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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY
(An Internationally & Nationally Indexed Journal)

VOLUME - IX
NUMBER I,
JAN-JUNE, 2015
ISSN-0974-5262
Indexed in Index Copernicus International plc, Poland (http://indexcopernicus.com)
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The Official Publication of the Association of Otolaryngologists of India, Orissa State Branch
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Email: abhoya.kar@gmail.com
Editor:
Prof. R.N. Biswal, Cuttack
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Email: rudra.biswal7@yahoo.com
Associate Editor
Dr K.C.Mallik
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CDA, Cuttack, Odisha, India,
PIN-753014,
Cell-09437092087
drkrishnachandramallik@gmail.com
Member
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Prof. B.K. Das, Cuttack
Prof. D.R. Nayak, Manipal
Prof Sanjeev Mohanty, Chennai
NATIONAL ADVISORY BORAD
INTERNATIONAL ADVISORY BOARD
Prof. K. K. Ramalingam, Chennai
Dr. James P. Thomas, USA
Prof. T.V. Krishna Rao, Hyderabad
Dr. Asutosh Kacker, USA
Prof. M. Kameswaran, Chennai
Dr. Arun Gadre, USA
Prof. R. Jaya Kumar, Trivandrum
Dr. Ludwig Moser, Germany
Prof. Ahin Saha, Kolkata
Dr. Sylvester Femandes, Australia
Prof. Bachi Hathiram, Mumbai
Dr. Sharat Mohan, U.K.
Prof. Achal Gulati, New Delhi
Dr. Ullas Raghavan, U.K.
Prof. Vikas Sinha, Jamnagar, Gujarat
Dr. Ravinder Ahluwalia, U.K.
Prof. P.S. N. Murthy, Vijayawada
Dr. Naishadh Patil, U.K.
Dr. Madan Kapre, Nagpur
Prof. Andree A. Sultan, France
Prof. B. vishwanatha, Bangalore
Prof. Prepageran Narayanan, Malayasia
Prof. T.S. Anand, New Delhi
Prof. Peter Catalano, U.S.A.
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)
January-June 2015 Volume-IX Number-I
Contents
Pages
Sl.No Tittle and authors

EDITORIAL
MAIN ARTICLES
1.
Role of Ultrasonography in Thyroid Swellings
DSouza Caren, Vaidyanathan Vinay, M B Sandeep

2.
10
14
18
22
28
33
37
41
44
47
51
54
59
Anterior Nasal Packing and Eustachian Tube Dysfunction: Are They Related
Nudrat Parvez Kamal, Vivek V. Harkare, Nitin V. Deosthale,

Sonali P. Khadakkar, Kanchan S. Dhote
4.
05
Importance of Pre-operative HRCT Temporal Bone in Chronic Suppurative Otitis Media
Sunita M, A.P. Sambandan

3.
Tissue Myringoplasty: A Simple & Cost Effective Technique
Rupam Borgohain, Swagata Khanna

REVIEW ARTICLE
5.
Paediatric Bronchoscopy- An Overview
V. J. Vikram, S. K. Jha, D. Roy, B. Chowdhury, G. C. Sahoo

CASE REPORTS
Insular Carcinoma of Thyroid - Unusual Variant of Thyroid Malignancy
Dipak Ranjan Nayak, Asheesh Dora, Ranjani Kudva, Shekar Patil

7.
Solitary Parotid Mass Presenting as Sarcoidosis: Unusual Presentation
V. V. Rokade, N. A. Pathak, S. V. Nemade

8.
Nasal Glioma in 18 Month Child
D Kumar, A Agrawal, N Shree, C Gupta, AP Verma

9.
Congenital Choanal Atresia
C. S. Ray, Rabindra Kumar Khatua

10.
Familial Ankyloglossia [Tongue-Tie] - A Rare Case Report
Siva Subba Rao Pakanati, Vineeth Abraham Anchery, Fouzia Moidu

11.
Second Branchial Sinus Presenting with Oral Hair
Charu Singh, Jaya Gupta, Samiullah, Ranveer Singh, Pankaj Verma

12.
Bilateral Antrochoanal Polyp in an Elderly Male - A Rarity
Sandesh Chodankar, Markandeya Tiwari, Nicola Barreto, Ehrlson de Sousa

13.
6.
Diagnostic Dilemmas Leading to Fatality in Mucosal Malignant Melanoma of Hard Palate:

A Rare Clinical Presentation
Mohammad Shakeel, Gaurav kumar, Iram Khan, Ritu Sharma

INSTRUCTIONS TO AUTHOR
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Editorial...
During the past decade scientific research has improved our understanding of migraine
pathogenesis, leading to more efficient- pharmacological treatment protocols. However, many
patients with migraine remain dissatisfied with antimigraine medications because these agents
are not sufficiently effective or have unpleasant side effects. Complementary and alternative
medicine (CAM) have been used more often in adults with migraine & severe headache. These
include acupuncture, homeopathy, naturopathy, manual therapy like massage and chiropractic
care, biological based therapy like herbs, food elimination and mind & body therapy like meditation,
hypnosis and relaxation.
Many antimigraine drugs have been studied in large randomized placebo controlled and are
the main stay of treatment cited in evidence based international treatment guidelines. Such
guidelines are chiefly focused on efficacy but seldom take into account of the side effects. However
complementary and alternative medicine therapies usually lack evidence based data. Adequate
controlled trials should be performed.
Migraine is known to be a co-morbid with many somatic diseases like musculoskeletal disordersfibromyalgia which are highly prevalent. Co-morbidity with psychological disorder like anxiety,
panic disorder and depression is widespread. Most of the migraine patients use CAM therapy for
migraine & severe headache.
One should take account the paroxysmal nature of migraine and into reversible neurological
symptoms for diagnosis especially if a precise headache history and aura description is ascertained.
The association of migraine with ischemic stroke is well known. Migraine with coronary heart
disease, subclinical brain lesion and metabolic disorders should be investigated. Aggravating and
trigger factors like effect of hormones nutritional (food, chocolate, wine etc.) weather, stress,
tension & emotional influences should the taken into account. The trigeminocervical complex
and migraine, neurophysiological basis of muscle related pain to the head should be understood
before treating migraine. Multidisciplinary management of migraine is necessary.
Prof. A.K.Kar
Editorial chairman
Prof. R.N.Biswal
Editor
Dr. K.C.Mallik
Associate editor
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
ROLE OF ULTRASONOGRAPHY
IN THYROID SWELLINGS
*DSouza Caren, **Vaidyanathan Vinay, ***M B Sandeep
ABSTRACT :
INTRODUCTION:
Thyroid swelling is one of the commonest clinical
Thyroid swelling is one of the most common neck
presentations witnessed by a practicing surgeon.
swellings seen by a surgeon. Although the classical
Ultrasonography is one of the established tools of
presentation provides a working diagnosis, clinical
assessment, it provides valuable data about morphology
diagnosis is limited with only differentiation between
and character of the disease. It also helps to detect
solid and cystic lesions and in describing the anatomical
neolplasia. We performed a descriptive study to see
associations. The neck also poses a unique challenge to
the usefulness of ultrasonography in assessing thyroid
the surgeon as many of the supporting and deep
swelling and its ability to detect neoplasia.
structures are beyond the scope of topographic
Keywords : Thyroid, ultrasound, thyroid neoplasia.
evaluation. Hence the clinical examination is often

inconclusive and some form of diagnosing imaging is
Address of Correspondence:
necessary to come to a diagnosis.

Radiologic imaging provides an effective solution
Dr. Vinaya Vaidyanathan

Asst. Professor
in differentiating neck masses and intrathyroidal masses.
Dept. of ENT.
The major limitation of ultrasound (USG) in thyroid
Father Mulles Medical College,
imaging is that it cannot determine thyroid function, i.e.,
Mangalore-575002
if it is hyper or hypoactive. Simultaneous use of blood
Ph.: 8050076660
tests and radioactive isotope uptake test are helpful.
E-mail: drvinayvrao@gmail.com
These recent practices have revolutionized assessment
AIMS AND OBJECTIVES :

1.
To evaluate the site, size and consistency of the

thyroid swelling.
2.
To study the any abnormal features like internal

echos , calcifications etc.
3.
To assess the use of USG as an effective screening

tool to detect thyroid neoplasia.
*Assistant Professor, Dept of General Surgery, **Assistant Professor, Dept of ENT, ***Assistant Professor, Dept of Radiodiagnosi,
Father Muller Midical College, Mangalore, Karnataka-575002
of thyroid masses.(1,2)
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METERIALS AND METHODS
DISCUSSION
It is a descriptive study which was conducted in
USG imaging has been in use for over 4 decades
the department of general surgery, ENT and
to assess neck swellings, use of which cannot be
Radiodiagnosis at Father Muller Medical College,
overemphasised. USG is non-invasive and non-ionizing
Mangalore between the period of May 2011 - April 2012.
tool. It uses sound waves of different frequencies to
200 cases of thyroid swellings were taken up by
assess the densities and elasticity of tissues and it utilizes
purposive sampling technique.
the pulse echo method to produce an image. In
Inclusion criteria: Thyroid swellings presenting

for first time without previous surgical treatment.
Exclusion criteria: Neck swellings other than
thyroid enlargement.
Detailed general and local examinations were done.
Apart from routine haematological tests, X Ray soft
tissue neck, lateral and anterioposterior view were
taken. USG examination was done to note the size,
echotexture, consistency (solid/cystic) and calcification.
assessment of neck B-scans are of primary concern.

The head and neck is scanned in horizontal, vertical
and oblique directions (3).
Ultrasound of thyroid provides information
regarding echo texture and intralesional character of
the gland which help to characterize benign/malignant
nodule, detect nodal metastasis, can be used for follow
up or screening. It also provides image guidance for
FNAC (4).
All studies were done using HD 11 Phillips Ultrasound
The incidence of all thyroid diseases is higher in
unit with 10-12 MHz transducer. The diagnosis was
females than males. Nodular thyroid disease is the most
confirmed with fine needle aspiration cytology (FNAC)
common cause of thyroid enlargement in our series and
/ histopathology. The collected data was analysed using
most of the clinical studies worldwide. Nodularity within
chi square test.
thyroid is normal signifying normal maturation.
RESULTS
Incidence of thyroid nodule is very high on USG, ranging

from 50% to 70%. Thyroid neoplasia accounts for less
200 cases of thyroid swellings were enrolled in
than 7% (5,6).
this study. Out of those 180 (90%) were females and

20(10%) were males, sex ratio being 9:1. Age
distribution ranged from 11-76 years. Most of the
patients presented with complain of neck swellings

(84%), followed by swallowing difficulty, pain, fever.
On USG examination nodular thyroid disease was the
Diffuse thyroid enlargement can be due to

multinodular goitre, thyroiditis or Graves disease.
Multinodular goitre is the commonest of all. On USG
multiple nodules within a diffusely enlarged gland is often
seen. Most of the nodules are iso or hyper-echoic in
most common presentation (distribution of cases as
nature (fig 1a & 1b). These nodules undergo
mentioned in table 1).
degeneration causing USG features of cystic

degeneration, haemorrhage or infection seen as moving
8 cases of thyroid malignancy were missed on
internal echoes/ septations.
USG. Sensitivity of USG to detect thyroid neoplasia in

the present study is 66.67% and specificity is 100%.
Iso or hyper-echogenic thyroid nodule showing
Positive predictive value being (PPV) 100% and
spongiform appearance are considered benign. Eggshell
negative predictive value (NPV) being 95.65%.
calcification and comet tail artefact are useful ancillary
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
signs (fig 2). Punctate calcifications with irregular

margins are suggestive of malignancy (6,7).
Flow pattern is of help in differentiating benign
from a malignant nodule. A complete avascular nodule
is very unlikely to be malignant. Chaotic intranodular
vascularity on colour flow imaging, nodal secondaries,
cystic necrosis, microcalcificatons, pre and para
tracheal cervical nodal metastasis are sonological
features associated with thyroid malignancy (8).
In our study, sensitivity to detect thyroid neoplasia
on USG was 66.67% as comparable to the range of
Fig 1a: intrathyroidal multiple nodules along with a
discrete nodule seen (white arrow).
60% to 80% in majority of the studies. It was highly

specific with PPV of 100% and NPV being 95.65%.
Various studies have been done highlighting the
usefulness of ultrasonography imaging, one such study
done by Radecki and colleagues compared high
resolution ultrasonography and CT scan for thyroid
imaging. Both imaging modalities detected and localized
the same number of abnormalities and neither one of
them was considered to have any specific advantage
over the other. However, to study extensions and
invasion, CT is better (9).
Fig 1b: on Doppler, vascularity is well preserved hence minimizing

the possibility of malignancy.
Rodrigues et al found the result of ultrasound for

detecting neoplastic disease was 65% sensitive and 80%
specific (10), which is comparable to our study where
we had 66.67% sensitivity and 100% specificity. This
be attributed to the variation amongst radiologists in other
studies, we had one radiologist performing all the scans
in our study so we didnt come across this variation .
USG guided FNAC is an advantage in difficult to
access lesions with a relatively high accuracy of 74.8%
(11). In one such case where repeated blind FNAC were
inconclusive we got an aspirate positive for papillary
carcinoma which was USG guided. It can be used as
Fig 2: nodular goitre with calcification (comet tail appearance).
very valuable adjunct tool in occult cases.

