICAL TECHNIQUE
All cases were operated under general anaesthesia
with 0 and 30 degree rigid endoscope. The nasal cavity
infiltrated with lidocaine and 1:1,00,000 adrenaline.
Septoplasty is done if the visualisation is hampered,
maxillary antrostomy; adequate exposure of the defect
is done by ethmoidectomy, sphenoidotomy or middle/
superior turbinectomy.
For defect in the posterior table of frontal sinus,
a modified Lothrop approach is taken and leak from
the lateral recess/ Sternbergs canal is reached through
transpterygoid route. If the leak is not well visualised Fig.-8 Turbinate Flap
during intra operative period, valsalva manoeuvre is
performed. After identifying the defect, about 5mm
of mucosa is removed surrounding the defect to make
expose the bone and dural defect. Associated
encephalocele is reduced by bipolar cauterisation. Rest
of the brain tissue is mobilised from the dural edges.
Graft is then placed covering the defect. Finally, surgicel
and tissue glue are applied to keep the graft in position
(Pictures 6-10).
Fig.-9: Hadad Flap

Fig.-6: Meningoencephalocoele Fig.-10: Operative Picture
38
Table-1: Showing sites of CSF leak. radiological investigation was around 95% in our study.
Most common site of leak was found to be from
area of cribriform plate. The least common site was
the lateral recess/ Sternbergs canal. For congenital
Meningoencephalocoele, the defect was found anterior
to middle turbinate in all the cases. Defect in the
posterior table of frontal sinus were seen in cases of
RTA. During surgery the defect was detected in 99%of
the cases. For those who had a positive reservoir sign
but no active leak intraoperatively, graft was placed
over the whole of skull base.
The success rate for us in the repair of CSF
rhinorrhoea was 98% in the first attempt. The rest 2%
The choice of grafts has evolved over time. Initially
of failure cases were corrected successfully in the second
free septal flap, fat and fascia lata were used for defect
attempt. None of the patients required more than 2
closure. Now that has been changed to pedicled naso
attempts for defect closure
septal Hadad Bassagasteguy flap, the results of which
are found to be very promising. If defect requires more Mean hospital stay was around 0.75 days.
tensile strength, fascia lata is used. Large defects more Maximum period of hospital stay was 2 days. Nasal
than 5-6 mm are given additional support with either pack was removed from 4th to the 7th day. The thigh
middle turbinate flap or septal cartilage. sutures for harvesting fascia lata were removed on 7th
POSTOPERATIVE MANAGEMENT day. No major complications were encountered in the
group except for transient headache which resolved
The patients are discharged the next postoperative
spontaneously.
day. Postoperative antibiotics, stool softeners are given
DISCUSSION
for a week. Patients are asked to avoid blowing the
nose, sneezing or do strenuous activities which are likely This study reviews 400 cases which were operated
to increase intracranial tension. Lumbar drains are over a period of 19 years. All the surgeries were
placed for patients who have high pressure leaks or large performed by the main author. Due to panoramic
defects more than 5-6mm for a day or two. Nasal pack visualisation and also lesser morbidity and mortality,
is removed in 4- 7 days. Patients are followed up weekly endoscopes were used by the author since 1997 The
for four weeks. success rates were 98% with the first attempt and 100%
with the second attempt. None of the patients required
RESULTS
a craniotomy approach.
We reviewed 400 cases which were operated
Craniotomy and subsequent brain retraction is
during the time period of 1997 to March 2016. Of the
associated with significant morbidity including
400 cases, 248 cases were spontaneous leak, 146 were
anosmia, intracranial haemorrhage, postoperative brain
traumatic including iatrogenic trauma and 6 congenital
oedema etc. Moreover the accessibility is poor due to
cases.
adjacent neurovascular structures. The failure rate of
Majority of the patients were between the group craniotomy is as high as 20-40%[14].
of 30-50. The only exceptions were congenital In our study, spontaneous leaks were found to be
Meningoencephalocoele which accounted for 6 of our more (86%) which were supported by few studies[15, 16,
cases with 5 of them less than 10years of age. 17]
. The traumatic cases including the iatrogenic leaks
The investigations which we do are CSF analysis accounted for the remaining.
and CT Cisternography. Only glucose is tested to A patient presenting with unilateral nasal discharge
confirm CSF. CT Cisternography was used to identify was sent through a diagnostic algorithm. A positive
the site of the defect. The success rate with this reservoir sign/ drip test, corroborated with an
39
endoscopic examination to visualise the leak, CSF cerebrospinal fluid leak. It gives excellent visualisation
analysis for glucose of the collected specimen and CT with precise graft placement. Our study of 400 cases is
Cisternography[18] were done. Intraoperatively the leak one of the largest studies regarding the subject. All the
was visualised with endoscope. Inactive leak were defects including those in the lateral recess as well as
demonstrated with Valsalva manoeuvre. Intrathecal posterior table of frontal sinus can be operated on using
fluorescein was never administered due to associated endoscope. In our experience, Hadad flap gives very
neurological risks[19]. good results in defect closure. Multi-layered closure is
Cribriform plate was the most common site of advocated. Lumbar drain is required only for patients
leak which accounted for about 86 % similar to many with high pressure leak. Our success rate of 98% in the
other articles[16,19,20, 21, 22]. The least common site of defect first attempt and 100% in second attempt emphasises
was lateral recess/ Sternbergs canal which amounted the effectiveness of this approach. Postoperative care is
to 1.5% of all the cases. 6 cases of congenital a very important factor in determining the outcome.
Meningoencephalocoele treated during this time period DISCLOSURES:
had the defect anterior to the middle turbinate. a) Competing interests/Interests of Conflict- None
Many graft materials have been proposed for CSF b) Sponsorships None
leak repair in the literature. Fascia lata is the flap of
c) Funding - None
choice in many[3,16]. We usually perform a 2-3 layer
repair and our first choice of preference is Hadad flap. d) Written consent of patient- taken
Additional Septal cartilage/ Middle turbinate flap[22] are e) Animal rights-Not applicable.
applied. Long standing and large defects are closed with G. Sundhar Krishnan, V. J. Vikram, ShruthiSatish.- Endoscopic transnasal
fascia lata. Recently, for a defect of 1.5cm, a 5 layer repair of cerebrospinal fluidrhinorrhea - analysis of 400 cases. Orissa J
closure was done using two layers of fascia lata, septal Otolaryngology & Head & Neck Surgery 2016 Dec; 10(2): 36-41.
DOI : https://doi.org/10.21176/ojolhns.2016.2.6
cartilage, Hadad flap and middle turbinate flap. Tissue
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Many authors advocate continuous lumbar
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drainage after defect closure[14]. But we have observed
Browning, Martin J Burton, Ray W Clarke, John
that lumbar drain is required only for a high pressure
Hibbert, Nicholas S Jones, Valerie J Lund, Linda
leaks. This observation is supported by[18].
Luxon, John C Watkinson. Scott-Browns
We achieved a 98% success rate in the first attempt Otorhinolaryngology, Head and Neck Surgery.
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2. Ibrahim AA, Okasha M, Elwany S (2015)
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Endoscopic endonasal multilayer repair of
The duration of hospital stay has reduced with traumatic CSF rhinorrhea. Eur Arch
the endoscopic management. The mean hospital stay Otorhinolaryngology. Doi:10.1007/s00405-015-
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3. Persky MS, Rothstein SG, Breda SO, Cohen IlL,
after 4-7 days.
Cooper P, Ransohoff J. Extracranial repair of
The use of prophylactic antibiotic is always a cerebrospinal fluid rhinorrhoea. Laryngoscope.
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and few against it. We advocate prophylactic antibiotic
4. Martin J. Citardi, SamerFakhri. Cerebrospinal
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CONCLUSION Cummings Otolaryngology,Head and neck
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success rate with minimal morbidity for a patient with 2007. p. 785-95.
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7. Lanza DC, OBrien DA, Kennedy DW. Research (IJSR). 2014 Jan; 3(1): 20-24.
Endoscopic repair of cerebrospinal fluid fistulae 17. Avani Jain, PawanSinghal, Man Prakash
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8. Lorenz RR, Dean RL, Hurley DB, et al. Fluid Rhinorrhea Repair: Our experience of 35
Endoscopic reconstruction of anterior and middle cases. Clinical rhinology. 2014 May- August;
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29(4): 191196.
Husain, M.D., and Rakesh K. Gupta,
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Bhupender Singh Rathod, B. Vyshnavi, K. Sushma
Reddy, P. AmreethaKaurDiagnosis and
41

INTERLAY MYRINGOPLASTY: HEARING GAIN AND OUTCOME
IN LARGE CENTRAL TYMPANIC MEMBRANE PERFORATION
*Gaurav Kumar, **Ritu Sharma, ***Mohammad Shakeel, ****Satveer Singh Jassal

ABSTRACT
Background: Chronic otitis media is an inflammatory process of the mucoperiosteal lining of the middle ear
space and mastoid. The main aim of surgery of chronic ear disease is to eliminate disease process and to give the
patient a dry safe and functioning ear. Interlay myringoplasty a newer technique has shown promising results
with higher success rates than other conventional methods of myringoplasty. We aimed to study the hearing
gain in terms of air bone gap and outcome of graft uptake.
Materials & methods: This is a prospective study of 18 months duration from January 2013 to June 2014 carried
out in ninety (90) patients of chronic suppurative otitis media (CSOM) with large central perforation (more than
50% of tympanic membrane). All patients underwent through interlay myringoplasty after clinical examinations,
audiometric tests & routine investigations. Patients were called for regular follow up for 16 weeks.
Results: Pre operatively mean air bone gap was 27.505.53 dB. Post operatively after 16 weeks mean air bone
gap was 13.675.56. On last follow up at 16 weeks, maximum numbers of graft rejections were observed in 6
patients (6.7%). Success rate was 93.3%.
Conclusion: Myringoplasty is a safe and effective technique to improve the quality of life of patients. The
interlay technique had a better graft take up and hearing improvement and also showed promising results in
terms of limited follow up period and limited number of cases involved.
Keywords: Interlay, Myringoplasty, Air bone gap, CSOM.
INTRODUCTION squamous epithelium around the margins of perforation

