Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)
VOLUME - XI ISSUE I, JANUARY-JUNE, 2017
Journal is listed in:- ICMJE- International Committee Of Medical Journal Editors (08.08.2016)
NLM.(Medline)-Uniquie ID- 101648238
Indexed in :- Index Copernicus International plc, (Poland), Google scholar,
Cosmos indexing(Germany), CiteFactor (USA), DRJI- Directory of research journals indexing(India), WCOSJ-World
Catalogue of science journals (Poland), SciLit (Switzerland), ISI- International society of Indexing (India),
RootIndexing (India), Infobase Indexing (India), SiFactor- Systematic Impact Factor (India)
Sci- Scientific citation indexing,Polindex (Poland) And Scribd.
This journal is an Official Publication of the Association of Otolaryngologists of India, Orissa State Branch. All rights
owned by the Association of Otolaryngologists of India, Odisha State Branch (OSB.) ISSN-0974-5262
Email- editorodishaentjournal@gmail.com, Website: www.ojolhns.com URL https://www.ojolhns.com DOI - 10.21176/ojolhns.0974-5262

EDITORIAL BOARD
Editorial Chairman/Editor-in Chief Address for Correspondence
Prof Abhoya Kumar Kar Cell- 09437165625, 09437036411
Editorial Advisory Board Member of International Email: rudra.biswal7@yahoo.com
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
10703 Elliston Way NE REDMOND,
WA-98053,USA. Email: drkrishnachandramallik@gmail.com
Phone(Res): +1-425-216-3700 / (Cell): )425-638-9286. Assistant Editor
Email- abhoya.kar@gmail.com Dr. Subhalaxmi Rautray
Editor Assistant Professor, Dept of ENT and HNS
Prof. R. N. Biswal
S.C.B. Medical College, Cuttack, Odisha,
Professor of ENT and Head and Neck Surgery,
Kalinga Institute of Medical Sciences (KIMS), Mob.82802165585
KIIT University, Bhubaneswar Email: drsubhalaxmirautray123@gmail.com

NATIONAL EDITORIAL ADVISORY BOARD

Prof. G. C. Sahoo Prof. Sanjeev Mohanty
M.S., FIMSA, MANFP & TMJO (USA) Prof and HOD, ENT. SRMC, PORUR S33, I-Block, Jains
Dean & Principal Avantika Apartment Manapakkam,
Gouri Devi Institute of Medical Sciences & Hospital Chennai-600116 ,
G T Road, Rajbandh, Durgapur, 713212 Mob-: 9840131091
West Bengal E mail: drsanjeevmohanty@gmail.com
Mob- 9083249550 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;
Kasturba Medical College, Opp. Saibaba Temple;
Manipal, KARNATAK Mumbai- 400 036; Maharashtra, India
E-mail: drnent@gmail.com Email: bachi.hathiram@rediffmail.com
Prof. S. K. Behera Prof. B. Viswanatha
Department of ENT-Head & Neck Surgery, # 716, 10th Cross, 5th Main; MC Layout, Vijayanagar;
S.C.B.Medical College, Cuttack, Odisha. Bangalore 560030;
Mob- 9437015511 Email: drbviswanatha@yahoo.co.in

ii Vol.-11, Issue-I, January-June - 2017


Prof. K. K. Ramalingam
K.K.R ENT Hospital & Research Institute,
274 Poonamalllee High Road,
Kilpauk, Chennai- 600 010,
Tamil Nadu.
Phon: 044-26411444.
E mail: kkramalingam@hotmail.com
Dr. Madan Kapre;
Neeti Clinics & Nursing Home (ENT);
NeetiGaurav Complex; 21, Central Bazar Road;
Ramdaspeth; Nagpur 440010; Maharashtra.
Email: madankapre@gmail.com
Prof R. Jayakumar,
Senior Consultant, Dept ofE.N.T.,
Kerala Institute of Medical Sciences(KIMS),
P.B. No. 1, P.O. Anayara, Trivandrum-695029, Kerala
Email: jkrmenon@rediffmail.com
Prof. Achal Gulati;
Prof ENT, Mualana Azad Medical College
A-72, SwasthyaVihar; Delhi-110092.
Email: achalgulati@rediffmail.com
Prof T.S. Anand;
4, Hemkunt Colony;Opp. Nehru Place; New Delhi-110048.
Email: doctoranand50@yahoo.com
Prof. Vikash Sinha,
Dean, MP Shah Medical College,
Pt. Nehru Road, Jamnagar-361008, Gujerat.
E mail: dr_sinhavikas@yahoo.co.in
INTERNATIONAL EDITORIAL ADVISORY BOARD
Prof. Ashutosh Kacker M.D
Professor of Clinical Otorhinolaryngology
Weill Cornell Medical College,
NY, NY 10021, USA
Personal address:-
1305 York Avenue, 5th floor, NY, NY 10021
USAT:(646)962-5097, F: 646) 962-0100
Email: ask9001@med.cornell.edu
Prof. Arun K. Gadre, MD, FACS
Heuser Hearing Institute
Professor of Otology and Neurotology,
Division of Otolaryngology
Head and Neck Surgery, University of Louisville,
401 E Chestnut St Suite 710,Louisville,
KY 40202, USA
Email: arungadre@yahoo.com
Prof.Ludwig Moser
University of Wuerzburg
Department of Oto-Rhino-
Laryngology, Plastic, Aesthetic,
and Reconsructive Head and Neck Surgery
Wuerzburg, Bavaria, Germany
Email: l_u_moser@hotmail.com
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Prof. P. S. N. Murthy,
Head of Dept of E.N.T.,
P.S.I. Medical College, Chinoutpalli,
At/P.O. Gannavaram, Vijayawada,
Andhra Pradesh.
E mail: drmurtypsn@gmail.com
Prof. Mohan Kameswaran
Madras E.N.T. Research Foundation(P) Ltd; 1,
1st Cross Street; Off. 2nd Main Road;
Raja Annamalaipuram; Chennai-600028; Tamil Nadu.
E mail: merfmk@yahoo.com
Prof T. V. Krishna Rao
Uma Krishna; 5-9-30-1/27 AB,
Basheerbagh Palace; Hyderabad-500053;
Andhra Pradesh.
E mail: drrao@mmdsofttech.com
Prof. Krishna Kishore T.
Superintendent, and HOD, Dept. of ENT & HNS,
Govt ENT Hospital and Andhra Medical College,
China Waltair, Visakhapatnam, 500017,
A P India, Mob.919849116868
Email: drkktent@hotmail.com
Dr. Kumar Pravash
Senior Consultant,Tata Memorial Hospital
Shivam-6, TMC Colony, SION Tromba, Mumbai-88
Mob.09224182898
E mail: kpravashi1@gmail.com
Prof. Sylvester Fernandes
22 Kelton St Cardiff NSW Australia
Sylvester.
Email: fernandes@newcastle.edu.au
Dr. Sharat Mohan
ENT & Voice surgeon
National Health Services
Derby, United Kingdom
Email: sharatmohan@hotmail.com
Prof.Ullas Raghavan
Department of ENT, Doncaster Royal Infirmary,
Armthorpe Road, Doncaster DN2 5LT UK
Email: ullasraghavanent@yahoo.com
Prof. Prepageran Narayanan
Dept ofOtolaryngologyand Head & Neck Surgery.
University Malaya Medical Center, Malaysia.
Email: prepageran@yahoo.com
Prof. Peter Catalano, MD, FACS, FARS
Chief of Otolaryngology
St. Elizabeths Medical Center
Professor of Otolaryngology
Tufts University School of Medicine
Medical Director of ResearchSteward Health Care
Email: peter.Catalano@steward.org
Vol.-11, Issue-I, January-June - 2017 iii
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

Prof.Sady Selaimen da Costa Prof. Dan M. Fliss

Federal University of Rio Grande do Sul, Professor and Chairman Deprtment of
Faculty of Medicine, Department of Otolaryngology Head and Neck Surgery
Ophthalmology and Otorhinolaryngology,
Tel Aviv Sourasky Medical Center
Rua Ramiro Barcelos, 2350
Zone 19 Room 1922Good End, 6 WEIXMANN ST.TELAVIV-64239 ISRAEL,
Porto Alegre, RS. TEL-972-3-697-3573,
Brazil - CEP 90035-003 Email - fliss@tlvmc.gov.il
Email: selaimen@gmail.com Prof. Shigeru Hirano, M.D., Ph.D.
Prof. Douglas D. Backous, MD, FACS. Department of Otolaryngology
Medical Director Head & Neck Surgery
Center dor Hearing&SSkull Base Surgery
Kyoto Prefectural University of Medicine,
Swedish Neurosciences Institute Seattle
Washington, USA JAPAN, Ph.: 075-251-5603
Email: douglas.backous@swedish.org Email: hirano@koto.kpu-m.ac.jp

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, Karnatak
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
indirectly for the quality or efficiency of any product or services described in the advertisements in this issue,
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

iv Vol.-11, Issue-I, January-June - 2017


INSTRUCTIONS TO AUTHORS
The Orissa Journal of otolaryngology and Head &
Neck Surgery is a half yearly medical journal indexed
, Internationally (Index Copernicus international plc,
Poland: http: // indexcopernicus.com) & Nationally
(Nircar, ISSN 0974-5262) Indexed], which publishes
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All articles are reviewed by one or more experts to
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Case reports should be restricted to 2000 words.
All submissions should include (i) a letter transferring
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Authors should not be more than five. The copyright
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From the year 2017 we are encouraging the authors to
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Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Biomedical journals. Published by the international
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Vol.-11, Issue-I, January-June - 2017 v
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
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vi Vol.-11, Issue-I, January-June - 2017
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1. Standard journal article
List the first six authors followed by et al. Halpern SD,
Ubel PA, Caplan AL. Solid-organ transplantation in
HIV-infected patients. N Engl J Med. 2002 Jul 25;
347(4):284-7.
A. More than six authors:
Rose ME, Huerbin MB, Melick J, Marion DW, Palmer
AM, Schiding JK, et al. Regulation of interstitial
excitatory amino acid concentrations after cortical
contusion injury. Brain Res. 2002;935(1-2):40-6.

B. Optional addition of a databases unique identifier
for the citation:
Halpern SD, Ubel PA, Caplan AL. Solid-organ
transplantation in HIV-infected patients. N Engl J Med.
2002 Jul 25; 347(4):284-7. Pub Med PMID: 12140307.
Forooghian F, Yeh S, Faia LJ, Nussenblatt RB. Uveitic
foveal atrophy: clinical features and associations. Arch
Ophthalmol. 2009 Feb;127(2):179-86. PubMed PMID:
19204236; PubMed Central PMCID: PMC2653214.
C. Optional addition of a clinical trial registration
number:
Trachtenberg F, Maserejian NN, Soncini JA, Hayes C,
Tavares M. Does fluoride in compomers prevent future
caries in children? J Dent Res. 2009 Mar;88(3):276-9.
PubMed PMID: 19329464. ClinicalTrials.gov
registration number: NCT00065988.
2. Organization as author
Diabetes Prevention Program Research Group.
Hypertension, insulin, and proinsulin in participants
with impaired glucose tolerance. Hypertension.
2002;40(5):679-86.
3. Both personal authors and organization as author (List
all as they appear in the byline.)
Vallancien G, Emberton M, Harving N, van Moorselaar
RJ; Alf-One Study Group. Sexual dysfunction in 1, 274
European men suffering from lower urinary tract
symptoms. J Urol. 2003;169(6):2257-61.
Margulies EH, Blanchette M; NISC Comparative
Sequencing Program, Haussler D, Green ED.
Identification and characterization of multi-species
conserved sequences. Genome Res. 2003 Dec; 13(12):
2507-18.
4. Article not in English
Ellingsen AE, Wilhelmsen I. Sykdomsangst blant
medisin- og jusstudenter. Tidsskr Nor Laegeforen.
2002;122(8):785-7. Norwegian.
5. Volume with supplement
Geraud G, Spierings EL, Keywood C. Tolerability and
safety of frovatriptan with short- and long-term use for
treatment of migraine and in comparison with
sumatriptan. Headache. 2002;42 Suppl 2:S93-9.
6. Issue with supplement
Glauser TA. Integrating clinical trial data into clinical
practice. Neurology. 2002;58(12 Suppl 7):S6-12.
7. Volume with part
Abend SM, Kulish N. The psychoanalytic method from
an epistemological viewpoint. Int J Psychoanal.
2002;83(Pt 2):491-5.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
8. Issue with part
Ahrar K, Madoff DC, Gupta S, Wallace MJ, Price RE,
Wright KC. Development of a large animal model for
lung tumors. J Vasc Interv Radiol. 2002;13(9 Pt 1):923-8.
9. Issue with no volume
Banit DM, Kaufer H, Hartford JM. Intraoperative frozen
section analysis in revision total joint arthroplasty. Clin
Orthop. 2002;(401):230-8.
10. No volume or issue
Outreach: bringing HIV-positive individuals into care.
HRSA Careaction. 2002 Jun:1-6.
11. Pagination in roman numerals
Chadwick R, Schuklenk U. The politics of ethical
consensus finding. Bioethics. 2002;16(2):iii-v.
12. Type of article indicated as needed
Tor M, Turker H. International approaches to the
prescription of long-term oxygen therapy [letter]. Eur
Respir J. 2002;20(1):242.
Lofwall MR, Strain EC, Brooner RK, Kindbom KA,
Bigelow GE. Characteristics of older methadone
maintenance (MM) patients [abstract]. Drug Alcohol
Depend. 2002;66 Suppl 1:S105.
Books and Other Monographs
13. Personal author(s)
Murray PR, Rosenthal KS, Kobayashi GS, Pfaller MA.
Medical microbiology. 4th ed. St. Louis: Mosby; 2002.
14. Editor(s), compiler(s) as author
Gilstrap LC 3rd, Cunningham FG, VanDorsten JP,
editors. Operative obstetrics. 2nd ed. New York:
McGraw-Hill; 2002.
Charges Payable: According to the decision of the AOI,
Orissa State Branch contributors of the articles are to
pay Rs. 2,500/- for printing charges. Diagrams & Tables
over 2 diagrams or 2 tables or 1 diagram and 1 table is
charged extra at the rate of Rs. 250/- for each diagram/
table in addition to Rs. 2,000/- The total Publication
cost should be sent along with the CD by Registered/
Speed Post. D.D. for such payments are to be made in
the name of Orissa Journal of Otolaryngology & HNS
Payable at Cuttack, Odisha.
Addressed To:-
Dr. K. C. Mallik
Associate Editor,OJOLHNS
Plot. No. 460/3C, Sector -8, CDA, Cuttack,
Odisha, India, PIN-753014, Cell- 09437092087
Email: editorodishaentjournal@gmail.com
Vol.-11, Issue-I, January-June - 2017 vii
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

EDITORIAL

AN OBITUARY TO PROF A.MAHADEVAIAH

Doyen of Otology
NOBILITY THY NAME IS MAHDEVAIAH
A Short Biography of Dr. Mahadevaiah

Its a great honor for me to write the biography
of one of the great ENT surgeon of the country who
is none other than Dr.Agadurappa Mahadevaiah. Dr.
Mahadevaiah was born on 16th August 1935 in the
outskirts of Bangalore. He was the 1 st son to
Mr.Agadurappa and Mrs Nanjappa along with 6
brothers and 3 sisters. His rural background and sense
of human service, influenced his aspirations to become
a doctor. However, at the point of time the
independence moment in our country was active and
Dr. Mahadevaiah used to take part in the Bhoodana
movement launched by Vinoba Bhave during his school
holidays in 1950s. He did his MBBS from Bangalore
Medical College in 1956. Having been reared up in rural
platform, his thinking was molded to serve the people
by offering them good health. This motivation
transpired him to enter medical profession. As a medical
student, he aspired to become an ENT surgeon since
his friend who was moderately deaf and for want of
monetary circumstances could not get his deficiency
repaired. This all the more prompted Dr.Mahadevaiah
to adore the role of an ENT surgeon so as to restore
hearing of moderately deaf patient.
At that point of time the ENT faculty of India
was grossly under developed. Since he has immense
thirst for Otology he moved to US with the hope of
acquiring Otologic surgical skills. Having landed in the
US in 1963 he proceeded to Canada for his internship
for one year and six months in Neurosurgery under
Dr.Eric Peterson and another 6 months in ENT under
Dr. Guy Lambramboise at Ottawa General Hospital
Ottawa. To obtain his ENT training he proceeded back
to US, but it necessitated one year residency program
in general surgery that he completed successfully at
Norwalk hospital, Norwalk, Connecticut. This was the
turning point in his life. He was very much aspired for

viii Vol.-11, Issue-I, January-June - 2017


Otologic program and applied for the same. However
as there was immense competition for ENT training
program, he was put on a waiting list for several
months. Probably this might have been the most
depressive feeling for a man with such a positive,
blossoming and optimistic outlook. During the waiting
period, to prolong his stay in USA, he has to do some
other residency for which he has to sign a contract to
do pediatric residency at Hale University in New
Heaven, Connecticut. Before starting that residency
program, fortunately with the blessings of God, he got
ENT residency at St. Lukes Hospital, New York with
the help of Dr. Stanley Whitefield, Director of ENT
Department in a second interview.
When he joined the residency in 1965, in St.Lukes
Hospital, New York, he was blessed with 100 temporal
bones given by Lempert Institute. At that point of time
he utilized the opportunity and dissected many
temporal bones to master temporal bone anatomy. As
a resident he had performed more than 714 ENT
surgeries which included 21 stapedectomies and 2
spheno-ethmoidectomy and open external
ethmoidectomy for CSF repair. In 1968 he obtained
his American Board degree in Otorhinolaryngology
in the first attempt. This is the most difficult
examination where the candidate is examined by 21
external examiners. After passing the American Board,
he underwent 18 months fellowship in otology at
Columbia University. In 1969 October he left the USA
for India to serve fellow Indians. He had forfeited a
lucrative carrier in the US for the benefit of poor and
downtrodden. Many of his Professors in US refused
to relieve him but Dr. Mahadevaiah was steadfast and
bound open coming to India to live with our people
and train young ENT surgeons. He was a great
nationalist with deep involvement in Gandhian
principle.
Having landed in India, he stated his ENT practice
in a small way and had a short stint of Govt. service as
a lecturer in Bangalore Medical College. At this point
of time there were a few otologists in our country to
perform ear surgeries. Since he had acquired the
advanced otological experience, he could effectively put
into practice in Bangalore. Which slowly but steadily
established his name. He was also associated with
NIMHANS, Bangalore as a ENT and Skull Base
surgeon. He had performed numerous skull base
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
surgeries and was first to repair C.S.F. leak by external
ethmoid route using operating microscope in India. As
years started rolling by, he felt that he should have his
own organization and that saw the birth of
BASAVANGUDI ENT CARE CENTRE, Bangalore
which is the alma mater to many practicing ENT
surgeon including me.
Having commenced his ENT practice at the above
centre from 1976, there was no looking back. He has
performed more than 25000 chronic ear surgeries and
had done innumerable number of nasal surgeries. Even
till recently before he demised, he was one of the best
rhinoplasty surgeon in India in comparison with any
plastic surgeon. He could have accomplished all these
at USA with more monetary gain. But he felt Honor
and Pride was above the external advantages of rank
and fortitude. He was an absolute non commercial
person and was very particular that no one should walk
out of his centre for want of money to cure their disease.
Further he commenced temporal bone dissection and
live surgical demonstration in his own centre along with
Dr.Vijayendra. Together they have conducted more
than 25 courses in the past decade. These courses were
widely attended by ENT surgeons across the country.
He was the past president of AOI 1995-96 and president
of Indian society of Rhinology from 2004-2005. He
was also the President of Karnataka state of AOI and
Bangalore branch of AOI. In the domestic front he
was blessed with beloved wife and two daughters.
It was a dream comes true when he wrote a book
on Surgical techniques in chronic otitis media and
otosclerosis. For which he had burnt the midnight
oil for several months and accomplished the same. As a
human being one had duties to God, to his family,
neighbors, and countrymen. Dr Mahadevaiah has
accomplished his duties to God in a divine manner. To
his family member he was an excellent husband and
father. To his neighbors he had acted on the square
such that he could do what he felt must be done. To
his fellow countrymen he had done charity, practiced
honesty and served his best.
What has been mentioned above is just the tip of
iceberg of Dr Mahadevaiahs life. His sudden demise
has shocked the entire ENT fraternity of the country.
Our deepest condolences
Dr. H. Vijayendra
Vol.-11, Issue-I, January-June - 2017 ix
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

ORISSA JOURNAL OF OTOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)
Volume-XI, Issue-I, January-June 2017

Contents
Sl.No Tittle and authors Pages

Editorial Board : ii - iv
Instructions to Authors : v - vii
EDITORIAL
An Obituary to Prof. A. Mahadevaiah
Dr. A. Mahadevaiah : viii - ixi
MAIN RESEARCH ARTICLES
1. Deep Neck Space Infections: Presentations and Management
G.M Puttamadaiah, H.S. Satish, B. Viswanatha : 01-06
2. Prevalence and Factors Related to Hearing Impairment among mainstream
Primary School Children in rural Southern India
Jeeva Thankom Philip, Rejee Ebenezer Renjit : 07-15
3. Oncological outcome analysis of trans-nasal minimally invasive endoscopi
resection of sino-nasal malignancy not transgressing the DURA:
A single centre study
Dipak Ranjan Nayak, Suraj Nair, Apoorva N Reddy, Balakrishnan
Ramaswamy, Rohit Singh : 16-24
4. Anterior Nasal Packing vs Septal clips type III, in Post Nasal Septal
Submucus Resection & Septoplasty Surgeries: A Comparative Study
CB Nandyal, Ravy Udgir, LR Shankar Naik, Vinayak Kurle : 25-31
5. Comparison of Hearing Results of Type III Tympanoplasty with
Mastoidectomy with or without Augmentatiion of Stapes Head
Netra A Pathak, Vidya V Rokede : 32-36
6. Utility of Hadad Flap in Reconstruction of Anterior Skull Base Defects
Following Endoscopic Transnasal, Trans Sphenoidal Approach to
Pituitary- Our Experience
Harshita V. Sabhahit, Shruthi GS, Santosh AN, G Prabhakar, Ananthkrishnan : 37-42
7. An Analysis of Inside out Mastoidectomy with Tympanoplasty with or
without Ossiculoplasty for Management of Middle Ear Cleft Cholesteatoma
Chandra Manish, Rajeev Krishna Gupta, Satveer Singh Jassal, Sikhar Saxena : 43-48
8. 4 Hands Reaching out Endoscopically to the Pituitary- Our Experience
G Sundhar Krishnan, George Nitha Mary : 49-53
CASE REPORTS:
9. A Case Report of Papillary carcinoma in Toxic Multinodular Goitre
Gopalakrishnan Midhun P, Sajikumar NR : 54-56
10. Wooden Foreign Body in Nasal Cavity: An Unusual Case Report
Subrat K Behera, Girija S Mohanta, Pitabas Nayak : 57-59
11. Tornwaldts Cyst - A Hidden Entity- A Case Report
Sanket D Vakharia, Seema R Gupta, Maya Shankar B Vishwakarma, S A Jaiswal : 60-62

x Vol.-11, Issue-I, January-June - 2017

 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

MAIN RESEARCH ARTICLE

DEEP NECK SPACE INFECTIONS:

PRESENTATIONS AND MANAGEMENT
*
G.M Puttamadaiah, **H.S Satish, ***B.Viswanatha

HOW TO CITE THIS ARTICLE Date of receipt of article - 19-11-2016

Puttamadaiah GM, Satish HS, Viswanatha B. Deep neck space
infections: presentations and management.Orissa J
Otolaryngology Head Neck Surgery 2017 June; 11(1): 1-6. DOI:
10.21176/ojolhns.2017.11.1.1
Date of acceptance 09-01-2017
DOI- 10.21176/ojolhns.2017.11.1.1
DOI URL- https://doi.org/10.21176 ojolhns.2017.11.1.1

ABSTRACT:
Deep neck space infections include, infections involving para-pharyngeal, retropharyngeal and submandibular
spaces. Intrinsic or deep neck space infections usually represent the overgrowth of the normal flora with most
infections being polymicrobial. The infections are of dental origin in a majority of the cases. The purpose of this
study was to determine the various presentation, diagnosis and management outcomes of deep neck space infections.
This study was conducted in the department of ENT, Bangalore Medical College and Research Institute, Bangalore
from January 2014 to December 2015. Fifty (50) cases presenting with signs and symptoms of deep neck space
infections to our Centre in the above period were evaluated. Dental infections were the most common aetiology
followed by recurrent tonsillitis. Ludwigs angina was the most common form of abscess, Incision and drainage
was the most effective treatment. Diabetes mellitus (18%) was the most common associated systemic disease &
complications encountered were airway obstruction and necrotizing fasciitis.
Key words: Deep neck space, infections, management.