7
slight discrepancy in almost comparable results may
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Rosario et al in his work has highlighted the use of
pathologies. Inflammatory and neoplastic changes can
imaging with radioiodine scans and serum thyroglobulin
be appreciated well. It can be used as a screening tool
to detect early local recurrences and how this practice
to detect thyroid neoplasia. USG guided FNAC provides
can be beneficial in follow up of patients (12). We could
sensitivity to the test & Acts as effective adjunctive tool
not assess this aspect of imaging as such patients were
to CT and MRI.
not included in our study, however as this is a purely
DISCLOSURES
diagnostic efficacy study such data can be used for

prolonged follow up and assess early recurrence of
disease.
CONCLUSION
Ultrasound is one of the most valuable tools
available. It can effectively differentiate between
different types of thyroid masses and intrathyroidal
(a) Competing interests/Interests of Conflict- None

(b) Sponsorships - None
(c) Funding - None
REFERENCES
1.
Solbiati L, Charboneau JW, Osti V, James EM,

Hay ID. The thyroid gland. In: Rumack CM,
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
in thyroid ultrasound. J Clin Ultrasound, 1996;
Wilson SR, Charboneau JW, editors. Diagnostic

rd
24: 129-33.
Ultrasound. 3 ed, Vol !. St. Louis, Missouri:

elsevier Mosby; 2005. P. 735-70.
3.
Chaudhary V, Bano S. Imaging of the thyroid:
Zigman Z, Delic-Brkljacic D, Drinkovic I.
Recent advances. Indian J Endocrinol Metab 2012;
Ultrasonic evaluation of benign and malignant
16: 371-6.
nodules in echographically multinodular thyroids.
Diagnostic Radiology; A text book of medical

rd
5.
7.
9.
Radecki PD, Argetr PT, Arenson RL. Thyroid

Imaging: Comparison of High Resolution Real
imaging, 3 ed. Vol 1, Edinborough; Churcill
Time Ultrasound and Computed Tomography
Livingstone 1997:83-85.
Radiology, 1984;153:145-47.
Baskin HJ. Ultrasound of thyroid nodules. In:
10. Rodriguez JM, Reus M, Moreno. High resolution
Baskin HJ, editor. Thyroid Ultrasound and
ultrasound with aspiration biopsy in the follow up of
Ultrasound-guided FNA Biopsy. Boston: Kluwer
patients with differentiated thyroid cancer.
Acadmic Publisher; 2007.p.71-86.
Otolaryngol Head & Neck Surg ,1997;117: 694-97.
Moon WJ, Jung SL, Lee JH, Na DG, Baek JH,
11. Kim EK, Park CS, Chung WY. New sonographic
Lee YH, et al. Benign and malignant thyroid
criteria for recommending fine needle aspiration
nodules:
biopsy of nonpalpable solid nodules of the thyroid.
US
differentiation-multicenter
retrospective study. Radiology, 2008; 247: 762-70.

6.
J Clin Ultrasound, 1994; 22: 71-6.
Cosgrove DO. Ultrasound, general principles. In

Grainger RG, Allison D. Eds. Grainger and Allison
4.
Brkljacic B, cuk V, Tomic-Brzac H, Bence-
AJR, 2002; 178: 687-91.
Hoang JK, Lee WK, Lee M, Johnson D, Farrell
12. Rosario PW, Faria S, Bicalho L. Ultrasonic
S. US features of thyroid malignancy: Pearls and
differentiation between metastatic and benign
pitfalls. Radiographics, 2007; 27: 847-60.
lymph nodes in patients with papillary thyroid
Ahuja A, chick W, King W, Metreweli C.

Clinical significance of the comet-tail artifact
carcinoma. J Ultrasound Med, 2005; 24:

1385-89.
2.
8.
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IMPORTANCE OF PRE-OPERATIVE HRCT TEMPORAL BONE

IN CHRONIC SUPPURATIVE OTITIS MEDIA
* Sunita M, **A.P. Sambandan
ABSTRACT
INTRODUCTION
ossicular chain involvement, tegmen, scutum and lateral
Diagnostic imaging to know the extent of disease

in chronic suppurative otitis media whether it is
tubotympanic type or atticoantral type was only x-ray
of the mastoids, routinely. After the advent of CT scan,
high resolution computed tomography of the temporal
bone has become very valuable in identifying the extent
of the disease. HRCT temporal bone is not regularly
recommended for routine CSOM patients.1,2 However
they are recommended in those patients with
cholesteatoma. 3-5 This study highlights the importance
of HRCT in both tubotympanic and atticoantral type of
CSOM.
semicircular canal erosion, and facial canal dehiscence.
MATERIALS AND METHODS:
Aim: The role of pre-operative HRCT temporal

bone in evaluating the extent and severity of disease in
patients with chronic suppurative otitis media.
Setting and design: A prospective study in a
tertiary care centre
Materials and methods: Study done on 50 patients
of chronic suppurative otitis media with pre-operative
HRCT temporal bone and the results analyzed.
Results: HRCT is useful in detecting the extent of
soft tissue involvement in the middle ear and mastoid,
Conclusion: HRCT is useful prior to surgical

approach in patients with actively discharging
tubotympanic and atticoantral type of CSOM.
Keywords: HRCT temporal bone, CSOM
This is a prospective study in which pre-operative

HRCT temporal bone with 0.6mm cuts was done on 50
patients with chronic suppurative otitis media both
tubotympanic and atticoantral type.
tubotympanic type, CSOM atticoantral type, Surgery.

1.
Presence of mastoid pneumatisation
Dr. Sunitha. M
2.
Soft tissue density
Assistant Professor,
3.
Erosion of scutum, tegmen, lateral semicircular

canal, sinus plate, mastoid cortex
Sri Muthukumaran Medical College
4.
Facial canal dehiscence
Hospital & Research Institute,
5.
Ossicular chain status
Address for correspondence:
The parameters studied are:
Department of ENT,
Chennai-600069.
Mobile: 09488037684
E-mail: drsunithavasu@gmail.com
10
The patients were evaluated with clinical history

and thorough examination including otoscopy,
otoendoscopy or examination under microscope,
diagnostic nasal endoscopy and pure tone audiometry.
*Assistant Professor, Department of ENT, **Professor & HOD, Department of ENT, Sri Muthukumaran Medical College
Hospital & Research Institute, Chennai.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
The patients were subjected for x-ray both mastoids and

HRCT temporal bone. These patients underwent surgery
accordingly.
OBSERVATIONS:
In this study 31 patients(62%) were in the age group
20-30years and the mean age group was 27 years. The
youngest was 11 years and the oldest was 59 years.
Male:female ratio was 0.9:1.
Based on clinical diagnosis, tubotympanic type of
CSOM was seen in 31 cases, of which 25 cases were
inactive type and 6 were active type. Atticoantral type
of CSOM was seen in 19 cases.
On x-ray mastoids, pneumatisation was seen in
30%, diploeic in 8%, sclerosed mastoid in 54% and
cavity in 8% of the cases. On HRCT temporal bone,
pneumatisation was seen in 38%, diploeic in 4%,
sclerosed in 50% and cavity in 8% of the cases.
Whereas in atticoantral type of CSOM, the extent of

involvement was more in the epitympanum, followed
by antrum, aditus, posterior tympanum, rest of middle
ear and mastoid air cells.
The ossicular destruction was more common with
incus, followed by stapes in actively discharging
tubotympanic type of CSOM. In atticoantral type of
CSOM, incus was most commonly eroded, followed
by stapes and malleus.
In inactive tubotympanic type of CSOM, there was
no soft tissue opacity in the middle ear and mastoid,
and the ossicular chain was intact in all the 25 cases.
Table II: Other HRCT findings in TT type and AA type.
Soft tissue density was seen in 6 cases in actively

discharging tubotympanic type of CSOM and in all the
19 cases of atticoantral type of CSOM. The extent of
involvement of the disease in this tubotympanic type of
CSOM was more in the antrum followed by
epitympanum, aditus, mastoid air cells and middle ear.
Scutum, tegmen, lateral semicircular canal,

mastoid cortex and sinus plate erosion was seen in
atticoantral type of CSOM, but not in tubotympanic type
of CSOM.
Facial canal dehiscence was seen in 1 case in
tubotympanic type and in 4 cases in atticoantral type of
CSOM.
DISCUSSION:
The pneumatisation and the status of the mastoid
was better appreciated on HRCT temporal bone. These
findings were similar to study by Vlastarakos et al.
11
Table I. HRCT findings of site and extent of soft

tissue density in the middle ear and mastoid in TT type
and AA type.
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(2010), who found strong agreement for mastoid cell

aeration.6
On HRCT, soft tissue opacity was noted in 6 cases
out of the 31 cases of tubotympanic type of CSOM. Intraoperatively there were granulations in 3 cases and
edematous mucosa in 3 cases of tubotympanic type of
CSOM.
On HRCT, soft tissue opacity was noted in all 19
cases in atticoantral type of CSOM. Mafee et al,
OReilly et al and Tripti had similar results.7-9 Intraoperatively there was cholesteatoma in 10 cases and
granulations in 9 cases of atticoantral type of CSOM.
HRCT could not differentiate the soft tissue density.
Mafee, OReilly, Jackler and Garber et al are in
agreement with this finding.7,8,10,11
Erosion of scutum was seen in 42.1%, tegmen
erosion in 31.6% of cases with atticoantral type of
CSOM. This finding was similar to Gaurano and
Joharjy.12 HRCT could detect erosion of ossicular chain
which were similar to study by Tatlipinar et al.13
When comparing the HRCT findings with surgical

correlation in CSOM, HRCT could detect soft tissue
density and extent of spread with 98% sensitivity and
89% specificity. These findings were similar to OReilly
et al and Tripti. 8,9 HRCT could detect ossicular
destruction with sensitivity of 100% in malleus erosion,
86% in incus erosion and 82% in stapes suprastructure
erosion. However the specificity was 100%. These
findings were similar to Alzoubi et al.18
HRCT was 100% sensitive and specific to detect
lateral semicircular canal erosion and tegmen erosion,
but 83% sensitive to detect facial canal dehiscence with
100% specificity. CT failed to identify facial canal
dehiscence in one case. These findings were similar to
Alzoubi et al. 18 HRCT was found to be 100% sensitive
and specific to detect mastoid cortex erosion and sinus
plate dehiscence. These findings were similar to Sirigiri
and Dwarkanath.16
Table III: Correlation between HRCT and surgical
findings.
Lateral semicircular canal erosion was noted in

15.8% of the cases of atticoantral type of CSOM on
HRCT. These findings were similar to Chee and Tan.14
Mastoid cortex erosion was seen in 5.3% of the
cases with atticoantral type. These findings were similar
to Suat Keskin et al.15 Sinus plate erosion was seen in
5.3% the cases with atticoantral type of CSOM. These
findings were similar to a study by Tripti.9 Facial canal
dehiscence was seen in 4 cases of atticoantral type of
CSOM which was similar to a study by Sirigiri and
Dwarkanath.16
6 patients of tubotympanic type of CSOM
underwent cortical mastoidectomy and 25 patients
underwent tympanoplasty. In atticoantral type of CSOM,
2 cases underwent atticotomy, 2 cases underwent
atticoantrostomy, 3 cases underwent canal up
mastoidectomy and the remaining canal wall down
mastoidectomy depending on the HRCT findings. These
findings were similar to Payal et al.17
12
CONCLUSION:
HRCT temporal bone could detect bony erosion
accurately and also the extent of soft tissue involvement
with ossciular chain status. This was very much useful
in planning the surgical approach not only in atticoantral
but also in tubotympanic type of CSOM. We emphasize
the need for HRCT temporal bone study pre-operatively
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
scanning in chronic suppurative otitis media. J

Laryngol Otol 1991;105:990 4.
not only in atticoantral but also in tubotympanic of CSOM

with actively discharging ears.