Perforation of the tympanic membrane primarily with possible consequent cholesteatoma formation
results from middle ear infections, trauma or iatrogenic (Bluestone et al., 1979)[4].
causes. Up to 80% of these perforations heal Many techniques of myringoplasty are described
spontaneously (Galdstone et al., 1995)[1]. Myringoplasty in the literature. A few of the numerous techniques
is a surgical technique used to restore the integrity of include Underlay (Shea, 1960)[5], Overlay (House,
tympanic membrane and to improve hearing level

Affiliations:
(Aslam and Aslam, 2009)[2]. It was introduced by
*Assistant Professor, Deptt. Of E.N.T. Head and neck Surgery, TSM
Berthold (1878)[3]. HOSPITAL & MEDICAL COLLEGE, Lucknow, India.
**Assistant Professor, Deptt. Of Pathology, TSM HOSPITAL & MEDICAL
Repair of eardrum by doing myringoplasty may COLLEGE, Lucknow, India.
confer considerable benefits to patients with tympanic ***
Associate Professor, Deptt. Of E.N.T. Head and neck Surgery, Eras
membrane perforation. These benefits include Lucknow Medical College & Hospital, Lucknow, India.
****
Junior Resident 3rd Year, Deptt. Of E.N.T. Head and neck Surgery,
prevention from middle ear infections, aural discharge Eras Lucknow Medical College & Hospital, Lucknow, India.
and improvement in hearing along with protect against Address of Correspondence:
long-term middle ear damage by preventing the Dr. Gaurav Kumar
ossicular pathology. It also prevents migration of Deptt. Of E.N.T. Head and neck Surgery, TSM HOSPITAL & MEDICAL
COLLEGE, Lucknow, India.
42
1960)[6], Inlay (Eavey, 1998)[7], Interlay (Komune et al., membrane) (Fig. 2) in the age group of 16 - 49years
1992)[8], Gelfilm Sandwich (Karlan, 1979)[9], Swinging conducted in
Door (Schwaber, 1986)[10], Triple C (Fernandes, 2003)11, Eras Lucknow Medical College & Hospital
Double breasting (Juvekar, 1999)[12], Anterosuperior (ELMCH). Ethical committee approval had been taken.
anchoring (Huang et al., 2004)[13] and Laser assisted spot
Relevant information regarding chief complaints,
welding (Eocudero et al., 1979)[14] techniques.
clinical findings, routine blood investigation, Pure tone
Although different types of grafts such as audiometry (PTA) and X-ray mastoid, examination
autogenous, homologous and allografts have been under microscope (EUM) along with diagnostic nasal
attempted for performing Myringoplasty but endoscopy (DNE) were collected from the individual
temporalis fascia graft remains the mainstay of almost patients. Only those patients diagnosed as chronic
all the procedures of Myringoplasty having advantages suppurative otitis media with inactive mucosal disease
of its physiological similarity with tympanic membrane and suitable for myringoplasty on the basis of inclusion
(Sheehy, 1973)[15], It can be easily obtained from the and exclusion criteria were enrolled.
operative field, survives longer and is resistant to
Patient included were cases of safe CSOM with
infections also.
pure conductive hearing loss, age ranging from 16-49
Although each technique is improvised version of years of both male & female, having dry ear (no
the other technique yet the choice of technique is discharge for at least four weeks) and patients with all
mostly dependent on the surgeons familiarity with the follow-up of 4 months.
particular procedure. No doubt, in such a scenario, it
Patient excluded from the study were patients with
is difficult to claim the relative superiority of a single
active foul smelling discharge, vertigo, tinnitus,
technique.
granulation or cholesteatoma, those having
Out of the myriad of various myringoplastic Sensorineural hearing loss or mixed hearing loss, cases
procedures in Interlay technique the graft is placed with tympanosclerosis, revision or combined
between inner endothelial layer and middle fibrous procedures (mastoidectomy and ossiculoplasty), any
layer of tympanic membrane. From the point of view deformity or congenital anomaly of external ear,
of access, Interlay technique is also considered to be unusual infections such as Malignant otitis externa and
better as getting an interlay plane (between the fibrous complication of chronic ear diseases (Meningitis, Brain
layer and mucosa) is easier and faster. Moreover, it has abscess, Lateral sinus thrombosis), active focus found
no fear of residual epithelium. The Interlay in the nose, sinuses or throat. Patients with inadequate
myringoplasty approach has shown promising results follow up were excluded from the study.
with success rates higher than 90% (Komune et al., 1992;
Pre-operatively all patients had a pure tone
Guo et al., 1999; Vishal, 2006; Hay and Blanshard,
audiogram with an average of four frequency (0.5/1/
2014)[8,16,17,18].
2/4 kHz) calculated for both air conduction and bone
AIM & OBJECTIVES: conduction. Post-operatively a pure tone audiogram
To assess Interlay myringoplasty procedure in using (0.5/1/2/4 kHz) was performed at 4 months (last)
cases of chronic suppurative otitis media with inactive follow-up. Tuning fork tests should be done on all
mucosal disease in large central perforation. This aim patients to confirm the audiologic findings.
was fulfilled with the help of following objectives: Interlay myringoplasty in all cases was carried
1. Hearing gain in terms of air bone gap. under general anesthesia (GA) by same surgeon. Post
2. Outcome of graft uptake. auricular approach was used and temporalis fascia used
as a graft material in every case. Karl-Zeiss operating
MATERIALS & METHOD:
microscope was used in all surgeries using proper
This is a prospective study of 18 months duration magnification
from January 2013 to June 2014 on ninety (90) patients
(Fig 1). Postauricular region and four quadrants
of chronic suppurative otitis media (CSOM) with large
of the cartilaginous external auditory canal were injected
Central perforation (more than 50% of tympanic
with 2% lidocaine with 1:100,000 epinephrine solution
43
Figure 3: Showing graft placed by Interlay technique per-

Figure 1: Instruments used in Surgery. operatively.
absorbable suture (Vicryl). The postauricular incision

is approximated with absorbable suture in an
interrupted simple fashion using a subcuticular closure.
A cotton ball is placed in the meatus and a mastoid
dressing is applied. On the day of surgery patient was
kept on IV antibiotics (Ceftriaxone) and analgesics.
Patients were discharged on the next day of surgery
with same mastoid dressing. They were advised oral
antibiotics for 2 weeks (amoxycillin-clavulinic acid)
thrice a day along with oral antihistamine (levocetrizine
Fig. 2: Showing large central perforation preoperatively. 2.5mg) and diclofenec sodium 50 mg given twice a day.
Mastoid dressing stitches were removed on 7 th
for vasoconstriction. The auricle and external auditory postoperative day and endomeatal cotton was also
canal was flushed with povidone-iodine [Betadine] removed. After this Antibiotic ear drop containing
solution and then sterile saline. ofloxacin and dexamethasone were started and
A postauricular Wildes incision was made about continued for next 3 weeks.
3 mm behind the postauricular crease using a 15 No. Follow Up of the patients done weekly in first
scalpel blade. Temporalis fascia graft was harvested. operative month, biweekly for next two month
Periosteal flap was elevated. followed by final visit after four month. At every follow
After meatotomy Mollisons self retaining up patients were examined under ear microscopy
haemostatic mastoid retractor was applied. Margins of (EUM) to assess the graft uptake and complication (if
the remnant tympanic membrane were freshened. any) at every follow up visit. In the last follow up visit
Vascular strip incision given and tympanomeatal flap pure tone audiometery (PTA) was done and compared
was elevated. In Interlay technique fibro-squamous layer with pre operative air bone gap to evaluate the hearing
the remnant tympanic membrane along with the improvement.
annulus was elevated leaving behind the mucosal layer Change in Hearing Status: For the purpose of
and the temporalis fascia graft was placed between evaluating the change in hearing status, the following
fibrous layer and the endothelial (mucosal) layer the criteria were used: AB Gap of:
drum remnant (Fig 3). Very few gelfoam pledgets 1. 0 to 20 dB - Successful
soaked in an antibiotic ear drop solution, placed in 2. >20 dB/Graft rejection Failure
middle ear cavity. The ear canal was packed with
Results were tabulated and statistical analysis was
gelfoam pledgets soaked in an antibiotic eardrop
done using statistical software. Paired t test was applied
solution. The periosteal incision was closed with 3-0
44
for the statistical analysis of pre-operative and post- or more, 26.7% had air bone gap of 25 dB and 23.3%
operative air-bone gap. Comparison in various groups had air bone gap of 20 dB. Mean air bone gap was 27.5
was done by using two sample t test for proportion. dB. (Table 1)
RESULTS: Post operatively on 28th day, fourth follow up
The study was carried out on ninety patients at maximum number of graft rejections were observed in
ELMCH, Lucknow in the period from January 2013 six (6) patients (6.7%) while graft accepted in eighty
to June 2014. The minimum age of a patient in the four (84) patients. (Table 2) Majority of cases had air
study was 16 years and the maximum was 49 years. Pre bone gap within 20 dB (86.7%), 25dB (10%) and 30 dB
operatively air bone gap ranged from 20 to 35 dB. Out (3.3%). Mean air bone gap was 13.675.56. (Table 3)
of total ninety patients 50% had air bone gap of 30dB The significant mean reduction in air bone gap was
observed. Statistically, difference in reduction in air
Table 1: Shows Pre Operatively air bone gap bone gap was significant (p<0.0001). (Table 4) Success
rate was 93.3%. (Table 5)
Table 4: Shows change in air bone gap in last follow up (16

weeks)
Table 5: Shows Outcome of graft uptake at last follow up (16

weeks)
Table 2: Shows Graft rejection at fourth follow up (28 days)
Table 3: Shows Post Operatively air bone gap at last follow

up (16 weeks)
Table 6: Success rate for Interlay Technique (Graft take) as

reported in different case series.
45
DISCUSSION: disease in large central perforation were enrolled in the