INTRODUCTION: surgical and medical management are very important

Deep neck space infections include infections
involving para-pharyngeal, retropharyngeal and
submandibular spaces1. Intrinsic or deep neck space
infections usually represent the overgrowth of the
normal flora; with most infection being polymicrobial2.
Deep neck infections spread along the fascial planes and
spaces of the head and neck region. Despite the
widespread use of antibiotics for the early treatment
of cervical infections and improvements in dental care
and oral hygiene, deep neck infections still remain
relatively frequent3.
The management protocols of these infections
have not been well defined and are often challenging
due to the proximity of vital neck structures. Decision
making between only medical management versus
in the management of deep neck space infections.
The objectives of this study to determine the
following aspects with respect to deep neck space
infections are:- 1. Aetio-pathogenesis and risk factors
associated, 2. Clinical presentation, 3. Different
diagnostic modalities available & 4.Management and
outcome.
Affiliation:
*,**,***-ENT Department, Bangalore Medical College
& Research institute, Bangalore, India
Address of correspondence:-
B. Viswanatha
Professor, ENT department
Bangalore Medical College & Research Institute
Bangalore, INDIA
email: drbviswanatha@yahoo.co.in
Mob.: 91984594283

Vol.-11, Issue-I, January-June - 2017 1

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

METHODOLOGY: trismus, that seen in 40 patients (90%), followed by

This study was conducted in the department of neck swelling (38 patients,84%), poor oral hygiene
ENT, Bangalore Medical College and Research (32patients,64%), and caries tooth (34 patients 68%).
Institute, Bangalore from January 2014 to December Cause was not known in 18patients (36%). Dental
2015. The prospective study was conducted on patients infections were the cause in 25patients (50%), followed
with deep neck space infections, presenting with by Recurrent Tonsillitis in 5patients (10%) [Graph-1].
complaints of throat pain, dysphagia, odynophagia,
fever, neck swelling, trismus, halitosis, and change in
voice. A total of 50 patients with deep neck space
infections were chosen for the study. A detailed physical
examination was carried out to determine the extent
and cause of the deep neck space infections. In cases
where clinical diagnosis was uncertain, radiological
investigations were done to confirm the diagnosis.
Only clinically or radiologically confirmed cases
of deep neck space infections of all age groups and both
sexes were included in the study. Needle aspiration or
incision and drainage were done at the earliest stage in Graph- 1: Showing the etiology of dental space
majority of the patients. Pus was sent for culture and infection.
sensitivity analysis. All patients were initially started
on a combination of third generation cephalosporin The most common infection was Ludwigs angina
and metronidazole. The antibiotics were modified on seen in 32 patients (64%), followed by peritonsillar
culture sensitivity reports or on clinical responses. abscess (12 patients, 24%), parapharyngeal abscess (3
Supportive therapy, in the form of intravenous fluid, patients, 6%), sub mental abscess (1 patient, 2%),
analgesics, antipyretics, mouth washes was given. Retropharyngeal Abscess (3 patients, 6%), Parotid
RESULTS: Abscess (2 patients, 4%). In 47 patients (94%) single
space was involved. In 3 patients, more than one space
This study consists of 50 cases of deep neck space
was involved. All three patients had co-existing
infections seen over a period of 3years. Youngest
Ludwigs angina (fig 1) and parapharyngeal abscess.
patient seen was 6yrs old and the oldest patient was 76
Clinical diagnosis was certain in 20 cases (40%) and
years old. It was observed that, the maximum numbers
of cases were seen in the age group of 31-40. Of 50
patients studied, 34 were male and 16 were female. The
male/female ratio is 1:0.47 with a slight male
preponderance. The most common symptoms with
which the patient presented were odynophagia
(45patients-90%), restricted mouth opening or trismus
(40 patients 80%) , pain in the throat (34patients 68%),
Neck Swelling (39 patients 78%), Neck pain (31patients,
62%), difficulty in breathing (11patients, 22%). 18
patients (36%) had associated systemic disease. 9 patients
(18%) had history of diabetes mellitus and were on
irregular treatment, 1patient (2%)was on treatment for
hypertension, 6 patients (12%) had coexisting diabetes
mellitus and hypertension. 1patient (3.3%) had
Retroviral infection and 1 patient had tubercular
infection. The most common clinical finding was Fig. 1: Photograph showing Ludwigs angina.

2 Vol.-11, Issue-I, January-June - 2017


patients improved symptomatically. In the remaining
cases, diagnosis was made radiologically (fig. 2).
Ultrasound was used in 2 cases (35.71%) of parotid
abscess, 5 cases (10%) of Ludwigs angina. In 40 cases
(80%) X-rays neck, antero-posterior and lateral views
were taken to assess the airway.
Fig.-2: Photograph showing submandibular And
parapharyngeal abscess.
Table-1: Showing the percentage of different
complications.
In 9 (18%) patients of Ludwigs angina
Computerized Tomogram (CT) was used to diagnose
and in three cases contrast was used. Of the 50 patients,
36(72%) cases were treated successfully by incision and
drainage (fig 3). Out of them 27 cases were Ludwigs
angina, 6 cases of peritonsillar abscess and one case of
parotid abscess. 10(20%) patients were treated with
needle aspiration. 4(8%)patients with minimal abscess
were treated conservatively. Nine patients developed
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
complications [Table-1]. Two patients had necrotizing
fasciitis requiring repeated dressing and skin grafting.
Five patients with Ludwigs angina developed airway
obstruction and expired. One patient with HIV positive
status developed multi-organ failure and expired. The
complications were seen in patients with
immunocompromised status Of the 8patients, 2
patients had coexisting DM+HTN (4%), 3 patients had
DM(2%), 1 patient had HIV(2%), one patient had
HTN(2%).
All patients were under antibiotic coverage. Pus
was sent for culture and sensitivity in 46 patients.
It was sterile in 16 samples (32%). Organisms were
isolated in 34 samples (68%).Culture yielded growth
of polymicrobial organisms in 2 samples (4%)
[Table-2].
DISCUSSION:
The cervical fascia represents the condensation of
connective tissue lying between adjacent anatomic
structures and are generally described as being composed
of a superficial layer and a deep layer.4 The greatest
clinical importance of the cervical fascia is that it divides
the neck into potential spaces that function as a unit
but are anatomically separated.
For those infections involving the neck, the hyoid
bone is considered the most important structure
limiting the spread of infection. For this reason,
infections of the neck are classified by dividing the
potential spaces into three general divisions. Spaces
involving entire length of the neck, Suprahyoid spaces,
Infrahyoid spaces.4,5,6,7
Spaces of head and neck:
Spaces of the face:
Maxillary spaces, Buccal space, Canine space,
Mental space.
Spaces of the neck:
1. Spaces involving the entire length of the neck.
Superficial space (space 1), Deep neck spaces (all
involve only posterior side of neck), Retropharyngeal
Vol.-11, Issue-I, January-June - 2017 3
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
space (space 3, posterior visceral space, Danger space
(space 4) Prevertebral space (space 5), Visceral vascular
space (within carotid sheath).
2. Suprahyoid spaces
Masticator space, Superficial temporal space, Deep
temporal space, Masseteric space, Pterygomandibular
space , Mandibular spaces, Submandibular space,
Submental space, Sublingual space, Space of the body
of the mandible, Lateral pharyngeal space
(pharyngomaxillary, peripharyngeal or
parapharyngeal), Peritonsillar space, Parotid space.
3. Infrahyoid spaces (involves anterior aspect of
the neck only)
Pretracheal space, Suprasternal space of Burn,
Supraclavicular space.
The etiology of deep neck infections varies
depending on the space involved such as Dental
infections, Oropharyngeal infections, Upper aero
digestive tract trauma, Retropharyngeal lymphadenitis,
Potts disease, Sialadenitis, Bezolds abscess, Infections
of congenital cysts and fistula, Injection of illicit drugs,
Malignancies.
Pain and swelling of upper neck are the commonest
symptoms present in all patients. Other symptoms were
fever, odynophagia, respiratory distress. Trismus is
present when the anterior (prestyloid) compartment is
involved ,because of inflammation of the pterygoid
muscles but trismus may be absent when only the
posterior (post-styloid), compartment is involved.5,6
These infections are frequently accompanied with
systemic toxicity and localized aero-digestive tract
compromise, and sometimes by life-threatening sequelae
like severe airway obstruction, mediastinitis,
pericarditis, internal jugular vein thrombosis, epidural
abscess and carotid artery erosion. These are attributable
to the delayed presentation of the patient to a tertiary
care center and diagnostic dilemma posed in certain
cases.4
They present with a wide variety of
symptomatology ranging from vague throat pain to
4 Vol.-11, Issue-I, January-June - 2017
severe respiratory embarrassment and dysphagia. Hence
the treating surgeon should have a high index of
suspicion in making the diagnosis of deep neck space
infections. Clinical examination alone seems to
underestimate the extent of disease in 70% of cases,
hence appropriate radiologic imaging can reveal
infection spreading between spaces.3
In this study, out of fifty patients, the maximum
numbers of patients were seen in their third to fourth
decade of life. About 64% of patients were in the age
group of 21-50, which correlates with the study
conducted by Parhiscar8 in which almost 50% of their
patients were in their third or fourth decade of life6.The
most common presenting complaints in our series was
odynophagia (90%).This was followed by pain in throat
(68%), difficulty in opening mouth and neck swelling.
Earlier studies have also shown neck pain, odynophagia
and fever to be the commonest presenting complaints.3,
8,9,10
In more than 50% of cases etiology was found to
be of dental etiology as the cause for deep neck infections
in our study. Parhiscar8, DS Sethi3 and Kamath10 have
found dental infections as the commonest etiology in
their studies.
Ludwigs Angina was the commonest deep neck
space infection in our series, followed by peritonsillar
abscess. 3 patients had co-existing Ludwigs angina and
para parapharyngeal abscess. In our study culture was
negative in 16 cases (32%), which might be attributed
to improper or inadequate use of antibiotics prior to
presenting to our Centre. Pseudomonas aeruginosa was
the commonest organism isolated, followed by
Staphylococcus and Beta hemolytic streptococcus.
Polymicrobial infections were diagnosed in 2cases. Most
of the organisms isolated in our study showed good
susceptibility to Cephalosporins, Gentamycin and
Amoxycillin+clavalunate potassium.
Out of the 50 cases, 36(72%) cases were treated
with Incision & Drainage, 10 cases were treated with
needle aspiration, and 4 cases were treated
conservatively. All cases received antibiotic treatment
 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

empirically with third generation Cephalosporins, aspiration or conservatively. The complications of deep
gentamycin and metronidazole later modified according neck infection although less common now are still
to sensitivity report. present and are higher in immunocompromised patients
In study by D. S. Sethi 3 , 19% of patients requiring aggressive management.
developed complications, 6 developed necrotizing
cervical fasciitis. One had aspiration pneumonia, two Table 2: Showing Organisms isolated.
developed acute myocardial infarctions, and four
patients developed septicemia and multi organ failure.
Mortality rate was 8%.
In our study, we encountered two cases of
necrotizing fasciitis, five cases of airway obstruction,
one case of multi organ failure.
In our study six patients (12%) expired, amongst
whom five patients expired due to cardio respiratory
arrest & one patient due to multi organ failure.
Mortality rate was 12%.
CONCLUSION:
Deep neck space infections continue to occur
despite the wide spread use of antibiotics. In our study, DISCLOSURES
Deep neck space infections have a male preponderance
(a) Competing interests/Interests of Conflict- None
and are more common in third and fourth decade of
life. Ludwigs angina is the commonest deep neck (b) Sponsorships None
infection. Patients with coexisting immunocom- (c) Funding - None
promised states such as Diabetes Mellitus and HIV tend (d) Written consent of patient- taken
to have severe presentation, prolonged course and (e) Animal rights- Not applicable
higher complication rate.
ABBREVIATIONS:-
Contrast enhanced computed tomography
DM-diabetes melitus
(CECT) is essential in the appropriate management of
deep neck infections especially in those involving HTN-hypertension
Parapharayngeal and Retropharyngeal spaces. Early HIV-human immune deficiency virus
presentation of the patients to the hospital, has led to a
REFERENCES:
decrease in the morbidity and mortality.
1. Clarke P.Benign neck disease: Infections and
Antibiotic coverage should include Gram positive,
Swellings, Clarke M, Browning CG, Burtan MJ,
Gram negative and anaerobic microorganisms. A
Clarke R, Hibbert J, Jones NS et al .Eds., in Scot-
combination of third generation Cephalosporins,
Browns Otorhinolaryngology & Head and Neck
Aminoglycosides and Metronidazole are effective in the
surgery, 7 th edition, Volume 3, (Great Britain,
treatment of deep neck space infections. Incision and
Hodder Arnold, (2008) 1785
drainage as a treatment for deep neck space infections
is successful and cost effective in most of the cases. 2. Eric R. Oliver, M. Boyd Gillespie. Chapter 14,
Smaller abscesses can be managed either by needle Charles W. Cumming, Paul W. Flint, Lee A.

Vol.-11, Issue-I, January-June - 2017 5

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

Harker, Bruce H. Haughey, Mark A. Richardson,

K. Thomas Robbins, Cummings
Otorhinolaryngology & Head and neck surgery, 5th
edition, volume 1, part 2 (Elsevier Mosby, 2010)
201.
3. Sethi DS, Stanley RE, Deep neck abscesses-changing
trends. J Laryngol Otol, J Laryngol Otol. 1994
Feb;108(2):138-43
4. Neil W. Ancient History, Chapter 2,
Otolaryngology, An Illustrated History
Neil. Weir, London,Butterworths, 1990;10-23.
5. Sethi DS, Stanley RE, Parapharyngeal abscess. J
Laryngol Otol . 1991 Dec;105(12):1025-
1030.DOI: https://doi.org/10.1017/
S0022215100118122
6. Yellon R.F. Head and Neck Space Infections, in
Paediatric Otolaryngology, IV Edition,C D
Bluestone et al.Eds.,Vol.2,pp. 1681-
1701.Saunders, Philadelphia,USA. 2003
7. Gerd Jrgen Ridder et.al. Spectrum and
Management of Deep Neck Space Infections: An 8-
Year Experience of 234 Cases. Otolaryngol Head
Neck Surg .11 2005;133 (5): 709-714.
8. Parhiscar A, Har-El G, Deep neck abscess: A
retrospective review of 210 cases.Ann Otol Rhinol
Laryngol. 2001 Nov;110(11):1051-4
9. Neil W, The middle ages and Renaissance, Chapter
3, Otolaryngology : An Illustrated History, Neil
Weir (London, Butterworths,1990:24-38.
10. Kamath P, Shetty AB, Hegde MC, Sreedharan S,
Bhojwani K, Padmanabhan K et al. Presentation
and management of deep neck space abscess, Indian
J Otolaryngol Head and Neck Surg (Oct-Dec, 2003)
55:270-274.

6 Vol.-11, Issue-I, January-June - 2017

 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

PREVALENCE AND FACTORS RELATED TO HEARING

IMPAIRMENT AMONG MAINSTREAM PRIMARY SCHOOL
CHILDREN IN RURAL SOUTHERN INDIA
*
Jeeva Thankom Philip, **Rejee Ebenezer Renjit

HOW TO CITE THIS ARTICLE Date of receipt of article -24-11-2016

Philip J T, Rejee E R . Prevalence and factors related to hearing Date of acceptance 09-01-2017
impairment among mainstream primary school children in Rural
Southern India. Orissa J Otolaryngology Head Neck Surgery DOI- 10.21176/ojolhns.2017.11.1.2
2017 June; 11(1): 7-15. DOI : 10.21176/ojolhns.2017.11.1.2 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.2

ABSTRACT:
Background and objective: Hearing impairment among children is a momentous health problem which has
adverse consequences on their functional development and academic performance. In this context the present
study was conducted to determine the prevalence and factors related to hearing impairment among primary
school children in rural Kerala, India.
Materials and methods: 1160 children between 5-10 years were subjected to otoscopy and tuning fork testing.
Children with abnormal tuning fork test results were further evaluated by pure tone audiometry and
tympanometry.
Results: The prevalence of hearing impairment was 8.10%. The mean value of hearing loss was 32.36dB with a
standard deviation of 8.95dB. Permanent and possibly progressive sensorineural type of hearing loss was detected
in 4.3% of cases, whereas treatable conductive type hearing loss was in 95.7% of cases.
Conclusions: Majority of the aetiological factors of hearing impairment identified were preventable or treatable.
This highlights the relevance and requirement of effective school screening programmes for eliminating these
preventable cases of deafness from our community, as there is no such well-established programme in the country.
Keywords: cerumen, child health, hearing loss, otitis media with effusion, prevalence, suppurative otitis media.

INTRODUCTION: avoidable. Hence early identification of risk factors of

The sense of hearing enriches our lives and enables
us to participate in social life. It plays a critical role in
the development of speech and language in children.
Nevertheless hearing impairment among school-going
children is still a momentous health problem in the
developing world.
Prevalence of hearing impairment among rural
school children reported by various Indian studies is
about 9.311.9%1, 2, 3. WHO has estimated that about
50% of causes of hearing impairment are preventable
and 30% are treatable, though not preventable 4.
Therefore overall 80% of all cases of deafness are
deafness and timely intervention in the childhood itself
is of high significance in eliminating the preventable
Affiliations:
*Department of ENT, Dr. S.M.C.S.I. Medical College & Hospital,
Karakonam, Trivandrum, Kerala.
** Professor and Head of the Department of ENT, Dr. S.M.C.S.I. Medical
College & Hospital, Karakonam, Trivandrum, Kerala.
Address of Correspondence:
Dr. Rejee Ebenezer Renjit, MBBS, DLO, MS,
Professor and HOD of ENT,
Dr. SMCSI Medical College & Hospital, Karakonam,
Trivandrum, Kerala State, India - 695504.
E-mail: rejee72@gmail.com, Tel: +91 9447700355

Vol.-11, Issue-I, January-June - 2017 7

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
cases of deafness from our community. It is a well-
established fact that moderately severe to profound
hearing impairment in children has a detrimental and
devastating effect on their linguistic, social, scholastic
and emotional development. Such major degrees of
hearing impairment are easily identified by parents or
teachers in early age itself and are dealt with.
Meanwhile, even mild degrees of hearing loss is
also proven to have adverse effects on the functional
development and scholastic performance of
children5,6,7.Nevertheless, children with this type of
hearing impairment are not readily identified and are
often mistaken for having attention deficit disorder,
learning disabilities or cognitive disorders8. Therefore
an effective school hearing screening programme is
essential for the detection of such children, thereby
ensuring early intervention and prevention of
complications.
Relevance of a school hearing screening
programme in addition to new born screening is further
highlighted by the fact that for every 10 children with
permanent bilateral hearing impairment detected by
universal newborn screening, there are other 5 to 9
children with late onset hearing impairment9. About
10-20% cases of permanent childhood hearing loss are
late in onset and are unlikely to be detected by neonatal
hearing screening programmes10. Furthermore, the
prevalence of permanent hearing loss is estimated to
increase from 3/1000 in infants to 9-10/1000 in the
school age population11. Therefore, even after successful
implementation of neonatal hearing screening
programmes, many school children are likely to have
undetected hearing impairment, which can be detected
by effective school hearing screening programmes.
Efforts put forth to bring the children with
hearing impairment to manstream by providing
effective therapeutic as well as rehabilitative services will
create a rights-based and barrier-free society for these
differently able persons. In this context a study was
conducted to determine the prevalence and factors
related to hearing impairment and the pattern of ear
disease among primary school children.
MATERIALS AND METHODS:
This is a prospective cross-sectional study
conducted in rural Trivandrum district, Kerala state,
India from December 2012 to September 2014.
8 Vol.-11, Issue-I, January-June - 2017
Inclusion criteria
Children of the mainstream schools in the age
group of 5-10 years, who attend the school on the day
of the screening programme.
Exclusion criteria
Children in special schools
Sampling technique
Random sampling technique.
Sample size
It is calculated by the formula 4pq/d2, where p =
Available local prevalence rate in the target population
(from comparable studies1,2 ), i.e. 11.9.
q = 100-p
d = Relative precision (20% of previous
prevalence)
Hence required sample size = 741
Tools/instruments
1 . The questionnaire
Personal details - name, age, sex
Antenatal history- gestational diabetes,
hypertension, hypothyroidsm, exanthematous
fever, typhoid
Perinatal history - prematurity, low birth weight,
neonatal respiratory distress or ventilator
dependence, neonatal jaundice, neonatal sepsis
Past medical history - meningitis, mumps, measles,
head trauma, ototoxic drug intake, significant
noise exposure
Past or present otological history - ear pain, ear
discharge, hearing impairment, tinnitus, blocked
sensation in ear.
2. Otoscopy
All the lower primary school children in the study
sample were subjected to otoscopic examination by
residents pursuing Masters in Otorhinolaryngology and
positive findings were noted down.
3. Tuning fork testing
Rinne, Weber and absolute bone conduction tests
were performed in all children, using 512 Hz tuning
fork. Those children with abnormal or equivocal test
results were subjected to audiometric assessment.

4. Pure tone audiometry
Audiometric assessment was conducted by a
qualified audiologist in the quietest room in each school,
using a calibrated Classic I portable audiometer. Those
children having air conduction threshold levels more
than 20dB at any of 0.5K, 1K, 2K or 4K frequencies
were considered to have possible hearing loss. Such
children were referred to the ENT department in our
tertiary care centre for further detailed evaluation of
air and bone conduction thresholds in a sound
protected environment, on a later date. A pure tone
average above 25 dB at 0.5K, 1K, 2K and 4K Hz was
considered as abnormal. Hearing impairment was
grouped to mild (26-40dB HL), moderate (41-55dB
HL), moderately severe (56-70dB HL), severe (71-90dB
HL) or profound (>90dB HL), according to WHO
classification.
5. Tympanometry
Tympanometric assessment was done using a
portable GSI Autotymp Tympanometer in children
having any abnormal otoscopic or tuning fork test
findings.
6. Data collection process
At first, all primary schools in the specified area
were enumerated. From this, 12 schools were selected
by random sampling technique. The study details were
explained to the school management and consent was
obtained. A detailed questionnaire was issued before
the date of screening to be filled in by the parents, which
contains details pertaining to the antenatal, perinatal
and childhood medical history as well as informed
consent, so that the children could bring back the
questionnaire on the date of screening.
A total of 1160 lower primary school children
were included in the study. During screening, otoscopic
examination and tuning fork testing were done in all
children. Pure tone audiometry and tympanometry
were performed by quailified audiologists, in children
with abnormal initial findings.
After confirming hearing loss by pure tone
audiometry, appropriate therapeutic interventions were
initiated. Children with impacted wax were prescribed
wax solvents and directed for further follow up in our
hospital, during which wax removal and otoscopic
examination was done and the incidence of any tympanic
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
membrane or middle ear pathologies co-existing with
wax was ruled out.
Acute and chronic otitis media were diagnosed
based on tympanic membrane findings. Otitis media
with effusion was diagnosed on the basis of tympanic
membrane findings and type B tympanogram. Cases
having tympanic membrane retraction and type C
tympanogram were diagnosed to have Eustachian tube
dysfunction (without effusion).
7. Data analysis
The data collected was entered in Microsoft Excel
and was analysed using SPSS software. The factors
related to hearing impairment which were analysed
include age, sex, antenatal, perinatal & past medical
history and various ear examination findings. Bi-
variable analysis using Chi square test and Odds ratio
with 95% confidence interval was used to find out the
association between hearing impairment and various
factors related to it. P value less than 0.05 was considered
to be statistically significant. Binary logistic regression
was used for finding out the independent predictors of
hearing impairment.
RESULTS:
A total of 1160 school children were included in
the study. The age-gender distribution of the study
subjects is shown in Table I. The mean age was 7.68.
Out of the 1160 children, 578 (49.8%) were boys and
582 (50.2%) were girls.
1. Hearing impairment prevalence, characteristics
and aetiological factors
The prevalence of hearing impairment in the
present study was 8.10%, i.e. 94 out of 1160 children
were detected to have some degree of hearing
impairment by pure tone audiometry, even though 145
cases were initially evaluated in view of abnormal or
equivocal tuning fork test results.
Of these 94 cases, 90 (95.7%) had conductive and
4 (4.3%) had sensorineural type of hearing loss.
Moreover, out of the 94 cases with hearing impairment,
24 cases (25.53%) had right sided, 33 cases (35.11%) had
left sided and 37cases (39.36%) had bilateral
involvement.
The mean value of hearing loss was 32.36dB with
a standard deviation of 8.95dB. Out of the 94 cases
with hearing impairment, the majority (87 cases i.e.,
Vol.-11, Issue-I, January-June - 2017 9
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
92.6%) had mild degree of hearing loss (26-40dB HL).
Moderate (41-55dB HL), moderately severe (56-70dB
HL), severe (71-90dB HL) and profound (>90dB HL)
degrees of hearing loss was detected in 5(5.3%), 0(0.0%),
1(1.1%), 1(1.1%) cases respectively.
Considering the aetiology of hearing impairment,
the major proportion (42.6% in the right side and 45.7%
in the left side) was contributed by impacted wax. The
distribution of various aetiological factors is shown in
Figure I and II.
2. Factors associated with hearing impairment
Bi-variable analysis using chi-square test was done
to find out the association between hearing impairment
and various socio-demographic factors. Prevalence of
hearing impairment was more in 5-7 yrs age group
(8.5%) compared to 8-10 yrs age group (7.7%); more
among boys (8.8%) than girls (7.4%); more among
children studying in government schools (9.6%)
compared to children in private schools (7.3%).
However these differences were found to be statistically
insignificant [Table II].
3. Role of antenatal, perinatal and childhood
factors in the incidence of sensorineural hearing
loss.
Out of the 4 cases with sensorineural hearing loss,
3 had bilateral mild degree of hearing loss and the other
child had moderately severe loss in one ear and
profound loss in the other ear. Two of the cases with
mild loss had maternal history of gestational
hypertension as well as perinatal history of prematurity
and low birth weight. One of them had childhood
history of mumps and measles also. However, it was
not possible to make any statistical analyses on the role
of these factors in the incidence of sensorineural hearing
loss, due to the limited number of cases.
4. Pattern of ear diseases
The pattern of ear diseases is tabulated in Table
III. The prevalence of hearing impairment among
various ear diseases was analysed and found to be 8.22%
in impacted cerumen (58 out of 706 ears), 18.18% in
acute otitis media (2 out of 11 ears), 80.00% in otitis
media with effusion (48 out of 60 ears), 88.89% in
tubotympanic type of chronic otitis media (8 out of 9
ears), 100.00% in atticoantral type of chronic otitis
media (1 out of 1 ear) and 3.31% in eustachian tube
10 Vol.-11, Issue-I, January-June - 2017
dysfunction without middle ear effusion (4 out of 121
ears). On performing bi-variable analysis, significant
association was detected between hearing impairment
and impacted wax [Odds ratio (95% CI) - 2.017 (1.238 -
3.286); p value- 0.004], otitis media with effusion [Odds
ratio (95% CI) - 214.106 (62.425 - 734.345); p value- 0.001]
and chronic otitis media tubotympanic type [Odds ratio
(95% CI) - 48.761 (5.005 - 475.094); p value- 0.001].
DISCUSSION:
1. Study tools
Tuning fork tests, pure tone audiometry and
tympanometry were included as our study tools, in
addition to the detailed questionnaire collected from
the parents of the study subjects and otoscopic
examination findings. It has been established that for a
hearing screening protocol to be acceptable, the
sensitivity and specificity of the tool must be at least 90
95%12. In other words it should accurately detect at
least 90 95% of persons having hearing loss and it
shouldnt fail more than 5 10% of persons having
normal hearing12.
Burkey et al.13 established the sensitivity of Rinne
test using 512 Hz tuning fork in detecting conductive
hearing loss more than 10,20, 30 dB by experienced
otologists using masking were 89.1, 100 and 100
respectively, when equivocal results are included. In
unmasked situations, the sensitivity was 72.5, 92.3 and
100 respectively. Browning et al.14 found the specificity
of Rinne test using 512 Hz tuning fork to be more
than 90%. Hence the acceptance of tuning fork tests as
the primary screening tool in our study is justifiable.
In this study, all children with abnormal or
equivocal tuning fork test results were subjected to
audiometric assessment. Children with air conduction
threshold levels more than 20dB at any of 0.5K, 1K,
2K or 4K Hz frequencies were considered to have
possible hearing loss and were referred to the ENT
department, for further detailed evaluations. According
to American National Standards Institute, the cut off
intensity levels for identifying hearing impairment
varies between 20 to 30dB12. In literature, there is
evidence for greater sensitivity of screening level at 20dB
HL than 25dB HL in identifying minimal hearing loss
and educationally significant hearing loss 15. The
sensitivity/specificity rates for identifying minimal
hearing loss at 20 dB HL screening levels were 100/53