(c) Funding - None
REFERENCES:
1.
2.
3.
4.
Walshe, P, Walsh, RM, Brennan, P, Brennan, P,

Walsh, M (2002). The role of computerized
tomography in the preoperative assesment of
chronic suppurative otitis media. Clin Otolaryngol
Allied Sci 27: pp. 95-97.
Blevins NH, Carter BL. Routine preoperative
imaging in chronic ear surgery. Am J Otol 1998;
19:527535; discussion 535528.
Jazrawy H, Wortzman G, Kassel EE, Noyek AM.
Computed tomography of the temporal bone. J
Otolaryngol 1983; 12:3744.
Mafee MF, Valvassori GE, Dobben GD. The role
of radiology in surgery of the ear and skull base.
Otolaryngol Clin North Am 1982; 15:723753.
5.
Valvassori GE, Mafee MF, Dobben GD.

Computerized tomography of the temporal bone.
Laryngoscope 1982; 92:562565.
6.
Vlastarakos PV, Kiprouli C, Pappas S, Xenelis J,

Maragoudakis P, Troupis G, et al. CT scan versus
surgery: How reliable is the pre operative
radiological assessment in patients with chronic
otitis media? Eur Arch Otorhinolaryngol
2012;269:81 6.
7.
8.
Mafee MF, Levin BC, Applebaum EL, Campos

M, James CF. Cholesteatoma of the middle ear
and mastoid. A comparison of CT scan and
operative findings. Otolaryngol Clin North Am
1988;21:265 93.
OReilly BJ, Chevretton EB, Wylie I, Thakkar C,
Butler P, Sathanathan N, et al. The value of CT
9.
Rai T. Radiological study of the temporal bone in

chronic otitis media: Prospective study of 50 cases.
Indian J Otol 2014;20:48-55.
10. Jackler RK, Dillon WP, Schindler RA. Computed

tomography in suppurative ear disease: A
correlation of surgical and radiographic findings.
Laryngoscope 1984;94:746 52.
11. Garber LZ, Dort JC. Cholesteatoma: Diagnosis and
staging by CT scan. J Otolaryngol 1994;23:121 4.
12. Gaurano JL, Joharjy IA. Middle ear
cholesteatoma: Characteristic CT findings in 64
patients. Ann Saudi Med 2004;24:442 7.
13. Tatlipinar A, Tuncel A, Oredik EA, Gokceer T,
Uslu C. The role of computed tomography scanning
in chronic otitis media. Eur Arch Otorhinolaryngol
2012;269:33-8.
14. Chee NW, Tan TY. The value of pre operative
high resolution CT scans in cholesteatoma surgery.
Singapore Med J 2001;42:155 9.
15. Keskin S, etin H, Tre HG. The Correlation of
temporal bone CT with surgery findings in
evaluation of chronic inflammatory diseases of the
middle ear. Eur J Gen Med 2011;8:24 30.
16. Sirigiri RR, Dwaraknath K. Correlative Study of
HRCT in Attico Antral Disease. Indian J
Otolaryngol Head Neck Surg 2011;63:155 8.
17. Payal, Garg; Pranjal, Kulshreshtha; Gul,
Motwani; Mittal, M K; Rai, AK. Computed
Tomography in Chronic Suppurative Otitis
Media:Value in Surgical Planning. Indian J
Otolaryngol Head Neck Surg (JulySeptember
2012); 64(3):225229
18. Alzoubi FQ, Odat HA, Al Balas HA, Saeed SR.
The role of pre operative CT scan in patients with
chronic otitis media. Eur Arch Otorhinolaryngol
2009;266:807 9.
13
DISCLOSURES
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
ANTERIOR NASAL PACKING AND EUSTACHIAN TUBE

DYSFUNCTION: ARE THEY RELATED
*Nudrat Parvez Kamal, **Vivek V. Harkare ***Nitin V. Deosthale,
****Sonali P. Khadakkar, *****Kanchan S. Dhote
ABSTRACT
Eustachian tube is an osseo-cartilagenous tube
connecting gas filled middle ear with nasopharynx.
Nasal packs used after nasal surgery for haemostasis
and internal stabilization of bony and cartilaginous
structures, are considered to have an impact on
Eustachian tube function. As nasal packing is frequently
required following nasal surgery, the present study was
undertaken to evaluate the effect of nasal packing done
after nasal surgery on Eustachian tube function by
Tympanometry and to see the improvement in tubal
function after pack removal. The study was conducted
prospectively in 36 patients with a male: female ratio
of 2.28:1 and age ranging from 17 to 58 years having
bilateral normal type A tympanograms who underwent
bilateral anterior nasal packing after nasal surgery. The
study favors the clinical observation that bilateral
anterior nasal packing results in Eustachian tube
dysfunction and middle ear hypoventilation. This
phenomenon is temporary and reversible; removal of
packing results in normalization of tubal function in 7
days time. Hence, conventional nasal packing should
not be abandoned in favor of modern methods for
achieving haemostasis after nasal surgery.
Keyword: Nasal packing, Eustachian Tube,
Tympanometry.
CORRESPONDING AUTHOR:
Dr. Nudrat Parvez Kamal
K.M. Hospital, Behind Indian Coffee House
Banstal, Raipur (C.G.) 492001
Phone No. 8462811186
Email: nudratkamal86@gmail.com
14
INTRODUCTION
Eustachian tube is an osseo-cartilagenous tube
connecting gas filled middle ear with nasopharynx.
Numerous physiological or pathological factors of nose,
para-nasal sinuses and nasopharynx may alter its
function. Nasal packs are frequently used after nasal
surgery for haemostasis and internal stabilization of bony
and cartilaginous structures and are considered to have
an impact on Eustachian tube function. As nasal packing
is frequently required following nasal surgery, the
present study was undertaken to evaluate the effect of
nasal packing done after nasal surgery on Eustachian
tube function by Tympanometry and to see the
improvement in tubal function after pack removal.
METHODOLOGY
It was a hospital based prospective study in which
we investigated 36 patients with bilateral normal type
A tympanograms undergoing bilateral anterior nasal
packing after nasal surgery. Nasal packing consisted of
one quarter inch ribbon gauze impregnated with
bacitracin ointment inserted bilaterally for 48 hours.
Patients with pre-operative evidence of Eustachian tube
dysfunction (as evident by type B/C tympanogram) were
excluded, since it would be difficult to attribute changes
solely to nasal packing. Patients having congenital ear
or palate malformation, history of previous nasal or sinus
surgery, history of radiotherapy to head and neck region,
history of allergy as diagnosed clinically and by tests of
Department of ENT, NKP Salve Institute of Medical Sciences & Research Centre, Nagpur
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
allergy or patients requiring unilateral anterior nasal

packing after nasal surgery were also excluded from
the study. All patients underwent pre-operative
Tympanometry which was repeated 48 hours following
surgery just prior to removal of nasal pack and then 24
hours after pack removal and subsequently 7 and 14
days after pack removal. The tympanograms were
classified in the standard manner similar to that
originally described by Jerger 1. In the present study, a
tympanogram with peak middle ear pressure between
+ 200daPa and -99daPa was classified as type A. A
tympanogram with the peak middle ear pressure at 100 daPa or more negative was classified as type C. A
Figure 1: Stacked bar chart showing variation in the type of

tympanogram with time in patients undergoing nasal packing after
surgery (n=36)
tympanogram with flattened peak of 0.3 ml compliance

or less was classified as type B.
RESULTS
We investigated 36 patients, representing 72 ears,
with a male: female ratio of 2.28:1 and age ranging
between 17 58 years. 19 (52.7%) patients were
diagnosed with Deviated Nasal Septum (DNS), followed
by 9 (25%) patients with Chronic Rhinosinusitis, 6
(16.7%) with Nasal Polyposis and 2 (5.6%) with
Allergic Fungal Rhinosinusitis.
Table I: Variation in median Middle Ear Pressure (MEP) values

along with inter-quartile range with time for right and left ears
of variation in the type of tympanogram with time. Pre-
Thus, 21 out of 36 patients (58.4%) developed a type
operatively, all 36 (100%) patients showed bilateral
C tympanogram in at least one ear 48 hours after nasal
normal type A tympanograms. 15 (41.6%) patients
packing just before its removal which improved to 6 out
continued to show normal type A tympanograms
of 36 patients (16.6%) with persistent type C
bilaterally 48 hours following bilateral anterior nasal
tympanogram in at least one ear 24 hrs after pack
packing just prior to pack removal. However, 9 (25%)
removal. 7 days after pack removal, all 36 (100%)
patients developed a unilateral type C (Type A, C)
patients showed bilateral type A tympanograms. No
tympanogram and 12 (33.4%) patients developed
patient developed a type B tympanogram during the
bilateral type C tympanograms 48 hours following
period of study. The change in the proportion of patients
nasal packing. 24 hours after pack removal, there was
with bilateral type A tympanograms from pre-operative
improvement in middle ear ventilation with 30 (83.4%)
to 48 hours after packing was statistically significant
patients showing bilateral normal type A curve, 5
with P-value of 0.0004 as per chi-square test with Monte-
(13.8%) showing unilateral type C tympanogram and 1
Carlo simulation. The same level of significance was
(2.8%) patient showing bilateral type C tympanogram.
observed between 48 hours after packing and 7th day

15
Figure 1 provides the stacked bar chart presentation
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
after pack removal. This supports our hypothesis that
ventilation by 7 days after pack removal. This was
bilateral anterior nasal packing does lead to Eustachian
contradictory to what Salaheldin had observed in his
tube dysfunction evident by worsening of tympanograms
study of the effect of co-existent deviated nasal septum
48 hours after packing. But this effect is temporary and
and hypertrophy of inferior turbinate on middle ear
there is statistically significant improvement in
pressure in 35 patients and had analyzed the effect of
tympanograms and thereby tubal function by 7 days after
nasal packing on middle ear pressure3. He observed
pack removal.
statistically significant difference in MEP values

2
This was similar to what Thompson and Crowther
between pre-operative and 7 days after pack removal
observed in their study on 63 patients where they assessed
status and concluded that nasal packing worsens the
the effect of nasal packing following septal surgery on
middle ear pressure and ventilation.
Eustachian tube function by tympanometry. 55 of 126
DISCUSSION
ears (46%) developed a reduction in middle ear pressure

of at least 50 daPa. Of the 55, 42 ears (76%) became
To maintain normal ventilation of the middle ear,
normal within 24 hours of removing the nasal packing.
the nasopharynx must be ventilated, the Eustachian tube
34 of the 63 patients (54%) developed a type C
mechanically passable, and its opening and closing
tympanogram in at least one ear following septal
mechanism adequately functioning. Nasal packs are
surgery.
frequently used for haemostasis and stabilization of bony
Table I provides the variation in median Middle

Ear Pressure (MEP) values and inter-quartile range with
time for right and left ears. It is evident that median
and cartilaginous structures after septal surgery and are

considered to have an impact on Eustachian tube
function. In fact, etiopathogenesis of the effects of nasal
MEP was negative maximum 48 hours after packing
packs on tubal function are a matter of controversy.
with -90 daPa and -93.5 daPa in right and left ears
There are several explanations that have been offered
respectively. At 7th day after pack removal, the median
to account for the transient Eustachian tube dysfunction
MEP was -16 daPa in right ear, while -19 daPa in left
in association with nasal packing. These may be
ear. Pair wise comparison of MEP values for different
summarized briefly in the following manner:
time points showed insignificant difference between pre-
1.
operative and 7th day after pack removal for both right
Abolished ventilation of and absence of air current

through the nasopharynx during the packing period4.
and left ears (P-value: 0.061 & 0.091 respectively) as
per Wilcoxon signed rank test. The difference of median
2.
Mechanical obstruction of the Eustachian tube

orifice may occur in some cases especially if the
MEPs between preoperative and 48 hours after packing;

and 48 hours after packing and 7th day after pack removal
packs used are potentially long enough to impinge
for both right and left ears was statistically significant
on the orifice if fully inserted2.
with P-values < 0.0001 each. This again shows that
3.
Inflammatory oedema of the nasopharyngeal
bilateral anterior nasal packing leads to significant
mucosa is a likely consequence of both the presence
impairment of middle ear ventilation evident by
of the pack and of the nasal surgery itself; which
worsening of MEP values 48 hours after packing. But
leads to tubal dysfunction possibly by causing
this effect is temporary with statistically significant
peritubal inflammation or stasis of peritubal
improvement in MEP values and thereby middle ear
lymphatics2.
16
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
4.
Inflammation may inactivate the surfactant that

facilitates opening of the Eustachian tube and result
REFERENCES
1.
in dysfunction2.
5.
Increased secretions from seromucous glands in
audiometry. Arch Otolaryngol 1970; 92: 31124.