Chronic suppurative otitis media (CSOM) is the study. Selection of inactive mucosal disease was done
result of an initial episode of acute otitis media and is because active disease might have active infection which
characterized by a persistent discharge from the middle might confound with the results. Temporalis fascia was
ear through a tympanic perforation. It is an important used as a graft material because it is easy to take; large
cause of preventable hearing loss, particularly in the surface area is available, has a low metabolic rate and
developing world. According to a WHO report, India does not require special preparation[22,23].
is amongst the nations with highest burden of CSOM Pre-operative air bone gap ranged from 15 dB to
(WHO, 2004)[19]. 35 dB with a mean value ranging from 27.505.53. All
Tympanoplasty and/or Mastoidectomy are the patients had unilateral disease and having air bone
frequently necessary to permanently cure CSOM and gap indicating fair to poor hearing status, thus indicating
rehabilitate hearing loss patients. These procedures are the need for surgical intervention for all the patients.
readily available in tertiary centres with an otologic In all the cases, a unilateral procedure was
department, a standard service in all developed countries performed. Total 6 (6.7%) rejections took place and all
and is also recommended in national programme for of them within 14 days. No new rejection took place
deafness in our country. Tympanoplasty involves in subsequent follow up period up to 16 weeks after
closure of the tympanic perforation by a soft tissue surgery. Not any other complication noticed in any of
graft with or without reconstruction of the ossicular the patient during follow up period.
chain. Mastoidectomy involves removing the mastoid On evaluating the air bone gap at final follow up
air cells, granulations, cholesteatoma and debris using interval was observed to be 10 dB in majority of cases
bone drills and microsurgical instruments. Sequential (56.7%). Mean air bone gap 13.675.56 dB (Table 3).
destruction of the malleus, incus and stapes requires Eventually, the success rate was 93.3%.
progressively more medially placed tympanic grafts.
The results of Interlay technique were in close
The extent of damage to the ossicular chain determines
proximity with the results obtained by Komune et al.
the specific types of tympanoplasty; Tympanoplasty is
(1992)[8] who observed a success rate of 94.2% for
classified as type I, II, III, IV and V. Among these, Type-
Interlay technique. Interlay technique reportedly has a
I Tympanoplasty or Myringoplasty is the simplest
high success rate. A comparative account of success rate
operative procedure performed to repair the
for interlay technique as reported in various studies is
perforation in ear drum by repairing the tympanic
shown in Table 6.
membrane only. It is performed when only except for
ear drum, the entire ossicular chain is intact (Wullstein, It could be seen that all the studies, including the
1953)[20]. Myringoplasty is a beneficial procedure to present study the success rates for Interlay technique
protect the middle ear and inner ear from future have been quite promising, generally above 90%. The
deterioration and also gives improvement in hearing better graft take in Interlay method is that it provides
after surgery[21]. support to graft from both the sides.
Although myringoplasty involves simple closure However, given the number of studies and result
of tympanic membrane, however, there are at least a of Interlay myringoplasty, we find that it is not as much
dozen approaches to perform this procedure such as popular. The reason for its lower popularity is that it
Underlay, Overlay, Inlay, requires additional skill and it time consuming.
Preparation of margins for interlaying and tactical
Gelfilm Sandwich, Swinging Door, Triple C,
positioning of the graft needs precise handling and
Double breasting, Anterosuperior anchoring and Laser
manipulation of the graft and hence they are generally
assisted spot welding. Among these for the last few
attempted in a setup with adequate technical and
years, a newer technique Interlay is gaining popularity
physical infrastructure.
and is being successfully used with promising results.
As far as air bone gap resolution is concerned, the
For this purpose, a total of ninety patients of
results shown are variable in different studies for
chronic suppurative otitis media with inactive mucosal
different techniques. However, Patil et al. (2014)[24] in
46
their series of 100 cases who were approached using chronic suppurative otitis media (CSOM) with inactive
Interlay method showed a phenomenal reduction in mucosal disease.
air bone gap from a pre-operative mean value of DISCLOSURES:
36.4212.0 dB to 9.76.71 dB, thus showing a a) Competing interests/Interests of Conflict- None
reduction of almost 26.72 dB.
In accordance with the observations in these
c) Funding - None
studies, we found post-operative air bone gap up to 10
dB in majority (56.7%) of cases. A better air bone gap d) Written consent of patient- taken
reduction in Interlay method is mainly possible owing e) Animal rights-Not applicable.
to its better conductive efficacy. Owing to the flaps Gaurav Kumar, Ritu Sharma, Mohammad Shakeel, Satveer Singh Jassal. -
position between two interlaying layers the frequency Interlay myringoplasty: hearing gain and outcome in large central tympanic
loss is controlled and that is the reason for a better membrane perforation. Orissa J Otolaryngology & Head & Neck Surgery
2016 Dec; 10(2):42-48.
conduction and reduced air bone gap. There is also no DOI : https://doi.org/10.21176/ojolhns.2016.2.7
risk of lateralization or medialisation of the graft due
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to well supported by fibro-squamous layer laterally and
mucosal layer medially. The findings in present study 1. Galdstone HB, Jackler RK, Varav K. Tympanic
showed a better graft take in Interlay method which membrane wound healing. An overview.
coupled with a better post-operative air bone gap Otolaryngol Clin North Am.1995; 28: 913932.
provided a better overall outcome. As compared with 2. Aslam MA, Aslam MJ. Comparison of Over-
other method of myringoplasty Underlay technique Underlay and Underlay Techniques of
shows in previous studies of outcome of 85.7% in Guo Myringoplasty. Pak. Armed Forces Med. J. 2009;
et al (1999)[16], 88.8% in Crovetto et al (2000)[25], 87% in 3:online.
Ullah et al (2008)[26], 81% in Sheikh et al (2009)[27], 88.6% 3. Berthold E. Ueber myringoplastik. Wier Med
in Baloch et al (2012)[28] and 90% in Sharma & Saroch Bull. 1878;1:627627. cited by: Sismanis A.
(2013)[29] respectively. While Overlay technique in Tympanoplasty. In: Glasscock-Shambaugh
previous studies shows outcome of 55% in Ullah et al Surgery of the Ear. Vol. 1, 5th Edn, pp. 463-486.,
(2008)[26] and 74.4% in Rehman et al (2011)[30]. BC Decker Inc., 2003.
CONCLUSION: 4. Bluestone CD, Cantekin EI, Douglas GS.
Myringoplasty is a safe and effective technique to Eustachian tube function related to the results of
improve the quality of life of patients, avoiding tympanoplasty in children. Laryngoscope 1979;
continuous infections and allowing them contact with 89 : 450-8.
water. The present study showed that although Interlay 5. Shea JJ Jr. Vein graft closure of eardrum
technique requires additional expertise in surgery it gives perforation. J Laryngol Otol. 1960; 74: 358-62.
better graft uptake and hearing improvement. Above 6. House WF. Myringoplasty. Arch Otolaryngol.
findings in present study substantiate the results 1960; 71: 399-404.
obtained in some recent studies. However, there is

7. Eavey RD. Inlay tympanoplasty: cartilage
paucity of comparative literature on the issue.
butterfly technique. Laryngoscope. 1998; 108:
The advantage of Interlay myringoplasty is that 657661.
neither lateralization of tympanic membrane nor
8. Komune S, Wakizono S, Hisashi K, Uemura T.
blunting of the anterior tympanomeatal angle was
Interlay method for myringoplasty. Auris Nasus
observed. This means lower complications and thus
Larynx. 1992;19(1):17-22.
Interlay myringoplasty is an effective surgical technique
9. Karlan MS. Gelatin film sandwich in
over conventional methods for closure of perforation
tympanoplasty. Otolaryngol Head Neck Surg.
and hearing gain (audiological improvement) in large
1979; 87: 84-6.
central tympanic membrane perforation in cases of
47
10. Schwaber MK. Postauricular undersurface 20. Wullstein H. Theory and practice of
tympanic membrane grafting: some modifications myringoplasty. Laryngoscope. 1956; 66: 107693.
of the swinging door technique. Otolaryngol 21. Hussain A, Yousaf N, Khan AR. Outcome of
Head Neck Surg. 1986; 95: 182-7. myringoplasty. J Postgrad Med Inst. 2004; 18:
11. Fernandes SV. Composite chondroperichondrial 693-6.
clip tympanoplasty: the triple C technique. 22. Ghanem MA, Monroy A, Alizade FS, Niolau Y,
Otolaryngol Head Neck Surg. 2003; 128: 2: Eavey RD. Butterfly cartilage graft inlay
267-72. tympanoplasty for large perforations. The
12. Juvekar MR, Jurekar RV. The double breasting Laryngoscope 2006; 116: 55-58.
technique of tympanoplasty: a study of 200 cases. 23. She W, Dai Y, Chen F, Qin D, Ding X.
Indian Journal of Otology. 1999; 5: 3: 145-8. Comparative evaluation of over-under
13. Hung T, Knight JR, Sankar V. Anteriosuperior myringoplasty and underlay myringoplasty for
anchoring myringoplasty technique for anterior repairing tympanic membrane perforation. Lin
and subtotal perforations. Clin Otolaryngol. 2004; Chung Er Bi Yan Hou Tou Jing Wai Ke Za Zhi
29; 3: 210-4. 2008; 22(10):433-5.
14. Eocudero LH, Castro AO, Durmond M. Argon 24. Patil BC, Misale PR, Mane RS, Mohite AA.
Laser in human tympanoplasty. Arch Otolaryngol Outcome of Interlay Grafting in Type 1
1979; 105: 252-3. Tympanoplasty for Large Central Perforation.
15. Sheehy JL, Crabtree JA. Tympanoplasty: Staging Indian J. Otolaryngol. Head Neck Surg. 2014;
the operation, Laryngoscope, 1973; 83: 1594-1621. 66(4): 418-424.
16. Guo M, Huang Y, Wang J. Report of 25. Crovetto De La Torre M, Fiz Melsi L, Escobar
myringoplasty with interlay method in 53 ears Martnez A. Myringoplasty in chronic simple otitis
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Hou Ke Za Zhi 1999 Apr; 13(4) :147-9. overlay techniques. Acta Otorrinolaringol Esp.
2000 Mar;51 (2):101-4.
17. Vishal US. A one-year prospective study to
evaluate the results of superiorly based 26. Ullah N, Khan Q, Said M, Wahid FI.
tympanomeatal flap in endoscopic myringoplasty Tympanoplasty in young patients. JPMI 2008;
conducted in District Hospital, Belgaum and 22(4): 292-294.
KLES and MRC, Belgaum during July 2003 to 27. Shaikh AA, Onali MAS, Shaikh SM, Rafi T.
July 2004. Dissertation, MS (ENT), 2006, Outcome of Tympanoplasty Type - I by Underlay
RGUHS, Karnataka. Technique. JLUMHS 2009; 8(1): 80-84.
18. Hay A, Blanshard J. The anterior interlay 28. Baloch MA, Baloch SK, Rasheed S. Myringoplasty
myringoplasty: outcome and hearing results in in simple chronic otitis media. Gomal J Med Sci
anterior and subtotal tympanic membrane 2012; 10: 216-8.
perforations. Otol Neurotol. 2014
29. Sharma RC, Saroch M. Our experience with single