respectively. For detecting educationally significant
hearing loss, these rates were 100/92.2 respectively16.
Hence we used 20dB HL as the cut off screening level
for referring the children after the preliminary
audiometric assessment.
Various studies have shown that for identifying
the maximum number of cases of newly detected hearing
loss, a single failure in any of the frequencies must be
considered as a failure12. The American Speech Language
Hearing Association (ASHA-1990) screening guidelines
recommended screening at 500, 1000, 2000 and 4000
Hz frequencies12. FitzZaland et al17 while evaluating the
screening ability of 20 dB HL at 1000 & 2000 Hz and
25 dB HL at 500 & 4000 Hz have found out that 15%
of children with confirmed conductive hearing loss had
failed only at 500 Hz level. Therefore in our study,
children with air conduction threshold levels more than
20dB at any of 0.5K, 1K, 2K or 4K Hz were considered
to have possible hearing loss and were evaluated
further. After detailed evaluation, the hearing
impairment was classified to mild (26-40dB HL),
moderate (41-55dB HL), moderately severe (56-70dB
HL), severe (71-90dB HL) and profound (>90dB HL)
as per the WHO guidelines18.
2. Socio demographic factors
In this cross sectional study conducted among
school children in rural Kerala, out of the 1160 children
in the age group of 5-10 years, 49.8% were boys and
50.2% were girls. As per Indian population census 2011,
the only Indian state where the number of females is
Table-I: Age - gender distribution (n=1160)
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
higher than that of males is Kerala (1084 females per
1000 males)19. This pattern of sex ratio is reflected in
present study also (1007 females per 1000 males).
3. Prevalence and characteristics of hearing
impairment.
The prevalence of hearing impairment among rural
children in the present study (8.10%) is considerably
higher than that among urban children in the same state
(2.2%) as observed in a study by Ebenezer et al.19.
However this is lower than the prevalence among rural
children in neighbouring states like Karnataka and
Tamilnadu (11.9%)1,2 and also the urban areas of a
Northern state (9.3%) 3 . Reports regarding the
prevalence of hearing impairment from neighbouring
countries including Nepal, Myanmar etc. vary between
5.5% and 21.63%20,21.
As this was primarily a hearing screening study,
children having normal hearing in spite of ear wax were
not followed up further. Tympanic membranes of such
children were not visualized. Hence a proportion of
cases having tympanic membrane or middle ear
pathologies but with normal hearing, might have been
missed while estimating the prevalence of ear diseases
In present study, 95.7% of hearing loss was of
conductive type. Similar studies in India also showed
87.1% to 91.2% of conductive hearing loss among the
total hearing loss cases2,3. The overall prevalence of
sensorineural hearing loss in the present study was
0.34%, which also accounted for 4.3% of cases of
hearing impairment, similar to a comparable study in
Kerala19.
4. Aetiology of hearing impairment
The major proportion (42.6% in the right side and
45.7% in the left side) of hearing impairment in our
study was contributed by impacted wax. In other Indian
studies also, the most important aetiological factor was
detected to be impacted wax, contributing to 41.9 -
86.3% of cases with hearing impairment1,3,19.
The proportion of hearing impairment
contributed by otitis media with effusion was
disproportionately high in the present study (36.1-
37.1%) compared with some Indian studies3,19 (3.5-
6.5%), but this is in accordance with another study by
Jacob et al.2 in rural south India (41.9%) and various
studies in Egypt22 (30.7%) and Saudi Arabia23 (34.9%).
Chronic otitis media contributed to 4.3-9.8% of hearing
Vol.-11, Issue-I, January-June - 2017 11
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

Table - II: Hearing impairment versus demographic

factors.

Fig-1: Aetiology of right sided hearing impairment (n=61).

loss cases in our study, which is significantly lower than

that in other Indian3 as well as foreign studies22 (13.2-
23.3%). This lower incidence could be due to better
health awareness and utilization of health care facilities
in Kerala.
5. Pattern of ear diseases
In present study, the most prevalent ear disease
was found to be impacted wax (37.41%). Various south
Indian studies also have revealed a prevalence of wax
Fig-2: Aetiology of left sided hearing impairment (n=70).
impaction between 29.8-63.0%, which was the most

Table - III: Pattern of ear diseases (n=1160).
common ear disease1,2,19. A prevalence of 60.6-62.0% was
reported in other countries in Indian subcontinent24,25.
In the present study, 8.25% of ears with wax
impaction had associated hearing impairment. A similar
study conducted among the urban children of the same
district had revealed lower prevalence (3.91%) of hearing
impairment among the children with wax impaction19.
Other external ear diseases like foreign body and otitis
externa were found in only 0.09% and 0.26% of
children in our study which was comparable with the
prevalence detected by another study in a nearby urban
area (0.08% and 0.04% respectively)19. Among the
middle ear pathologies, Eustachian tube dysfunction
without middle ear effusion was detected to be the most
common disease with a prevalence of 5.86%, higher than
the prevalence in a comparable study (2.8%) in urban
Kerala19.

12 Vol.-11, Issue-I, January-June - 2017


The prevalence of otitis media with effusion
(3.10%) in our study was comparable with other studies
in other parts of India and neighbouring countries (3.3-
4.7%), but significantly higher than the prevalence
detected in urban areas of the same state19,24,25,26. In our
study, 80.0% of ears having otitis media with effusion
had associated hearing impairment. Similar studies in
south India also have revealed 50.0-100.0% prevalence
of hearing impairment among the cases with middle
ear effusion1,19. However, it is known that 50-75% of
the OME will resolve during 3-6 months without
leaving permanent sequelae. Hence these cases are
unlikely to cause any permanent hearing impairment
and associated developmental or educational deficits.
The prevalence of chronic otitis media was
significantly lower in the present study (0.69%)
compared to various other studies in India and
neighbouring countries (5.2-7.8%)2,24-26. The significantly
lower prevalence of chronic middle ear disease in our
study could be secondary to the better socioeconomic
environment, improved health education and effective
utilization of health facilities prevailing in Kerala, the
most literate state of India 19. The further lower
prevalence of chronic ear disease in a comparable study
among the urban children of the same state also
indicates the role of favourable socioeconomic factors
in urban area compared to rural areas. The inverse
relationship between prevalence of chronic middle ear
diseases and better socioeconomic background has been
established in literature also21,27,28
5. Strategy adopted to tackle the problem in our
area.
The individual cases having hearing loss identified
by the school screening programme were referred to
the ENT department in the tertiary care centre for
further detailed evaluations, necessary interventions and
rehabilitation, after informing the parents with the help
of class teachers.
In order to tackle the problem on community
basis, we have addressed the following aspects in a
Teachers awareness programme conducted by our
institution:
Adverse developmental and scholastic effects of
even mild degrees of hearing loss
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Advantages of early identification and treatment
of cases
When to suspect hearing impairment in class
rooms and the methods of identification of
probable cases
Availability of treatment and rehabilitative options
CONCLUSION:
This study has revealed the magnitude of hearing
impairment and other otological morbidities prevailing
in our rural community. We would like to give special
reference to the preventable or treatable cases of hearing
loss identified in our study, which constitute the major
proportion (95.7%). Children with mild degree of
hearing impairment are not readily identified and are
often mistaken for having attention deficit disorder,
learning disabilities or cognitive disorders. Meanwhile,
such degrees of hearing loss is proven to have adverse
effects on the functional development and scholastic
performance of children, even though the effects are
not so detrimental and devastating as in moderately
severe to profound hearing impairment. In this context,
we would like to highlight the magnitude of the
preventable or treatable deafness in our school children
and to emphasis on the relevance and requirement of
effective school screening programmes for eliminating
these types of deafness from our community, as there
is no such well-established programme in the country.
LEGENDS:
AOM - Acute otitis media
OME - Otitis media with effusion
CSOM TTD - Chronic otitis media tubotympanic type
CSOM AAD - Chronic otitis media atticoantral type
ETD - Eustachian tube dysfunction
SNHL - Sensorineural hearing loss
Un Ex HL - Unexplained hearing loss.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) No financial disclosures
(e) Animal rights-Not applicable
Vol.-11, Issue-I, January-June - 2017 13
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
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Vol.-11, Issue-I, January-June - 2017 15

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

ONCOLOGICAL OUTCOME ANALYSIS OF TRANS-NASAL

MINIMALLY INVASIVE ENDOSCOPIC RESECTION OF SINO-
NASAL MALIGNANCY NOT TRANSGRESSING THE DURA:
A SINGLE CENTRE STUDY
*Dipak Ranjan Nayak, **Suraj Nair, **Apoorva N Reddy ,*Balakrishnan Ramaswamy, ***Rohit Singh

HOW TO CITE THIS ARTICLE Date of receipt of article -27-5-2016

Nayak D R, Nair S, Reddy A N, Ramaswamy B, Singh R.Oncological Date of acceptance 30-05-2017
outcome analysis of trans-nasal minimally invasive endoscopic resection
of sino-nasal malignancy not transgressing the dura: a single centre DOI- 10.21176/ojolhns.2017.11.1.3
study.Orissa J Otolaryngology Head Neck Surgery 2017 June; 11(1):
16-24. DOI: 10.21176/ojolhns.2017.11.1.3
DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.3

ABSTRACT:
Objective: To evaluate the oncological results and efficacy of trans-nasal minimally invasive endoscopic resection
of nose and para nasal sinus malignancy.
Methods: A retrospective observational study including 29 cases of nose and paranasal sinus malignancy stage I-
IV of varied histopathological types operated from January 2006 to July 2016. All the patients underwent trans-
nasal laser/microdebrider assisted endoscopic resection of the primary tumor with adequate margins. Neck
dissection was carried out in 8 cases. All stage III/IV cases and 5 cases of stage-II including olfactory neuroblastoma
received post operative radiotherapy/ Chemo-radiotherapy and one case of malignant melanoma referred for
post-operative immunotherapy. Average follow up period was 7 months. Data was analysed using Kaplan Meier
method to estimate the overall and disease specific survival rate along with the median survival time wherever
applicable. Statistical analysis was carried out using STATA 13.
Results: The age range was 39-64 years with a mean of 49.4yrs. 67 % of the patients were males. Overall, there
were 2cases (7.1%) in T1, 8 (28.5%) in T2, 12(42.8%) in T3 and 6 cases (21.4%) in T4 stage. 22 patients (75.8%)
were N0, 5(17.2%) were N1 and 2(6.8%) were N2 to begin with. 24/ 29 patients had no disease on their last
follow up. One case of olfactory neuroblastoma in Kadish stage B had no recurrence on last follow-up after 18
months. 5 cases had local recurrence of which T1 and T2 cases had no contribution. Out of the 2 cases of
recurrence in T3, one at 14 months was managed with endoscopic re-excision and the other at 28 months with
external resection. 3 recurrences in T4were observed and open approach adopted for 2 cases at 16 and 34 months
respectively and one case refused treatment at 19 months. 2 patients had lung metastasis after 3 years. 15 out of
the 18 patients followed up for 2 years were disease free. The study showed an overall survival rate of 82.7%
while the 2 year disease specific survival rate was found to be 83.33%.
Conclusion: Endoscopic resection of paranasal sinus malignancy has provided an efficient tool to the skull base
surgeon for providing good oncological results with favourable cosmesis avoiding the potential morbidities of
open approaches.
Keywords: Endoscopic resection, paranasal sinus malignancy, microdebrider, skull base.

INTRODUCTION: Affiliations:
*Professor, **Resident, ***Associate Professor, Department of ENT-
Sino-nasal malignancies comprise 3-4 % of all head
Head & Neck Surgery, Kasturba Medical College, Manipal University,
and neck oncology workload. They have been Manipal.
traditionally attributed to poor prognosis owing to Address for correspondence:
Prof.Dipak Ranjan Nayak, Department of ENT-HNS,
close anatomical proximity to anterior skull base, orbit, Kasturba Medical College, Manipal University, Manipal-576104
cranial nerves, carotid vessels and morbid surgical Email: drnent@gmail.com

16 Vol.-11, Issue-I, January-June - 2017


approaches1. The landmark open craniofacial resection
(CFR) by Ketcham in 1963, Moores lateral rhinotomy
and Weber-Fergussons approach with its modifications
have been the standard options for surgical resection
of sinonasal malignancies for a long time1,2. However,
the recent advances in endoscopic surgical
instrumentation, intra-operative image guidance
technology, powered instruments, optical gadgets and
training programmes in endoscopic sinus surgery have
revolutionised the concept of trans-nasal endoscopic
resection of sinonasal tumours 3. Benign sinonasal
tumours were managed earlier using endoscopic
approach and the excellent results provided an impetus
to tackle malignant lesions with oncological results
comparable to open approaches. The changing
paradigms in the management of sinonasal malignancies
were based on the results of various studies comparing
the endoscopic and open approaches2,3.
The two major advantages of open approaches are
an en-bloc resection and easy reconstruction of anterior
skull base defect. Endoscopic resection includes a piece-
meal excision of the lesion due to the complex anatomic
location and access4. This piece-meal resection with
microscopically clear margin provides similar
oncological results as an en-bloc resection. The recent
techniques in endoscopic skull base reconstruction
has made it possible to reconstruct defects with
precision4, 5. With the advances in instruments and
training workplaces, endoscopic surgeons have
continued to improve their knowledge of the complex
paranasal sinus and skull base anatomy. Endoscopic
resection provides the major advantage of minimal
morbidity, shortened intra-operative time, faster post-
operative recovery and cosmetically superior with
similar oncological safety6,7.
MATERIALS AND METHODS:
A retrospective observational analysis of data was
conducted at our tertiary care centre with a total of 31
cases of biopsy proven sinonasal malignancy; those have
undergone trans-nasal endoscopic resection. Out of
these, 29 cases are included in this study for analysis. 1
case each of rhabdomyosarcoma and metastatic
malignant eccrine spiroadenoma of nape of neck were
excluded in this study due to incomplete/palliative
treatment. Patients undergoing external approach for
facial and cranial access, aided with endoscopy were
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
excluded. Cases with tumour transgressing dura
requiring resection were carried out by craniotomy
instead of trans-nasal neurosurgical intervention and
hence excluded from the study. Various
histopathological sub-types of sinonasal malignancies
in stages I-IV operated from January 2006 to July 2016
were included in the study. The cases had undergone
purely endoscopic resection of the sinonasal mass with
microscopically negative margins. The primary site of
origin in all cases was located in maxillo-ethmoidal
complex with variable local spread. Stringent inclusion
and exclusion criteria were formalised for the selection
of patients. All the subjects had undergone routine head
and neck clinical examination followed by nasal
endoscopy and contrast enhanced CT scan for
assessment of the lesion. Minimum follow-up period
was 7 months.
Records were evaluated for patient age, sex,
diagnosis, tumour staging, histopathological findings,
operative procedure, operative time, estimated blood
loss, complications, hospital stay, intensive care unit
(ICU) stay, postoperative course, follow-up, recurrence
rates, and metastasis, mortality and survival rates.
Olfactory neuroblastoma was staged according to the
Kadish staging system8. Other malignant tumours were
staged according to the tumour, node, and metastases
(TNM) staging system for nasal cavity and ethmoid
sinus malignancy of the seventh edition of the American
Joint Committee on Cancer (AJCC) 9. Staging was based
on preoperative examination, computed tomography
(CT) and magnetic resonance imaging (MRI).
Management of neck was individualised depending on
the nodal status. Adjuvant radiotherapy was provided
to all stage III/IV cases and those with poor histology.
Patients with tumours deemed unresectable
endoscopically due to its extension into orbit, intradural
and intracranial compartments, nasal bones, hard palate
were excluded. Cases with massive involvement of the
frontal sinuses, lateral bony wall of the maxillary sinus
and lacrimal apparatus were managed with combined
approach resection. Patients with recurrent or residual
lesions and also the radio-residual ones were not part
of the study group. None of the patients were subjected
to palliative resection or debulking procedure thus
strictly following oncological protocols. Cases requiring
cribriform plate resection were included and the defect
Vol.-11, Issue-I, January-June - 2017 17
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
was repaired after complete tumour excision. Data was
analyzed using Kaplan Meier method of estimation to
estimate the overall survival and 2 year disease specific
survival rate along with the median survival time
wherever applicable. Statistical analysis was carried out
using STATA 13.
Surgical technique:
10
Goffart et al (2000) and Casiano et al (2001) 11
popularised the technique of endoscopic resection of
sinonasal tumours. The addition of navigation and
powered instruments has provided a helping hand to
the skull base surgeon.
Some surgical landmarks which are of prime
importance:
Superior turbinate and Ostium of the sphenoid
sinus.
The maxillary sinus roof is used as a robust
landmark to allow safe dissection and debulking
of pathology.
Maxillary ostium guides the removal of pathology.
An alternative way is by proceeding posteriorly
to enable a safe entry to the sphenoid sinus, and thus
the true skull base, when normal structures such as the
superior turbinate and sphenoid ostium are not
available.
The primary aim in endoscopic tumour excision
is radical removal of the lesion with safe margins, as in
traditional procedures. The cornerstone of oncological
surgery i.e. enbloc resection to avoid the risk of
tumour spillage is outdated and is replaced by the
concept of disassembling of the lesion, having under
view the limits between normal and diseased mucosa10,11.
Surgical technique varies slightly from one patient to
another according to the site of origin and extent of
the lesion.We used a powered instrument like
microdebrider or/and KTP-532 laser for reducing the
bulk of the primary tumour for better manipulation
and visualisation of margins and assessment of extent
of resection. Bony cuts were then made with
osteotome/drill from the healthy area with a good
margin.
Some basic steps are followed during the resection
which can be modified depending on type of disease
and extent: (Fig 1, 2, 3, 4, 5)
18 Vol.-11, Issue-I, January-June - 2017
Disassembling tumour using powered
instrumentation and/or cutting instruments
which reduces the bulk of the tumour and helps
to visualise the margins clearly
Removal of the posterior nasal septum & sphenoid
rostrum.
Draf type IIb frontal sinusostomy in the case of
Unilateral mass with frontal sinus extension and
Draf type III median frontal sinusostomy is
performed if the lesion involves both sides by
identifying the cribriform plate.
Centripetal Removal: Exposure of antero-superior
and posterior inferior margin.
Endoscopic medial maxillectomy type III
Nasoethmoidosphenoidal complex is isolated and
pushed towards the central part of the nasal fossa
(centripetal technique) and removed12.
Skull Base Removal: Can be extended to resect
anterior cranial base.
Reconstruction: Endoscopic multilayer technique.
Reconstruction of skull base defect was done by
using fascia lata. The second layer was followed by
superiorly based local septal mucosal reflected from
other side of the septum or a pedicled nasoseptal flap
Figure-1: Adenocarcinoma (a&b) CT scan paranasal sinus
showing the tumour extention, (c) intra operative endoscopic
picture before resection (d) post operative endoscopic picture
after one year post operative period with no evidence of
disease.

Figure-2: Squamous Cell Carcinoma (a)pre operative& (b)
post operativeCT scan.
Figure-4: Inverted Papilloma with Transitional Cell
Carcinoma (a ) Showing the lesion (b) A Draf-II procedure
in progress (c) Showing resection of soft tissue attached to
tumour that was extended to the nasopharynx with KTP laser
from skull base after a posterior septectomy(d) Additional
drilling of bone is being done for clearance from sphenoid
sinus floor and nasopharynx).
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Figure-3: Olfactory Neuroblastoma (a,b ) pre operative CT), (c,
d) post operative CT), (e)showing the lesion occupying the superio
aspect of nasal cavity, (f) showing exposure of skull floor of frontal
sinus anterior to 1st olfcory neurone. Note the tumour along with
healthy mucosal margin has been separated (g) A Draf-II sinusostomy
has been performed to identify the skull base & the tumour has been
resected completely from dura after removal of adjacent bone, (h)
Showing reflection of septal flap from opposite side to cover the
dura.
Figure-5: Residual Chordoma following neurosurgical
resection in nasal cavity extending into into the sphenoid sinus
and nasal cavity (a) Showing the lesion, (b) Resection of
tumour from nasal cavity ethmoid and sphenoid sinus, (c)
showing posterior septectomy being done to facilitate tumor
removal from the floor of the sphenoid sinus and clivus (d)
Showing the removal of the tumor from the roof of
nasopharynx.
Vol.-11, Issue-I, January-June - 2017 19
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
(Haddad flap) for support13. Nasal packing was done
with moistened absorbable nasal packs. All cases
anticipated for CSF leak, were provided complete bed-
rest keeping the head in a 20 degree elevated position
until the 3rd post-operative day. Intravenous third-
generation cephalosporin therapy was started the day
before surgery and continued for at least 7days. Nasal
irrigation and cleaning with normal saline solution was
started after 2-3 days with topical antibiotic ointment.
Regular nasal endoscopic cleaning of the nasal cavity
was done and looked for suspicious lesions. All patient
with T3 and T4 disease and 5 cases of stage II disease
received post operative adjuvant Radiotherapy/Chemo-
Radiotherapy.
RESULTS:
The age range was 39-64 years with a mean of
49.4yrs. 67 % of the patients were males. The histological
subtypes of the sinonasal malignancies managed via
endoscopic approach are given in Table 1.
Table 1: Histological Subtypes (Includes tumours14,15,16
treated with endoscopic approach only)
20 Vol.-11, Issue-I, January-June - 2017
Malignancy of Salivary gland origin
(Adenocarcinoma and Adenocystic carcinoma)
comprised the majority (34.4%) of cases followed by
squamous cell carcinoma (24.1%), malignant melanoma
(3.4%) and others. 1 case of olfactory neuroblastoma
belonging to Kadish stage B was a part of the study
group. The remaining 28 cases were stage-wise
categorised as given in Table 2. Adjuvant radiotherapy
was advised in stage III/IV cases and in cases with
aggressive tumour behaviour. One patient of malignant
melanoma received immunotherapy. A case of smooth
muscle tumour of unknown malignant potential was
treated with endoscopic resection only.14 24 of the 29
patients had no disease on their last follow up. 5 cases
had loco-regional recurrence of which stage I and II
cases had no contribution. We had 2 recurrences in
stage III out of which one at 14 months was re-excised
using endoscopic technique and the other one at 28
Table 2: Stage Wise Classification Of Cases.