2.
the pharyngeal portion of the Eustachian tube may
Thompson AC, Crowther JA. Effect of nasal

packing on Eustachian tube function. J Laryngol
accumulate and block the tube2.

Thus, our study favors the clinical observation that
Jerger J. Clinical experience with impedance
Otol 1991; 105(7): 539-40.

3.
bilateral anterior nasal packing results in Eustachian
Salaheldin AH. Effect of deviated nasal septum

and hypertrophy of inferior turbinate on middle ear
tube dysfunction and middle ear hypoventilation. This
pressure. Arab J Rhinol 2012 Oct; 2(2): 59-65.
phenomenon is temporary and reversible; removal of

packing results in normalization of tubal function in 7
days time. Hence, conventional nasal packing should
not be abandoned in favor of modern methods for
achieving haemostasis after nasal surgery.
4.
Tos M, Bonding P. Middle ear pressure during

and after prolonged nasotracheal and/or
nasogastric intubation. Acta Otolaryngol (Stockh)
1977; 83: 353-9.
DISCLOSURES
(c) Funding - None
17
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
TISSUE MYRINGOPLASTY :
A SIMPLE & COST EFFECTIVE TECHNIQUE
*Rupam Borgohain, **Swagata Khanna
ABSTRACT:
Introduction: Chronic suppurative otitis media is
a prevalent condition in country like India due to poor
socioeconomic conditions & lack of awareness. This
results in increased financial constraints & loss of work
days. CSOM may follow a benign course causing great
morbidity to the patient.
Objective: The aim of this study is to determine
the efficacy of Fat plug or Tissue myringoplasty
(T.M.P.) which is a simple and cost effective technique.
Material & Methods: The study was undertaken
on patients who have attended the ENT OPD from
January 2005 to December 2013. A total of 203 cases
with simple tympanic membrane perforation,
underwent T.M.P. operation.
Discussion: In the present study, a total of 203
patients were studied in terms of graft material used
for operation as well as size of perforation
(microperforation comprising 25% of par tensa). The
Success Rate Achieved Was 84.23%.
Conclusion: This technique is found to be effective
for closure of smaller perforation involving lesser
morbidity and cost. Iatrogenic trauma were negligible.
It is easy, quick, minimally invasive, can be done as
OPD procedure and an effective way in tackling
microperforation following a conventional myringoplasty
and perforations following trauma.
Keyword: Chronic suppurative otitis media, Fat
plug / Tissue myringoplasty.
Address for Correspondence:
Dr. Rupam Borgohain, Assistant Professor
Gauhati Medical College And Hospital,
Guwahati, Assam.
E-mail: mailrupam70@gmail.com
Cell : +91 9435030540
18
INTRODUCTION:
Due to chronicity of the disease and lack of absolute
surgical technique, CSOM is still a troublesome
pathology.This is a disease of children and adult alike.
Perforation of tympanic membrane is a challenge to
this fraternity. Permanent cure of this condition is
essential to prevent repeated infection which is attained
by closing the perforation Person with an aural discharge
is restricted from aquatic activities and it is also a social
stigma.
Due to morbidity, surgical closure is essential.
Various techniques of plastic repair i.e. myringoplasty
have been developed for surgical closure of ruptured
tympanic membrane. Myringoplasty is reserved for
simple repair without any reconstructive procedure of
the ossicular chain. Myringoplasty involves skill on the
part of surgeon. Even with proper skill and technique
rejection might occur due to virulence of the bacteria
or Eustachian tube anomaly.
A newer technique was deviced to tackle tympanic
membrane perforation with small perforation which
involve 25% of pars tensa. This technique is simple,
requires lesser skill, less hospital stay and medical
expenditures.
Microperforation following tympanoplasty or
tympanic membrane perforation due to trauma or
CSOM are repaired with fat graft. It can be performed
as OPD procedure and is less time consuming. Adipose
*Assistant Professor, **Prof. & H.O.D. of E.N.T., Gauhati Medical College & Hospital, Guwahati, Assam
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
tissue is usually harvested from ear lobule or from the
complete ENT examination was done. Audiological
abdomen. Microscopic comparison of the fat shows that
evaluation and microscopic examination was done in
fat cells of the ear lobule were found to be more compact
every case.
and contain more fibrous tissue. It provides scaffolding

for the growth of tympanic membrane epithelium and
mucous membrane by bridging the gap.
AIMS AND OBJECTIVES:
Predisposing factors like sinusitis, deviated nasal

septum, tonsillitis were taken care by preoperative
conservative treatment and required surgical
intervention. Necessary blood examination for Hb%,
The aim of this procedure is to deliver dry and
sugar were done. Radiological examination of PNS,
safe ear to the patient.
mastoid and chest were also included. Aural culture to
The aim of this study is to find out the success rate
identify the organism was also done in cases where
of this procedure in terms of graft uptake and
necessary:
hearing improvement.
Selection criteria:
REVIEW OF LITERATURE:
1.
than 25% of tympanic membrane by otoscopic
Myringoplasty is a known operation to all ENT
evaluation.
surgeons.
1.
A small central perforation the size being no more
Wulstein & Zoellner (1951): Popularized

Myringoplasty technique with improved optics and
2.
At least dry for 68 weeks preoperatively.
3.
Air bone gap better than 25 dB on operation side.
4.
No major Eustachian tube dysfunction problem.
used since this time are skin, amniotic membrane,
2.
3.
mucous membrane, dura mater, cornea,
The ears were prepared with standard antiseptic
periosteum, perichondrium, vein, adipose tissue
precaution. Commercially available 2% xylocaine with
and finally temporalis fascia.
adrenaline 1 in 200,000 infiltration was used to achieve
Ringenberg (1962): Successfully used adipose
local anaesthesia. The ear lobe was also infiltrated in
tissue ( fat ) to repair small tympanic membrane
the posterior aspect. The margin of the perforation was
perforation.6
deepithelized circumferentially (Schematic Diagram
Mitchell et al (1997): Used fat in 342 children to
I). A fat plug was harvested from the ear lobule ( Pic 1
close small tympanic membrane perforation
& 2 ) The size of the graft is about 2 times the size of
achieving 92% success rate.5
the perforation.
The fat plug was inserted into the perforation
MATERIALS AND METHOD:

The study was undertaken on patients who have
attended the ENT OPD
from
January 2005 to
December 2013. A total of 203 cases with simple

tympanic membrane perforation, underwent T.M.P.
operation.
resembling a DUMB BELL (Schematic DiagramII &

III). The graft was supported with tiny gel foam pledges
soaked in antibiotic solution. The graft was covered with
gel foam sponge soaked with antibiotic preparation till
the middle part of external auditory canal. Later, a
ribbon pack soaked in antibiotic skin ointment was used
A thorough clinical history was recorded and a
to obliterate the remaining part of the canal.

19
microsurgery. Various graft material has been
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
All the patients were followed up at 6 weeks, 3

months and 9 months.
RESULTS AND OBSERVATION:
A total of 203 patients were included in the study
during 9 years period (January 2005 to December 2013).
All the cases had dry ear for 3 months prior to operation
Pic 1 &2 shows harvesting of fat from lobule
and pathologies of sinuses and throat were managed

accordingly during this period.
They belonged to age group between 16 years and
48 years. We have encountered 147 males (72.41%)
and 56 female (27.58%) cases 77 (37.93%) patients
belonged to middle economic class and 126 (62.06%) to
poor economic class. 126 patients (62.06%) were from
rural background and 77 (37.93%) from urban
background.
Of 203 cases, 17 (8.37%) cases had bilateral
perforation and had undergone tissue myringoplasty in
Schematic Diagram-I
Schematic Diagram-II
Refreshing of the margin of the Gel foam sponge in the middle
perforation
ear cavity
the same sitting. Adequate fat was collected from one

lobule. 77 (37.93%) had perforation on right side and
109 (53.69%) on left side
All the cases presented with conductive hearing
loss. 128 cases had mild conductive loss and 75 had
moderate loss.
All the cases gave history suggestive of infection
in the past. None gave history of trauma.
19 cases who underwent myringoplasty earlier but
had microperforation on follow up were taken up. All
these 19 cases had intact tympanic membrane during

SCHEMATIC DIAGRAMIII
FAT PLUG INSERTED
INTO THE PERFORATION
SCHEMATIC DIAGRAMIV
FOLLOW-UP
PICTURE
(3
MONTHS) SHOWS GRAFT
BEING TAKENUP
subsequent checkups.
32 (15.76%) patients had persistent perforation at
3 months after operation and the remaining 171 (84.23%)
cases had intact tympanic membrane. The success rate
Patients were discharged with advice to prevent

nose blowing, straining or any other vigorous exercise.
was 84.23%. The average gain in hearing was 5 dB.

DISCUSSION:
The pack was removed after 10 days and patient advised

to apply topical ear drop.
In the present study, a total of 203 patients were

studied in terms of graft material used for operation as
20
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
well as size of perforation (microperforation
comprising 25% of par tensa).
tackling microperforation following a conventional

myringoplasty and perforations following trauma.
The Success Rate Achieved Was 84.23%

The above results bear a close resemblance to:
1.
2.
Deddens et al (1993) described adipose
DISCLOSURES
myringoplasty as a simple cost effective technique.
Success rate in their study was 89%.2
(c) Funding - None
Mitchell et al (1996) presented a study in 370
REFERENCES:
children over a period of 6 years. Successful
1.
closure was achieved in 349 i,e. 92%.5
for closure of smaller perforation involving lesser
2005;57:43-44
2.
morbidity and cost. Iatrogenic trauma were negligible.
1993;103:216-9.
3.
central perforation.
It is easy, quick and cost effective way with
It can be done as OPD procedure.
Fat is readily available from ear lobule and
Gold SR, Chaffoo RA. Fat myringoplasty in the

Guinea Pig. Laryngoscope 1991;101:1-5.
4.
minimal morbidity.1,3,4
Deddens AE, Muntaz HR, Lusk RP. Adipose

myringoplasty in children. Laryngoscope
CONCLUSION:
Fat plug is an under used technique to repair a small
Chalishazar U. Fat plug myringoplasty. Indian J

Otolaryngol Head Neck Surg Neck Surg
To sum up, this technique is found to be an effective
This technique is also found to be very effective in
Gross C, Bassila M, Lazar RH, et al. Adipose

plug myringoplasty: An alternative to formal
myringoplasty techniques in children. Otolaryngol
Head Neck Surg 1989;101:617-20.
abdomen.
5.
Mitchell RB, Pereira KD, Lazar RH. Fat graft

myringoplasty in children - A safe and successful
Fat cells from ear were found to be more compact
day-stay procedure. J Laryngol Otol 1997;111:106-
and contain more fibrous tissue.
As there is no disturbance to middle ear structures,

there is a negligible risk of any iatrogenic otological
trauma making this procedure very safe even for
8.
6.
Ringenberg J. Closure of tympanic membrane

perforation by the use of fat. Laryngoscope
1978;88:982-93.
bilateral repairs.
21
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
PAEDIATRIC BRONCHOSCOPY AN OVERVIEW

* V. J. Vikram, **S. K. Jha, **D. Roy, **B. Chowdhury, **G. C. Sahoo
ABSTRACT
INTRODUCTION
Bronchoscopy is frequently required procedure to
Bronchoscopy in children for removal of foreign
diagnose and treat various pathologies affecting the
bodies (F.B.) in the hand of a skillful endoscopist is very
airway like malignancies, foreign body, tumors etc. This

article aims to exemplify the proper technique and
handling of the bronchoscope in children, where it is
frequently performed to remove foreign bodies stuck in
the airway.
safe now due to advanced anesthetic techniques with

constant monitoring of cardio-pulmonary function unlike
some years ago when cardiac monitor or pulse oximeter
were not available, cyanosis and pallor were the only
signs of imminent cardiac arrest with impending danger
Key Words: Pediatic bronchoscopy.