Oct;35(9):1569-76. sitting bilateral myringoplasty. Indian J Otol
19. World Health Organization. Chronic suppurative 2013;19:59-61.
otitis media : burden of illness and management 30. Rehman HU, Wahid FI, Javaid M, Ahmad I,
options. WHO Child and Adolescent Health Khan N. Otitis Media: Comparison of outcome
Department: Prevention of Blindness and of underlay versus overlay myringoplasty. Pak J
Deafness, Geneva, 2004. Med Sci 2011; 27(5): 1076-1078.
48

ROLE OF BILATERAL CORONOIDECTOMY WITH BUCCAL PAD
OF FAT RECONSTRUCTION IN MANAGEMENT OF OSMF
*Loknath Sahoo, **Rajesh Kumar Padhy, M.S, ***Sandeep Kumar Samal, MDS, ****Ritesh Roy, M.D,
*****Kshitish Chandra Mishra,MD
ABSTRACT
Background: Oral submucosal fibrosis (OSMF) is described as a swelling within the oral cavity and throat with
burning, prickling, pain, hemorrhage, putrid and necrosed muscle. Reduced mouth opening can result from
trismus as in case of OSMF. Coronoidectomy holds an importance in management of OSMF by enhancing the
mouth opening.
Aims and Ojectives : To evaluate the effectiveness of coronoidectomy with buccal pad fat in advanced stages of
Oral Submucosal Fibrosis (OSMF).
Material and methods: An observational study comprising of twenty cases of oral submucosal fibrosis (OSMF)
histopathologically proven as well as surgically treated had been carried out from December 2014 to September
2016, in the Otorhinolaryngology department of Hi-tech Medical College & Hospital, Bhubaneswar, Odisha,
India.
Results: As a result of a successful surgical procedure, the size of the intraoperative mouth opening range after
carrying out the coronoidectomy their mouth opening was almost 40 42 mm on the OT table. The patients
were discharged 5-7 days after the operation. The range of the mouth opening measured at that time was 20-30
mm. The pedicled grafts took uneventfully and epithelialized in 3-4 weeks. The remaining patients did cooperate
and exercised daily, and the postoperative mouth-opening range at six months was 26-43 mm (mean: 40. 5 mm).
Conclusion: Coronoidectomy with buccal pad of fat is an effective adjunct in increasing intraoperative and
stabilizing postoperative mouth opening.
Keywords: Oral Submucosal Fibrosis(OSMF), Buccal pad fat, coronoidectomy.
INTRODUCTION fibrous tissue in the juxta epithelial region results in

Oral submucosal fibrosis (OSMF) has been well stiffness of oral mucosa. In addition to this, subsequent
established in Indian medical literature since the time muscle degeneration leads to fibrosis and scarring of
of Sushruta .In Sushruta Samhita, it is described as a temporalis muscle, further enhancing the limitation in
swelling within the throat with burning, prickling pain,

Affiliations:
hemorrhage, putrid, and necrosed muscle and caused *PG student, **Professor, Department of Otorhinolaryngology,
by pitta known as vidari, occurring in mouth, ***Department of Oral and Maxillofacial Surgery,
particularly in the side by which patient lies [1] . It was ****Professor, Department of Anaesthesia,
first described by Schwartz [2] and has been reported *****Associate Professor, Department of Oncology,
Hi-Tech Medical College and Hospital, Bhubaneswar, Odisha, India
almost exclusively across all socioeconomic status in
India as a result of increased popularity of the habit of
chewing pan masala, betel leaves and other similar Dr. Loknath Sahoo
PG student, Department of Otorhinolaryngology,
products. Hi-Tech Medical College and Hospital,
Reduced mouth opening can result from trismus Bhubaneswar, Odisha, India.
as in case of OSMF, where accumulation of inelastic Email id: drloknathsahoo@gmail.com,
Mobile no: 09437507605.
49
mouth opening[3] . Table 2

In the management of OSMF, coronoidectomy
plays an important role in increasing mouth opening.
Canniff et al recommended temporal myotomy or
coronoidectomy to release severe trismus caused by the
atrophic changes in the tendon of temporalis muscle
secondary to the disease[4] .
Thus, coronoidectomy holds an importance in
management of OSMF by enhancing the mouth
opening. Apart from this, if buccal pad of fat/facial
flap are used alone, there is scarring of the muscle,
limiting mouth opening unless an ipsilateral or bilateral
coronoidectomy is performed[5,6] . objective outcome over a follow-up period of 6 months
The present study was therefore undertaken to [Table 2]. Of the twenty patients 3 were females and
assess the benefits of coronoidectomy with buccal fat 17 were males. Non of the patients previously treated
pad reconstructon in mouth opening in twenty patients for OSMF. The mouth opening measured as the inter
by achieving a stable mouth opening with minimum incisal distance was ranging between 4-22mm with a
morbidity in the treatment of OSMF. mean of 15.
MATERIAL AND METHODS: The operations were performed under general
After ethical approval, an observational study anesthesia with nasal intubation. The incisions were
comprising of twenty cases of oral submucosal fibrosis made with an electrosurgical knife along each side of
(OSMF) histopathologically proven as well as surgically the buccal mucosa at the level of the occlusal plane away
treated had been carried out from December 2014 to from the Stensons orifice(Fig-1). They were carried
September 2016 , in the Otorhinolaryngology posteriorly to the pterygomandibular raphe or anterior
department of Hi-tech Medical College & Hospital, pillar of the fauces and anteriorly as far as the corner
Bhubaneswar, Odisha , India. Informed consent was of the mouth, depending upon the location of the
obtained and 20 patients clinically diagnosed as grade fibrotic bands which restricted the mouth opening.
III / IV OSMF scheduled to underwent elective surgery These fibrotic bands were always detectable by
entailing coronoidectomy with buccal pad fat palpation. The wounds created were further freed by
reconstruction. The defects in the buccal area were
grafted with a pedicled BFP under general anesthesia
with nasal intubation followed by vigorous mouth
opening exercises. Patient evaluation included:1)the
preoperative amount of mouth opening[Table 1], 2)the
intraoperative mouth opening; and 3) the postoperative
mouth opening. The results were evaluated using the
interincisal distance at maximum mouth opening as the
Table 1
Fig.1 Showing pre and per operative pictures
manipulation until no restrictions were felt. The mouth

was then forced open with a mouth opener or Heisters
mouth gag to an acceptable range of approximately 35
50
RESULTS AND OBSERVATION:

As a result of a successful surgical procedure, the
size of the intraoperative mouth opening ranged from
40 to 42 mm. However after carrying out the
coronoidectomy their mouth opening was almost 40
42 mm on the OT table. The patients were discharged
5-7 days after the operation. The range of the mouth
opening measured at that time was 20-30 mm. The
pedicled grafts took uneventfully and epithelialized in
3-4 weeks. Two patients (cases 5 and 9) failed to exercise
several times daily, and finally experienced a significant
relapse. The remaining patients did cooperate and
exercised daily, and the results were satisfactory [Table-
Fig.2 showing pre and post operative pictures
2]. The postoperative mouth-opening range at six
months was 26-43 mm (mean: 40. 5 mm). Overall
to 40 mm. The coronoid processes were approached follow-up period was 6months.
from the wounds created and resected if a 35-40mm
mouth opening could not be achieved. Coronoid was DISCUSSION:
held with Kochers forcep and the osteotomy cut was Submucous fibrosis is an insidious, chronic disease
made extending from the depth of sigmoid notch to which may affect any part of the oral cavity and
anterior border of the ramus. After completion of sometimes the pharynx, leading to stiffness of the oral
osteotomy the coronoid was placed on traction with mucosa, and causing trismus [7,8]. This disease is most
Kochers forcep, remaining temporalis muscle and frequently found in India, and is not uncommon in
tendon attachments were cut facilitating removal of Southeast Asia. It has also been reported from other
coronoid. countries, and it is no longer considered to occur
After unilateral coronoidectomy, mouth opening exclusively in Indians and Southeast Asians, as
was recorded followed by bilateral coronoidectomy and immigration has resulted in a worldwide distribution.
recording of maximum mouth opening. Fergussion Betel nut chewing appears to be the main factor
mouth gag was applied to record achieved maximum correlating with this disease. Most patients complain
mouth opening. A mouth opening of 35 mm as of an irritable oral mucosa during the early stage of the
measured from the incisor edges was considered to be disease, especially when spicy foods are eaten. Clinically,
the minimum acceptable opening in an adult. The BFP there are erosions and ulcerations. Subsequently, the
was approached via the posterior- superior margin of oral mucosa becomes blanched and loses its elasticity,
the created buccal defect, and then dissected with an and vertical bands occur in the buccal mucosa, the
index finger. The BFP was teased out gently until a retromolar area, the soft palate, and the
sufficient amount was obtained to cover the defect pterygomandibular raphe. A fibrotic ring forms around
without tension .The Buccal fat pad(BFP)was then the entire rima oris. Some patients have difficulty in
harvested bilaterally and sutured to the mucosal defect whistling and tongue movement.
with 3-0 vicryl suture. The remaining defect was left The literature contains few references to the
for secondary epithelialization. successful treatment of OSF. Various treatments to
Postoperatively patients were put on Ryles tube improve mouth opening have been attempted,
feeding for 1week. All patients received prophylactic including surgical elimination of the fibrotic bands but
antibiotics and a liquid diet for 1 week. Physiotherapy have been reported as generally unsatisfactory or
was started from 3rd postoperative day with the help impossible[9,10]. Yen was the first to succeed in covering
of Heisters jaw exerciser and wooden spatulas to the buccal defect with a split thickness skin graft in
prevent contractures and relapse. Patients were trained treating a case of OSF[11]. Khanna & Andrade recently
and encouraged to continue these exercises at home reported the new surgical technique of covering the
three to four times a day for 15 min each. Every patient buccal defects with a palatal island flap in combination
was followed-up postoperatively at regular intervals till with temporalis myotomy and coronoidectomy[15].
at least 6 months. They had applied it to 35 patients with good results.
51
The main mass of the BFP occupies the buccal DISCLOSURES:

space bound medially by the buccinator muscle and a) Competing interests/Interests of Conflict- None
laterally by the masseter muscle, and rests on the b) Sponsorships None
c) Funding - None
periosteum that covers the posterior buccal aspect of d) Written consent of patient- taken
the maxilla. The BFP has a constant blood supply e) Animal rights-Not applicable.
through the small branches of the facial artery, the HOW TO CITE THIS ARTICLE
internal maxillary artery, and the superficial temporal Loknath Sahoo, Rajesh Kumar Padhy, M.S, Sandeep Kumar Samal, MDS,
artery and vein by an abundant net of vascular Ritesh Roy, M.D, Kshitish Chandra Mishra, MD. - Role of bilateral
coronoidectomy with buccal pad of fat reconstruction in management
anastomoses[12,13,14]. On an average, the volume is 9. 6 cc
of OSMF. Orissa J Otolaryngology & Head & Neck Surgery 2016 Dec;
(range 8. 3-11. 9 cc)[14] . Defects up to 3x5 cm can be 10(2): 49-52.
closed with a BFP alone without compromising the DOI : https://doi.org/10.21176/ojolhns.2016.2.8
blood supply. The buccal extension and the main body REFERENCES:
of the fat pad are in close proximity to the buccal defect, 1. Sushruta Samhita. In Ch. 16. S.L. Bhaduri,B.L. 10. Kaviraj
and may be approached through the same incision. In Kunja Lal Bhishagratna., translator. Calcutta: Kashi
addition, the buccal fat pad pedicled flap can cover the Ghoses Lane; 1907. pp.152- 4.
whole surgical defect. The BFP also improves the 2. Schwartz J. Atrophia idiopathica tropica mucosa oris.
physiologic functions of the cheek after the operation; 11th Int Dent Congress; London. 1952.
e. g., suppleness and elasticity. With this technique, there 3. Shevale VV,Kalra RD,Shevale VV,Shringarpure MD.
is no need for a second operation site. The pedicled Management of oral submucosal fibrosis: A review.
BFP graft is well vascularized and is more resistant to Indian J Dent Sci. 2012;4:107-14.
infection than other kinds of free graft. Therefore, 4. Raveh J, Vuillemin T, Ladrach K, Sutter F.
normal eating can begin after the surgical treatment. Temporomandibular joint ankylosis: Surgical treatment
Patients can be discharged 5-7 days after the operation. and long term results. J Oral Maxillofac Surg.
Early and intensive postoperative mouth opening 1989;47:900-6.[PubMed: 2547919]
exercises are very important to achieve adequate mouth 5. Azaz B,Zeltser R,Nitzan DW.Pathoses of coronoid
opening afterward. These exercises should be started as process as a cause of mouth opening restrictions.Oral
early as possible. The mouth opening showed Surg Oral Med Oral Pathol.1994;77:579-
progressive improvement and became maximum within 84.[PubMed:8065719]
6. Omura S, Fujita K.Modification of the temporalis muscle
six months with a mean of 40. 5mm [Table-3]. And
and fascia flap for the management of ankylosis of the
throughout this period it was ensured that the patients
temporomandibular joint.J Oral Maxillofac Surg.1999;
had continued with active aggressive mouth opening 57: 1058-65. [PubMed: 8648490]
Table-3 7. Pindborg Jj, Sirsat Sm. Oral submucous fibrosis. Oral
Surg 1966; 22:764-779.
8. Pindborg Jj, Bhonsle Rb, Murti Pr, Gupta Pc, Dafrary
Dk, Mehta Fs. Incidence and early forms of oral
submucous fibrosis. Oral Surg 1980; 50: 40-44.
9. Simpson W. Submucous fibrosis. Br Dent J 1969; 6: 196- 200.
10. Paissat DK. Oral submucous fibrosis. Int. J Oral Surg
1981; 10: 307-312.
11. Yen Djc. Surgical treatment of submucous fibrosis. Oral
excersises. The grafted BFP became rigid from fibrotic Surg 1982;54 :269-271.
change. Routine temporalis myotomy, and 12. Tideman H, Bosanquet A, Scott J. Use of the buccal fat
coronoidectomy [15]. Clinically the Buccal mucosa pad as pedicled graft. J Oral Maxillofac Surg 1986;44:
appeared normal, retaining its texture without any signs 435-440.
of fibrosis. The softness and elasticity of the buccal 13. Dubin B, Jackson It, Halim A, Triplett Ww, Ferreira M.
tissue had improved. Symptoms such as painful Anatomy of the buccal fat pad and its clinical
significance. Hast Reconstr Surg 1989;83: 257-262.
ulceration, burning sensation, and intolerance to spices
14. Stuzln Jm, Wagstrom L, Kawamotohk, Baker Tj, Wolfe
had been eliminated in most patients. Sa. The anatomy and clinical applications of the buccal
CONCLUSION: fat pad. Plast Reconstr Surg 1990; 85: 29-37.
Coronoidectomy with buccal fat pad(BFP) is an 15. Khanna Jn, Andrade Nn. Oral submucous fibrosis: a
effective adjunct in increasing intraoperative and new concept in surgical management. Report of 100
stabilizing postoperative mouth opening. cases. Int J Oral Maxillofac Surg 1995; 24:433-439.
52

PHONOMICROSURGERY FOR BENIGN VOCAL FOLD LESIONS
USING MEDIAL-MICROFLAP TECHNIQUE WITH COLD
INSTRUMENTS IN A TEACHING HOSPITAL OF INDIA
*Dipak Ranjan Nayak,**N Apoorva Reddy,***Shilpa Rudraraju,****Gopi Krishnan, ****Balakrishnan R, ****Ajay Bhandarkar
Date of acceptance -1.12.2016
ABSTRACT
Background: Phonomicrosurgery is a challenging and evolving field. One of the key techniques used for this is
micro-flap technique used along with cold micro instruments.
Objective: To convey the role of Microflap technique in phonosurgery and the role of basic microlaryngeal
instrumnets in such surgery when sophisticated phonomicrosurgical instruments are not available.
Methods: This is a retrospective study of 33 patients of benign vocal fold lesions who have undergone
phonomicrosurgery using microflap technique from the year January 2011 to January 2016. Majority of these
cases were vocal nodules (16cases) followed by Cyst in the vocal cord (10 cases) and 5 cases of polyps.
Results: Cases were analyzed using GRBAS scoring and stroboscopic findings. A significant improvement was
noted in the voice outcome of these patients except two cases where endoscopic paraglottic fat injection was done
along with hyaluronic acid with steroid infiltration into the Reinkes space, after which there was improvement
in voice.
Conclusion: Microflap technique for vocal fold lesion is a unique surgical procedure that allows preservation of
vocal cord morphology and at the same time prevents post surgical scarring with excellent voice outcome.
ThisThis surgery can be performed with good quality regular microsurgical instruments.
INTRODUCTION revolutionized the principle of microlaryngeal surgery

Phonomicrosurgery is a challenging and evolving including phonomicrosurgery. [5] Use of general
anesthesia through endotracheal tube during
field. The term phonosurgery was first described by G
microlaryngoscopy was introduced by Priest (1960)[6].
E Arnold & V H Leden with an intent to improve
Since then various laryngoscopic developments have
and/or restoration of voice.[1] The credit of injection
laryngoplasty goes to Bruenning (1911) for treating a Affiliations:
Professor, Associate Professor, Resident,**Department of ENT-Head
paralyzed vocal cord.[2] The phonomicrosurgery was
& Neck Surgery, Kasturba Medical College, Manipal University, Manipal.
developed as a model of consistent vocal cord vibration ***Deapartment of Speech and Hearing, College of Allied Health
Science,Manipal University, Manipal.
based on Body (Deep lamina propria & Muscle) and
Presented at the 2nd SARC International Conference and 5th Annual
Cover (Epithelium & superficial lamina propria) conference of Laryngology and Voice Association, from30th Sep.- 2nd
Oct, 2016 at Ahemedabad in How I Do It Video session by Prof.
concept (Fig.1) that can vary to different circumstances
Dipak Ranjan Nayak as a faculty.
of laryngeal adjustment (Hirano 1974). [3] Kirstein Address of Correspondence:
introduced the concept of direct laryngoscope in the Prof. Dipak Ranjan Nayak,
Deparment of ENT-Head & Neck Surgery,
form of autoscope in 1895 [4] and Kleinsaussers
Kasturba Medical College, Manipal University,
development of suspension micro-laryngoscope used Manipal-576104, Karnataka, India
Email: drnent@gmail.com
in conjunction with microscope in 1960 that has
53
remains the foundation for phonomicrosurgery.