months was managed with an external total maxillo-
ethmoidectomy. In stage IV with extension of disease
into sphenoid or frontal sinuses, 3 cases had loco-
regional recurrences, two of which at 16 and 19 months
respectively were managed with external approach using
total maxillo-ethmoidectomy and sphenoidotomy or
external frontoetmoidectomy procedure. One patient
with recurrence at 34 months, refused any further
treatment. 2 patients had lung metastasis after 3 years
(1 death at 42 months).
No significant complication was noted intra-
operatively and during post-operative recovery.
Epistaxis was noted in 3 cases and was managed
conservatively during post-operative period. Hyposmia
was observed in 2 patients who are still on regular
follow-up. We did not encounter any CSF leak
probably due to the multi-layered skull base defect
closure technique and vigilant post- operative care. The
overall survival rate for the study population was found
to be 82.7%. 15 out of the 18 patients followed up for
2 years were found to be disease free and hence the 2
year disease specific survival rate was 83.33% (Fig.6)
DISCUSSION:
The extensive use of endoscopic approach for
dealing with chronic sinusitis made the skull base
Figure 6a: Kaplan-Meir Graph showing Overall survival rate.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Figure 6b: Kaplan-Meir graph showing 2 year specific survival
rate.
surgeons all over the globe realise the possibility of
managing sinonasal tumours with this approach4. While
there have been many reports describing its use in
benign tumours, there has been a dearth in literature
on its efficacy in managing malignant lesions17.In
addition to the excellent visualization owing to better
optics and imaging advances, endoscopic approaches
have significantly reduced the need for craniofacial soft-
tissue dissection, skeletal disassembly, and cerebral
retraction for tumor access and resection 17,18.The
endoscopic approach facilitated better access to difficult
areas such as the frontal recess, sphenoid sinus, orbital
apex, pterygomaxillary space and inferior part of the
septum while avoiding dissection of vital non-involved
structures thus providing an added advantage over open
techniques 18. The lack of external incisions and
improved cosmesis makes it a patient friendly and
compliance inducing approach. Dave et al19stated the
advantages including , avoidance of craniotomy, facial,
gingival, and bi-coronal incisions, extensive facial
osteotomies, lumbar drains, tracheotomy, and frontal
lobe retraction in this endoscopic technique. Other
potential advantages include decreased operative time,
reduced anesthetic risk, shorter hospital stay, less
postoperative pain, and fewer complications4,18,19. These
advantages probably provided an impetus for the
increased adoption of endoscopic approaches for
surgical management of selected sinonasal malignancies.
Vol.-11, Issue-I, January-June - 2017 21
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
With respect to oncological results, Nicolai et al20
reported the largest series to date, with 184 patients
with naso-ethmoidal malignancies of which one
hundred thirty-four patients (72.8%) were managed
exclusively by an endoscopic approach, whereas 50
required an adjunct craniotomy with mean follow-up
of 34.1 months. The overall rates of disease-free survival,
alive with disease, died of disease, and died of other
causes were 80.9%, 4.4%, 11.4%, and 2.2%, respectively.
Ehab et al17 concluded that out of his 120 patients, 18
(15%) experienced local recurrence, with local disease
control of 85%. The 5- and 10-year disease-specific
survival rates were 87% and 80%, respectively. The 5-
and 10-year overall survival rates were 76% and 50%,
respectively. Lund et al21in their work, reported a 49-
patient prospective cohort that underwent endoscopic
resection as an alternative to CFR. Overall survival was
88% at 5 years, with 36 patients free of disease, seven
patients with residual disease, and six patients died of
disease. Ganly et al22 reviewed pooled data on 334
patients from 17 institutions and noted overall survival
and recurrence-free survival of 48% and 46%,
respectively. Dulguerov et al23retrospectively reviewed
220 patients of olfactory neuroblastoma from 1975 to
1994 with a minimum 4-year follow-up. The 5-year
actuarial survival rate was 63% with 57% local control
rate. Batra et al18 studied 31 patients and calculated
overall survival was 86.2% and 58.6% at 2 and 5 years
respectively. They also found the disease-free survival
to be 64% and 51.7% at 2 and 5 years respectively.
Literature has witnessed better oncological results
with Esthesioneuroblastoma compared with other
sinonasal malignancies and hence results on only these
tumors cannot be extrapolated on other pathological
types22,24. The pathology of primary tumor was noted
to be an important predictor of survival in the
international collaborative study4. The 5-year disease-
free survival rates for Esthesioneuroblastoma, SCC, and
melanoma were 75%, 50%, and 27%, respectively. This
is very comparable to the 5-year disease-specific rates
of 88%, 51%, and 18% for the same three pathologies
reported by Bentz et al24. This comparison must be
viewed keeping in mind the small sample size in each
subgroup. We had 1 case of olfactory neuroblastoma
which was disease free on their last follow-up. Our 3
cases of malignant melanoma were managed
endoscopically and adjuvant radiotherapy was taken
by one patient. One case received immunotherapy post-
22 Vol.-11, Issue-I, January-June - 2017
surgery. Proper selection of cases amicable to endoscopic
resection forms the backbone of success in endoscopic
resection of sinonasal tumors. Accurate clinical and
radiological assessment of the lesion with neurosurgical
back-up is an added advantage 25,26. Tumors with
involvement of dura, orbital contents, palate and those
with intra-cranial extension were better managed with
open approaches26.
On the other hand, various concerns have been
raised regarding the safety and efficiency of this
technique as well. En-bloc resection of tumour was not
possible in most cases using this technique but literature
suggests that piece-meal resection has no oncological
disadvantage4,18,19,. Generous margins are often not
possible even in external approach owing to the close
proximity to critical structures and the delicate ethmoid
septations which prevent the specimen from being
intact. Moreover, multiple endoscopic series employing
the piecemeal approach have not demonstrated
compromise in survival17, 18, 19, 24. The anterior skull base
reconstruction was also an area of concern. However,
use of local flaps and free non-vascularised flaps with
fat and absorbable nasal packing material in multi-
layered technique provided excellent results13.Whereas
the endoscopic approach allows clear visualization
through different angled endoscopes, an external
approach relies primarily on tactile discrimination,
direct visualization and preoperative anatomic imaging
during tumour resection. The lack of tactile sensation
in endoscopic resection is compensated by the advanced
optics, powered instruments, magnified view and
navigation system17, 18, 19. The addition of intra operative
frozen section examination has undoubtedly improved
resection margins and oncological results, but is only
optimal when combined with adequate visualization
using an endoscope18, 19.
Despite the debate on the surgical approach, the
oncological objective of complete tumour removal with
adequate margins must be balanced with minimal
morbidity and better quality of life. At this juncture,
data from multiple reports suggests that the endoscopic
approach provides similar surgical objectives while
decreasing intra operative complications and
minimizing long-term patient morbidity compared to
the open techniques 1,4,17 . Our study is a single
institutional one, with a small sample size which needs
further addition over the next few years. Local
recurrence, poor outcomes, and decreased survival are

all associated with positive surgical margins4, 18.In our
series, there were no positive margins. Some of the cases
with significant inferior extension to the floor of the
nose, anterior extension onto the facial soft tissues,
lateral extension to the maxillary sinus, orbit,
pterygomaxillary space, or Infratemporal fossa were
taken up for a combined endoscopy assisted open
approach and are not included in this study. We had 3
cases (10%) of post-operative epistaxis which were
managed conservatively and 2 cases (6%) of hyposmia
on regular follow-up. Nicolai et al. noted mean
hospitalization time of 3.7 days for the exclusive
endoscopic group while it was 4.2 days for our patients.
Moreover, major complication noted in the exclusive
endoscopic approaches (6% CSF leaks), following dural
resection and repair. Successful separation of the
intracranial and sinonasal compartments and multilayer
reconstruction provides the best opportunity for water
tight closure for large skull base defects 4,5 .
Reconstruction was not a major problem in this series
as tumours transgressing the dura were not in the study.
In accordance with the work by Bentz et al24, adjuvant
radiotherapy was provided in tumors that had higher
T stage, high-grade pathology, positive margins, large
volume of disease, or extensive local invasion, bone
invasion, positive nodal status. Atrophic rhinitis,
blindness, frontal lobe necrosis, and radiation induced
malignancies were some adverse effects of radiotherapy
at this site noted in literature.
The challenges in endoscopic management of
sinonasal tumors begin with a proper case selection
using strict endoscopic and radiological parameters for
successful outcome and to prevent mishaps intra-
operatively4,5. The operating surgeon must be well-
versed in both; endoscopic nasal surgery and surgical
oncology principles which needs a prolonged learning
curve. The hospital should be dedicated and equipped
for managing critical patients with a good neurosurgical
support. A tailor-made, incremental, systematic
approach to increasing complex cases may improve
outcomes and decrease risk of complications. Relative
contraindications for endoscopic resection include
highly vascular tumors, extensive bilateral disease, and
significant orbital or Infra temporal fossa
involvement25,26. The surgeon must be well equipped
with skills and instruments to convert the planned
endoscopic procedure into an open approach if need
arises. Adjuvant radiotherapy using Intensity
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
modulated radiotherapy has improved the outcomes
with minimal toxicity18.
CONCLUSION:
Endoscopic resection of malignant sinonasal
tumours has made a path-breaking change in the
management of these cases. Providing similar
oncological safety with minimal morbidity and
improved cosmesis forms the corner-stone of this
technique. We uphold the fact that endoscopic
approaches are not a replacement to conventional open
techniques which have to be the choice in advanced
cases. However, with proper case selection, we could
provide the patient in selected cases with this alternative
option of endoscopic resection provided; the surgeon
is oncologically skilled and equipped to manage the
expected complications. Adequate expertise in skull base
reconstruction is also mandatory prior to embarking
on such surgical voyages, especially when dural breach
is noted, necessitating resection and reconstruction.
Endoscopic technique of resection and reconstruction
is indeed a boon to the new generation of skull base
surgeons in providing patient friendly results with
improved compliance.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) No financial disclosures
(e) Animal rights-Not applicable
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 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

ANTERIOR NASAL PACKING VS SEPTAL CLIPS TYPE III, IN POST

NASAL SEPTAL SUBMUCUS RESECTION & SEPTOPLASTY
SURGERIES: A COMPARATIVE STUDY
*CB Nandyal, **Ravy Udgir, ***LR Shankar Naik, ****Vinayak Kurle

HOW TO CITE THIS ARTICLE Date of receipt of article -30-12-2016

Nandyal C B, Udgir R , Shankar Naik L R, Kurle V.Anterior
nasal packing vs septal clips type III in post nasal septal submucus Date of acceptance 24-02-2017
resection & septoplasty surgeries: a comparative study. Orissa J DOI- 10.21176/ojolhns.2017.11.1.4
Otolaryngology Head Neck Surgery 2017 June; 11(1): 25-31.
DOI: 10.21176/ojolhns.2017.11.1.4 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.4

ABSTRACT:
Background & Objectives: The objective of present study is to compare 2 techniques of nasal packing after
SMR (submucus resection) or septoplasty surgeries i.e anterior nasal packing (ANP) & nasal septal clip type III
(NSCT).
Materials & methods: This is a prospective randomized comparative study including 50 patients above 18 years
who underwent SMR or septoplasty for deviated nasal septum (DNS). The patients were randomly divided into
two equal groups for nasal packing using NSCT or ANP.
Results: Intra operatively, packing with NSC was easier, faster. And support provided to the septum could be
assessed visually when compared to ANP (t = 7.52, p < 0.001). Trauma to mucous membrane occurred during
packing was 8% in ANP and 4% in NSC group. In immediate post op we noted headache, 20 % in NSC and 92%
in ANP, epiphora 12% in NSC and 100% in ANP. Sleep disturbance 16 % in NSC and 18 % in ANP, dysphagia
80% in ANP and 0 % in NSC and bleeding 20% in NSC who were managed with nasal decongestants (p<0.001).
At pack removal severe pain was experienced in 100% ANP and 8 % in NSC. Bleeding occurred during pack
removal was16% in ANP and 8 % in NSC (x2= 12.39, p<0.05). Follow up complications noted were synechiae
in 8% in ANP, 4% in NSC, septal hematomas in 4% in each. The necrosis of the mucous membrane was noted
in 4% in ANP group and treated conservatively. None suffered septal perforation.
Conclusion: Purpose of packing was served by both methods more or less equally but NSC was better tolerated
in post operative period with less post operative discomfort and follow up complications when compared to
ANP.
Keywords: Deviated nasal septum (DNS); SMR; Septoplasty; Nasal septal clip type III (NSC); conventional
anterior nasal packing (ANP).
Affiliations:
*Associate Professor &HOD,**Senior Resident,*** & ****Post graduate,
INTRODUCTION: Department of ENT
Though the history of nasal packing after Mahadevappa Rampure Medical College (MRMC)
Gulbarga, Karnataka, India
septoplasty or SMR dates back to 1847 from the time
Address of Correspondence:
of Gustay Killian of Germany & Otto Tiger Freer of Dr. Vinayak Kurle
USA, yet the systematic nasal packing post septoplasty Post Graduate
or SMR was started in 1882 by Ephraim in Chicago & Dept of ENT
M.R.Medical College
Peterson in Germany1 which was routinely followed Kalaburgi, Karnataka, India
for many decades to give the functional support to the Ph.: 9844035399.

Vol.-11, Issue-I, January-June - 2017 25

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

nasal septum with good flap opposition minimizing conventional anterior nasal packing with saline soaked
the risk of complication like bleeding & adhesions. antibiotic ribbon gauze (fig2) or with Nasal septal clip
However nasal packing itself causes postoperative type III (fig 1) on both sides of nose by dividing 25
distress, periorbital oedema, excessive lacrimation, patients for each study group randomly.
sleeplessness, dry mouth, cardiopulmonary In NSC Type III group after completion of
complications2, 3, 4 & some says its removal as the most surgery, the horizontal incision at lower border of
painful experience of their life2. Thus alternatives like mucoperiosteal flap on one side to drain any residual
BIPP gels5, Vaseline gauze, merocel6 were used to blood or collection in between the septal flaps. A cut
address mainly bleeding but other complications were was given along the dotted line in the middle of the
debatable7. septal soft rubber splint & lubricating it with
In this view Stucker & Ansel8 questioned the soframycin ointment was gently inserted by crimping
benefits of nasal packing, since then with alternative the splint through the nostrils and then along the floor
techniques using absorbable materials like platelet rich of nasal cavity & manipulated to pass medial to middle
gels6, tissue adhesives6, bovine gelatin mixed with & inferior turbinate to approximate both the flaps on
thrombin9, modified hyaluronase6 to obviate the need both sides. A thread is passed into the holes in the splint
of pack removal, but biocompatibility & cost issue was and tied loosely in front of columella. Then holding
raised9. To get out from this customary nasal packing the thread loop, the septal clip is held open by the nasal
alternative techniques like, through & through speculum and is introduced over the splint to make
absorbable sutures10, septal splints with quilting sutures sure that the metallic septal clip does not touch the
or clips 4,11, septal magnets12, were used with comparisons mucosa to maintain the septum in corrected position
with merits & demerits introduced without & post nasal bleed was checked to confirm the
standardization regarding the complete details of the hemostasis.
technique & purpose served along with postoperative
morbidity & complications. Hence a clinical
comparative study was conducted between customary
antibiotics soaked gauze nasal packing with that of
commercially available nasal septal clip type III
consisting of soft rubber splint & septal clip, to see
which technique is better overall & to give functional
support to nasal septum after post SMR & septoplasty
surgeries.
MATERIALS AND METHODS:
This is a prospective, comparative study of 50
patients conducted at M.R Medical College attached
Fig. 1- Nasal septal clip type III.
to Basaweshwara Teaching and General Hospital,
Kalaburgi from September 2010 to September 2011.
Ethical clearance was taken from the institute.
Informed and written consent was taken from all
patients of 18 yrs & above with thorough history and
clinical examination. Those who were diagnosed as
having DNS as the only cause for nasal obstruction
were included in study. They were all operated on the
basis of Cottles line, those DNS that were anterior to
line were subjected to Septoplasty and posterior to the
line were subjected to SMR.Post-surgery, bilateral nasal
packing was done after complete hemostasis using Fig.2- Anterior nasal packing.

26 Vol.-11, Issue-I, January-June - 2017

 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

In anterior nasal packing group, nasal packing was commercially available. As insertion of pack was
done using saline soaked ribbon gauze treated with concerned it was easy to introduce NSC T III but not
soframycin antibiotic cream was inserted to fill the nasal so easy with ANP .The time required for ANP was
cavity stalked layer by layer from floor to roof gently more compared to NSC T III.Mean and S.D for ANP
to approximate & support the nasal septal flaps on both is 4.32+/-1.12 and Mean and S.D for NSC T III is
sides & post nasal bleeding was checked for hemostasis. 2.04+/-1.03. Hence the statistical difference of time
Postoperative signs & symptoms like headache, required in packing is highly significant.
epiphora, dysphagia, disturbance of sleep, bleeding was The postoperative symptoms Headache, epiphora,
noted & tabulated. One day later nasal packing removed dysphagia, sleep disturbance, bleeding which occur after
& assessed for signs & symptoms suffered during pack surgery due to packing were compared and found that
removal. Follow up done weekly for one month & with NSC T III symptoms noted were Headache in 5
clinical observations were noted & any complication patients(20%), Epiphora in 3 patients(12%), dysphagia
was managed with minor intervention, conservatively. in 0 patients(0%), sleep disturbance in(4) patients(16%),
Finally both the groups were compared along with bleeding in 5 patients(20%).
statistical significance.
RESULTS: Table 2. Post- operative subjective signs & symptoms.
50 patients attending ENT, OPD with clinical
features of DNS were selected randomly. According
to Cottles line those who had anterior deviation were
subjected to Septoplasty and those posterior to line
were subjected to SMR. Two groups were made of 25
in each group irrespective of type of surgery for nasal
packing in the form of NSC Type III and anterior nasal
packing randomly. The following observations were
made, tabulated as below (Table-1).
Intraoperatively nasal packs were available in the
OT i.e ribbon gauze piece and antibiotic
soframycin,whereas NSC Type III were to make it

Table-1: Intra operative nasal comaprision.

Sense of discomfort in 4 patients (16%) out of total

25 patients (100%).Whereas in ANP group Headache
in 23 patients(92%), Epiphora in 25 patients (100%),
dysphagia in 20 patients (80%), sleep disturbance in 20
patients (80%), bleeding in 0 patients(0%), Senses of
discomfort in 23 pts (92%) out of total 25 patients (100%)
were noted (Table-2).
Looking at the x2 and p value for individual signs
and symptoms the study carries a significant difference

Vol.-11, Issue-I, January-June - 2017 27

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
between the two groups.In ANP group pain occurred
in all 25 patients during pack removal and bleeding in
4 patients, whereas in NSC T III group 2 suffered pain
during clip removal and 2 had bleeding. Statistically
x2=12.39, p<0.05 hence a significant difference
between the symptoms suffered during pack removal
(Table-3).
Table 3: Signs & Symptoms at pack technique and
findings removal.
Statistically x2=12.39, p<0.05.
FOLLOW UP INDEX
Table 4: Follow up index.
After follow up for a period of one month on
regular basis we found that with ANP group following
complications occurred necrosis of mucous membrane
in 0 pt (0%), septal haematoma in 1 patient (4%),
synechiae in 1 patient (4%), septal perforation in 0
patient (0%) of total 25patient (100%). In NSC T III
group the complications seen were necrosis of mucous
membrane 1patient(4%), septal haematoma 1patient
28 Vol.-11, Issue-I, January-June - 2017
(4%), synechiae 2pt (8%), septal perforation 0patient
(0%) of total 25pt (100%). Statistically there is no much
difference between the two groups (Table-4).
DISCUSSION:
In our study 50 patients were taken with only
symptomatic DNS in which 26 patients had anterior
deviation who underwent septoplasty and 24 patients
had posterior deviation that underwent SMR
respectively. Accordingly 2 groups were made; 25 in
each group irrespective of type of surgery for nasal
packing in the form of NSC TYPE III & conventional
anterior nasal packing randomly. Among study group
patients were in the age group of 18-50years with 26
males (41.7%) & 24 females (58.3%).
In all other studies the age group selected is 15
years and above11, 13, 15& in our study was 18 years and
above, for better compliance in terms of giving accurate
subjective signs and symptoms suffered in the immediate
post-operative period and in follow up period. The
other reason would be that the septal splint and clip
are available in sizes to fit this age group. As far as
ANP is considered it can be done in any age group. In
total the age distribution & sex does not have any
significant attribute towards our study.
The parameters of intra-operative technique of
packing have not been commented upon in literature
for comparison.
As insertion of pack was concerned it was easy
to introduce NSC Type III but not so easy with ANP
with minor difference in mucosal trauma which varies
& depends on the care taken during the insertion of
nasal packing technique used. The time required for
ANP was more as it require more time in assessing the
pack insertion layer by layer with equal amount of pack
to be inserted on both sides when compared to NSC T
III which can be directly applied under direct vision
with equal pressure on both sides of nasal septum.
Visual Assessement of bilateral pressure was possible
with the NSC TypeIII as the pressure is constant and
predetermined as per the make whereas with ANP this
was not so because the volume of gauze could fill any
of the corner of nasal cavity. So mean time consumed
for ANP is more than NSC type III as the mean time

S.D for ANP is 4.32+/-1.12 and Mean time S.D for
NSC T III is 2.04+/-1.03. Hence the statistical
difference (p<0.001) of time required in packing is
highly sinificant. In Anand et al study on septal clips
and ANP group4, the technical details & advantages of
insertion & time duration was not mentioned.
So technically when intraoperatively compared for
conventional ANP, NSC type III is better as it is more
easy, quick, under direct vision for proper assessement
to support the operated septum except the cost &
availablity.
Postoperative observation on symptom & sign
noted in our study in ANP group were Headache in
92%, Epiphora in 100%, Dysphagia in 80%, Sleep
disturbance in 80%, bleeding in 0%, Sense of discomfort
in 92% as compared to study conducted by Md Sohail
Awan et.al in ANP group Headache in 90.90%,
Epiphora in 100%, Dysphagia in 95.50%, Sleep
disturbance in 81.8%, bleeding in 0%, Sense of
discomfort was not commented13. In M.M.Adrehali
et.al study, pain as per Visual Analogue Scale (VAS) - 5
was noted11. In Al Raggad et.al study bleeding noted
was 13% in the ANP group14. In Anand et al study
headache was 72.5%, dysphagia 95%, epiphora 100%,
bleeding 3%, dryness of mouth 40%4. As per the above
data the subjective signs and symptoms suffered in
immediate post operative period were more or less
similar when compared to ANP groups of other studies.
The post operative complaints are attributed to the effect
of complete block of Nasal Cavity and pressure of the
ANP on Lateral wall of the nose.
In our study with NSC TypeIII we noted
Headache in 20%, Epiphora in 12%, Dysphagia in 0%,
Sleep disturbance in 16%, bleeding in 20 %, Sense of
discomfort in 16%. In the study by Md Sohail Awan
et.al they used through and through suture and
observed Headache in 20.50%, Epiphora in 11.40%,
Dysphagia in 4.50%, Sleep disturbance in 15.90%,
bleeding in 2.30%, Sense of discomfort were not
commented13. In M.M.Adrehali et.al study quilting
suture group, pain as per Visual Analogue Scale (VAS)
2 was noted11. In Al Raggad et.al study suture group,
bleeding noted was 15.3 %14. In Anand et al study on
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
septal clips showed headache was 15%, dysphagia 2%,
epiphora 3%, bleeding 0%, dryness of mouth 4%4 . In
this regard if we look at the data in the table the
technique of NSC T III and through and through
suturing, quilting suturing with 30 vicryl5 or septal
clips4 had not much significant difference in terms of
subjective signs and symptoms except bleeding in
immediate post- op up to 24 hrs period.
Coming back to our comparative clinical study it
is evident by our data that for the individual
postoperative signs & symptoms the study carries a
significant difference between the two groups as the
p<0.05 for all postoperative symptoms where NSC
Type III scores 5-8 times more better than the ANP.
During Pack removal in our study in ANP group
pain was seen in 100% and some complained it as most
horrible experience of life .Similarly in Md Sohail
study it was 97.80%13 and in M.M.Adrehali study it
was 10%11. Bleeding was seen 16% and in Md Sohail
study 13 and in M.M.Adrehali study it was not
commented, whereas in Al Raggad study it was 4.8%14.
So when compared to other studies, pain and bleeding
is directly attributed to ANP as it causes pressure and
ulceration on nasal mucus membrane.
In NSC T III group in our study pain was noted
in 8%, in Md Sohail study it was 0%13 and in M.M
Adrehali study it was 0% in suturing group11. Bleeding
was noted in 8%, in Md Sohail study it was 0%13 and in
M.M Adrehali study it was 0% in suturing group11.
Minimal pain and bleeding experienced in our study is
attributed to pressure effect of clipping on nasal septum
and in other study the suture material used is absolutely
not removed in post operative period. Coming back
to our study pain and bleeding is 10 times less in NSC
T III group when compared to ANP group. So NSCT
III is an excellent packing method compared to ANP
as far as pack removal is considered.
During follow up period of one month in our
study of ANP group we noted necrosis of mucous
membrane in 4%, septal haematoma in 4% and
synechiae in 8% was less when compared to Anand et
al study had synechiae in 12.5% & raw area/mucosal
necrosis in 25% & residual DNS 7.5% 4, in Md Sohail
Vol.-11, Issue-I, January-June - 2017 29
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
Awan (et.al) study which were necrosis of mucous
membrane in 57% and septal haematoma in 7%,
synechiae in 18%13, in M.M.Ardehali (et.al) study 3%
synechiae and 3% septal perforation was noted11, in Al
Raggad et. al study septal haematoma in 4.8% synechiae
in 5.9% and septal perforation in 2.4% was noted14. In
Z.M.Raahat et.al study 2.7%, septal haematoma was
noted10. The lower incidence of complications in our
study is attributed to use of saline soaked antibiotic
ribbon gauze.
In our study in NSC type III group septal
haematoma in 4% and synechiae in 4% was noted and
when compared to Anand et al study had synechiae in
2.5%, raw area /mucosal necrosis in 17.5% & residual
DNS 7.5% 4, in M M Ardehali (et.al) study synechiae
in 2% and septal perforation in 1%11, in Al Raggad (et.al)
study synechiae in 1.1% was noted14. In our study all
the complications which occurred were treatable. The
complication which occurred in Anand et al (residual
DNS), in M.M.Ardehali et.al study and Al Raggad
study (i.e. septal perforation) caused due to the suture
which causes trauma to flaps bilaterally and the knot
pulls on itself were difficult to treat. The treatment
protocols for septal perforation & residual DNS repair
are also controversial.
In our comparative study the complications noted
in both groups except synechiae which occurred in 8%
in ANP group as compared to 4% in NSC T III group.
This is because the packs exert pressure on both the
septum and lateral wall of nose when compared to NSC
T III which exerts pressure on the septum only and the
pressure induced is less than the capillary pressure as
per the make.
So NSC T III is better in giving less follow up
complications than ANP.
CONCLUSION:
The Comparative results confirmed that patients
with ANP and NSC T III were benefited more or less
equal as per the purpose of nasal packing was considered
to give functional support to septum but the objective
evidence suggests that, NSC T III was technically quick,
easy to insert under direct vision in giving uniform
support on both sides of septum and can be removed
30 Vol.-11, Issue-I, January-June - 2017
with minimal tolerable pain. The subjective signs and
symptoms in the immediate postoperative period and
the follow up complications were significantly less
compared to ANP group. As far as ANP is concerned
except for its availability and cheaper cost we did not
find any advantage.
So we conclude that, those who underwent septal
surgeries with NSC T III as a packing method, were
benefited more though being costly.
In the last in our opinion when NSC T III is
available it is advisable to use the same to merit its
advantages to the patients.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships None
(c) Funding - None
(d) Written consent of patient- taken
(e) Animal rights- Not applicable
REFERENCES:
1. Wolfgang Pirsig; The origins of systematic SMR
of the nasal septum, facial plastic surgery;
2006;22:217-22.
2. Fairbanks DN. Complications of nasal packing.
Otolaryngol Head Neck Surg 1986 Mar;
94(3):412-15.
3. Sunita C, Inita Matta, Pratima Marker .
Comparision of blind nasal packing vs endoscopic
control of epistaxis in emergency setting;
international journal of head & neck surgery, may-
august 2011;2(2); 79-82.
4. Anand V, Sachin H, Santosh S. Nasal septal clips:
An alternative to nasal packing after septal
surgery? Indian J otolaryngol head neck surg;
Oct- Dec 2012; 64(4): 346-350; DOI 10.1007/
s12070-011-0388-2.
5. S Shah, S Kumara, N Thappa. Outcomes of
endoscopic quilting of nasal septum versus nasal
packing following septoplasty. The internet
Journal of Otorhinolaryngology; 2010; vol 13;
No 2.
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6. Weber RK .Nasal Packing & Stenting, GMS