Dr. S. K. Jha
32, Upendra Kishore Path
City Centre, Durgapur
to the child. Bronchoscopy is perhaps the most common

endoscopic procedure usually done for the possibility of
airway foreign body in children but unfortunately, it is
still being regarded as a risky and unsafe procedure
due to concern about the possible anesthetic
complications in partially obstructed airway. However,
West Bengal-713216
contrary to this, bronchoscopy in children can help in
Phone: +91-8335055714
sucking out the insipid secretions or mucous ping thereby
Email: sandeep.kr.jha@gmail.com
removing the block in the obstructed airway where it is

not possible for the child to cough it out to clear out the
airway. Whenever there is a suspicion of tracheabronchial F.B., the otolaryngologist must prepare for
an early endoscopic intervention with adequate and
careful preparation. As per Holinger, If two hours
are spent in preparations, the safe endoscopic procedure
may take two minutes but if only two minutes are taken
for preparation, the endoscopist may find himself
attempting ineffective procedure for the next two
hours1. Bronchoscopy in children with airway F.B. may
22
*Madras Medical college, Chennai, Tamil Nadu, **IQ City Medical College and Narayana Multispecialty Hospital, Durgapur, West
Bengal
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
cause hypoxia or anoxia at times. Hence, all the
and the thyrohyoid membrane is very short. This unique
equipments must be chosen & assembled carefully
relationship of high larynx in child makes its
before administration of anesthesia to avoid any
visualization and intubation difficult for the anesthetist.
catastrophic complications during the tenuous situation
The chances of respiratory failure in infants are also
for immediate and adequate control of the airway by
high due to low respiratory reserve, narrow airway and
the endoscopist.
high peripheral airway resistance. In infants and small

children the functional residual capacity of lung is less,
HISTORY:
the BMR and oxygen consumption per minute are more

Pioneering work was done by Chevalier Jackson
in designing various useful instruments for safe &
successful removal of foreign bodies2. Other pioneers
who developed the science of bronchoesophagology
subsequently are Jackson Jr., Holinger and Tucker.
Broyles (1963) and Holinger (1965) demonstrated fiber
optic light and fiber optic carrier respectively for
and hence the heat loss is considerable to cause

dehydration with rapid respiratory rate. All these
anatomic & physiological peculiarities in the infants &
children are challenging not only for the anesthetist but
also for the otolaryngologist to perform a risky
procedure as both of them fight for the same space in
the airway which is already compromised.
illumination in endoscope without any impingement on

the narrow lumen3. Brubaker and Holinger in 1972
introduced the method of still and motion picture
INDIACATIONS8:
photography through Storz Hopkins telescope4. Wood

and Fink in 1977 demonstrated the use of fiber optic
cough & ipsilateral diminished air entry.
flexible endoscope in children5.

SURGICAL
ANATOMY
Classical Diagnostic triad of unilateral wheezing,
High degree of suspicion of F.B aspiration by

pediatrician or parents.
&
APPLIED
Shifting consolidation from one side to another.
Tracheo-bronchial obstruction
Atypical Asthma not responding to usual treatment.
Persistent pneumonia or bronchitis
History of violent cough or choking
Presence of stridor or any evidence of airway
PHYSIOLOGY OF PAEDIATRIC AIRWAY:
soft and sensitive but also it is high up and the submucosa

is prone for edema6. The glottis of a new born infant
has an antero-posterior length of 7-8mm and posterior
transverse breadth of around 4-6 mm in which a mere
1 mm of mucosal edema can reduce the glottis space
obstruction
by 35-50% and similarly the sub glottis region with a

diameter of 5-6mm can reduce the space by more than
Presence of radiological findings like obstructive
40% and bronchus by mere 11% which may compromise
emphysema on one side, collapse of lower lobe on
the airway dangerously7. The epiglottis at birth is at the
either side and consolidation or collapse of lung
level of first cervical vertebra and cricoids at third

vertebra. The infant hyoid bone is very close to the larynx
Mediastinal shift to normal side in check valve

obstruction
23
The larynx in infant is not only relatively small,
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
Early atelectasis & collapse with mediastinal shift
& a tracheotomy set should be kept ready for any
towards the involved side ball valve obstruction.
eventuality on side. The photographic equipment with
EQUIPMENTS & INSTRUMENTS:
light source should be kept ready on right side for

documentation. All the emergency drugs & all sizes of
Storz ventilating bronchoscopes of various sizes

from 2.5 mm to 6.0 mm with distal fiber optic
illumination are usually used for pediatric bronchoscopy
and it is better to use one size smaller endoscope for
diagnostic purpose than optional. Fiber optic conventional
rigid endoscopes with Halogen light source (250 Watts
Halogen Lamp) & built in spare bulbs along with various
types of F.B. holding forceps, suction canulas, cup
shaped biopsy forceps, Y type of suction tube to collect
aspiration materials are basic requirements. 00 and 300
Hopkins Telescope are necessary for diagnostic and
photographic purposes with Xenon light source. Flexible
endotracheal tube must be kept ready including extra

full oxygen & gas cylinder. In most cases, experienced
& skilled anaesthetist is the key person for the success
of the procedure who takes full charge of the situation
to oxygenate the child adequately and give sufficient time
to the surgeon to perform the procedure. In the event of
slight evidence of bradycardia or falling of oxygen level,
the surgeon should move out to give all the space &
assistance to anaesthetist for avoiding cardiac arrest.
Induction should be done with thiopentone, relaxation
& apnoea with scoline & oxygenation is maintained with
jet ventilation after introduction of endoscope. Many
fiber optic pediatric bronchoscopes are though ideal for

diagnosis but are not useful for any endoscopic surgical
procedure in infants & children as it may sometimes
obstruct an airway already obstructed9. It must be noted
that the numbers indicating the size of the endoscopes
are not on the outer diameter but the inner diameter.
The table given below is a guide to use the correct size
of bronchoscopes as per the age of the child11.
Operation Theatre Layout & Anaesthesia:
There should be proper operation room set up
before taking the child for endoscopy besides having

checked all the necessary instruments & equipments.
The surgeon usually sits at the head end & the
anaesthetist on the left side of the child for consistently
monitoring of heart & oxygen saturation by cardiac
monitor and pulse oximeter. The light source should be
kept behind the right hand side of the surgeon including
the instrument trolley & suction machine. The assistant
& the nurse should stand on the right side of the patient
24
Advantages & Disadvantages of Rigid Vs Flexible

Bronchoscopy:
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
anaesthetists also prefer induction with inhalation
bronchus with slight angulation towards the left. Then it
anaesthesia or using halothane and maintain spontaneous
can be withdrawn slightly and angled towards the right
breathing. Some anaesthetist use intravenous Ketamine
to visualise the left main bronchus. During the whole
instead of Pentothal but it is not as safe in endoscopic
procedure, suction should be done from time to time to
procedure as it does not abolish the pharyngeal &
cleanse the secretions13. The bronchus, bronchoscope
laryngeal reflexes. Before starting anaesthesia, a firm
and the F.B. should lie in one straight line before it is
intravenous line should be established & infusion should
removed. The blades of F.B. forceps should be opened
TECHNIQUE OF BRONCHOSCOPY
After selecting an appropriate size bronchoscope
according to the age of the child, it should be checked
for proper illumination and cleaned thoroughly. A
correct size suction cannula should be checked and
passed through the bronchoscope. Out of various types
of F.B. forceps like toothed, non-toothed, cupped,
serrated, flat, crocodile, alligator etc. Selection should
be done keeping in mind the type of bronchial F.B. which
can assure a firm grip of the F.B. without damaging the
bronchial mucosa. After visualising the larynx after
lifting the epiglottis by the laryngoscope, the
bronchoscope should be gently introduced into the glottis
with the tip upwards and under the epiglottis.
Bronchoscope should be held in the right hand with pen
after it crosses the tip of the endoscope and then the

F.B. should be caught firmly and brought near the tip of
the bronchoscope. Then the bronchoscope along with
the F.B. forceps should be gently withdrawn
simultaneously till it reaches the glottis. After this, the
bronchoscope should be tilted slightly upwards with the
held F.B. to pass out through the posterior part of the
glottis which is wider. Loose F.B. in trachea are more
difficult which should not be caught directly when they
are in the trachea, rather it should be pushed down to
let them lodge in either main bronchus, usually the right
main bronchus, after which it is easy to catch and
remove. Otherwise, loose trachea F.B. may get stuck
in the subglottic region which is the narrowest one in
the airway, causing total airway obstruction until unless
removed as early as possible.
hold grip and should be gently slid into the trachea after
After the removal of the F.B. the anaesthetist
visualising the vocal chords. The anaesthetist should then
should oxygenate the child and allow the endoscopist to
start inflating the lungs with Jet ventilation by the side
reintroduce the bronchoscope for inspection of
of the bronchoscope. Failure to inflate the lungs with
tracheobronchial tree for any remnant of F.B. or a
Jet ventilation and inability to identify the tracheal rings
second F.B. rarely14. The tracheobronchial tree should
should alert that the bronchoscope is not in the air
be cleaned with suction and bronchoscope should be kept
passage but in the oesophagus. After it is confirmed the
in trachea for proper oxygenation till the breathing is
endoscope is in trachea then it should be glided down
spontaneous. Both the surgeon and anaesthetist should
over the left hand fingers without undue force and always
observe the child till the muscle tone returns to normal,
under vision. The next step is the identification of carina
cough reflex is present and child starts crying and air
and introduction of the bronchoscope into the right main
entry is checked on either side. The child should be kept
25
be started.
12
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
in left lateral position before shifting to ward and if there
2.
Giddings CE, Rimmer J, Weir NJ Laryngol Otol.
is any evidence of sub glottis oedema in the form of
Chevalier Jackson: pioneer and protector of
brassy cough or strider, then intravenous steroid should
children. 2013 Jul;127(7):638-42. doi: 10.1017/
be given including strict observation of child.
S0022215113001084. Epub 2013 May 24.
COMPLICATIONS:
3.
optic laryngoscopes, bronchoscopes and
Hypoxia, cardiac arrhythmia, hypercarbia,
esophagoscopes. Ann Otol Rhinol Laryngol. 1965
respiratory acidosis & other anaesthetic
Dec;74(4):1164-7.
complications.
Laryngeal or subglottic edema due to oversize
4.
Sub glottis impaction of F.B while removal.
Post operative laryngeal spasm
Aspiration of secretion or vomiting
Inadequate ventilation leading to bradycardia,
esophagus through endoscopic telescopes. Ann Otol

Rhinol Laryngol. 1972 Dec; 81(6):809-11.
5.
Wood RE, Fink RJ. Applications of flexible

fiberoptic bronchoscopes in infants and children.
Chest. 1978 May;73(5 Suppl):737-40.
cyanosis, pallor & cardiac arrest.

CONCLUSION:
Holinger PH, Brubaker JD. Still and motion picture

photography of the tracheobronchial tree and
endoscope & repeated instrumentation.
Holinger PH. Presentation of instruments. Fiber-
6.
Pierre Fayoux, Bruno Marciniak, Louise

Devisme, and Laurent Storme. Prenatal and early
Paediatric Bronchoscopy is very safe and the most
postnatal morphogenesis and growth of human
common indication is suspicion of F.B in airway. The
laryngotracheal structures. J Anat. 2008 Aug;
anesthetist, endoscopist and assistants should work in
213(2): 8692.
tandem for a successful & safe procedure. The

bronchoscope must never be pushed with undue force
7.
Ohad Ronen, MD, Atul Malhotra, MD, and Giora

Pillar, MD, PhD Influence of Gender and Age on
against resistance & should be always under vision. A
Upper-Airway Length During Development.
meticulous planning & assessment is must by the
Pediatrics. 2007 Oct; 120(4): e1028e1034. doi:
surgeon & anesthetist before bronchoscopy.
10.1542/peds.2006-3433.
DISCLOSURES
8.
Karan Madan, Ritesh Agarwal, Ashutosh N.
Aggarwal, and Dheeraj Gupta.Therapeutic rigid
bronchoscopy at a tertiary care center in North

India: Initial experience and systematic review of
(c) Funding - None
Indian literature. Lung India. 2014 Jan-Mar; 31(1):

REFERENCES:
1.
Holinger PH, Johnston KC. Bronchoscopic

problems in the newborn. Ill Med J. 1952
Feb;101(2):68-77.
26
915. doi: 10.4103/0970-2113.125887.

9.
Wojciech Korlacki, Klaudia Korecka, and Jzef

Dzielicki.Foreign body aspiration in children:
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
diagnostic and therapeutic role of bronchoscopy.

Pediatr Surg Int. 2011 Aug; 27(8): 833837.
10.
Amith. I. Naragund, R. S. Mudhol, A. S.

Harugop, P. H. Patil, P. S. Hajare, and V. V.
Metgudmath Tracheo-Bronchial Foreign Body
Aspiration in Children: A One Year Descriptive
Study. Indian J Otolaryngol Head Neck Surg. 2014
Jan; 66(Suppl 1): 180185. Published online 2011
Dec 7. doi: 10.1007/s12070-011-0416-2.
11. Daniel G. Nicastri, MD, Todd S. Weiser, MD.