Benign lesions are best dealt with cold instruments
especially when micro-flap technique is used. The
authors would like to convey the readers that one
should never resort to plucking of vocal cord lesions
or excise them at the cost of normal mucosa and
underlying lamina propria of vocal cord with scissors.
A phonomicrosurgery with microflap technique can
well be done with basic good quality microlaryngeal
instruments as the author has adopted in this series.
MATERIALS AND METHODS:
A total of 33 patients having benign vocal fold
lesions, who have undergone phonomicrosurgery with
microflap technique in the Unit-1 of the department
Fig.1: Showing body cover concept of vocal cord histology of ENT-HNS from January 2011 to January 2016 were
described by Hirano taken for the study retrospectively. All the patients were
operated by the 1st author. Amongst the 33 patients, 8
taken place for better and comfortable visualization[7]. were females and 25 were males. Informed consent was
Bouchayer M & Cornut G (1992) introduced the taken from the entire patients regarding surgery and
microflap technique in France for benign laryngeal vocal outcome. The entire patients underwent pre-
lesions[8]. The term phonomicrosurgery was first used operative counseling. The lesions included 16 cases of
by Zietels in 1994 to describe the importance in vocal cord nodules, 12 cases of vocal cord cysts and 5
preservation of the vocal cord epithelium and its cases of unilateral hemorrhagic polyps out of which
superficial lamina propria[9]. Microflap techniques was pre-op and post-op GRBAS scoring analysis was
further refined to a mini microflap technique by Satalof available for 21 patients (10 cases of vocal cord nodules,
etal, in 1995[10]. Thus the concept of lateral (larger lesions 6 cases of vocal cord cysts and 5 cases of vocal cord
like reinkes edema) and medial microflap technique polyps). Pre & Post operative video telescopy & video-
developed. 11,12,13 In India, Phaneendra Kumar and stoboscopy findings were available in all the 33 cases.
Nerukar have popularized the phonosurgery[14, 15]. The speech therapy was started 2 weeks post-operatively
Nerukar has also popularized the microflap technique for all cases. Patients having benign vocal fold lesions
in India by using hydro-dissection with cold in which microflap technique was not used or removed
instruments[14]. traditionally due to technical problems, were excluded
There are various array of cold instruments (good from this study.
quality micro knife, sickle knife, micro-scissors of Surgical Technique:
various angles, angled elevators and spatula, straight and Patient is kept in a supine position with neck flexed
angled dissector, different angled fine and curved micro-
and extension of atlanto-occipital joint as done in routine

scissors, angled heart shaped grasping forceps, curved microlaryngoscopy, using a pillow under the shoulder.
alligator forceps, sharp right handle hook, vascular It is necessary to chose appropriate size and type of
knife, fine laryngeal suction cannula etc.) are available laryngoscope to achieve optimum exposure of vocal
for phonomicrosurgery using microflap technique. The cord. Sometimes assistants help is crucial especially for
1st author has adopted the routine microlaryngeal cold short neck and obese patient. The key to
instruments (microlaryngeal right and left curve angle, phonomicrosurgery is hydro-dissection and
micro -cup forceps, fine micro-suctions, 18 and 23 gauge decongestion. Subepithelial infiltration of normal saline
needles for fitting into suction cannula for injection/ with 1 in 2,00,000 epinephrine into reinkes space lifts
infiltration) to perform such surgeries as most of these the lamina propria off the vocal ligament. A superficial
phono-microsurgical instruments are not available in cordotomy was performed by placing incision just
teaching centers across India. Usage of cold instruments lateral to the lesion with an angled scissors opposite to
54
the cord, i.e. a left angle scissors for right side vocal dissection. The cup forceps help in blunt dissection.
cord and vice versa instead of a micro-laryngeal knife. The lesions like vocal nodule (Singers nodule) were
The author adopted the left/ right angled curved micro- removed precisely without disturbing the lamina
scissors for giving incision, raising microflap as well as propria with mucosal preservation (Fig. 4). The sessile
dissection of the vocal cord lesions from the bed. A polyps are removed in similar way and the redundant
small cotton ball soaked with epinephrine was often mucosa is resected precisely. The dissected bed was
used to dissect further. Precise dissection helps further
separation of the cyst from the bed and is then removed
(Fig.2 & 3). Microlaryngeal cup forceps/ alligator
forceps were used to retract the microflap during
Fig.2: a. After incision just lateral to polyp margin, b. Raising

of medial microflap using curved micro scissors, c. Showing
cyst being almost dissectd out before removal, d. Re-draping
of microflap after removal Fig.4: a. Showing infiltration of left vocal cord in case of singers
nodule, b. Raising of medial microflap after giving the incision
just lateral to the lesion, c. Blunt dissection of sub-epithelial
nodule from the vocal ligment,d. Showing the sub-epithelial
collection between the micro flap and vocal ligament, e. After
removal on the left side, the microflap is raised and retracted
on the right vocal cord and sub-epithelial dissection is being
done, f. After complete removal of the vocal cord nodule
applied hyaluronidase injection mixed with steroid
solution to prevent scarring and fibrosis. After
completing the removal of the lesion microflap was
draped back in situ. In case a cyst gets ruptured the
entire cyst wall needs to be removed or else to be
removed traditionally with scissors. In case of residual
phonatory gap due to cord atrophy following long
Fig.3: a. Showing a large cyst on the left vocal cord in a patient standing large polyp removal, fat injection was done
with sulcus vocalis, b. Microdissection of cyst after raising using 18 gauge disposable needles attached to the suction
and retracting the microflap with fine cup forceps, c. Showing
vocal ligament with a thin cover of lamina propria after
cannula into the paraglottic space and additional
complete removal of cyst. d. Draping of the microflap insitu. infiltration of hyaluronidase with steroid into the
55
reinkes space was carried out (Fig.5). All the patients

were kept on voice rest for two weeks. Postoperatively
patients were kept on anti reflux measures. Budesonide
Fig.5: a. Showing persistent phonatory gap and depression on Fig. 6: Histogram showing, a. Preoperative GRBAS score and
the left vocal cord following cyst excision, b. Showing b. Post operative GRBAS score
paraglottic fat injection, c. Post fat injection left cord position,
d. Hyaluronic acid with steroid being injected into left score was 0, 1 for 15 and 6 patients respectively.
reinkes space. Stroboscopic findings were analyzed as described by
Stankovi et al (2008).
200 micrograms inhaler at a dose of 2 puffs once a day
Out of 33 patients stroboscopic findings, 29
for one month was advised post operatively.
patients showed normal vocal cord mucosal wave pattern,
OBSERVATION AND RESULTS: 4 patients had irregular mucosa with disturbed vibratory
Results were analyzed with pre and post-operative pattern and 3 patients had phonatory gap out of which
GRBAS scoring (Fig.6) and stroboscopic findings 2 patients underwent micro-endoscopic hyaluronic acid
(Table-1). An auditory-perceptual evaluation method injection along with steroid infiltration into Reinkes
for hoarseness is the GRBAS scale (G Grade, R space and paraglottic fat injection (Table-I).
Roughness, B Breathiness, A Asthenicity, S Strain)
of the Japan Society of Logopedics and Phoniatrics, is Table-I: Showing pre & post operative stroboscopic analysis
in all the 33 cases.
simple and reliable (Hirano 1981)[16,17]. It gives scores
of 0, 1, 2, or 3 where 0 is normal, 1 is a slight degree, 2
is a medium degree, and 3 is a high degree[16]. Out of 21
cases analyzed, 17 patients had pre op G score of 3, 4