current topics in Otorhinolaryngology- head &
neck surgery 2009, vol 8, https://
www.ncbi.nlm.nih.gov/pmc/articles/
PMC3199821.
7. Basha SI, Gupta D, Kaluskar SK. Routine nasal
packing following nasal surgery-Is it necessary?
Indian J Otolaryngol Head & Neck Surg, 2005
Jan;57(1):69-71. DOI:10.1007/BF02907637.
8. Stucker FJ, Ansel DG. A case against nasal
packing. Laryngoscope 1978;88(8 Pt 1):1314-17.
9. Reiter D, Alford E, Jabourian Z. Alternatives to
packing in septorhinoplasty. Arch Otolaryngol
Head Neck Surg 1989 Oct;115(10):1203-5.
10. Z.M.Raahat, Nadeem Uddin Naqvi,
NusratRaza,Qazi Ahsan Azeem,RajaMushtaq
Hussain JavedIqbal,Babar Hussain : Post SMR
Intranasal Packing Do We Really Need It?
Pakistan Journal Of Otolaryngology
2008;24:66-67.
11. M.M.Ardehali, S Bastaninejad. Use of nasal packs
and intranasal septal splints following septoplasty.
International J Oral Maxillofac. Surg.
2009oct;38(10):1022-24, doi:10.1016/
j.ijom.2009.05.012.Epub2009Jul 4
12. Albert P seltzer, The use of magnets to maintain
centralization of the nasal septum following
submucus resection: Journal of the national
medical association; 1968 May; 60( 3).210-12
13. Md sohail Awan, MoghiraIqbal. Nasal packing
after septoplasty: a randomized comparison of
packing versus no packing in 88 patients. Ear Nose
Throat J. 2008 Nov;87(11):624-7, PMID:19006062
14. Al-Raggad Daifallah K; El-Jundi Ali M; Al-
Momani Osama S; Al-Serhan Mefleh M;
Nawasrah Omar O; Qhawi Muafaq A;
Husban Adnan M; Suturing Of The Nasal
Septum After Septoplasty, Is It An Effective
Alternative To Nasal Packing?Saudi Medical
Journal 2007, Oct; 28(10):1534-36
15. Muhammad Hafeez, Inayatullah, Kamran Iqbal,
Zakirullah; Septoplasty without nasal packing
Gomal Journal of Medical Sciences July-December
2010, Vol. 8, No. 2:141- 142.

Vol.-11, Issue-I, January-June - 2017 31

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

COMPARISON OF HEARING RESULTS OF TYPE III

TYMPANOPLASTY WITH MASTOIDECTOMY WITH OR
WITHOUT AUGMENTATION OF STAPES HEAD
*Netra A Pathak, *Vidya V Rokade

HOW TO CITE THIS ARTICLE Date of receipt of article - 08-02-2017

Pathak Netra A, Rokade Vidya V. Comparison of Hearing results of Date of acceptance 21-02-2017
type III tympanoplasty with mastoidectomy with or without
augmentation of stapes head. Orissa J Otolaryngology Head Neck DOI- 10.21176/ojolhns.2017.11.1.5
Surgery 2017 June; 11(1): 32-36. DOI: 10.21176/ojolhns.2017.11.1.5
DOI URL- https://doi.org/10.21176ojolhns.2017.11.1.5

ABSTRACT:
Background: To assess and compare the hearing results in patients undergoing tympano mastoidectomy with
classical type III tympanoplasty using temporalis fascia alone and with cartilage augmented type III tympanoplasty.
Methods: Patients of 5 years of age or more with the diagnosis of chronic otitis media (squamous) with conductive
or mixed hearing loss, who underwent classical type III tympanoplasty with or without cartilage augmentation,
were included in the study. Pure tone audiometry (PTA) was performed and patients were clinically evaluated.
Post- operative hearing was assessed in terms of average air bone gap (ABG) and size of ABG closure. Post-
operative hearing results were compared in between classical type III and cartilage augmented type III tympanoplasty
groups.
Results: When comparing average post-operative ABG and size of ABG closure between classical and cartilage
augmented type III tympanoplasty, cartilage augmented group showed marginally better results but this difference
was statistically not significant.
Conclusions: Hearing results after type III tympanoplasty varied widely. There was no statistically significant
improvement in post-operative hearing results in cartilage augmented tympanoplasty when compared to classical
type III tympanoplasty, suggesting possibility of the effects of multiple other factors.

INTRODUCTION: The goal of tympanoplasty is to restore sound

Chronic otitis media (COM) is a common pressure transformation at the oval window by coupling
condition, affecting 0.530% of any community. an intact tympanic membrane with a mobile stapes
Therefore, a conservative estimate of the number of footplate via an intact or reconstructed ossicular chain
people in the world suffering from COM is over 20 and to provide sound protection for the round window
million1. The prevalence of squamous type of chronic
Affiliations:
suppurative otitis media (CSOM) is 3.5%2. The objective
*Professor,** Associate Professor
of tympanomastoid surgery for chronic otitis media, Smt. Kashibai Navale Medical College & General Hospital, Pune
in decreasing order of priority are elimination of disease (Maharashtra)
to produce safe and dry ear; alteration of anatomy to Corresponding address:
prevent recurrent disease, optimization of cleaning and Dr.Vidya V.Rokade
A-2,303 Sun Empire, Sun City Road
otological monitoring; and reconstruction of the middle Vadgaon Bk., Pune-51
ear to achieve serviceable and stable postoperative Phone no. 9922160881
E-mail- vidyarokade@hotmail.com
hearing 4.

32 Vol.-11, Issue-I, January-June - 2017


membrane by a closed, air containing, mucosa lined
middle ear3. The modern era of tympanoplasty was
ushered in by Wullstein and Zollner. Wullstein
classified the operations as types I through V4.
In classical type III tympanoplasty or
myringostapediopexy, disease is removed from
tympanomastoid compartment and advancement of the
tympanic membrane (TM) or placement of tissue graft
is done on top of the stapes capitulum. After this
procedure, air-bone gap (ABG) range is around 10-60dB.
Merchant et al. in laboratory model demonstrated that
improved hearing results could be achieved in
myringostapediopexy by interposing a thin cartilage
disc between the graft and stapes head4. For augmented
type III tympanoplasty, either cartilage or sculptured
cortical bone can be kept between the intact stapes and
the fascial graft3.
Cartilage disc was hypothesized to improve the
effective vibrating area of the graft that was coupled
to the stapes head. Cartilage also offers the advantage
of higher mechanical stability compared with
membranous transplants thus preventing retraction of
tympanic membrane in the long run but others argue
that it may alter the acoustic transfer characteristics of
the graft due to its increasing mass and stiffness of the
reconstructed tympanic membrane.
MATERIALS AND METHODS:
A Prospective study was performed from October
2006 to April 2008. Patients who were 5 years and
above of both sexes with intact and mobile stapes
suprastructure at tympanomastoidectomy surgery for
COM squamous type were included. Total number of
patients enrolled during the study were 80. Out of
which CWD(canal wall down) mastoidectomy.and
classical type III tympanoplasty was done in 40 patients
and CWD mastoidectomy and cartilage augmented type
III tympanoplasty in another 40 patients.
Pure Tone Audiometry was performed within
seven days prior to the operation. The test was
performed through Air Conduction and Bone
Conduction mode. Air and Bone Conduction threshold
were calculated by taking the averages of 500, 1000,
2000 and 4000 Hz frequencies. The ABG was calculated
by taking differences between Air conduction and Bone
Conduction threshold. The Air and Bone conduction
threshold were recorded both pre and post-operatively.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Postoperative ABG closure was calculated by taking
the difference between preoperative and postoperative
ABG of the average frequencies of 500, 1000, 2000 and
4000 Hz. Audiometry results were reported. For
classical type III tympanoplasty, a temporalis fascia graft
was used to bridge the middle ear air space and placed
in contact with the stapes head. For cartilage
augmentation, thin disc of conchal cartilage of partial
thickness and of 4-6 mm in diameter was interposed
between the stapes head and temporalis fascia graft.
Cartilage disc did not touch the external auditory canal
or facial nerve canal.
The follow up was performed after 10th week
postoperatively. During follow up, patients were
subjected to pure tone audiometry (PTA) assessment.
Results were analyzed in terms of average postoperative
ABG and ABG closure. The results between both were
compared. The data analysis was performed with the
help of SPSS 11.5 software package. P value was
calculated using the independent samples test and P
value of < 0.05 was taken as significant.
RESULTS:
Total numbers of patients enrolled during the
study were 80. Out of which CWD mastoidectomy
and classical type III tympanoplasty was done in 40
patients and CWD mastoidectomy and cartilage
augmented type III tympanoplasty in another 40
patients.
The difference in post-operative ABGs between
classical type III tympanoplasty and cartilage augmented
type III tympanoplasty at different frequencies (500Hz,
1000Hz, 2000Hz, and 4000Hz) were analyzed and
found to be statistically not significant. The difference
in four frequency average post-operative ABG between
these two groups was also found to be statistically not
significant with p value of >0.001.
However, the post-operative ABG was better by
2.5dB and 1.5dB at frequencies 500Hz and 2000Hz in
cartilage augmented type III tympanoplasty as
compared to classical type III tympanoplasty, but it
was worse by 1.3dB and 2.2dB at frequencies 1000Hz
and 4000Hz in cartilage augmented type III
tympanoplasty as compared to classical type III
tympanoplasty. On an average, there was 0.1dB
improvement in cartilage augmented type III
Vol.-11, Issue-I, January-June - 2017 33
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
tympanoplasty as compared to classical type III
tympanoplasty, which was statistically not significant
(Table 1).
Table 1 : Comparison of frequency wise post-operative
PTA-ABG between patients with classical type III
tympanoplasty and cartilage augmented type III
tympanoplasty(n=40 each group)
Table 2: ABG Closures in different categories (n=40
each group)
34 Vol.-11, Issue-I, January-June - 2017
However, in CWD mastoidectomy and cartilage
augmented type III tympanoplasty, ABG closure was
good at frequencies of 1000Hz, 2000Hz, and 4000Hz
and was average as compared to CWD mastoidectomy
and classical type III tympanoplasty whereas it was
worse in 500Hz . The ABG closure was again divided
into different categories like 0-5dB, 0-10dB, 0-20dB, 0-
30dB and 0-40dB. It was noted that 3(7.5%) cases fell
within 0-5dB and 12(30%) cases within 0-20dB in CWD
mastoidectomy and cartilage augmented type III
tympanoplasty whereas 4(10%) cases within 0-5dB and
12(30%) within 0-20dB in CWD mastoidectomy and
classical type III tympanoplasty. (Table 2).
DISCUSSION:
The objectives of this study were to access, analyze
and compare post-operative hearing results in terms of
average ABG and the size of ABG closure in patients
of classical type III tympanoplasty using temporalis
fascia alone and with cartilage augmented type III
tympanoplasty with masoidectomy. During the length
of follow up, there were no cases of cartilage extrusion.
Different methods have been used by different authors
to report the pure tone audiometric post-operative
hearing results in middle ear surgery in the literature.
Among these ABG closure, post operative ABG
presented in 10 dB bins and air conduction threshold
gain are commonly reported indicators of
tympanoplasty outcome. We had applied average PTA-
ABG and size of the ABG closure for audiological
assessment. For calculation of the size of the post-
operative PTA- ABG closure ABGs were divided into
different bins of 0-5dB,0-10dB,0-20 dB,0-30 dB, and
>30 dB.
In our study, while comparing the average post
operative air bone gaps between classical type III
tympanoplasty and cartilage augmented type III
tympanoplasty at various frequencies the differences
were found to be statistically not significant (P>0.001).
The difference in four frequency average post-operative
air bone gap between these two groups was also found
to be statistically not significant with a p value of 0.965.
However, the post-operative ABG was better by 2.5
dB and 1.6 dB at frequencies 500Hz and 2000Hz in
cartilage augmented type III tympanoplasty as
compared to classical type III tympanoplasty but it was
worse by 1.4 dB and 2.3 dB at frequencies 1000Hz and

4000 Hz in cartilage augmented type III tympanoplasty
as compared to classical type III tympanoplasty. Our
findings are to some extent in agreement with those of
Merchant et al who observed a 5 dB improvement at
250Hz, 500Hz and 2000Hz with interposition of thin
disc of cartilage between the graft and the stapes head
in both of their temporal bone model as well as in their
clinical study6. Variation in functional hearing results
between the two studies may also have occurred due to
this difference in the technique used. While analyzing
the frequency wise post-operative average PTA-ABG
in both the groups it was seen that ABG was the smallest
at 2000 Hz as compared to other frequencies. Similar
findings were also noted by Merchant et al in 20037.
Similarly, there is no clear explanation for the cause of
the air conduction thresholds showing to be the lowest
at 2000Hz however; it could have resulted from
resonances generated in the mastoid cavity and ear canal.
Twenty (52.6%) cases in classical type III
tympanoplasty of our study fall within 30 dB ABG
closure. Our result following classical type III
tympanoplasty compare well with myringos-
tapediopexy as a tympanoplasty procedure in canal wall
down mastoid surgery as reported by Cheang et al (n
=22) who observed PTA-ABG closure within 30 dB
in 61.9 % of his patients8.
Our results however are different from those of
natural myringostapediopexy (n=15) and surgical canal
down myringostapediopexy (n=35) as reported by
Dawes who observed PTA ABG closure within 30 dB
in 87.0 % and 90.0% of his cases in these two groups
respectively 9 ,10.
Another study performed by Cook et al showed
that the ABG closure in CWD mastoidectomy with
cartilage from stapes to drum technique were 30%
within 10 dB, 69% within 20 dB and 75% within 30 dB
which are close to our results11. In our study, 20 (58.8%)
cases in cartilage augmented type III tympanoplasty fell
within 30 dB ABG closure. Cheang et al in his
myringolenticulopexy group (n= 20) achieved an ABG
of less than 30 db in 92 % and ABG of less than 20 dB
in 64% of has cases8. Moustafa and Khalifa in their
myringo-cartilago-stapediopexy group (n=95) achieved
an ABG of less than 20 dB in 84%10. Kyrodimos et al in
their cartilage shield type III tympanoplasty (n=52)
using a 0.8 mm thick cartilage piece with no capitulum
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
for stapes head report that post-operative PTA-ABG
of 25dB or less was achieved in 41 (79%) of patients and
of 20 dB or less in 54% of patients12. However their
study included both canal wall up and canal wall down
procedures13. One year after surgery, a post-operative
ABG of 20 dB or less occurred in 84.3% (n=27) of
patients and this after a mean follow-up of 7 years, post-
operative ABG of 20 dB or less occurred in 81% (n =
26) of patients. Another factor leading to failure of
tympanoplasty is total or partial non-functional results
which are often influenced by wide variability in the
surgical techniques employed, criteria used to evaluate
hearing results and a number of other anatomical,
physiological and pathological events that occur post-
operatively in the middle ear as mentioned above. It
must be remembered that fibrosis could be due to the
underlying middle-ear or upper airway pathology that
caused the disease it may not be caused, in part or
full, by surgery. Equally important may be the extent
of destruction by the disease that may adversely affect
the ultimate functional results. Such issues may be more
relevant in an underdeveloped country like ours.
CONCLUSION:
The post-operative PTAABG ranged from 15
61.2 dB in classical type III tympanoplasty while the
post-operative PTA ABG ranged from 15 47.5 dB in
cartilage augmented type III tympanoplasty, suggesting
the possibility of effect of multiple other factors .The
post-operative PTA-ABG was 2.5dB and 1.6dB less at
frequencies 500Hz and 2000Hz in cartilage augmented
type III tympanoplasty as compared to classical type
III tympanoplasty but this difference was not
statistically significant. In comparison of size of ABG
closure between classical and cartilage augmented type
III tympanoplasty, cartilage augmented group showed
marginally better results. In classical type III
tympanoplasty 30% (12) cases and 32.5% (13) cases in
cartilage augmented type III tympanoplasty fell within
30 dB ABG closure. But this difference was statistically
not significant. However, cartilage augmentation type
III tympanoplasty in canal wall down mastoid surgery
is a worthwhile procedure.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships None
(c) Funding - None
Vol.-11, Issue-I, January-June - 2017 35
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
(d) Written consent of patient- taken
(e) Animal rights- Not applicable
REFERENCES:
1. Sad J. Introduction. (eds) Cholesteatoma and
mastoid surgery. illus, Kugler Publications BV,
Amsterdam, The Netherlands, p-1-3. 1982.
2. Adhikari P, Sinha BK, Pokhrel NR, Kharel B,
Aryal R, Ma J. Prevalence of chronic suppurative
otitis media in school children of Kathmandu
District. Journal of Institute of Medicine. 2007;
29(3):10-12.
3. Merchant SN, Rosowski JJ. Auditory
physiology.Glassock-Shambough Surgery of the
Ear, 5th edition. Elsevier India, New Delhi.2003,
64-78.
4. Merchant SN, McKenna MJ, Rosowski JJ.
Current status and future challenges of
tympanoplasty. Eur Arch Otorhinolaryngol.
1998; 255:221228.
5. American Academy of Otolaryngology-Head
Neck Surgery Foundation, Inc. Committee on
Hearing and Equilibrium guidelines for the
evaluation of results of treatment of conductive
hearing loss. Otolaryngol Head Neck Surg. 1995;
113:186-7.
6. Merchant SN, McKenna MJ, Mehta RP, et al.
Middle ear mechanics of type III tympanoplasty
36 Vol.-11, Issue-I, January-June - 2017
(stapes columella): II clinical studies. Otol
Neurotol 2003; 24(2):186 94.
7. Goode RL, Friedrichs R, Falk S. Effect on hearing
threshold of surgical modification of the external
ear. Ann Otol Rhinol Laryngol.1977; 86:441451.
8. Cheang PP, Kim D, Rockley TJ.
Myringostapediopexy and myringolenticulopexy
in mastoid surgery. J Laryngol Otol. 2008;
17(3):1-5.
9. Dawes PJ. Myringostapediopexy: surgical
expectation The Journal of Laryngology &
Otology. 2003 March; 117:182185.
10. Moustafa HM, Khalifa MA. Tympano-cartilago-
stapediopexy: a method to improve hearing in open
technique tympanoplasty. J Laryngol Otol. 1990;
104:942-4.
11. Cook JA, Krishnan S, Fagan PA. Hearing results
following modified radical versus canal-up
mastoidectomy. Ann Otol Rhinol Laryngol .1996;
105(5):379-83.
12. Kyrodimos E, Sismanis A, Santos D. Type III
cartilage shield tympanoplasty: an effective
procedure for hearing improvement. Otolaryngol
Head Neck Surg. 2007; 136(6):982-5.
13. Malafronte G, Filosa B,and Mercone F. A new
double cartilage block ossiculoplasty: long term
results. Otol Neurotol 2008; 29:531-33.
 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

UTILITY OF HADAD FLAP IN RECONSTRUCTION OF

ANTERIOR SKULL BASE DEFECTS FOLLOWING
ENDOSCOPIC TRANSNASAL, TRANS SPHENOIDAL
APPROACH TO PITUITARY-OUR EXPERIENCE
*Harshita V. Sabhahit, **Shruthi GS, ***Santosh AN, ****G Prabhakar, *****Ananthkrishnan

HOW TO CITE THIS ARTICLE Date of receipt of article -08-02-2017

Harshita V.S, Shruthi GS, Santosh AN, G Prabhakar, Ananthkrishnan.
Utility of Hadad flap in reconstruction of anterior skull base defects Date of acceptance 25-04-2017
following endoscopic transnasal, Trans sphenoidal approach to DOI- 10.21176/ojolhns.2017.11.1.6
pituitary-our experience. Orissa J Otolaryngology Head Neck Surgery
2017 June; 11(1): 37-42. DOI: 10.21176/ojolhns.2017.11.1.6 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.6

ABSTRACT:
Objective: To study the utility of Hadad flap in reconstruction of anterior skull base defects following endoscopic
transnasal, transsphenoidal approach to pituitary tumours in conjunction with multi-layered reconstruction.
Setting: The study was conducted in the departments of Otorhinolaryngology and Neurosurgery in a tertiary
care referral hospital.
Patients: 20 consecutive patients with pituitary tumours underwent endoscopic transnasal transsphenoidal
approach for resection followed by reconstruction of consequent skull base defects with Hadad flap in conjunction
with multilayered approach.
Results: 3 out of 20 (15%) patients had early postoperative CSF leak, 2 out of which ceased after repositioning
of malaligned Hadad flap.1/20 (5%) patients continued to have delayed postoperative CSF leak.
Conclusion: Hadad flap has proved itself to be the workhorse of anterior skull base reconstruction in most
instances. It has heralded an era of vascularised flap based reconstruction in endoscopic transnasal transsphenoidal
surgeries.
Key words: Nasoseptal flap, endoscopic transnasal transsphenoidal surgery.