Rigid Bronchoscopy: Indications and Techniques.
Operative Techniques in Thoracic and
Cardiovascular Surgery. Volume 17, Issue 1,
13. Petrella F, Borri A, Casiraghi M, Cavaliere S,

Donghi S, Galetta D, Gasparri R, Guarize J,
Pardolesi A, Solli P, Tessitore A, Venturino M,
Veronesi G, Spaggiari L. Operative rigid
bronchoscopy: indications, basic techniques and
results. Multimed Man Cardiothorac Surg. 2014
May 27;2014. pii: mmu006. doi: 10.1093/mmcts/
mmu006.
14. Daniel G. Nicastri, Todd S. Weiser. Rigid
Bronchoscopy: Indications and techniques.
Operative
techniques
in
Thoracic
and
Cardiovascular Surgery. Spring 2012, Volume 17,

Issue 1, pg 44-51.
Spring 2012, Pages 4451.

12. Patrick T. Farrell. Rigid bronchoscopy for foreign
body removal: anaesthesia and ventilation.
Pediatric Anesthesia 2004 14: 8489.
27
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
INSULAR CARCINOMA OF THYROID UNUSUAL VARIANT

OF THYROID MALIGNANCY
*Dipak Ranjan Nayak, *Asheesh Dora, **Ranjani Kudva, ***Shekar Patil
ABSTRACT
A rare case of histologically distinct aggressive
Thyroid malignancy is one of the common
thyroid cancer that has been termed recently as poorly
endocrine malignancies seen in clinical practice and its
differentiated (Insular) thyroid cancer is reported. The
incidence has progressively increased in the last three
FNAC was suggestive of a follicular lesion. CT scan
decades all over the world 1 . The thyroid cancer
was strongly suggestive of malignancy. Total
originating from the follicular cell has been traditionally
thyroidectomy with bilateral MRND and central

compartment clearance was done and was confirmed
histopathologically as insular carcinoma of thyroid. The
patient was advised EBRT with radioiodine ablation.
The patient reported back 7 months after with dysphagia
and was found to have recurrence in the cervical
esophagus and superior mediastinum along with lung
classified further into well differentiated (papillary,

follicular etc.) and Undifferentiated/Anaplastic (Patel
& Saha 2006)2. About 90% of thyroid malignancies are
well differentiated thyroid carcinomas (WDTCs) with
current modality of treatment 3. Undifferentiated
(Anaplastic) thyroid carcinoma (UDTC) is a rare
and liver metastases on hypopo-haryngoscopy and CT
presentation with an aggressive clinical course and with
scan and underwent 5 cycles of palliative chemotherapy.
early distant metastases. There is one more group of
On last follow-up there was gross regression of tumor
thyroid carcinoma which neither can be classified as
and the swallowing was improved. Relevant literature
WDTC nor UDTC. They are classified as poorly
has been reviewed and the role of chemotherapy to
differentiated thyroid carcinoma (PDTC) 3. Patel and
improve survival has been discussed.
Saha described poorly differentiated thyroid carcinoma
Key words: Insular thyroid cancer, poorly
INTRODUCTION:
differentiated thyroid cancer, chemotherapy.
as a group of thyroid cancer that include carcinomas of

follicular thyroid epithelium that keep ample
differentiation to generate spread of tiny follicular
structures but are free from usual morphological picture
Prof.Dipak Ranjan Nayak
of papillary and follicular carcinoma although they have
Department of ENT-Head & Neck Surgery,
some thyroglobulin. They also broadly divided these
Kasturba Medical College, Manipal.
tumors into Insular and Other (Large cell) type2. This
E-mail: drnent@gmail.com
article discussed about the role of multimodal treatment

in these cases especially adjuvant chemotherapy to
improve survival and quality of life.
28
*Department of ENT-Head & Neck Surgery, **Dept. of Pathology, Kasturba Medical college, Manipal.Karnataka, India, ***Consultant
Medical Oncologist, HCG, Bengaluru, Karnataka, India
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
The final histopathology report showed sheets and
A 28 year old female, with no co-morbidities,
islands of malignant cells with focal peritheliomatous
presented with swelling in the anterior neck of 2 months
pattern with high N:C ratio, hyper chromatic round to
duration. Swelling was insidious in onset and gradually
ovoid pleomorphic nuclei with scanty cytoplasm and
progressive in size. History of any breathing difficulty
coarse chromatin seen infiltrating into adjacent thyroid
and dysphagia were not reported. Ultrasonography of
tissue. It was reported as poorly differentiated
neck showed an enlarged hypo-echoic nodule in the right
Carcinoma (Insular carcinoma of thyroid).
lobe of thyroid (5cm x 3cm x4cm) with enlarged level
Immunohistochemistry and immunofluorescence was
VI lymph node on the right side. Fine needle aspiration
done and tumour cells were diffusely positive for
cytology was done and was suggestive of follicular lesion
cytokeratin and focally positive for synaptophysin. Cells
of thyroid and suggested a frozen section.
were negative for Chromogranin and LCA. Ki67 was
Contrast enhancement CT of the neck and thorax
positive for 30-40% cells.
was done as the clinical picture was suggestive of
Radio nuclide scan was done after 1 month which
malignancy and suspicious nodes on ultrasound. On the
showed traces of thyroid tissue in the thyroid bed and
scan there was heterogeneously enhancing lesion in the
Patient was advised and counseled for radio iodine
right lobe of thyroid and also involving the isthmus with
ablation and also EBRT in view of gross infiltration into
infiltration into the right sided strap muscles with
the surrounding structures which she wanted to receive
enlarged discrete lymph nodes at level II and VI on right
at his native place. Patient was lost on follow up and
side. Lesion was abutting the internal jugular vein and

carotid artery. There was no evidence of the
involvement of lung or mediastinum and the patient was
clinically staged as T4 N2Mx.
presented 7 months later with dysphagia of insidious,

gradually progressive and more for solids than liquids.
She could not undergo for neither radio iodine ablation
nor EBRT for financial and personal reason. A barium
Patient was counselled about the condition. All
swallow was done which showed eccentric filling defect
haematological parameters were normal including the
with mucosal irregularity at the level of C7-T2
thyroid profile and routine investigations. Patient was
suggestive of esophageal involvement.
planned for a frozen section and then proceeds for total

thyroidectomy. Intra operatively there was a gross
infiltration of the tumor into the strap muscles and
trachea pushed toward the opposite. Frozen section was
sent from the right lobe of thyroid and also the strap
Patient later underwent hypopharyngoscopy on

which two ulcerative lesions were found at the level of
15cms and 17cms from the incisors. Separate biopsies
were taken from the lesions and were sent for HPE.
muscles and was suggestive of malignancy with muscle
Biopsy was reported as consistent with malignancy and
infiltration suggestive of follicular neoplasm. Patient
infiltration from the insular carcinoma thyroid. Patient
underwent total thyroidectomy with bilateral modified
was not willing for any surgical procedures and advised
radical neck dissection and central compartment
a metastatic workup followed by palliative chemo at a
clearance with preservation of sternocleidomastoid
nearby place. A Radio Iodine scan was repeated that
muscle and IJV. Strap muscles were resected. Left
did not show any uptake. CECT showed cervical &
inferior parathyroid gland was preserved.
mediastinal Lymph node with lung and liver metastasis.

29
CASE REPORT:
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
She was started on oral Sorafenib tosylate. 5months later
Histopathological diagnostic criteria also known as the
a PET scan was done and it showed progressive disease
Turin criteria were published by Volante et.al (2007)
and she was started on Gemox Regimen (Gemcitabin
which include: (a) the presence of solid/trabecular/
1gm / M D1, D8 + Inj. Oxaliplatin 135 mg / M ).
insular pattern of growth. (b) The absence of the
After 3 cycles, on assessment with CT scan Thorax
conventional nuclear features of papillary carcinoma
showed significant regression in mediastinal Lymph
(c) the presence of at least one of the following
node and lung and liver lesion. Patient completed 5 cycles
microscopic features: convoluted nuclei; mitotic activity
of chemotherapy and there was poor tolerance. So was
e 3 x 10HPF; or tumour necrosis8.
again started on oral Sorafenib tosylate. Patient has

significant symptomatic improvement including better
swallowing at 1 year 4 months.
DISCUSSION:
Insular carcinoma is an aggressive form of thyroid
cancer that has been included recently under poorly
differentiated thyroid cancer4. Sakamoto et al (1983)
coined the term of poorly differentiated thyroid
carcinoma for the histology variants that are showing
non-papillary/non-follicular growth pattern with poor
prognosis. Five-year survival for PDTC is less than 65%
in contrast to a WDTC, which is more than 95%5.
Carcangiu et al. also proposed a similar description for
aggressive thyroid malignancies and used the term
initially describes by Langhans in 1907. They
reintroduced the term insular carcinoma to the
histological type characterized by the presence of
insulae which included small cells with round to oval
hyper chromatic nuclei, increased mitotic activity over
a necrotic background. The term insular was used to

describe these tumors because the cellular appearance
was similar to that seen in the insular type of carcinoid
tumors.6. In 2004 WHO defined PDTC as a neoplasm
developing from thyroid follicle cell, presenting
restricted differentiation to it and having both
morphological and biological intermediate behavior
between well-differentiated thyroid carcinomas and
undifferentiated carcinoma7. PDTC may also develop
in the persistent well differentiated thyroid carcinoma.
30
The FNAB can give useful information but not a

definitive preoperative diagnosis. The thyroglobulin (TG)
and thyroid transcription factor1 (TTF1) are positive
on immunohistochemical analysis as these tumors are
of follicular origin and p53 may stain positive from 038% cases of insular carcinoma2. Due to high incidence
of regional metastases, a total thyroidectomy with
central compartment and bilateral modified neck
dissection should be considered2. Surgery followed by
radioiodine therapy is considered to be the standard
treatment protocol even for the PDTCs. There is data
that shows that Insular variant has the ability to take up
radioiodine in up to 85% of cases and sometimes even
better compared to the predominant solid or trabecular
growth patterns 3. The efficacy of External beam
radiotherapy has also been described. The external
beam treatment for PDTC should be considered in
T3N0M0tumours, all T4 and in Any TN1M0tumours.
Chemotherapy in patients with PDTCs ought to be
considered individually. Use of methotrexate,
vinblastine, doxorubicin, and bleomycin in monotherapy
has been proposed. Combination therapy composed of
chemotherapy and external radiotherapy is considered
experimental3. In the present case Sorafenib to sylate
was tried with limited response, so Gemcitabin and
Oxaliplatin was tried with good response but had poor
tolerance after 5 cycles and has now being maintained
on Sorafenib. There was good symptomatic relief and
excellent over all response.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
CONCLUSIONS
Poorly differentiated thyroid carcinoma is a
condition yet to be explored. The low incidence,
aggressive clinical course and fatal outcome due to very
low five year survival rate pose a greater difficulty in
Illustrations:
Fig. 3(a) H&E x 40- shows a tumor composed of small cells arranged
in solid, trabecular and insular pattern (b) H&E x 20- Focal
peritheliomatous pattern of tumor cells seen.
thorough understanding and treating this condition

satisfactorily.
DISCLOSURES
Fig.1: CECT neck (a)axial cut, (b)showing the tumor which is
infiltrating the Left Sided strap muscles .The trachea has been pushed
laterally.