patients had score of 2; post operatively, 15 patients
had score 0, 6 patients had a score of 1. Pre op scoring
with respect to R was 3 and 2 for 13 and 8 patients;
post op score was 0, 1, and 2 for 17 patients, 3 patients
and 1 patient respectively. B scoring was 3, 2, and 0
for 14, 2 and 5 patients; post op score was 0, 1 for 17
and 4 patients respectively. Scoring for A was 3, 2, 0 DISCUSSION:
for 11, 5, 5 patients pre operatively; 0, 1, 2 for 11, 7 Laryngology and phonosurgery is the most
and 3 patients respectively post operatively. Pre op evolving subspeciality in the field of ENT-Head & Neck
score for S was 3, 2, 0 for 5, 12, 4 patients; post op Surgery with tremendous practical advancement during
56
the last three decades[18]. One of the key development the vocal ligament causing scarring and can permanently
of this speciality is phonomicrosuergery. Removal of derange the mucosal wave pattern with dismal voice
vocal fold mass lesion by separating the superficial outcome. Microflap technique can still be perfomed
lamina propria from the lesion while preserving the with good regular microlaryngeal instruments and can
mucosa for protecting the vibratory area of the vocal prevent permanent vocal cord damage. It is an excellent
cord was the main idea in the development of microflap technique to preserve the crucial histological layers of
technique. Microflap technique is the cornerstone of the vocal cord described by Hirano (fig 1), including
phonomicrosurgery. It has revolutionized the surgical mucosa and lamina propria.Post surgery voice therapy
technique in the management of vocal cord pathology is crucial in such cases.
after the concept of body cover principle for vibration
DISCLOSURES
of vocal cord was recognized.3 Phonomicrosurgical
techniques are planned to facilitate aerodynamic (a) Competing interests/Interests of Conflict- None
competence and vocal quality by creating a smooth (b) Sponsorships - None
vocal fold edge. As there is remote possibility of (c) Funding - None
superficial lamina propria to regenerate after damage, (d) No financial disclosures.
utmost care needs to be taken while raising a large HOW TO CITE THIS ARTICLE
microflap for removal of vocal cord lesion[7]. The Dipak Ranjan Nayak, N Apoorva Reddy, Shipla Rudraraju, Gopi
Krishnan, Balakrishnan R, Ajay Bhandarkar. Phonomicrosurgery for benign
microflap technique have been further divided into vocal fold lesions using medial-microflap technique with cold instruments
lateral and medial microflap techniques, the concept of in a teaching hospital of India. Orissa J Otolaryngology & Head & Neck
which came in 1995 and 1997 by Courey etal from Surgery 2016 Dec ;10(2):53-58.
Vanderbilt University Medical Center[11,12,13].The lateral
flap techniques are more suitable for reinkes edema, REFERENCES:
larger lesions and vocal cord scarring where identifiction 1. Leden HV. The history of Phonosurgery. In: Ford
of vocal ligament becomes easy with this flap and has CN, Bless DM(Hrsg), Rds; Phonosurgery,
little risk of injury to vocal ligament,11 where as medial Philadelphia, PA: Raven Press 1991
microflaps reduces the injury to basal membrane 2. Phua CQ, Mahalingappa Y, Homer J, Karagama
complex[10,12,19]. The medial microflap is most suitable Y. Injection Laryngoplasty; Otolaryngologist
for smaller lesions (like cysts, sessile polyps etc.) where 2013; 6(2): 111-118
post surgery scarring can be significantly minimized 3. Hirano M. Morphological structure of vocal cord
by reducing the exposure of vocal ligament and lamina as a vibrator and its variations Folia
propria[13]. The medial microflap technique is mostly Phoniatr.1974; 26, 89-94
indicated for lesions situated on the medial aspect of
4. Kirstein A. Autoscopy of the Larynx and Trachea
the vocal cord, especially with a thinner mucosal cover
(Direct Examination Without Mirror). 1897; FA
and are most suited for cyst and sessile polyp[12] and
Davis,Philadelphia
can be separated easily form underlying vocal
ligament[12]. Postoperative voice rest is important in 5. Kleinsausser O, Microlaryngoscopy and
Endolaryngeal Surgery. Philadelphia Pa: W B
facilitating healing and a period of two weeks helps
collagen bridge formation for fixation of flap. The Saunders. 1968
author applies hyaluronic acid along with steroid at 6. Priest, RE. and Wesolowski S. Direct
the dissected site, after removal of the lesions following laryngoscopy under general anaesthesia
microflap technique to prevent post opertive scarring. anesthesia. Trans Am Acad of Ophthalmol and
Hirano described the role of extracellular matrix Otolaryngol. 1960; 64: 639-48
component, including hyaluronic acid, atelocollagen to 7. Zeitels SM. Phonomicrosurgery Principles and
help regeneration of vocal cord mucosa[21]. Equipment:Otolaryngologic Clinics of North
CONCLUSION America.2000;33(5):1047-62
This work is presented to emphasize that 8. Bouchayer M & Cornut G. Microsurgical
unscrupulous excision of vocal cord lesions can damage treatment of benign vocal cord lesions: indications,
57
technique and results, Folia Phoniatr( Basel).1992; unilateral vocal cord paralysis. Indian journal of
44:155-184 Otolaryngology-Head & Neck Surgery.1997;49:
9. Zeitels SM. Premalignant epithelium and 262-64.
microinvasive cancer of the vocal fold: The 15. Nerukar N, Narkar N, Joshy A,Katel K, Bradoo
evolution of phonomicrosurgical R. Vocal outcomes following subepithelial
management. Laryngoscope. 1995; 105: 151 infiltration technique in microflap surgry- A
10. Sataloff RT, Spiegel JR, Heuer RJ, et al. Laryngeal review of 30 cases. J laryngol otol 2007; 121:768-
mini-microflap: A new technique and reassessment 71
of the microflap saga. J Voice 1995; 9:198-204 16. Hirano M. Clinical examination of the voice (New
11. Courey MS, Gardner GM, Stone RE, Ossoff RH. york, Springer)
Endosscopic vocal fold microflap: a three-year 17. Omori K. Diagnosis of voice disorers. JMAJ,
expirience. Ann Otol Rhinol Laryngol July/August 2011; Vol. 54(4):248-53
1995;104:267-273 18. Murty PSN. Phonosurgery a new subspeciality
12. Courey MS,Garret CG, Ossoff RH. Medial in Otolaryngology; J NTR University of Health
Microflap for excision of benign vocal fold lesions: Sciences. 2012;1: 7-11
Laryngoscope; 1997; 107:340-344 19. Ford CN. Advances and refinements in
13. Stankovi P, Vasi M, Djuki V, Jano Lj, Vuka M. phonosurgery. Laryngoscope 1999; 109:1891-00
Vocla fold mass removal-The sub-epithelial 20. Hirano M. Tissue Engineering for voice disorders.
microflap technique: Acta chirurgica Iugoslavica JMAJ, July/Aug 2011; 54(4):254-57.
2008 Volume 55, Issue 4, Pages: 43-47
14. Phaneendrakumar V, Reddy SR, Das MH.
Medialization thyroplasty with silastic implant for
58
CASE REPORT
A RARE CASE REPORT:- INTACT EYE BALL IN MAXILLARY
ANTRUM FOLLOWING TRAUMATIC INJURY TO RIGHT ORBIT
*Souvagini Acharya, **Debasis Jena, ***Utkal P Mishra

ABSTRACT
Accidental impaction of foreign body in maxillary antrum is not uncommon, but finding an intact eyeball in
maxillary antrum with intact orbital rim is very rare. We have reported a very rare case of intact eyeball in
maxillary antrum of right side in a 42 year old male admitted in our Dept. Of ENT VIMSAR, BURLA,
ODISHA. The diagnosis was confirmed by clinical examination and further by CT-Scan findings. After diagnosis
was made the eyeball was repositioned back in to the orbit under general anaesthesia by Caldwell-Lucs and infra-
orbital approach.The defect of floor of orbit was repaired by iliac crest graft. Perception of light was negative
before surgey which remained unchanged even after surgery on follow-up for 3month post-op, which may be
due to delay in surgery due to late presentation to us, but the structural function of eyeball was preserved, giving
a good cosmetic result to patient.
Key words:-Intact eyeball, maxillary antrum, Caldwell-Lucs approach, infra-orbital approach, iliac crest bone
graft.
INTRODUCTION right eye following trauma by horn of a cow since 5

Fracture of orbital floor is the most common days prior to attend this hospital.
presentation following blowout fracture 3, but its 5 days back following injury he was treated
presentation as, herniation of intact eyeball in to the primarily at a local hospital then referred to
maxillary antrum with intact orbital rim is a very rare Ophthalmology opd& admitted there on 10/8/15, again
presentation.The structure and function of the eyeball from there the patient was referred to our ENT Dept.
can be preserved if urgent surgery is done by keeping and was admitted.
back the eyeball into the orbit with orbital floor repair, On general examination, patient was conscious,
which can be done by combined Caldwell-Lucs co-operative, and well oriented to time place and
approach and infra-orbital approach. The eyeball along person, Temperature was 370c, Pulse rate: 78 per
with orbital contents should be removed from the minute, Blood pressure: 124/78 mm Hg in right arm Vol.-10, Issue-II, July-Dec - 2016
antrum immediately to preserve the function of eyeball supine position and Respiration rate: 16 breath per
as well as to prevent serious infection inside the antrum, minute abdomino-thoracic, systemic examinations were
if left inside antrum as such. The orbital floor defect with in normal limits.
should be repaired with iliac bone graft, nasal septal
On local examination, there was mildswelling over
cartilage or graft taken from rib cartilage, to prevent
further herniation of orbital content in to the antrum12. Affiliations:
CASE REPORT:- *Asso. Prof. Dept. of ENT, VIMSAR, BURLA, ODISHA.
**3rd year PG student, DEPT. OF ENT, VIMSAR, BURLA
A 42 year old Hindu male from Bhawanipatna ***2nd year PG student, DEPT. OF ENT, VIMSAR, BURLA
attended to our ENT OPD of VIMSAR, BURLA, Address of correspondence:
Odishaon with the chief complaints of swelling of right Dr Utkal P Mishra
PG student, DEPT. OF ENT, VIMSAR, BURLA
maxillary antrum along with sudden loss of vision of
59
right maxillary area, on palpation there was no CT SCAN with CONTRAST showed: Pure
tenderness over maxillary antrum. There was loss of orbital blow out fracture, Fracture of roof of maxillary
sensation along the distribution of infraorbital nerve antrum, whole of the intact eyeball inside Right
on right side. On Anterior rhinoscopy, vestibules were maxillary antrum, Optic nerve seemed to be intact,
normal, nasal mucosa of both nostrils were normal,nasal Herniation of whole of right eyeball into the right
septum was in midline, nasal cavity on both sides were maxillary antrum (Fig 4 A, 4B).
found to be free. On Posterior rhinoscopic examination
of nasopharynx, choana was found to be free. Oral
cavity, oropharynx were normal. On ocular
examination there was swelling of both upper and lower
eye lids of right eye (figure 2), which were tender to
touch, inter palpebral fissure (IPF) was narrow in right
eye (figure 2). Visual acuity was Negative on Right eye
and normal on Left eye. Conjuctiva was congested and
chemosed. Right eyeball was found to be absent from
right orbit (figure 1). After admission contrast CT scan
was advisedto confirm diagnosis.
Fig-4A:Intact & whole of the eyeball in max.antrum.
Fig-1: Absence of eye ball in orbit.
Fig-4B: Absence of eyeball in rt.orbit.
Patient was planned for surgery under general