INTRODUCTION: transnasal transsphenoidal surgeries as an approach to

Hadad flap has been proven to be the work horse pituitary tumours.
for anterior skull base defects in most instances. It is
very effective in separating the nasal cavity from the
Affiliations:
cranial cavity and has proven to be very robust. It helps *, ** Assistant Professors,Dept of ENT, ***Associate Professor,Dept. of
in preventing ascending infection into the cranial cavity ENT, ****Professor ,Dept of ENT, *****Professor and HOD, Dept of
and is very useful in preventing CSF leaks. It is based Neurosurgery. Vydehi Institute of Medical Sciences and Research Center,
Bangalore.
on the posterior septal branches of sphenopalatine Corresponding Author:
artery. The pedicle is very stable and provides adequate Dr Harshita V.Sabhahit
supply to the flap ensuring good reconstructive results. #1052, 11th Main, Judicial Layout, GKVK Post,
Bangalore- 560065
In this study we present our experience with
Ph: 9886025627
reconstruction using the Hadad flap for endoscopic Email id: havisa276@gmail.com

Vol.-11, Issue-I, January-June - 2017 37

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
MATERIALS AND METHODS:
20 patients who came to our institute with
pituitary tumours were operated. Detailed history was
taken and a complete clinical examination including
neurological work up, ophthalmological work up and
hormonal level evaluation was done. CT scan of nose,
paranasal sinuses and brain with one millimetre cuts in
all planes along with MRI of the brain was done.
Informed and written consent was taken from all
patients. The institutional ethics committee approval was
taken.The procedures were performed by a team of
neurosurgeons and otolaryngologists at our institute.
After intubation and an oropharyngeal pack, the nasal
mucosal corridor was decongested with cottonoids
dipped in a combination of 4% lignocaine and 1:10,000
adrenalines. The nasal septums on either sides or middle
turbinates were infiltrated adequately with 1 in 100,000
adrenaline under endoscopic guidance (zero degree,
4mm wide, and 18cm length). Partial middle
turbinectomy was done in order to visualize superior
turbinate and sphenoidal ostium. The first incision was
made at the junction between nasal floor and septum
postero-anteriorly. If a larger defect was expected, the
incision was taken more laterally along the floor of the
nose to increase the width of the flap. The second
incision was made along the inferior most aspect of
the sphenoidal opening and advanced superiorly and
anteriorly, the limit being the septo columellar junction.
Care was not to include the olfactory mucosa and the
dorsal strip of cartilage. The third vertical incision
connected to the most anterior aspect of the previous
two incisions. The nasoseptal flap was then elevated
using an elevator in the mucoperichondrial and
mucoperiostial plane from anterior to posterior
direction till the posterior choana. A relaxing incision
was made along the arch of the choana to increase the
range of rotation. This flap was placed temporarily in
the nasopharynx or the maxillary sinus after rotating
so as to prevent damage during tumour removal and
to obtain a better access to the tumour site. This was
followed by posterior septectomy. Mucoperiostium of
the sphenoidal rostrum was elevated bilaterally.
Widening of the sphenoid ostium was done bilaterally
so as to open the anterior face of sphenoid and gain
access into the sphenoid cavity. Intersinus septum was
identified and dissected. Mucosa of the sphenoid sinus
38 Vol.-11, Issue-I, January-June - 2017
resected after visualizing internal carotid artery bulge
and optico carotid recess. Sella was identified and the
floor was thinned out upto the limit of tuberculum
sellae superiorly and cavernous sinuses bilaterally thus
exposing the dura. After placing incision over the dura,
the tumour was visualized and resected meticulously
using a two surgeos, two/four handed technique
wherein one surgeon handled the endoscope and a
dissector and the other surgeon provided suction and
held a forceps. After excision of the tumour, the
reconstruction was done using surgicel, fascia lata, fibrin
glue and flap. The dead space after tumour removal
was filled with surgicel, fascia lata was placed in an
underlay fashion and then the dural defect along with
sellar floor was covered with Hadad flap sealed with
fibrin glue. This was followed by packing bilateral nasal
cavities with Merocel after ensuring haemostasis. Prior
to this, a barrier of gelfoam was created over the flap
so as to prevent misplacement of the graft during nasal
pack removal. Under the cover of intravenous
antibiotics, the nasal pack remained insitu for 3 days.
Imaging was done in the form of CT scan with contrast
on the first post operative day to check for evidence of
residual tumours. Patients were placed on bed rest with
head end elevation of 30 degrees and asked to avoid
straining. The pack was removed on the 3 rd post
operative day.
The patients were followed up after 1 week, 2
weeks, one, two , three and six months and one year
after surgery.
RESULTS:
Out of the 20 consecutive patients who were
operated, eight were females and twelve patients were
males, with ages ranging from nineteen to sixty two(19-
62yrs.). Most of the patients presented with headache
and diminished vision. 3 patients had
craniopharyngioma, one with Rathkes pouch cyst,
while the rest had pituitary macroadenoma. Patients
were operated using endoscopic transnasal
transsphenoid approach. All the skull base defects were
repaired using Hadad flap and fibrin glue. Fascia lata
was used in 18 patients in an underlay fashion for added
support to the flap. Intraoperative CSF leak was noted
on table in 10 patients. Three (15%) of the above patients
who had intraoperative CSF leak had post operative
leak too. When re-explored surgically, the Hadad flap
 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

had misaligned due to loss of alignment between the

bony defect and the flap in two patients. CSF leak
ceased after repositioning the flap. One (5%) of the
patient continued to have CSF leak after replacing flap

Fig.-4: Incisions on superior part of septum and floor.

Fig.-5: Tumour Exposure.

Fig.-1. Preoperative CT images showing Pituitary

tumours.

Fig.-6: Skull base defect after tumour resection.

Fig.-2: Inferior limit of pedicle above choana.

Fig.-3: Superior limit of pedicle below sphenoid os. Fig.-7: Reconstruction with surgicel.

Vol.-11, Issue-I, January-June - 2017 39

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
Fig.-8: Reconstruction with Hadad flap.
and this had to be strengthened with additional fascia
lata, fat and fibrin glue. In this particular patient the
tumour had invaded the arachnoids membrane. Minimal
crusting was noted in the immediate postoperative
followup period which may be attributed to the post
posterior septectomy status. Thus 1 /20 (5%) patients
had late post operative CSF leak in our study.
DISCUSSION:
The advent of endoscopes has revolutionized a new
era in modern pituitary surgeries. Transnasal,
transsphenoidal endoscopic surgeries have become the
mainstay of management in pituitary and skull base
lesions in the recent past. Transnasal approaches have
many advantages over the traditional open transcranial
approaches, which includes absence of brain retraction
and manipulation, better visualization using endoscopes,
lesser post operative morbidity and better cosmesis.
However, it comes with its own complication which
includes a high rate of post operative CSF leakage
consequent to large skull base defects after tumour
removal. The introduction of nasoseptal flap famously
known as Hadad- Bassagasteguy flap in 20061, a novel
reconstruction technique based on the pedicle nasoseptal
flap with blood supply from posterior septal branch
of sphenopalatine artery, a terminal branch of the
internal maxillary artery, has been the most significant
advance in transnasal endoscopic surgeries. This
technique was earlier devised by Oskar Hirsh in 19522,
but it was based on random vascular supply. Ever since
the reintroduction of a modified, robust nasoseptal flap
based on the posterior septal artery, it has been
40 Vol.-11, Issue-I, January-June - 2017
unanimously considered as the workhorse for closure
of skull base defects and has heralded an era of
vascularised flaps in sealing the skull base defects
following transnasal endoscopic skull base surgeries.
The nasoseptal artery lies within a strip of
mucoperisotium between the inferior margin of the
natural sphenoid ostium and superior edge of the
choanae, thus making these the superior and inferior
limits of Hadad-Bassagasteguy pedicle1,3. The use of this
flap to separate the nasal cavity from intracranial space
minimizes the risk of postoperative CSF leaks,
pneumocephalus and meningitis. The nasoseptal flap is
a versatile flap with a wide arc of rotation that allows
the flap to reach the defects from the frontal sinus to
lower clivus. It has decreased the incidence of CSF
leak significantly.
One of the significant advantages of the nasoseptal
flap is that it can be endoscopically harvested prior to
forming a skull base defect, therefore alleviating the
need for external flap harvesting. Additionally, being a
vascularised flap, it promotes faster healing, lower
chances of graft migration in addition to providing a
large surface area to cover larger defects. The nasoseptal
flap is a safe, no cost, malleable, easy to harvest flap in
the same field of surgery without causing any
complications or side effects4.
Depending on the dimensions of the nasal septum,
HBF flap can extend from the frontal recess anteriorly
to the clivus posteriorly in length and from one lamina
papyracea to the other in width. The robust blood
supply of the flap, pliability and extensive arc of rotation
allows the coverage of a wide array of anterior, middle
and posterior cranial base defects3,5.
Hadad et al1, in their landmark paper, reported a
4.7% rate of post operative fistula based on a study on
43 patients which included 20 cases of pituitary macro
adenomas. Kassam3 et al demonstrated a 10.66% rate of
post operative CSF fistula in patients who required intra
arachnoid dissection and also pointed out that, there
was a learning curve associated with the success of HBF.
In our study including 20 cases, there was a persistent
post operative CSF leak of 5%, which is consistent with
the results obtained in similar contemporary studies.

In addition to adequate exposure and complete
resection of the lesion, the outcome of endoscopic
surgery depends largely on the ability to reconstruct
the skull base defects. Smaller skull base defects can be
sealed with materials like fat, fascia lata, middle turbinate
mucosa etc6. However, due to expansion of the horizon
of endoscopic surgeries to the extent of resecting larger
lesions and the consequent larger skull base defects, the
need for self sustaining flaps arises and this is addressed
adequately by the nasoseptal flap. The average surface
area of HBF is approximately 25cm2.7The flap is tailored
the size of the defect expected, although it is wise to
overestimate the size and later resect the excess flap if
necessary.
Many authors4,8 emphasize on the need for using
a multilayered approach to reconstruction , even while
using a vascularised flap in order to support the flap,
to help it remain fixed and reduce the effect of
cerebrospinal fluid. Most importantly, it must be
ensured that the flap must not be twisted during
reconstruction and the mucosal surface is facing the
nasal cavity and not the intracranial defect and that the
flap is covering the bony edges of the defect.
Advance planning is of paramount importance as
posterior septectomy during transsphenoidal surgery
can hamper its usage because of destruction of the
vascular pedicle9. Addressing this issue, Rivera Serrano
et al developed nasoseptal rescue flap (NSRF)5, in which
HBF is only partially raised ,permitting access to the
anterior face of the sphenoid avoiding injury to the
feeding vessels. If there is an intraoperative CSF leak,
the NSRF can be completely harvested and converted
to HBF. His observation was further supported by
Rawal RB et al10 who in their study stated that the
success rate of nasoseptal flap was 100%.
Other endonasal pedicled flaps that could be used
in cases where HBF is contraindicated consequent to
the compromised vascular supply are posterior inferior
turbinate flap based on inferior turbinate artery11,
middle turbinate flap12 based on middle turbinate artery
which are both branches of posterior lateral nasal artery
and lateral nasal wall flap (HB2)13 flap based on branches
of facial and anterior ethmoidal arteries. Pedicled
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
extranasal flaps include palatal flap, pericranial flap, and
facial buccinator flap and temporoparietal fascial flap14.
CONCLUSION:
Hadad - Bassagasteguy flap is a reliable method in
repairing skull base defects after transnasal
transsphenoidal skull base surgeries in conjunction with
multilayered reconstruction. Its use has considerably
reduced incidences of post operative CSF leaks even
after large skull base defects and plays a pivotal role in
endoscopic skullbase surgeries.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) No financial disclosures
(e) Animal rights-Not applicable
REFERENCES:
1. Hadad G, Bassagasteguy L, Carrau RL, et al. A
novel reconstructive technique after endoscopic
expanded endonasal approaches: Vascular pedicle
nasoseptal flap.Laryngoscope 116:1882-1886,2006.
2. James K.Liu , Richard F. Schmidt, Osamah J et
al. Surgical nuances for nasoseptal flap
reconstruction of cranial base defects with high
flow cerebrospinal fluid leaks after endoscopic
skull base surgery.Neurosurg Focus 32(6):E7,2012.
3. Kassam AB, Thomas A, Carrau R, et al.
Endoscopic reconstruction of the cranial base using
a pedicled nasoseptal flap. Neurosurgery. 2008
Jul;63(1 Suppl 1):ONS44-52; discussion ONS52-
3. doi: 10.1227/01.NEU.0000297074.13423.F5.
4. Wang Xuejan, Hu Fan, Zhang Xaobao, Yu
Yong et al. Endonasal Endoscopic Skull Base
Multilayer Reconstruction Surgery with Nasal
Pedicled Mucosal Flap to Manage High Flow
CSF Leakage. Turkish Neurosurgery 2013;23( 4):
439-445.
5. Riverra Serrano CM, Synderman CH, et al. The
posterior pedicle inferior turbinate flap:A new
vascularized flap for skull base reconstruction.
Laryngoscope. 2007;117:1329-1332.
Vol.-11, Issue-I, January-June - 2017 41
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

6. Neto CDP, Pinheiro SD.Use of Pedicled Flaps 13. Hadad G, Rivera Serrano CM, , Bassagasteguy LH
for Skull Base Reconstruction after Expanded et al. Anterior pedicle lateral nasal wall flap: a
Endonasal Approaches. Int.Arch. Otorhin- novel technique for the reconstruction of anterior
olaryngol. 2007;11(3):324-329. skull base defects.Laryngoscope.2011 Aug;
7. Pinheiro- Neto CD, Prevedello DM, Carrau RL 121(8):1606-10. doi: 10.1002/lary.21889.
et al.Improving the design of pedicled nasoseptal 14. Camilo Reyes,Eric Mason et al. Panorama of
flap for skull base reconstruction:a radioanatomic reconstruction of skull base defects: from
study.Laryngoscope 2007 Sep;117(9):1560-9. traditional open to endonasal endoscopic
8. Cavallo LM, Messina A, Esposito F et al. Skull approaches, from free grafts to microvascularflaps.
base reconstruction in the extended endoscopic Int. Arch. Otorhinolaryngo l.2014Oct; 18(suppl
transsphenoidal approach for suprasellar lesions.J 2):S179-86.
Neurosurg. 2007 Oct;107(4):713-20.
9. Joseph Brunworth, Tina Lin, David b Keschner
et al. Use of Hadad Bassagasteguy flap for repair
of recurrent cerebrospinal fluid leak after prior
transsphenoidal surgery.Allergy and Rhinology (
Providence). 2013 Fall;4(3): e155-e161. doi:
10.2500/ar.2013.4.0072
10. Rawal RB, Kimple AJ ,Dugar DR et al.
Minimizing morbidity in endoscopic pituitary
surgery:outcomes of the novel nasoseptal rescue
flap technique.Otolaryngol Head Neck Surg2012
Sep;147(3):434-7.
11. Fortes FS, Carrau RL, Synderman CH et al. The
posterior pedicle inferior turbinate flap: a new
vascularized flap for skull base reconstruction.
Laryngoscope 2007Aug; 117(8):1329-32.
12. Prevedello DM, Barges Coll J, Fernandez-
Miranda JC et al. Middle turbinate flap for skull
base reconstruction: cadaveric feasibility
study.Laryngoscope 2009 Nov;2094-8. doi:
10.1002/lary. 20226.

42 Vol.-11, Issue-I, January-June - 2017

 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

AN ANALYSIS OF INSIDE OUT MASTOIDECTOMY WITH

TYMPANOPLASTY WITH OR WITHOUT OSSICULOPLASTY FOR
MANAGEMENT OF MIDDLE EAR CLEFT CHOLESTEATOMA
*Chandra Manish, **Rajeev Krishna Gupta, ***Satveer Singh Jassal, ****Sikhar Saxena

HOW TO CITE THIS ARTICLE Date of receipt of article -9-1-2017

Chandra Manish, Gupta R K, Jassal S S, Saxena S. An analysis of
inside out mastoidectomy with tympanoplasty with or without Date of acceptance 21-02-2017
ossiculoplasty for management of middle ear cleft cholesteatoma. DOI- 10.21176/ojolhns.2017.11.1.7
Orissa J Otolaryngology & Head & Neck Surgery 2017 June; 11(1):
43-48. DOI: 10.21176/ojolhns.2017.11.1.7 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.7

ABSTRACT:
AIMS: To evaluate the advantages and shortcomings of inside out mastoidectomy with tympanoplasty with or
without ossiculoplasty for management of middle ear cleft cholesteatoma.
Material and Methods: It is a Prospective Observational study. 40 patients of chronic otitis media with
cholesteatoma in the age group of 10 years to 50 years who underwent inside out mastoidectomy were included
in the study. Reconstruction was done with autologus ossicle, PORP or TORP as required. Temporalis fascia
graft was placed over the assembly.
Results: 21(52.5%) patients had attic cholesteatoma, 17(42.5%) had postero-superior retraction pocket and 2
(5%) patients had both attic cholesteatoma and postero-superior retraction pocket on otoscopic examination.
During follow up 2 patients (5%) had persistent ear discharge within 6months of surgery and 2 patients (5%)
developed ear discharge after 7 months and 1 year after surgery. Recurrence rate was 10%.The mean gain in air
conduction was 16.2dB.
Conclusion: By this study it can be concluded that inside out mastoidectiomy provides advantages over both
outside in canal wall down mastoidectomy and intact canal wall mastoidectomy.
Keywords: Cholesteatoma, Canal wall down mastoidectomy, canal wall up mastoidectomy, inside out technique.

INTRODUCTION: associated with higher recidivism rate than canal wall

Surgical management of cholesteatoma has down mastoidectomy due to poor visualization and
underwent numerous changes since the 1st published Affiliation:
report of mastoidectomy 350 yrs ago by Schwartze and * Assistant Professor,
Eysell who popularized Cortical mastoidectomy in year **,*** & **** Resident,
Department of ENT,
1873. Radical mastoidectomy was described by Zaufal Eras Lucknow Medical College, Lucknow,
in 18901. Bondy revised this Technique2. With the Uttar Pradesh,India-226003
advent of operating microscope, mastoidectomy Address of Correspondence:

underwent further refinement. At present debate Dr. Rajeev Krishna Gupta,

Department of ENT
between canal wall up and canal wall down Eras Lucknow Medical College.
mastoidectomy is ongoing 3 . Canal wall up Sarfrazganj, Hardoi road, Lucknow
Uttar Pradesh,India-226003
mastoidectomy provides good hearing outcome and is +919506890745
not associated with mastoid cavity problem but it is Email: dr.rajeevgupta11@gmail.com

Vol.-11, Issue-I, January-June - 2017 43

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
increased chances of postoperative retraction pocket
formation4. Canal wall up mastoidectomy is not a
suitable option in situations like extensive disease, low
lying dura, disease in a well pneumatised mastoid,
anterior placed sigmoid or a cleft palate. In these
situations canal wall down procedure is the surgery of
choice5. Recurrence of cholesteatoma and occurrence
of postoperative retraction pocket is low in canal wall
down mastoidectomy due to good intraoperative
exposure.
Canal wall down mastoidectomy allows better
visualization, greater confirmation of cholesteatoma
eradication and lower rate of recurrence than canal wall
up mastoidectomy but at the cost of need for a lifelong
cavity care 6,7,8. Canal wall down mastoidectomy can be
approached either through outside in or inside out
technique.
Inside out mastoidectomy is performed through
trans-meatal route via retro auricular or endaural
approach. There has been very few published studies
on the technique and surgical outcomes after inside out
mastoidectomies.Our study gains importance as we have
analyzed 40 cases of inside out mastoidectomy with a
minimum follow up period of 1.5 yrs in homogenous
study condition.
MATERIAL AND METHODS:
This is a prospective observational study carried
out at Eras Lucknow Medical College, Lucknow
between May 12 to May 15. 40 patients of chronic
otitis media with cholesteatoma in the age group of
10years to 50 years who underwent inside out
mastoidectomy during this period were included in
study.
Otomicroscopic findings, preoperative pure tone
audiometry were noted, HR C.T. temporal bone and
middle ear cleft was done in all the patients. All the
patients were operated by single surgeon. All the
patients were operated under general anesthesia. All the
patients were admitted and 1 dose of injection
ceftriaxone was given prior to surgery, postoperatively
injection ceftriaxone was continued for 3 days and then
patients were kept on oral medications. Sutures were
removed on 7th post operative day.
Patients were followed up for minimum period
of 1.5 years. Follow up were done at 1st, 2nd, 3rd week
44 Vol.-11, Issue-I, January-June - 2017
after discharge from hospital, then after 3, 6, 12,
18months, and in between if required.
Surgical Tehnique:
A Post auricular approach was used in all the
patients. Meatotomy was performed and microscopic
findings were noted. Tympanomeatal flap was elevated
and ossicular status was checked. Inside out
mastoidectomy was started with the widening of EAC
followed by drilling of outer attic wall. Drilling was
continued posteriorly depending on the extent of
cholesteatoma sac. Cholesteatoma sac was removed along
with granulations. Drilling was stopped once the
healthy mucosa was seen(Fig 1). When cholesteatoma
extended beyond the aditus canal wall down
mastoidectomy was performed. Sinus tympani region
was inspected by drilling the posterior canal wall upto
the level of base of pyramid, to look for hidden
cholesteatoma, which was subsequently removed. Incus
along with head of malleus and occasionally whole
malleus was removed to facilitate eradication of disease
from anterior attic.
Reconstruction:
Reconstruction was done with autologus ossicle,
PORP or TORP as required. Reconstruction was done
in same sitting. Incus long process was drilled and a
groove was created with a diamond burr on the body
to accommodate the capitulum of stapes. The short
process was placed under the malleus long process to
complete the ossicular continuity. When the stapes
suprastructures were absent incus was refashioned and
placed over the stapes footplate. Conchal cartilage was
used to construct the attic and posterior canal
wall.Temporalis fascia graft was placed over the
assembly. Meatoplasty when required was done.
Analyzed Parameters:
We analyzed the intraoperative advantages and
disadvantages, postoperative hearing status, recidivism
of cholesteatoma, complications and postoperative
healing of cavity.
RESULTS:
Of 40 patients included in study 24(60%) were
male and 16(40%) were female(Table-1) with mean age
24.8 years (range10-50 years)(Table-2) .21 patients had
attic cholesteatoma, 17 had posterosuperior retraction
pocket and 2 patients had both attic cholesteatoma and
 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

posterosuperior retraction pocket on otoscopic

examination(Table-3). Otorrhoea was present in
39(97.5%) cases. Hearing loss was present in all cases.
1(2.5%) case presented with only hearing loss. Extent
of disease as revealed during surgery was as
follows.Cholesteatoma was limited to tympanum in 14
patients while in 26 patients it extended to mastoid.
Ossicles were eroded in 30 patients. Long process of
incus was eroded in 20 patients, body of incus in 6
patients, stapes suprastructure was eroded in 12 patients
and malleus was eroded in 4 patients. Tympanic sinus
was involved in 14 patients and disease extended Fig.-1: Mastoid cavity after completion of inside out
anteriorly to Eustachian tube in 4 patients. mastoidectomy.
Ossicular reconstruction was performed in 30 cases
using remodeled incus (n=17), malleus head (n=4), Table-1: Distribution of patients according to sex
partial ossicular reconstruction prosthesis (n=6)
(PORP)or total ossicular replacement prosthesis (
n=3)(TORP).
Post operative complications:- Postoperative
transient vertigo in 4 patients and postoperative
transient facial palsy observed in 3 patients. All cases Table-2: Distribution of according to age group:
were followed up for a minimum period of 1.5 years.
A dry and trouble- free ear was found in 36 (90%)
patients in follow-up.
Complications during follow-up period (Table-
4) were as follows-
(a) 2 patient had persistent ear discharge.(5%)
(b) 2 patient developed ear discharge after follow up
period of 7months and 1 year respectively. (5%)
(c) 1 patient developed perichondritis postoperatively. Table-3: Distribution of patients according to otoscopic
(2.5%) findings:
(d) 2 patient had temporalis fascia graft infection.(5%)
Maximum patients achieved a dry cavity in 3
months time duration (Table-5). The postoperative
hearing assessment was done 6 months after surgery
(Table-6). In 4 Patients(10%) postoperative air
conduction gain was between 21-30 dB, in 11
patients(27.5%) it was between 10-20 dB, in 19(47.5%)
it was less than 10 dB. In 6 patients (15%) there was no
gain in air conduction. The mean hearing gain was 16.2
dB. In none of the patient deterioration in hearing status
was noted. The mean preoperative bone conduction
was 13.16 dB and remained unchanged postoperatively
at six months after surgery.