(c) Funding - None
REFERNCES :
1.
Gabriella P,Francesco F, and Riccardo

V:Worldwide Increasing Incidence of Thyroid
Factors; Journal of Cancer Epidemiology Volume,
2013, Article ID 965212, 10 pages http://
dx.doi.org/10.1155/2013/965212.
2.
Patel K, Saha A: Poorly differentiated and

Anaplastic thyroid cancer; Cancer control, April
2006, Vol. 13, No. 2, P 119-128.
Fig-2 (a) Showing mobilization of left thyoid lobe after the right side
was sent for frozen section ( b) per-operative photograph after
completion of total thyroidectomy and bilateral modified neck dissection
with central compartment clearance.
3.
Agnieszka W, Aldona K, Jacek S: The clinical

course of poorly differentiated thyroid carcinoma
31
Cancer: Update on Epidemiology and Risk
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
(insular carcinoma) own observations; Polish
4.
7.
Journal of Endocrinology, Volume 61; Number
typing of thyroid tumors, In: World health
5, Page 467-473,2010
organization,
thyroid gland: an aggressive subset of
8.
Poorly Differentiated Thyroid Carcinoma: The
Dec;104(6):963-70.
Turin Proposal for the Use of Uniform Diagnostic

Criteria and an Algorithmic Diagnostic Approach;
Sakamoto A: Definition of poorly differentiated
Carcangiu ML, Zangi G, Rosai J: Poorly

differentiated (insular) carcinoma of thyroid;
Am J Surg Pathol 8:655-68, 1984
Marco Volante, Paola Collini, Yuri E. Nikiforov:
differentiated thyroid neoplasm: Surgery1988
EndocrPathol. 2004; 15:307311.
32
histological
Verlag 1988, 3-8.
Am J Surg.Pathol 2007; 31:12561264.
carcinoma of the thyroid; the Japanese experience.
6.
International
classification of tumors, 2nd ed Berlin: Springer-
Flynn SD, Forman BH, Stewart AF, Kinder BK:

Poorly differentiated (insular) carcinoma of the
5.
Hedinger c, Williams ED, Sobin LH: Histological
9.
Sanders EM Jr, LiVolsi VA, Brierley J et al: An

evidence-based review of poorly differentiated
thyroid cancer. World J Surg 2007; 31: 934945.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
SOLITARY PAROTID MASS PRESENTING AS

SARCOIDOSIS : UNUSUAL PRESENTATION
*V. V. Rokade, **N. A. Pathak, ***S. V. Nemade
Objective: To demonstrate an unusual case of

sarcoidosis in which the patient presented with
solitary parotid mass and no other manifestations of
the systemic disease.
INTRODUCTION:
Jonathen Hutchinson first reported sarcoidosis in
1869. Several causative agents have been implicated in
its aetiology which includes infective agents like
mycobacterium and no infective agents like exposure
Case report: A 12years old girl child presented

with history of swelling in right parotid region since
three years. On local examination there was firm smooth
non tender swelling palpable in right parotid region.
FNAC was suggestive of chronic granulomatous
disease. Sr Calcium, ACE enzymes, Serology, ANCA
was normal. Monteux test was negative. ECG was
normal. Superficial parotidectomy was done.
Histopathology features were suggestive of sarcoidosis.
to beryllium dust. Detection of mass of parotid gland is
Conclusion: We believe that this case is of interest

as descriptions of such presentations of sarcoidosis as
a solitary discrete mass in parotid gland and absence of
systemic involvement are not prevalent in the literature.
As all the investigations were
normal, only
histopathology report after superficial parotidectomy
guided us to reach up to final diagnosis of sarcoidosis .
with history of swelling in right parotid region since
Keywords : Parotid Sarcoidosis, Non caseating

granulomatous disease.
opening was normal. There were no signs of facial
Corresponding Address:
Dr.Vidya V.Rokade.
A-2, 303 Sun Empire, Sun City Road
Vadgaon Bk., Pune-51
Ph.: 9922160881
E-mail: vidyarokade@hotmail.com
generally considered an indication for superficial

parotidectomy. In most cases pathology will identify a
euplastic process. We describe a case in which patient
presented with discrete solitary parotid mass that was
turned out to be sarcoidosis on histopathology.
CASE REPORT:
A 12years old girl child presented in ENT OPD
three years with no history of fever or fluctuations in
size with or without eating. General practitioner treated
her with antibiotics with no improvement.
On local examination there was firm smooth non
tender swelling palpable in right parotid region. Duct
paralysis. General examination revealed no evidence
of
peripheral
lymphadinopathy
&
no
hepatosplenomegaly. CVS, RS and CNS examination

were within normal limits.
On diagnostic work up her haemogram and ESR
was normal. FNAC
showed plenty of epithiloid cell
granulomas with multinucleated giant cells; features

suggestive of chronic granulomatous disease.
*Assistant Professor of ENT, **Assistant Proffesor ENT Dept., ***Assistant Proffesor ENT Dept., Smt Kashibai Navale
Medical College and General Hospital Ambegaon Narhe, Pune
33
ABSTRACT :
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
To rule out various granulomatous diseases various

investigations carried out. Biochemical investigations:
for AFB.
All the features were suggestive of
sarcoidosis (Fig II).
Blood Sugar, KFT, LFT, Sr Calcium, ACE enzymes,

Serology, ANCA were normal. Monteux
test was
negative. ECG was normal. Radiological investigations:

Xray
chest,
USG
abdomen
revealed
no
abnormality.USG patotid with colour Doppler showed

enlarged right parotid gland with multiple lymph nodes
in it.
CT& MRI
(plain & contrast) demonstrated
enlargement of right parotid gland with homogenous

enhancement with involvement of superficial lobe of
gland with multiple lymph nodes in it (FIG I).
Fig.-2: H & E Stain400X
Postoperative period was uneventful. Patient is

under close follow up for last one year without any
medical treatment. Her x ray chest remained normal
and had not manifested any symptoms of systemic
sarcoidosis.
Fig.-2: Showing homogenous enhancement of superficial labe of
parord in Right side in C.T.
Inspite of long list of investigations we could not

arrive at the final diagnosis. Hence, to obtain tissue
diagnosis superficial parotidectomy was done.

Intraoperatively we found firm mass in superficial lobe
of parotid gland with two to three enlarged lymph
nodes. Deep lobe was normal on palpation.
Histopathogy
showed numerous non caseating
epitheloid cell granulomas surrounded by lymphocytes
DISSCUSION:
Despite extensive studies, no agent has been
identified as the cause of sarcoidosis. Sarcoidosis is
currently considerd as a chronic inflammatory disease,
distinguished by hyperimmune reactions to an unspecified
agent at the lesion sites.1
Sarcoidosis affects lungs in 90% of cases followed
by lymph nodes & spleen. Salivary glands are rarely
involved.
& Langerhans type of giant cells.Also seen were
Parotid gland involvement occurs in 0.5to 15%
Schwamanns bodies in giant cells & asteroid bodies
patients of systemic sarcoidosis.2 However, in 6% of
as well as Hamazaki Wegenbreng inclusions with no
patients it is confined to parotid gland only& may
evidence of malignancy. Z N staining was negative

34
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
manifest as uni or bilateral painless swelling. Parotid
the cornerstone of treatment for symptomatic patients
enlargement is a more frequent finding in children
and those with the progressive disease, although the
diagnosed with early onset sarcoidosis.
dosage and the duration of the treatment are not well
Parotid gland involvement in sarcoidosis may
defined and no consensus exists as to whether treatment
manifest itself in a variety of clinical patterns. The most
should be given to asymptomatic patients and patients
common pattern is represented by bilateral diffuse
with only mild disease. Patients are usually treated for
enlarged parotid gland. 3 A second pattern is
at least six months initially.
characterized by asymptomatic parotid lesions. Third
Methotrexate. Azathioprine, Cyclophosphamide &
pattern is in the form of Herefords syndrome. A
recently Infliximab has been tried with varying success
Clinical pattern of sarcoidosis characterized by isolated
rate for the patients refractory to steroids.10
parotid enlargement with absence of general symptoms

of sarcoidosis would be extremely uncommon.
However, spontaneous regression of this disease

has been reported. Early diagnosis and treatment can
In cases of solitary parotid sarcoidosis preoperative
slow up or stop the progression to organ destruction.
clinical diagnosis is difficult as there is no specific lab
Research is still on going regarding better diagnostics
test as such. However FNAC can be helpful. Depending
& treatment modalities.
upon the conclusion of FNAC we have to rule out various

infective and granulomatous conditions. Markers of
activity for sarcoidosis include raised serum ACE
SUMMARY:
We believe that this case is of interest as
levels, abnormal calcium metabolism, positive Kveim
descriptions of such presentations of sarcoidosis
Siltzbach skin test & radioactive gallium scanning
as a solitary discrete mass in parotid gland and
(Gallium-67 Citrate)
4,5
absence of systemic involvement are not prevalent
. However, ACE levels are
in the literature.
typically elevated in 80% of children 6,7and 60% of adults

8
with late onset sarcoidosis. The ACE test has proven
As all the investigations were
normal, only
to be less sensitive in patients diagnosed with early onset
histopathology
sarcoidois. Many other conditions are associated with
parotidectomy guided us to reach up to final
elevated ACE levels like milliary TB, Leprosy and
diagnosis of sarcoidosis
report
after
superficial
Gauchers disease.9It is important to rule out various

history and physical examination, serologic testing and
special tissue staining techniques. The combination of
So we believe this makes the case
an unusual
presentation.
Acknowledgement: We would like to express our
an elevated ACE levels and positive gallium-67 scan is
appreciation to
85% specific for sarcoidosis.
Department of Pathology SKNMC, Pune for prompt
A definitive diagnosis of sarcoidosis is best

achieved by integrating clinical data with presence of
noncaseating granulomas. The main goal of the
treatment is to minimize or prevent inflammation &
granuloma formation that ultimately causes end stage
organ destruction by hyaline fibrosis. Steroids remains
Dr S.D.Deshmukh Professor,
and accurate diagnosis.

DISCLOSURES
(c) Funding - None
35
infectious and granulomatous diseases on the basis of
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
REFERENCES:
1.
6.
EL,Serum ACE activity in normal children and in
Dubois RM,Kirby M, Balbo B , Saltini C, Crystal
those with sarcoidosis.
RG-T-lymphocytes that accumulates in the lung in

sarcoidosis have evidence of recent stimulation of
2.
7.
G,Baumann FC,Giboudeau J. Serum ACE activity
1992;145;1205-11.
in healthy and sarcoidotic children.Clin

chem1990;36;344-6.
Loddenkemper R,Kloppenborg A,Schonfeld,

8.
1998;15:178-82.
of sarcoidosis- report of two cases.J Oral
therapy for childhood sarcoidosis.JPediatr
Maxillofac Surg 1994;52;1208-10.
1997;130:25-9.
James DG- Sarcoidosis 2001. Post grad med- J
Lubat E; Kramer EL Gallium-67 citrate

in sarcoidosis. Clin Nucl Med 1985 Aug;10(8);593.
Gedalia A, Molina JF, Ellis GS, Galen W,

Moore C, Espinoza LR.Low dose methotrexate
accumulation in parotid and submandibular glands
36
9.
Mandel L,Kayner ,sialadenopathy:a clinical herald
2001; 11;177-80.
5.
Steinberg MJ,Mueller DP,Treating oral

sarcoidosis.JADA 1994;125:76-9
Sarcoidosis Vass Diffuse lung disease
4.
Beneteau- Burnat B, Baudin B, Morgant
Tcell antigen receptor. Am Rev Respire Dies
Grosser H, Constable U,Walt study group.
3.
Rodriquez GE, Shin BC,,Abernathy RS,Kendig
10. Baughman RP. Theraputic options for sarcoidosisCurrent opinion Pulmonary med 2002:8:46329.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
NASAL GLIOMA IN 18 MONTH CHILD

*D Kumar, **A Agrawal, ***N Shree, ****C Gupta, *****AP Verma
ABSTRACT
INTRODUCTION
Nasal gliomas are uncommon congenital benign
Nasal glioma is rare, benign, congenital mass
lesions arising from abnormal embryonic development.
more accurately referred to as sequestered glial tissue1.
Clinically, these masses are firm and noncompressible.
The nasal glioma first described by Schmidt in 19002,3.
Proper management of a nasal glioma requires a

multidisciplinary
approach
including
an
otorhinolaryngologist, radiologist, and neurosurgeon.