anaesthesia for repositioning of right eyeball into the
orbit by Caldwell-lucs approach and repair of the

fracture of roof of the maxillary antrumby infra-orbital
approach.
The patient was operated in ENT OT under
general anaesthesia. Caldwell-Lucs operation was done
by giving a sublabial incision starting from 2nd incisor
to 2nd molar on right side, periosteum was elevated , an
opening was made over canine fossa, after which
maxillary antrum was reached (fig 5).Through antrum
whole of the intact eyeball was pushed up into the orbit
Fig-2: Swelling of both eye lids and decreased IPF. through the defect over roof of maxillary antrum (fig7).
60
After that an incision was given over lower eyelid

margin, periosteum was elevated and roof of of
maxillary antrum was reached(fig 6). The eyeball which
was already pushed up from maxillary antrum was
repositioned manually into the orbit by ophthalmolgy
surgeon(fig 7). The defect over roof of maxillary antrum
was repaired by a graft taken from iliac bone(fig 8).
On gross examination, eyeball was found to be intact,
pupils appeared dilated, cornea was hazy. Optic nerve
and extraoccular muscles were found to be intact. Fig-8: Repair of the defect with iliac bone graft
Postoperatively, the patient had no light perception
with restricted mobility of the eyeballof the right eye.
Fig-9: postoperative
DISCUSSION
Zygomatic and Le Fort II fractures are always
accompanied by fractures of orbital floor[3]. However
Fig-5: Caldwell-Lucs approach isolated fractures of orbital floor, is seen mainly when
a large blunt object strikes the globe directly i.e. orbital
blow out fractures, in which orbital rim remains intact
with fracture of one of the walls of orbit.Soft tissues
of orbit, such as extraoccular muscles, ligaments, and
orbital fat always herniates in to the fracture hole, when
there is a blow out fracture to the orbit[4-6]. . However,
complete dislocation of an intact globe into the maxillary
antrum after an extensive blowout fracture is a rare
incidence. In this case, a pure blow out fracture of the
floor of the orbit occurred due to trauma by a cow
Fig-6 lower eye lid incision horn with intact orbital margins, which resulted in the Vol.-10, Issue-II, July-Dec - 2016
eyeball completely dislocated into the maxillary sinus.
The floor of the orbit might be broken by an instant
top-down force, which pushed the globe into the
maxillary sinus[6-7]. Because the eyeball sank into the
maxillary sinus, globe lesions could not be checked.
Although CT scan with contrast indicated that the
integrity of the globe was not impaired. However
contusion of the eyeball may result in anterior and central
vitreous hemorrhage, lens dislocation, secondary glaucoma,
optic nerve damage and other complications[8-11]. Urgent
Fig-7: Repositioned eye ball in to the orbit
61
surgery was done to reposition the eyeball in to the 4. Zhang-Nunes SX, Jarullazada I, Mancini R. Late
orbit, by combined Caldwell-Luc and Infraorbital central visual recovery after traumatic globe
approach, and the defect over the roof maxillary antrum displacement into the maxillary sinus. Ophthal
was repaired by iliac bone graft[1-2[. After surgery the PlastReconstr Surg. 2012;28(1):e1719.
eyeball was saved and wasstructurally intact. 5. Saleh T, Leatherbarrow B. Traumatic proplapse
CONCLUSION:- of the globe into the maxillary sinus diagnosed as
Traumatic dislocation of intact eyeball into the traumatic enucleation of the globe. Eye
maxillary antrumwith intact orbital rim is very rare. (Lond) 1999; 13(Pt 5):678680.
By doing urgent surgeries we can save the structure 6. Abrishami M, Aletaha M, Bagheri A, Salour SH,
and function of eyeball. In our case the patients vision Yazdani S. Traumatic subluxation of the globe
could not be preserved because of late presentation of into the maxillary sinus. OphthalPlastReconstr
patient to our OPD following trauma due to which Surg. 2007;23(2):156158.
surgery required for this was delayed, but the structural 7. Smit TJ, Koornneef L, Zonneveld FW. A total
integrity of eyeball was achieved. orbital floor fracture with prolapse of the globe
DISCLOSURES into the maxillary sinus manifesting as
(a) Competing interests/Interests of Conflict- None postenucleation socket syndrome. Am J
(b) Sponsorships - None Ophthalmol. 1990;110(5):569570
(c) Funding - None 8. Akhaddar A, Elmostarchid B, Boucetta M. Images
(d) No financial disclosures in emergency medicine. Traumiticintraorbital
HOW TO CITE THIS ARTICLE stone with globe displacement into the maxillary
Souvagini Acharya, Debasis Jena, Utkal P Mishra.-A rare case report:-
intact eye ball in maxillary antrum follwing traumatic injury to right orbit.
sinus. Emerg Med J. 2010;27(11):828.
Orissa J Otolaryngology & Head & Neck Surgery 2016 Dec; 10(2):59-62. 9. Jellab B, Baha AT, Moutaouakil A, Khoumiri R,
Raji A, Ghannane H, Samkaoui MA, Ait BS.
REFERENCES:- Management of a severe cranio-orbito-faxial
1. Damasceno NAP, Damasceno EF. Traumatic trauma with a dislocation of the globe into the
orbital fracture with intact ocular globe maxillary sinus. Bull SocBelge Ophthalmol. 2008;
displacement into the maxillary sinus. Rev Bras (309-310):3741.
Oftalmol. 2010;69(1):5254. 10. Pelton RW, Rainey AM, Lee AG. Traumatic
2. Mller-Richter UD, Kohlhof JK, Driemel O, subluxation of the globe into the maxillary
Wagener H, Reichert TE. Traumatic dislocation sinus. Am J Neuroradiol. 1998;19(8):14501451
of the globe into the maxillary sinus. Int J Oral 11. Berkowitz RA, PuttermanAM, Patel DB.
Maxillofac Surg. 2007;36(12):12071210. Prolapse of the globe into the maxillary sinus after
3. Diseases ofENTand head and neck surgery by orbital floor fracture. Am J Ophthalmol. 1981;
PL Dhingra.6th edition. 91(2):253257.
62
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DOI : https://doi.org/10.21176/ ojolhns.0974-5262.2016.10.

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

NATIONAL EDITORIAL ADVISORY BOARD

West Bengal Prof. Bachi T. Hathiram

Prof. K. K. Ramalingam Prof Vikash Sinha

INTERNATIONAL EDITORIAL ADVISORY BOARD

Prof. Sady Selaimen da Costa Seattle Washington, USA

STATISTICAL ADVISORY BOARD

STATEMENT OF OWNERSHIP & OTHER PARTICULARS OF ODISHA JOURNAL OF

1. Place of Publication : Cuttack, Odisha

3. Nationality of Publisher : Indian

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

9. Phonomicrosurgery for benign vocal fold lesions using medial-microflap

BALLOON SINUPLASTY: AN HISTORICAL PERSPECTIVE

Date of receipt of article - 13.11.2016

INTRODUCTION There are well-known examplesof disruptive technolo-

tors such as innovative, revolutionary, and ingenious. *Chief of Otolaryngology

INSTRUMENTATION: of a submillimeter guide-wire and plus-millimeter bal-

morbid surgical intervention. In an attempt to be purely

MAIN RESEARCH ARTICLE

COMPARATIVE OUTCOME OF TEMPORAL FASCIA AND TRAGAL

Date of receipt of article - 16.12.2015

INTRODUCTION temporalis fascia graft and tragal cartilage graft were

Table 3. Perforation closure rate in temporal fascia and

was statistically significant conductive hearing gain (air

average of air-bone gap at 0.5, 1, 2 and 3 kHz

Fig. 2. Kaplan-Meier survival estimate. Fig. 3. Kaplan-Meier survival estimate.

in audiometry and tympanometry in the cartilage and

Laryngoscope 1968;78:1219-25. 17. Demirpehlivan IA, Onal, K, Aslanoglu S,

Otolaryngol Head Neck Surg. 40:295Y9.

SLEEP DISORDERED BREATHING DUE TO ADENO-TONSILLAR

Date of receipt of article - 06.11.2015

INTRODUCTION Primary snoring (PS).

disordered breathing (SDB) refers to a spectrum of

progressed[7]. Prof. B.Viswanatha,MS, PhD, FACS (USA)

Gozal and Kheirandish reported a cure rate of

III tonsils (enlarged tonsils that come in contact with

Table2: Showing preoperative and postoperative

Table1: showing Oxygen Desaturation Index

Pre-operatively most of the patients had ODI

operatively among study population.

Mouth breathing: Irritability on waking up:

Table 6: Showing preoperative and postoperative

Preoperatively most of the patients (48.33%) had

MAIN RESEARCH ARTICLE

Date of receipt of article -26.07.2016

INTRODUCTION have their own advantages and disadvantages. In the

department of oto-rhino-laryngology of Navodaya

Figure 3. Pre-operative ct image showing bilateral

Figure 1: Concha bullosa being crushed with straight

Figure 4: CT scan image at the end of 1 year in a patient

Medical Systems), which generated a volume from a

is markedly reduced in the nasal cavity with convexity

months. On the other hand, the study by Kieff and REFERENCES:

MAIN RESEARCH ARTICLE

Date of receipt of article -18.05.2016

INTRODUCTION reflex. Obtunded gag reflex is a good clinical indicator

Table II: Verbal analogue score (VAS) at rest and on

swallowing are depicted in Table II. The pain scores at

a) Competing interests/Interests of Conflict- None

REFERENCES the extent of obtunded gag reflex as a clinical

MAIN RESEARCH ARTICLE

Date of receipt of article - 18.06.2016

INTRODUCTION craniotomy for placement of a fascia lata graft.