Vol.-11, Issue-I, January-June - 2017 45

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
Table-4: Post operative Complications.
Table-5- Time of drying of cavity.
Note: 4 patients had persistent discharge posoperatively.
Table-6: Post op hearing status at 6 months.
DISCUSSION:
The 1st published description of cholesteatoma
dates back to 16th century when Duverney described it
to be abscess of bone originating from auditory canal9.
Cholesteatoma can be defined as cystic lesion formed
from keratinizing stratified squamous epithelium, the
matrix of which is composed of epithelium that rests
on stroma of varying thickness, the perimatrix9.Its
incidence can be upto 10% in people of chronic
suppurative ottitis media.There has been statistically
significant decline in the incidence of cholesteatoma10.
46 Vol.-11, Issue-I, January-June - 2017
Cholesteatoma itself is a morbid condition. The
surgical management of cholesteatoma also results in
detoriation of quality of life because of mastoidectomy
cavities which require lifelong care from moisture and
cleaning by trained personal.
Closed technique for management of
cholesteatoma entails preservation of posterior wall of
EAC but at cost of risk for recurrence of cholesteatoma
due to limited intraoperative exposure and occurrence
of post operative retraction pocket. Second stage
surgery is frequently recommended 9-12 months after
the initial surgery4,11. Canal wall down mastoidectomy
provides good exposure and lower recidivism rate but
at the cost of lifelong mastoid care. Inside out
mastoidectomy provides the advantages of both canal
wall down and canal wall up technique12,13. In our study
40 patients of chronic otitis media with cholesteatoma
were managed with inside out mastoidectomy. All the
patients were followed for a minimum period of 1.5
years. A dry and trouble free ear was found in 36
patients (90%) which is similar to previous studies13,14,15.
2 patient developed persistent ear discharge within 6
months of surgery and 2 patient developed ear discharge
after 7 months and 1 year after surgery. We defined
residual disease as persistent ear discharge starting within
6 months of surgery and recurrent disease as persistent
ear discharge after 6 months of surgery. HRCT was
done at end of 6 months to look for cholesteatoma and
differentiate between residual and recurrent disease.
Residual disease was due to incomplete removal of
cholesteatoma during surgery and recurrent disease was
due to new cholesteatoma formation because of
persistence of predisposing factors. Both residual and
recurrent diseases were designated as recidivism. A total
of 4 patients developed persistent ear discharge after
surgery making recidivism rate 10% which is in
accordance with previous literature16,17,18,19,20.
This study elucidates the advantages of inside out
mastoidectomy. Intraoperative advantages included
early identification of ossicles, facial nerve, lateral
semicircular canal and dural plate. Surgery could be
stopped once the healthy bone is encountered thus
reducing the size of the cavity as compared to outside
in canal wall down mastoidectomy, where cavity size
is usually large. Facial recess could be explored more
easily and early in the procedure. Limited size of cavity

favored easy reconstruction. A chance of injury to
lateral semicircular canal, dural plate and sigmoid sinus
plate is minimal because of early identification of
important landmarks. Ability to deal with Korners
septum is better as the aditus and lateral semicircular
canal comes into the operating view early in the surgery.
Reduced cavity size favors small meatoplasty which
looks cosmetically better. Maximum patients had a dry
cavity within 3 months time duration which is better
than those stated in literature21. Postoperative air
conduction gain 6 months after surgery was between
10-30 dB in 15 patients and in 19 patients it was less
than 10 dB. In 6 patients preoperative and 6 months
postoperative air conduction was same. Postoperative
hearing gain in this study was better than that stated in
studies of conventional mastoidectomy, this can be due
to small cavity size and ease of reconstruction 22,23,24. It
is a technically demanding surgery and should be
practiced after doing good number of temporal bone
dissection. The results of inside out mastoidectomy are
similar to outside in mastoidectomy but intraoperative
and postoperative advantage gives this technique an edge
over the outside in technique.
CONCLUSION:
It can be concluded that inside out mastoidectiomy
provides advantages of both outside in canal wall down
mastoidectomy and canal wall up mastoidectomy. By
this approach both eradication of disease and minimal
disturbance to functional status of ear can be achieved.
Because of early identification of landmarks chances of
injury to vital structures are less. For limited
cholesteatoma this approach provides the clear
advantage of being minimally invasive. Postoperative
cavity related problems are less, hearing status is better
compared to outside in mastoidectomy.
Aknowledgement:
Article was presented at AIIMS, in Otology
workshop and conference, New Delhi, India, held
between 3rd -5th September 2015.
DISCLOSURES:
1. Funding: There is no source of funding for this
study.
2. Conflict of interest: The authors declare that they
have no conflict of interest.
3. Informed consent: Informed consent was taken
from every patient.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
4. Ethical approval: All procedures performed in
studies involving human participants were in
accordance with the ethical standard of institution.
REFERENCES:
1. Bennett M, Warren F, Haynes. Indications and
technique in mastoidectomy. Otolaryngol Clin
North Am. 2006 Dec;39(6):1095-113.
2. Shambaugh G E, Glasscock MEIII: Surgery of the
ear, ed 3. Philadelphia, 1980, WB Saunders Co,
pp 248249. Google Scholar
3. Syms MJ and Luxford WM. Management of
cholesteatoma: status of the canal wall.
Laryngoscope.2003;113(3):443448.
4. Sanna M, Zini C, Scandellari R, Jemmi G .Residual
recurrent cholesteatoma in closed tympanoplasty.
Am J Otol. 1984;;5:277-82.
5. Abramson M. Open or closed tympanoma-
stoidectomy for cholesteatoma in children. Am J
Otol.1985; 6:167-9.
6. Khalil HS,Windle-Taylor PC . Canal wall down
mastoidectomy:A long term commitment to the
outpatients. BMC Ear, Nose and Throat
Disorders.2003 December;3:1.doi. 10.1186/1472-
6815-3-1.available at link.springer.com/article/
10.1186/1472-6815-3-1.
7. Quaranta A, Cassano P, Carbonara G.
Cholesteatoma surgery: open versus closed
tympanoplasty. Am J Otol. 1988 May; 9(3):
229-31.
8. Sheehy JL.Cholesteatoma surgery. Canal wall
down procedure. Ann Otol Rhinol Laryngol.
1988;97:30-5.
9. Semaan M T, Megerian CA .The pathophysiology
of cholestetoma. Otolaryngologic Clinics of
North America.2006;39( 6):11431144.
10. Djurhuus BD, Faber CE, and Skytthe A.
Decreasing incidence rate for surgically treated
middle ear cholesteatoma in Denmark 19772007.
Danish Medical Bulletin.2010; 57( 10):1-5. Article
ID A4186.
11. Hirsch BE, Kamerer DB, Doshi D . Single stage
management of cholesteatoma. Otolaryngol Head
Neck Surg.1992; 106(4): 351354.
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12. Dornhoffer JL. Retrograde mastoidectomy.
Otolaryngologic Clinics of North America.2006;
39( 6) :11151127.
13. Roth TN,Haeusler R.Inside-out technique
cholestetoma surgery:A retrospective long -term
analysis of 604 operated ears between 1992 and
2006.Otology and neurotology. 2008;30:59-63.
14. Godinho RA, Kamil SH, Lubianca JN, Keogh
IJ, Eavey RD. Pediatric cholesteatoma: canal wall
window alternative to canal wall down
mastoidektomie. Otol Neurotol. 2005;26:466-71.
15. Mukherjee P, Saunders N, Liu R, Fagan P . Long-
term outcome of modified radical mastoidectomy.
J Laryngol Otol. 2004;118:612-6.
16. Schimd H, Dort JC, Fisch U . Long-term results
of treatment of childrens cholesteatoma. Am J
Otol. 1991;;12:83-7.
17. Dornhoffer JL.Retrograde mastoidectomy with
canal wall reconstruction: a follow-up report. Otol
Neurotol. 2004 Sep;25(5):653-60.
18. Vadiya S, Kedia Anuja . Atticotomy, attic
reconstruction, tympanoplasty with or without
ossiculoplaty, canalplasty and cortical
mastoidectomy as part of intact canal wall
technique for attic cholestetoma. Indian J
Otolaryngol Head Neck Surg. 2015 Jun; 67(2):
128131.Published online 2015 Jan
9. doi: 10.1007/s12070-015-0821-z.
19. Glasscock ME, Miller GW . Intact canal wall
tympanoplasty in management of cholesteatoma.
Laryngoscope Glasscock ME, Miller GW. Intact
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canal wall tympanoplasty in the management of
cholesteatoma. Laryngoscope. 1976; 86:16391657.
doi: 10.1288/ 00005537- 197611000-00005.
[PubMed] [Cross Ref].
20. Mahadeviah A, Parikh B.Modified intact canal wall
mastoidectomy-long term results in hearing and
healing.Indian J otolaryngol Head Neck Surg.2008;
60(4): 317-323.
21. Singh M, Jain S, Rajput R, Khatua R, Sharma D.
Retrospective and prospective study of singapore
swing method on healing of mastoid cavity . Indian
J Otolaryngol Head Neck Surg. 2010 Oct; 62(4):
365371. Published online 2011 Jan 4.
doi: 10.1007/s12070-010-0058-9.
22. Artuso A, Nardo W, Corso E, Marchese MR,
Quaranta N .Canal wall down tympanoplasty
surgery with or without ossiculoplasty in
cholesteatoma: hearing results. Acta
otorhinolaryngol Ital 24, 2-7, 2004.
23. Cook JA, Krishnan S, Fagan PA Hearing results
following modified radical versus canal-up
mastoidectomy. Cook J A Krishnan S Fagan P
A Hearing results following modified radical
versus canalup mastoidectomy Ann Otol Rhinol
Laryngol 1996. May;105537983. [PubMed]
24. Berenholz LP, Rizer FM, Burkey JM, Schuring
AG, Lippy WH. Ossiculoplasty in canal wall
down mastoidectomy.Otolaryngol Head Neck
Surg. 2000 Jul;123(1 Pt 1):30-3.
 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

4 HANDS REACHING OUT ENDOSCOPICALLY TO THE

PITUITARY OUR EXPERIENCE
*G Sundhar Krishnan, **George Nitha Mary

HOW TO CITE THIS ARTICLE Date of receipt of article -10-10-2016

G Sundhar Krishnan, George N M.4 hands reaching out Date of acceptance 21-02-2017
endoscopically to the pituitary our experience. Orissa j
otolaryngology head neck surgery 2017 June; 11(1): 49-53. DOI: DOI- 10.21176/ojolhns.2017.11.1.8
10.21176/ojolhns.2017.11.1.8 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.8

ABSTRACT:
Objective: To examine three minimally invasive techniques of approaching the sella in pituitary tumors.
Study design: Retrospective case review of patients out of whom 275 patients were underwent Endoscopic
endonasal pituitary adenoma resection and rest by conventional methods between January 1996 and October
2016.
Patients: 500 cases of pituitary adenoma requiring surgical intervention were included in the study and thoroughly
investigated prior to surgical intervention. The various techniques of endoscopic hypophysectomy have been
compared in this study.
Main outcome Measure (S): Remission was defined as no radiological or hormonal evidence of recurrence
within the time-frame of the follow-up.
Results: 10% recurrence was noted at the end of 1 year- 5% in Trans septal trans sphenoidal, 3% in Trans
sphenoidal and 2 % by the 4 hand technique, which were re-operated successfully by the endoscopic trans
sphenoidal 4 hand technique. Mean follow-up period was 24.2 months.
Conclusions: In our 20 yrs of experience, endoscopic trans sphenoidal 4 handed technique is a safe and effective
method for complete pituitary tumor removal with better surgical outcomes and fewer complications compared
to the trans septal trans sphenoidal technique
Keywords: Endoscopic hypophysectomy, Four hand technique, Trans sphenoidal.

INTRODUCTION:
precise delineation of the sellar mass from its
Horseley (1906) was the first to decompress the
surrounding structures ensuring comprehensive tumor
pituitary gland by the transcranial route1. In 1909,
Cushing performed the sub labial trans septal approach.
Affiliations:
Chiari was credited for his demonstration of the trans
*Director & Chief ENT Surgeon,
ethmoidal trans sphenoid operation in 1912. By early **Junior ENT Consultant,
1980s trans sphenoidal approach came to stand.With Krishna Eye and ENT Hospitals,
No 39, Burkitt road, T Nagar, Chennai-600017
the advent of modern endoscopic techniques, the Tamil Nadu
momentum in the field of endoscopic pituitary surgery Address for correspondence:
has steamed up providing panoramic view, superior Prof (Dr) G Sundhar Krishnan,
visualization of microscopic relevant anatomy, better Krishna Eye and ENT Hospitals,
No 39, Burkitt road, T Nagar,
magnification and illumination for identification of Chennai-600017,Tamil Nadu
critical anatomical landmarks within the sphenoid and Phone-no:9500040702.

Vol.-11, Issue-I, January-June - 2017 49

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
removal with favorable results and reduced
postoperative morbidity 3 . In addition, angled
endoscopes allow tumor remnants extending into the
supra and parasellar areas to be seen improving the
surgeons ability to achieve complete tumor resection
reducing the likelihood of recurrence4. An added
advantage in endoscopic approaches is the possibility
of a 4 hand technique for faster & accurate dissection
by appropriate retraction and prompt hemostasis in a
magnified surgical field as against the single hand
endoscopic or 2 hand microscopic technique5.
Endoscopic pituitary surgery is a well-established
technique for the treatment of sellar tumors. The
efficacy and minimally invasive nature of Trans nasal
endoscopic approach in the treatment of pituitary
adenomas and other sellar lesions have provided a
benchmark to ambitious skull base surgeons6.
Pituitary adenomas can present in any age equally
affecting males and females. The clinical presentation
of pituitary adenomas varies depending upon the
location and severity of the tumor. Pituitary adenomas
are a diverse group of benign neoplasms. The
hormonally inactive, generally come to clinical attention
secondary to local mass effect or pituitary deficiency.
Whereas, the hormonally active tumors present with
well-recognized syndromes and include growth
hormone adenoma, prolactinoma, and corticotrophin
adenoma7.
Indications for endoscopic hypophysectomy8:
Tumor with mass effect (Macro adenoma: > 1cm)
Chiasmal compression and objective visual field
defect
Raised intracranial pressure Pituitary dependent
Cushings disease GH secreting tumor.
Prolactinoma
Failure of medical of treatment
Intolerance of medical management
Patient preference
TSHoma
Contraindications for endoscopic
9
hypophysectomy :
Highly vascular lesion
Lesions with carotid artery anomaly, where the
artery project into the sphenoid sinus and limit safe
access.
50 Vol.-11, Issue-I, January-June - 2017
Extensive lesions:
Anterior to tuberculum over the planum
sphenoidale
Behind the clivus into the posterior fossa
AIM & OBJECTIVE:
To compare three minimally invasive techniques
of approaching the sella in pituitary tumors and
conclude on the most conducive option for best patient
results.
MATERIALS AND METHODS:
A long-term retrospective study was done in
patients who underwent Endoscopic Endonasal
pituitary adenoma resection between January 1996 and
October 2016. The data in patient records as well as
the data obtained from postoperative follow-up visits
were used to determine outcomes. From a total of 500
pituitary adenomas, (75)15% were hormonally active,
while (425)85 % were non-functioning. The male to
female ratio was 1: 1.5 (Male200:Female300), with
average age group 35-50 years. In our 500 patints we
have operated 10(2%) patients by trans- septal trans-
sphenoidal approach and in the 215(43%) by trans-
sphenoidal technique and in 275(55%) of them (2005
onwards) were by the 4 hand technique.
Detailed notes on history of Headache, visual
symptoms, amenorrhea, galactorrhea, general physical
examination (Acromegalic features), CNS examination,
complete ophthalmic and ENT examination, from the
records were taken. Patients were subjected to various
imaging studies. The CT scan gave invaluable
information of the bony surgical anatomy of the nose
and sphenoid sinus whilst the MRI was extremely useful
for parasellar and vascular information. Hormonal
assays like LH, FSH, T3 T4 TSH, Prolactin, GH and
cortisol were done in patients suspected to have
secreting tumors.
Surgery was indicated whenever there was
evidence of compressive gland enlargement or
development of pituitary hormonal imbalances. The
first 10 patients were operated using the trans- septal
trans-sphenoidal approach and the rest by trans-
sphenoidal technique, of which around 275 patients
(2005 onwards) were by the 4 hand technique in trans-
sphenoidal technique. The average length of hospital

stay (LOS) was 1.5 days. Postoperatively, magnetic
resonance imaging (MRI) was done after 1 month to
assess residual or recurrent disease and those with
hormonally active tumors had hormonal studies.
Surgical Technique:
Following general anaesthesia, the nasal cavities
were decongested with nasal packs of 4% xylocaine with
1 in 10,000 units adrenaline. The approach could be
done by a Modified four handed technique without
the active participation of a neurosurgeon where in the
Chief Endoscopic ENT surgeon holds the endoscope
and one instrument and Assistant ENT surgeon aided
through both nostrils for retraction, irrigation,
suctioning etc. offering a bloodless field which would
aid in finer dissection for tumor removal.
The endoscope was advanced to expose the
anterior wall of the sphenoid sinus in the
sphenoethmoidal recess and ostia identified on both
sides. Posterior septal branch of sphenopalatine artery
cauterized bilaterally. Bilateral posterior
ethmoidectomy and posterior septectomy were done
for better visualization and to accommodate various
instruments used in 4 hand technique. Bilateral
sphenoid ostia widened and connected using a
Kerrisons punch till the entire extend of the sphenoid
sinus was well visualized (floor, sellar, planum, optic
nerve and carotid artery bulge, opticocarotid recess
medial and lateral). Intersphenoid septum and sphenoid
mucosa were removed for better access to the anterior
wall of sella whose thickness was assessed with a ball
probe and drilled using a long diamond coarse cutting
burr up to the dura. A horizontal H shaped incision is
made over the dura and dural flap raised. A punch
biopsy was taken from the prolapsed tumor mass for
frozen section histopathology. Blunt ring curettes and
2 suctions were used to remove the tumor completely
in a systematic manner, usually starting from the floor,
then laterally and finally along the supra sellar
component with the help of 30-degree endoscope,
thereby eliminating sources of any potential tumor
recurrence. In case of solid tumors, sharp dissection
was carried out using scissors and tumor removed with
the help of forceps until the diaphragm descends freely
with no attachments.
In case of bleeding, surgicel was used within the
sella for hemostasis. The preserved dural flap is
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
positioned over the anterior face of the sella. The
sphenoid sinus is packed with gelfoam. A small merocel
sponge is placed in nose. Pack removal was done after
24 hours of surgery.
In case of a CSF leak, we followed a 3 layered
technique wherein the defect was identified and fascia
lata graft was first placed with the edges tucked under
the dural opening and reinforced with Hadad flap,
fibrin glue and Merocel allowing pressure on the fascia
during healing which was to be removed after 1week.
If the CSF leak was profuse, a lumbar drain was inserted
postoperatively for 2 to 3 days.
Patient wass discharged from hospital on the 1st
postoperative day and reviewed after 1 week.
Postoperative MRI scan was done 1 month after surgery
and followed up MRI after 1 year.
Table-1: Clinical symptoms.
RESULTS AND DISCUSSION:
From a total of 500 pituitary adenomas,(75)15%
were hormonally active, while (425) 85 % were non-
functioning. The male to female ratio was 1: 1.5
(Male200:Female300), with average age group 35-50
years.
In our study, majority of patients had presented
with headache (60%) followed by visual symptoms
(25%), acromegalic features (10%) and Cushings disease
(5%) (Table 1). On further evaluation, 85 % were found
to be non-secreting and 15% secreting in natured as
compared to a study done in 300 patients by Kabil MS
et al, who observed that 46 % were hormonally active
and 54 % were non-functioning2. Paolo Cappabiancag
et al in their study on 30 patients observed secreting or
functioning adenomas in 53. 33% and non functioning
adenomas in 46.67%1. In this respect our study is
Vol.-11, Issue-I, January-June - 2017 51
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
Fig.-1: Pre and post-operative (1yr) MRI of a patient with
pituitary macro adenoma.
Fig.-2: Chart showing types of surgery adopted.
significantly different. In our 500 patints we have
operated 10(2%) patients by trans- septal trans-
sphenoidal approach and in the 215 (43%) by trans-
sphenoidal technique and in 275 (55%) of them (2005
onwards) were by the 4 hand technique. P Cappabianca
et al in their study in 30 patients 10 surgeries were
done by endoscopic endonasal transsphenoidal
approach and 20 were done by traditional transnasal
transsphenoidal approach (TTA)1. Remission was
defined as no radiological or hormonal evidence of
recurrence within the time-frame of the follow-up
period. In our series 10% recurrence was noted at the
end of 1 year (1% in Trans septal trans sphenoidal, 5%
in Trans sphenoidal and 4 % by the 4 hand technique),
which were reoperated successfully by the endoscopic
trans sphenoidal 4 hand technique. Our Mean follow-
up period was 24.2 months. Mean follow-up period
was 38.2 months in study of Kabil MS et al2. Paolo
Cappabianca et al followed up their patients after 6
months of follow up by MRI and hormonal study and
found improvement in pituitary function post
operatively in 4 patients, out of 10 patients whereas
pituitary hormone deficiency was present in 14 out of
52 Vol.-11, Issue-I, January-June - 2017
30 patients1. DHaens J et al observed that there is not
much significant hormonal improvement in either
endoscopic endonasal surgery or the traditional
microscopic techniques 6 . They reported the
endocrinologic outcome in 2 series of patients at the
same institution using these 2 different techniques6..
The remission rate for the pituitary adenomas in 4 hand
technique was 90 % ( in 248 patients out of 275 patients).
DHaens J et al observed remission rate of 63% in
endoscopic group and 50% in microscopic group
however they did not mentioned about any 4 hand
techniques and they operated in 60 hormonally active
patients6. Kabil MS et al reported better results as far
as complications are concerned in endoscopic
approaches in comparision to conventional microscopic
approaches 2. However they concluded that more
complete tumor removal is necessary in reducing
complications.We encountered CSF leak in 10 % cases
(28) in 4 hand tchnique which was repaired successfully
by the 3-layer technique. The morbidity with the
endoscopic technique was reported to be higher in
respect to the rate of postoperative CSF leaks (10%)
in the study by DHaens J et al6.
In our experience, adopting the endoscopic 4 hand
technique offers the best approach to the pituitary by
providing excellent magnification, angular visualization,
supra and para sellar tumour access. We noted not just
a marked reduction in complications but also an
improved outcome was evident with the above
technique. approach are: less traumatic, faster,
panoramic magnified view, increased exposure, angled
view with the use of different endoscopes, absence of
skin incisions- brain retraction - cranial nerve dissection
and possibility to explore the sella for residual tumor
at the end of operation. Its disadvantages are the lack
of 3D view and the need for an assistant to hold the
endoscope10. In our 20 yrs of experience, endoscopic
trans sphenoidal 4 handed technique is a safe and
effective method for complete pituitary tumor removal
with better surgical outcomes and fewer complications
compared to the trans septal trans sphenoidal technique.
CONCLUSION:
Advancements in endoscopy and experience in
pituitary surgery drives endoscopic ENT surgeons
toward new horizons. The advantages of endoscopic
approach are: less traumatic, faster, panoramic

magnified view, increased exposure, angled view with
the use of different endoscopes, absence of skin incisions-
brain retraction - cranial nerve dissection and possibility
to explore the sella for residual tumor at the end of
operation. Its disadvantages are the lack of 3D view
and the need for an assistant to hold the endoscope10.
In our 20 yrs of experience, endoscopic trans sphenoidal
4 handed technique is a safe and effective method for
complete pituitary tumor removal with better surgical
outcomes and fewer complications compared to the
trans septal trans sphenoidal technique.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) No financial disclosures
(e) Animal rights-Not applicable
REFERENCES:
1. Cappabianca P, Alfieri A, De Divitiis E.
Endoscopic endonasal Tran sphenoidal approach
to the sella: towards functional endoscopic
pituitary surgery (FEPS). Minim Invasive
Neurosurg 1998; 41: 66-73.
2. Kabil MS, Eby JB, Shahinian H. Fully endoscopic
endonasal vs. trans septal trans sphenoidal pituitary
surgery. Minim Invasive Neurosurg. 2005 Dec;48
(6):348-54.
3. Jho HD, Alfieri A. Endoscopic Endonasal
Pituitary Surgery: Evolution of surgical technique
and equipment in 150 operations. Minim Invas
Neurosurg; 2001;44:1-12.
4. Shah S, Har-El. Diabetes Insipidus after pituitary
surgery: incidence after traditional versus
endoscopic trans sphenoidal approaches. Am J
Rhinol 2001;15 (6)377-379.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
5. Cook RS, Jones RA. Experience with the direct
trans nasal trans sphenoidal approach to the
pituitary fossa. Br J Neurosurg 1994;8(2):193-196.
6. Haens J, Van Rompaey K, Stadnik T, Haentjens
P, Poppe K, Velkeniers B. Fully endoscopic trans
sphenoidal surgery for functioning pituitary
adenomas: a retrospective comparison with
traditional trans sphenoidal microsurgery in the
same institutiont.Surg Neurol. 2009 Oct;72(4):
336-40. doi: 10.1016/j.surneu. 2009.04.012. Epub
2009 Jul 14.
7. Rajesh Viswakarma, Neeraj Singh, Ratnadeep
Ghosh. Endoscopic Hypophysectomy. Indian
Journal of Otolaryngology and Head and Neck
Surgery 2006 April-June;58(2):162-164.
8. De Divitiis E, Cappabianca P, Cavallo LM.
Endoscopic trans sphenoidal approach:
Adaptability of the procedure to different sellar
lesions. Neurosurgery.2002; 51(3): 699-707.
9. Nishit J. Shah, Mukul Navnit,
Chandrashekhar E. Deopujari, Shraddha S.
Mukerji. Endoscopic Pituitary Surgery A
Beginners guide. Indian Journal of
Otolaryngology and Head and Neck Surgery.
January- March 2004. 56 ( 1) 56(1):71-78.
10. Landolt AM (2001): History of Pituitary Surgery
from the technical aspect. Neurosurgery clinics
of North America.2001; Vol 12/Number 1: pp
37-44.
Vol.-11, Issue-I, January-June - 2017 53
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

CASE REPORT
A CASE REPORT OF PAPILLARY CARCINOMA IN
TOXIC MULTINODULAR GOITRE
*Gopalakrishnan Midhun P, **Sajikumar NR

HOW TO CITE THIS ARTICLE Date of receipt of article -20-11-2016

Gopalakrishnan Midhun P, Sajikumar N R. A Case Report Of Date of acceptance 09-01-2017
Papillary Carcinoma In Toxic Multinodular Goitre. Orissa J
Otolaryngology Head Neck Surgery. 2017 June; 11(1): 54-56. DOI- 10.21176/ojolhns.2017.11.1.9
DOI : 10.21176/ojolhns.2017.11.1.9
DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.9

ABSTRACT:
Introduction: The incidence of papillary carcinoma in toxic multinodular goitre (MNG) is very low. The
prevalence is 1-4%.
Objective: To describe and report a case of papillary carcinoma thyroid in toxic multinodular goitre
with literature review.
Case report: A 39 year old female presented with features of toxic multinodular goitre. After evaluation
and controlling toxicity total thyroidectomy was done. The histopathology report came out as papillary carcinoma
thyroid.
Conclusion: Though rare there is a definite incidence of papillary carcinoma in toxic multinodular goitre.
Total thyroidectomy after controlling toxicity is the treatment of choice.
Key words: Papillary carcinoma, toxicity, multinodular goitre.

INTRODUCTION: (Fig.-5), tachycardia, tremor of hands and moist

Multinodular goitre (MNG) is a common palms were present.
thyroid disease. Development of toxicity is a Thyroid function test showed elevated T3
complication of long standing goiters. Most commonly and T4 with low TSH value.
it affects female population. The incidence of papillary
Patient was started on titrated dose of
carcinoma in toxic multinodular goitre is very low.
carbimazole and propranolol. After attaining
The prevalence is 1-4% 1,2. Such nodules are not
euthyroid status, USG (Ultra Sonogram) Neck and
considered alarming because they are assumed to be
benign3. Most of the diagnosis in such cases will
Affiliations:
come as a surprise after histopathology report. *Senior Resident in Surgical Oncology,
CASE REPORT Malabar Cancer Centre, Thalassery,
Kannur (DT), Kerala 670103
A 39 year old female presented to outpatient E-mail: drmidhungopalakrishnan@gmail.com
department with a thyroid swelling of 5 year duration. **Additional professor,
Department of General Surgery,
There was associated history of increased appetite, Govt. TD Medical College, Alappuzha
loss of weight, prominent eyes, and palpitation for Address for correspondence:
last 6 months. On examination diffusely enlarged Dr. Midhun P Gopalakrishnan,
Senior Resident in Surgical Oncology,
thyroid swelling of size 8x4 cms., nodular surface,
Malabar Cancer Centre, Thalassery,
and firm in consistency was present. No palpable Kannur (DT), Kerala 670103
cervical lymph nodes were there. Bilateral proptosis Email: drmidhungopalakrishnan@gmail.com
Mob. No. 09447314520

54 Vol.-11, Issue-I, January-June - 2017


FNAC (fine needle aspiration cytology) were done.
USG Neck showed a thyroid mass containing both
cystic and solid areas with multiple nodules in
both lobes, the largest measuring 2cms x 2 cms.
FNAC was consistent with colloid nodule. Total
thyroidectomy was done and histopathology report
came as nodular colloid goitre with two foci of
papillary carcinoma 1.5cms x 1 cms and 0.5cms x 0.5
cms (Fig 1, 2) along with toxic changes including
hyperplasia of acinii and vacuolated colloid with a
characteristic scalloped pattern (Fig 3). We stopped
carbimazole immediately after surgery and continued
propranolol till 7 days post operatively and stopped.
As one lesion was more than 1 cm we did Iodine
Fig-1: Nodular colloid goiter with two foci of
papillary carcinoma.
Fig 2. 1. Orphan Annie eyed nuclei
2. Overlapping of nuclei
3. Nuclear ridges
4. Nuclear pseudo inclusion bodies
Fig 3. Toxic changes including hyperplasia of acini
and vacuolated colloid with a characteristic scalloped
pattern.
Fig 4. Psammoma Bodies
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
Fig 5. Patient with bilateral proptosis
131 scan to assess the completion of thyroidectomy
and to detect metastasis if any. There was no
uptake of radio iodine in the neck suggestive of no
residual thyroid tissue there. There was no metastasis
elsewhere also. Later we put her on suppressive
dose of thyroxine and she is on follow up now.
DISCUSSION:
Papillary thyroid carcinoma constitutes
approximately 80% to 85% of malignant epithelial
thyroid tumors. Grossly, papillary carcinomas have
a variable appearance, from subcapsular white scars
to large tumors more than 5 to 6 cm that invade
nearby structures outside the thyroid gland. Cystic
change, calcification, and even ossification may be
identified4. Microscopically, papillary carcinomas are
characterized by the presence of papillae, the
characteristic nucleus containing Orphan-Annie nuclei,
nuclear grooves, and intranuclear pseudo inclusions
(Fig 1, 2). It may also contain concentric lamellated
calcified structures called Psammoma bodies (Fig 4).
Because the nuclei are enlarged, they frequently overlap
one another5. Papillary carcinoma has a propensity
to invade lymphatic spaces and therefore leads to
microscopic multimodal lesions in the gland as well
as a high incidence of regional lymph node metastases.
But the incidence of papillary carcinoma in toxic
multinodular goiter is rare. Overall prevalence is 1-
4%. In thyroid toxicity the TSH will be very low.
Actually in post total thyroidectomy patients for
differentiated thyroid cancers we use thyroxine for
TSH suppression i.e. to attain low TSH level to
prevent recurrence in follow up period. But here
in this case though the TSH is low there were foci
of papillary thyroid carcinoma. In the presence of
toxicity cytological and radiological characteristics
rarely predict malignancy2.
Vol.-11, Issue-I, January-June - 2017 55
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

CONCLUSION: 4. Vincent T. DeVita , Theodore S. Lawrence, Steven

Total thyroidectomy in all cases of A. Rosenberg,et.al. (Eds.) Cancer: Principles and
thyrotoxicosis after controlling toxicity should be Practice of Oncology; (Eds) 10 th Edition,
the norm in view of malignancy though it is rare Lippincott & Williams and Willkins, 2015: 1179-
to rule out the same. The detection of thyrotoxicosis 1181.
does not exclude the possibility of thyroid carcinoma 5. L. Cheng, David G. Bostwich.(Eds), Essentials
and warrants careful evaluation and appropriate of Anatomic Pathology 4th ed. Springer science
therapy6. and business media, LLC. 2011: 985-986.
Meeting at which the paper was presented: 6. Ruqqeri RM etal. Folicular Variant of Papillary
India Singapore International Conference on Thyroid Carcinoma presenting as Toxic Nodule
Head & Neck cancer, ISCON 2015 held in RCC in an adolescent: Co-existent polymorphism of
Trivandrum in February 2015. the TSHR and GS alpha genes: Thyroid. 2013
Feb; 23(2): 239-242.
Acknowledgements: We acknowledge the
support of Dr. K K Sukumaran, then the HOD
and Professor of General Surgery, Govt. TD Medical
College, Alappuzha in presenting this case report.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) Financial disclosures-none
(e) Animal rights -Not applicable
REFERENCES:
1. Sasan Mirfakhraee et al. A Solitary Hyper-
functioning Thyroid Nodule harbouring
Thyroid Carcinoma: : review of the literature
BMC; Thyroid Research. 2013 May, 6:7. avialble
at https://thyroidresearchjournal. biomedcentral.
com/articles/10.1186/1756-6614-6-7.
2. Polyzos etal. Coincidental Thyroid Papillary
Microcarcinoma in a patient treated for Toxic
Adenoma: Archives of Iranian Medicine. 2011
Mar; 14(2): 149-151.
3. Hala M. Ifayili etal. Papillary Thyroid
Carcinoma in a Autonomous Hyperfunctioning
Thyroid Nodule: Thyroid. 2010 Sep; 20(9):
1029-1032.

56 Vol.-11, Issue-I, January-June - 2017

 Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1

WOODEN FOREIGN BODY IN NASAL CAVITY:

AN UNUSUAL CASE REPORT
*Subrat K. Behera, **Girija S.Mohanta, ***Pitabas Nayak

HOW TO CITE THIS ARTICLE Date of receipt of article -22-02-.2017

Behera Subrat K, Mohanta Girija S, Nayak Pitabas. Wooden foreign Date of acceptance 30-02-.2017
body in nasal cavity: an unusual case report. Orissa J Otolaryngology
Head Neck Surgery 2017 June; 11(1): 57-59. DOI : 10.21176/
DOI- 10.21176/ojolhns.2017.11.1.10
ojolhns.2017.11.1.10 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.10

ABSTRACT:
Introduction: Nasal foreign bodies are more commonly encountered in pediatric age group. If an adult comes
with excoriation of nasal dorsum skin or non healing ulcer and have history of fall or road traffic accident, a
thorough clinical examination and diagnostic procedure is required to establish the diagnosis, skilled technique
may be required for removal.
Conclusion: Here we present a case of wooden object in the nose which is a rare of its kind in adult.
Keywords: Wooden foreign body, Nasal cavity.

INTRODUCTION: without any neurological deficit. There was small

Nasal foreign bodies are commonly encountered
in emergency departments, particularly among children
and mentally retarded patients.1 Nasal FB in adults are
uncommon. Wooden foreign bodies within nasal cavity
may remain asymptomatic for long duration and may
be missed in plain radiograph and CT scan.
Patients are presented with unusual symptoms
related to complication of FB. Successful diagnosis and
treatment of nasal foreign bodies depend on careful
nasal endoscopy and skilled technique of removal. We
are presenting a case of a lady , who implanted a wooden
bamboo stick accidentally due to fall from a tree and
presented to us after 1month of incident with unusual
complain of excoriation of nasal dorsum skin.
CASE REPORT:
A 32 year old woman was presented to Outpatient
department with chief complain of excoriation of nasal
dorsum skin since 15 days. She had history of fall from
a tree and a stick was pierced in to the dorsum which
was removed in local hospital 1month back. She had
pain and bleeding from nose, which did subsided on
medication. The symptoms were not associated with
nasal obstruction, decrease smell perception and nasal
discharge. There was no history of loss of consciousness,
vomiting and bleeding from ears. On examination the
patient was conscious, cooperative and well oriented
unhealing ulcer on dorsum of nose, just left lateral to
midline with excoriation of skin (Fig. 1) up to naso-
facial crease. There was no other wound or nasal
deformity externally. Local tenderness was present.
Eyeball movements were normal with normal vision.
On cold spatula test fogging on both side were normal.
Anterior rhinoscopy showed a yellow-pinkish,
firm foreign body on left nasal cavity. That was
insensitive to touch and did not bleed on probing.
Posterior rhinoscopic examination was normal.
Diagnostic nasal endoscopy was revealed, a yellowish
firm wooden stick foreign body in left nasal cavity
medial to middle turbinate, extending from roof to
the level of inferior turbinate (Fig. 2). The examination
of throat showed no abnormality. X ray of nose and
paranasal sinuses was inconclusive. CT scan was done,
which showed left maxillary mucosal thickening; but
Affiliations:
* Prof and HOD, ** & *** Post Graduate,
Deptt. Of ENT and Head and neck Surgery,
S.C.B.Medical.College,Cuttack,Odisha.
Address of Corresponding Author:-
Dr. Girija Shankar Mohanta
Post Graduate, Deptt. Of ENT and Head and neck Surgery,
S.C.B.Medical.College,Cuttack,Odisha.
Contact-9937644983
Email- girija.mohanta@yahoo.com

Vol.-11, Issue-I, January-June - 2017 57

Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
inconclusive.The detail hematological and routine
works up were done and were within normal limits.The
patient was planned for exploration of wound under
general anesthesia. We removed a 3cm 1 cm of
wooden bamboo stick from left nasal cavity found
attached to roof and hanging up to the level of inferior
turbinate through external approach.After removal
whole nasal cavity was washed with normal saline,
homeostasis was maintained and antibiotic soaked
anterior nasal pack was given. The pack was removed
on 2nd post operative day and patient was discharged.
Patient was follow up on 7th post operative day and
found to have normal nasal cavity and wound healed.
DISCUSSION:
Nasal foreign bodies are most common between
age 2-4 group2. They are more common in children
then adults because children are more likely to put
anything in to their nose or in to other childrens nose3.
Foreign bodies in adults are mainly seen in psychiatric
disorder patients, self inflicted harm as seen in suicidal
attempts person5,1,4 or prisoners who sometime attempts
to temporarily escape justice6. In normal adult, foreign
bodies may be implanted in to nose and Para nasal sinuses
accidentally like road traffic accident, fall from height
or drowning. These cases are often associated with
maxillo-facial injury.Foreign bodies are either animates
or inanimates1. Inanimates nasal foreign bodies are
classified as organic and inorganic. The plastics and metal
s are common as inorganic foreign bodies7. Organic
foreign bodies are seeds, food, wood etc.
Nasal foreign bodies are generally painless. Any
patient who presents with a unilateral nasal discharge
should raise suspicion of a nasal foreign body and in
children this must be regard as the case until proved
otherwise1. Accidentally implanted nasal foreign bodies
without much external and maxilla-facial injury are
difficult to diagnosis. Entry wound are contaminated
and presence of foreign body pieces makes the wound
unhealing. Irritation of wound and surround skin due
to presence of FB may lead to excoriation of skin (as in
our case).
The physical examination of nose involving
anterior rhinoscopy and use of 0 degree rigid endoscope
will often reveal foreign body. However on occasions
mucosal edema or granulation tends to hide it,
vasoconstrictors should be used to decongest the mucosa
prior to examination8.
Although standard plain radiographs clearly show
the presence of FB, for their precise and accurate
localization within the sinuses, orbits& soft tissues CT
scan may be required in high density foreign body9.
58 Vol.-11, Issue-I, January-June - 2017
Dry wood has air content 10, 11. On CT scan, in the
early stage, it presents as low attenuation linear or
cylindrical focus surrounded by hypo dense
inflammatory soft tissue. In late stage due to mineral
deposition, it becomes hyper dense. Intra nasal wooden
foreign body may be missed in early stage on CT because
of apparent air attenuation of FB and lack of contrast
with the surrounding intranasal air12 (as in our case).
The size and shape of the foreign bodies are
determining the method of removal and make difficulty
in removal. If foreign bodies are left inside may result
in chronic sinusitis, FB granulation formation,
secondary infection, osteomyelitis and sinus
formation13.
Transnasal endoscopic technique 9,13, 14 offers
excellent visualization and easy removal of FB. Other
external approaches like lateral rhinotomy may be
required in complicated and selected cases like in our
case we removed through external approach.
Complication during the removal may cause
epistaxis, injury to neighboring structure, aspiration,
orbital hematoma, rhinosinusitis etc.
If the CT is negative but a wooden foreign body
is suspected, MRI may be performed. MRI shows the
retained wooden foreign body to be hypo intense to
skeletal muscle on bothT1 and T2 weighted sequence.
However CT should be performed initially in a patient
suspected a harboring a FB, Since metallic FB may be
present and result in a severe or fatal injury if the metal
reacts to the magnet of the MRI3.
CONCLUSION:
Foreign body in nose with unusual presentation
need nasal endoscopy for diagnosis. Complicated cases
may require latral rhinotomy for removal for the same.
Fig.1: Small unhealing ulcer on dorsum of nose, just left lateral
to midline with excoriation of skin.

Fig. 2: A yellowish firm wooden stick foreign body in left
nasal cavity medial to middle turbinate, extending from roof
to the level of inferior turbinate.
Fig.3: Pre operative photograph.
Fig.4: Post operative photograph.
DISCLOSURES:
1. Funding: There is no source of funding for this
study.
2. Conflict of interest: The authors declare that they
have no conflict of interest.
3. Informed consent: Informed consent was taken
from every patient.
4. Ethical approval: All procedures performed in
studies involving human participants were in
accordance with the ethical standard of institution.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
REFERENCES:
1. Kalan A and Tariq M; Foreign bodies in the nasal
cavities; a comprehensive review of the aetiology,
diagnostic pointers and therapeutic measures
Postgrad Med J. 2000 Aug; 76(898): 484-
487.doi: 10.1136/pmj.76.898.484.
2. Kadish HA, corneli HM.Removal of nasal FB in
pediatric population.American journal of
emergency medicine. 1997;15 :54-6.
3. Kenji Takasaki, Kaori Enatsu, Eigo So, Haruo
Takahashi. Fifty-Four Wooden Toothpicks in the
Nasal Cavity. Otolaryngol Head Neck Surg. 2005;
132:669-70. doi:10.1016/j.otohns. 2004.09.073.
4. Werman HA. Removal of foreign bodies of the
nose. Emerg MedClin NorthAm1987;5 ;253-263.
5. Loh FC and Ling SY; Analysis of the metallic
composition of orofacial talismans. Oral Surg Oral
Med Oral Pathol 1992;73:281-283.
6. Krupp LB, Gelberg EA, Wormser GP. Prisoners
as medical patients. Am J Public Health
1987;77:859-60.
7. Figueiredo RR, Azevedo AA, K6s AOA, Tomita
S. Corpos estranhos de fossas nasais: descricao de
tipos e complicacoes em 420 casos. Rev Bras
Otorrinolaringol. 2006;72:18-23.
8. Walby AP. Foreign bodies in the ear or nose. In:
Kerr AG, ed. Scott-Browns otolaryngology. 6th
Ed. Oxford: Butterworth-Heinemann, 1997: 6/
14/16/14/6.
9. Lin WS, Hung HY. Transnasal endoscopic
surgery of sphenoid sinus aspergillosis. J Laryngol
Otol 1993;107:837-9.
10. Jeffrey J. Peterson,Laura W. Bancroft,Mark J.
Kransdorf ;Wooden Foreign Bodies:Imaging
Appearance. AJR 2002;178:557562.
11. Van Thong Ho, James F. McGuckin, Jr, and
Eleanor M. Smergel. Intraorbital Wooden
Foreign Body: CT and MR Appearance, AJNR
17:134136. Jan 1996 0195-6108/96/1701013.
12. Shailesh M Prabhu, Aparna Irodi, Phiji Philip
George , Ranjan sundaresan & VK Anand; Indian
J radiol Imaging. 2014 jan. mar ; 24 (1):72-74 doi-
10.4103/0971-3026.130703 PMCID:pmc4028920.
13. Mohiuddin SA, Rahiman S, Sultana S. Multiple
glass pieces in paranasal sinuses. Indian J Dent Res.
2011;22:847-9. doi: 10.4103/0970-9290.94683.
14. Kitamura A, zeredo JL. Migrated maxillary
implant removed via semilunar hiatus by transnasal
endoscope. Implant Dent. 2010;19.
Vol.-11, Issue-I, January-June - 2017 59
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.

TORNWALDTS CYST- A HIDDEN ENTITY- A CASE REPORT

*Sanket D Vakharia, **Seema R Gupta, ***Maya Shankar B Vishwakarma, ****S A Jaiswal

HOW TO CITE THIS ARTICLE Date of receipt of article- 08-02-2017

Vakharia S D, Gupta S.R. .Vishwakarma Mb,. Jaiswal Date of acceptance 24-02-2017
S.A.Tornwaldts cyst- a hidden entity- a case report. .orissa j
otolaryngology head neck surgery 2017 june; 11(1):60-62. DOI: DOI- 10.21176/ojolhns.2017.11.1.11
10.21176/ojolhns.2017.11.1.11 DOI URL- https://doi.org/10.21176/ojolhns.2017.11.1.11

ABSTRACT:
Introduction: Tornwaldts cyst is a benign developmental lesion originating within the midline of nasopharynx.
Etiopathogenesis of this cyst is outpouching of the pharyngeal mucosa caused by retraction of notochord. Most
of the cases are asymptomatic and are discovered as an incidental finding in patients undergoing diagnostic nasal
endoscopy or radiological examination. However, recently the cases are on an upsurge which could be attributed
to increased use of nasal endoscopy.
Case Report: Reported here is a case of 27-year-old man who complained of nasal obstruction and repeated nasal
discharge for which diagnostic nasal endoscopy was performed which revealed a deviated nasal septum and a
nasopharyngeal cystic lesion . Instead of CT Paranasal sinus, we opted MRI for further analysis of a
nasopharyngeal cystic lesion following which endoscopic surgery was performed.
Conclusion: This paper emphasises on the importance of radiological and endoscopic examination in the diagnosis
of the Tornwaldts cyst.
Keywords: Nasopharyngeal cyst, Tornwaldts cyst.

INTRODUCTION: Less common symptoms at initial presentation include

This entity is labelled in the memory of Dr.
Gustoff L. Tornwaldt (19th century), who first
described it. So, the accurate designation for this disease
is Tornwaldts Cyst and not Thornwaldts 1 .
Tornwaldts cyst is a benign developmental lesion
within the nasopharyngeal midline, above the upper
border of the superior constrictor muscle. It represents
the embryonic communication between mesenchymal
notochord remnant and endodermal-derived
nasopharyngeal mucosa 2. It is developmental in nature,
usually asymptomatic and found incidentally. So, the
age of diagnosis represents age of imaging of the
nasopharynx. It has an autopsy prevalence of
approximately 4%.3. Most Tornwaldts cysts appear
clinically in the second and third decades of life, with
both genders affected equally. Tornwaldts cyst
typically presents as occipital headaches, persistent nasal
discharge (more often post-nasal drainage), and halitosis.
stiff cervical muscles and ear fullness or Eustachian tube
dysfunction. On physical examination, nasal endoscopy
is required to diagnose this cyst which appears as a
smooth submucosal mass in the nasopharynx. It is
superior to the adenoid pad and may have a central
dimpling and/or yellow hue if infected or filled with
fluid from recent irritation. While history and
endoscopy can lead to the diagnosis, radiology is
recommended to rule out other possibilities in the
differential diagnosis.
Affiliations:
*Junior Resident, **Junior Resident, ***Assistant Professor,****
Professor & HOD
Dept.Of E.N.T.,DR.V.M.G.M.C., SOLAPUR
Address of Correspondence:
Dr. Seema R Gupta
Room No.-21, Resident Doctors Hostel
Civil Hospital Chowk, Solapur, Maharastra - 413003
Email: mailmeseema.gupta@gmail.com
Mob.: 9689470189

60 Vol.-11, Issue-I, January-June - 2017


CASE REPORT:
A 27 year old male patient reported to the OPD
with chief complaint of nasal obstruction and nasal
discharge since 6 months. Repeated episodes of upper
respiratory tract infection, snoring and nasal twang
were accompanying complaints. Past medical and
family history were not significant. History of multiple
courses of antibiotics and anti-inflammatory drugs
from physician with partial relief of symptoms was
present. On anterior rhinoscopy deviated nasal septum
to right, nasal mucosal congestion with discharge were
evident with no mass in the nasal cavity. On Diagnostic
Nasal Endoscopy a single midline well circumscribed
smooth surfaced cystic mass arising from posterior wall
of nasopharynx was seen (fig.1). The mass was covered
with normal looking mucosa. Oral, Ear and Neck
examination did not reveal any significant findings.
MRI of neck (Plain) revealed well defined round to
oval T1 & T2 hyperintense lesion of about 1.6 X 1.3
cm in the midline arising from posterior wall of
nasopharynx with no evidence of any invasion and intra-
cranial extension s/o cystic lesion- Tornwaldts
cyst(fig.2). Under general anaesthesia,the cystic lesion
was marsupialised via endonasal and transoral retrovelar
approach after endoscopic septoplasty. Patients post-
op period was uneventful with relief of all complaints
and the raw surface epithelialized within 14 days.
DISCUSSION:
The nasopharynx is a cuboidal compartment
extending from the base of the skull to the soft palate.
Due to the unique development of the nasopharynx,
Fig-1: Nasal endoscopic view of Tornwaldts cyst.
Issue DOI URL- https://doi.org/10.21176/ojolhns.0974-5262.2017.11.1
some authors argue that Nasopharyngeal cysts should
be classified according to their relation to the
pharyngobasilar fascia, which is the aponeurosis
attachment of the superior constrictor muscle to the
skull base 4. This fascia is only penetrated by the
eustachian tubes and the levator veli palatine muscles
and is a tight barrier between the superficial and deep
structures of the nasopharynx. Nasopharyngeal cysts
can also be classified according to their radiological
appearance, in context to their symptomatology.
Tornwaldts bursa, also known as nasopharyngeal
bursa, is a recess in the midline of the nasopharynx,
which is produced by persistent notochord remnants.
In 1912, Huber, in a description of the embryologic
formation of Tornwaldts bursa, reported that a
potential space could develop in the nasopharynx at
the point where the notochord retained its union with
the pharyngeal endoderm. His report was the first to
discuss this pathway for the ingrowth of respiratory
epithelium and the formation of a potential space in
the midline of the posterior superior angle of the
nasopharynx (nasopharyngeal bursa) 5. The cyst is lined
by respiratory epithelium and the cystic lumen contains
fluid with variable proteins. Tornwaldts cysts may also
be acquired, following nasopharyngitis, surgical trauma
(adenoidectomy) and chemoradiation for
nasopharyngeal carcinoma in adults. Tornwaldts cysts
can be classified as crusting cysts and true cystic cysts.6,7
The crusting types drain regularly and spontaneously
into the nasopharynx while the cystic types do not drain
because the drainage pathway is completely obstructed.
Fig-2: MRI of skull & skull base in sagital section
showing Tornwaldts cyst.
Vol.-11, Issue-I, January-June - 2017 61
Issue DOI- 10.21176/ojolhns.0974-5262.2017.11.1.
Most cysts are small, measuring less than 1 cm in
diameter and are discovered incidentally. Some are
larger, causing nasal obstruction, snoring, halitosis,
clearing of the throat, eustachian tube dysfunction, and
a feeling of ear fullness. When the cysts become inflamed
or infected, fluid may accumulate within the cyst
leading to symptoms of occipital headache, pharyngeal
pain, and purulent postnasal drip with a foul taste, neck
stiffness and changes in olfaction. The diagnosis of
Tornwaldts disease begins with a history of symptoms,
followed by confirmation by nasopharyngoscopy and
other imaging studies. The findings are that of a usually
centrally located smooth mass covered with intact
mucosa having yellowish hue due to the cystic contents.
The differential diagnosis should include meningocele
or meningo-encephalocele. Occasionally, the lesion can
be dark colored due to a hemorrhage or hemosiderin
content. Computed tomogram (CT) scan shows a well-
defined midline low density cyst on posterior
nasopharyngeal wall. On contrast enhanced CT scan a
rim of cyst may enhance but tornwaldts cyst itself
remains of low attenuation. MRI is now considered
the best radiographic imaging study to diagnose the
tornwaldts cyst as the findings are highly characteristic.
On MRI, it may have high signal on both T1- and T2-
weighted sequences, presumably because the cyst
contains a high concentration of protein, or blood
products from prior hemorrhage, or both. Post contrast
studies usually demonstrate peripheral enhancement of
the nasopharyngeal mucosa 8 . Also, it may be
hyperintense relative to gray matter on fluid-attenuated
inversion recovery images.
Asymptomatic cysts, which may be an incidental
finding on a CT or MRI, require no treatment9. When
the lesion is large, symptomatic, or close to the
eustachian tube torus, surgery by marsupialisation is
the treatment option10. For small lesions, the endonasal
approach is recommended but for large lesions, a
transoral retrovelar approach using a 70 degree
telescope is the method of choice.
CONCLUSION:
The diagnosis of a nasopharyngeal cyst is usually
incidental unless it is large causing obstructive
symptoms. Diagnostic Nasal endoscopy is a simple and
rapid procedure to visualize such cyst. Depending on
its appearance, surgical intervention may involve either
a simple excision or a marsupialisation of a cyst either
endoscopic or transoral approach. CT/MRI scan helps
62 Vol.-11, Issue-I, January-June - 2017
in the diagnosis and to know the exact extent of the
disease.
Acknowledgments- to Dr.PRIYA A. BHAGDE,
Resident of oral pathology, GOVT. DENTAL
COLLEGE, AURANGABAD.
DISCLOSURES:
(a) Competing interests/Interests of Conflict- None
(b) Sponsorships - None
(c) Funding - None
(d) No financial disclosures
(e) Animal rights-Not applicable
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