Radiological investigations such as computed
tomography or magnetic resonance imaging should be
Sixty percent of glioma are extranasal, 30% are

intranasal, and 10% are both4. Extranasal gliomas
appear near the root of the nose. The overlying skin
may be discolored or telangiectatic5. We described a
performed to exclude intracranial extension. The
nasal glioma, located extranasally.
mainstay of treatment is conservative surgical excision
CASE REPORT
because nasal gliomas are slow-growing, rarely

recurrent, and have no malignant potential. We report
An 18 month old female child presented to E.N.T.
one case of extranasal nasal glioma in 18 months female.
outpatient department of Sarojini Naidu Medical
She underwent surgical excision with good cosmetic
College, Agra, India with chief complaint of swelling
results. Postoperative period result was uneventful.
left side of nose since birth, which had gradually
Key words: nasal glioma, extranasal, benign.
increased in size since birth. She had not suffered pain
or epistaxis. She was a full-term child. There was no
Dr. Dharmendra Kumar
other relevant history. Physical evaluation revealed that
Prof. & H.O.D., Dept. of ENT
the subcutaneous swelling was 2x1 cm in size, at the
Sarojini Naidu, Medical College
root of nose just slightly left of the midline. It was not
Agra-282002, Uttar Pradesh, India
tender, non-mobile, and non-pulsatile, overlying skin is
Phone - +919412157647
normal. Anterior rhinoscopy was normal and there was
E-mail: Dharmendra.snmc@yahoo.co.in
no mass inside the nose. The mass did not increase in

size when the child cried and on coughing. Other
systemic examinations were unremarkable. Her CT
scan was done and it showed smooth outline soft tissue
density nodular lesion seen over left side of nose,
*Professor and Head ENT, **Assistant Professor Dept. of ENT, Department of Microbiology, ***Resident ENT ****Assistant professor, Post
Graduate Department of Pathology, *****Resident, Department of ENT, Sarojini Naidu Medical College, Agra, India
37
or nose bleeds. There was no history of nasal obstruction
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
measuring 1.5x1.6x2.0 cms in size smooth scalloping

is seen in antero-inferior aspect of underlying left nasal
bone. No significant contrast enhancement is seen within
the lesion. Intranasal extension of lesion is seen with
thickening of anterior aspect of nasal septum. Subtle
thickening in antero-superior aspect of nasal septum
seems to extend into the right side of cribriform plate
with small bony gap (likely thin connecting pedicle),
likely suggestive of nasal glioma. The mass was excised
with a lateral rhinotomy incision under general
anesthesia. The Histopathology showed features of a
glioma Postoperatively recovery was uneventful.
Fig.1: Swelling at nose
DISCUSSION
Nasal gliomas are not true neoplasms; they
originate from ectopic glial tissue left extracranially
following abnormal closure of the nasal and frontal bone
during embryonic period.
Therefore, some authors recommend using the
glialterm instead8. They are locally aggressive lesions
noticed at birth or during early childhood, but may be
present at any age4,5. The skin covering them may have
Fig. 2 : Excised swelling
telengiectasia. Nasal gliomas are seen more often in

females, with a female:male ratio of 3:15. Our patient
is an 18-month old female. Extranasal gliomas are skincovered nodules most often located at the bridge or root
of the nose, although they may also be found at the nasal
tip. They are often located slightly to one side of the

midline and range in size from 1 to 5 cm10. In our
patients, tumor was located at the root of the nose, just
slightly to one side of the midline, and it was nodular in
appearance. Nasal encephaloceles and nasal gliomas
have a similar embryological origin but, as the nasal
encephalocele is a herniation of the intracranial contents,
it must have an intracranial connection through a bone
defect. The nasal glioma, however, is ectopic
38
Fig. 3: Areas of glial differentiation H&E X100
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
sequestrated tissue and not a herniated structure,
REFERENCES
although a connection with CNS is present in 15-20% of
1.
Thomson HG, al-Qattan MM, Becker LE. Nasal
cases. It is considered important to distinguish nasal
glioma: is dermis involvement significant? Ann
glioma as from nasal encephaloceles because of the risk
Plast Surg 34: 168-72, 1995.
of infection spreading inward along the intracranial
2.
Dini M, Lo Russo G, Colafranceschi M. So-called
communication in the latter to produce meningitis3.
nasal glioma: case report with immuno-
Diagnosis of both intranasal and extranasal gliomas
histochemical study. Tumori 84: 398-402, 1998.
involves a detailed CT study of the nasofrontal area and
3.
anterior cranial fossa to rule out intracranial
Heterotopia: The so-called nasal glioma or
connections. Needle aspiration of these masses is to be
sequestered encephalocele and its variants. Pediatr
avoided, because of the danger of iatrogenic meningitis.

Other
intranasal
neural
tumors,
including
neurofibromas, and neurilemmomas may be
Yeoh GP, Bale PM, de Silva M. Nasal Cerebral
Pathol 9: 531-49, 1989.

4.
Brown K, Brown OE. Congenital malformations

of the nose. In: Cummings CW, Fredrickson JM,
distinguishable from intranasal gliomas. Extranasal
Harker LA, Krause CJ, Schuller DE, Richardson
gliomas with no obvious CNS connection may be excised
MA (eds). Otolaryngology Head and Neck
externally. Postsurgical defects of the nasal bones may
Surgery, 3rd edition, Mosby Year Book, St. Louis,
spontaneously fill in over time or may require bone
1998, pp: 92-103.
11
5.
a bifrontal craniotomy approach may be required.
Hengerer AS, Newburg JA. Congenital

malformations of the nose and paranasal sinuses.
Intranasal gliomas usually arise from the lateral
In: Bluestone CD, Stool SE, Scheetz MD (eds).
nasal wall and can be approached via a lateral rhinotomy
Pediatric Otolaryngology. W.B. Saunders
incision or endoscopic approach. For pure intranasal
Company, Philadelphia, 2nd edition, 1990, pp:
gliomas, a transnasal endoscopic approach is
718-28.
recommended for complete removal of the intranasal
6.
Haafiz AB, Sharma R, Faillace WJ. Congenital
mass with no postoperative facial deformity8. If an
midline nasofrontal mass. Two case reports with
intracranial connection is found, a craniotomy or an
a clinical review. Clin Pediatr (Phila)
external ethmoidectomy may be necessary5. Lateral
1995;34:482-6.
rhinotomy incision was done in our patient. During the
7.
10-month follow-up period no recurrences was seen.
Paller AS, Pensler JM, Tomita T. Nasal midline

masses in infants and children. Dermoids,
encephaloceles, and gliomas. Arch Dermatol
DISCLOSURES
1991;127:362-6.
8.
(c) Funding - None
Rahbar R, Resto VA, Robson CD, et al. Nasal

glioma and encephalocele: diagnosis and
management. Laryngoscope 2003;113: 2069-77.
39
grafting at a later date . If a CSF leak is encountered,
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
9.
Verney Y, Zanolla G, Teixeira R, Oliveira LC.
Diagnosis and management. J Dermatol Surg
Midline nasal mass in infancy: a nasal glioma case
Oncol 16: 1025-36, 1990.
report. Eur J Pediatr Surg 2001;11: 324-7.
11. Stanievich JF, Lore JM. Tumors of the nose,

paranasal sinuses, and nasopharynx. In: Bluestone
Rossi U, Toma P. Nasal glioma in an infant.
CD, Stool SE, Scheetz MD (eds). Pediatric
Pediatr Radiol 2002;32:104-5...Kennard CD,
Otolaryngology. W.B. Saunders Company,
Rasmussen JE. Congenital midline nasal masses:
Philadelphia, 2nd edition, 1990, pp: 780-92.
10. Oddone M, Granata C, Dalmonte P, Biscaldi E,
40
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
CONGENITAL CHOANAL ATRESIA

*C.S. Ray, **Rabindra K. Khatua
INTRODUCTION
Congenital choanal atresia (CCA) is the
Congenital choanal atresia (CCA) is an uncommon
developmental failure of the nasal cavity to communicate
malformation with an estimated incidence of1:5000to
with the nasopharynx. Bilateral choanal atresia is
1:10000 live births. Atresia may be bony, mixed bony-
potentially life threatening in newborns. Most of these
membranous or purely membranous1. Most cases of
cases present early in life with cyclical phases of
choanal atresia are isolated malformation, but
respiratory distress and apnoea, which gets relieved by
association with other congenital deformities has been
crying. In fewer cases it goes undiagnosed to present in
reported in literature. Commonest among which is
adult life with rhinorrhoea and nasal obstruction. We
CHARGE Syndrome( coloboma, heart defects, atresia
report a rare case of bilateral choanal atresia presenting
choanal, retarded growth, ear deformities)2.Unilateral
for the first time at 19 years of age with presenting with

bilateral nasal obsruction, rhinorrhoea and anosmia. His
neonatal history was unremarkable. Endoscopy and CT
scan confirmed atresia. The patient was successfully
treated by transpalatal technique.
Key words: Choanal atresia, adult.
Dr. C. S. Roy
Asst. Professor
Dept. of ENT. & HNS S.C.B. Medical College,
Cuttack-753007
Ph.: 9437309016
atresia may go undiagnosed and unrecognized until later

in life since respiratory distress is usually not
encountered at birth. Bilateral choanal atresia is a life
threatening condition in newborns. It is treated initially
in newborn stage conservatively, then surgically later.
However in rare cases like ours it may be diagnosed
late in adult life with other symptoms.
CASE REPORT
A 19-year-old male patient presented with long
standing bilateral nasal obstruction, mouth breathing,
mucoid nasal discharge, and anosmia. There was no
history suggestive of respiratory distress and his neonatal
history was unremarkable. There was no symptom
suggestive of any other anomalies. Local examination
revealed the patient had elongated face, high arched
palate and mucopurulent discharge in both nostrils with
no airflow at the anterior nares. An attempt to pass a
suction catheter into nasopharynx was unsuccessful.
Diagnostic endoscopies revealed complete blockage of
*Asst. Professor, **Senior resident, Dept. ENT & Head & Neck Surgery, SCB Medical College Cuttack.
41
ABSTRACT
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
both nostrils posteriorly. The diagnosis of bilateral

choanal atresia was confirmed by axial CTscan that
showed bilateral bony atretic plate with bony septal
deviation posteriorly to left side (figure 1). A trans
palatal approach was used to provide a nasal airway.
Bilateral atretic plates were removed and the deviated
bony spur was removed. The neo-choana was stented
with no.5/6portex endotracheal tube for 8 weeks (figure
2). Check endoscopies and local debridement was done
every month for few months. On left side dilatation was
required twice, which was done endoscopically. CT scan
after 10 months of surgery revealed a patent choana on
Fig 2: C.T. scan of same patient co................
both sides (figure3).

DISCUSSION:
Congenital choanal atresia was first reported
in18303. Especially bilateral cases are usually part of
various craniofacial syndromes4.
Bilateral choanal atresia causes acute life
threatening respiratory distress in newborns within hours
of parturition as neonates are obligate nasal breathers.
The symptoms gets relieved by crying and worsened by
feeding. The diagnosis is established easily in neonate
Fig 3: C.T. scan showing bilateral choanal atresia.
age by the inability to pass a suction catheter into

nasopharynx. However, CT scan of nose and skull base
is confirmatory both for diagnosis and assessing the
extent and thickness of atretic plate5.

Our case is unusual since he presented for the first
time at 19 years of age with bilateral disease and with
no significant history of postnatal respiratory distress
or intubations or surgery in early childhood as reported
by patients parents.
Baker et al have hypothesized that very rarely a
newborn with bilateral choanal atresia may compensate
Fig 1: Patient with stents in both nostrils.
42
by rapidly learning mouth breathing and therefore the
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
atersia without prolonged stenting.Arch otolaryngol
diagnosis may be delayed for months or years in few

instances.
Head Neck Surg.2002;128:936-40.
For providing a nasal airway two techniques are
3.
Menschen under thiere.berlin:RuckerA.,1830.
used: Endo- nasal and trans -palatal approach. Endonasal method can be by use of rigid endoscopes7,8 or
Otto AW.Lehrbuch der pathologie,Anatomy des
4.
microscope9. These methods are used for primary repair
Ferguson JL,NeelHB.Choanal atresia; treatment

treands in 47 patients over 33 years.Ann Otol
of membranous or thin bony atresias. But, restenosis
Rhinol Laryngol.1989;98:110-113.
remains an important problem. But, these have been

attributed to local infection, local granuloma, foreign
5.
tomograghy in evaluation of choanal atresia in
boby reaction to stent and synechia. Although,
infants and children. Laryngoscope. 1997;97:174-
transpalatal repair is a bigger operation, has some
183.
bigger advantages like wider exposure, creation of

larger neo-choana initially and decreased incidences of
Crockett DM,Healy GB,Mc Gillt J,et al.Computed
6.
Baker DC Jr, Walter JG, Novick W.Posterior
restenosis. In our case,since the patient was adult with
choanal atresia. Ann Oto RhinolLarygol. 1960;
thick bony atretic plate and posterior bony septal
69:805-809.
deviation, we preferred the trans-palatal method.
7.
Laera RH,Yonnis RT.Trannasal repair of choanal

atresia using telescopes.Arch Otolargol Head Neck
DISCLOSURES
Surg.1995;121:517-520.
8. Kumar AMS,Naik AS,PraveenDS.Choanal
atresia:experience with transnasal endoscopic
(c) Funding - None
technique.Ind J Otolaryngol Head Neck

REFERENCE:
Brown Orval E., Pownell Patrick, Manning
ScottC. Laryngoscope (1996);106(1):97-101.
2.
VanDen
Abbeele,
Francois
9.
Maher A.,Belal A.,Microsurgery.2005;3(4):231238.
M,Nancy
P.Transnasal endoscopic treatment of choanal
1.
Surgery.2005;57:96-8.
43
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
FAMILIAL ANKYLOGLOSSIA [TONGUE TIE]

A RARE CASE REPORT
*Siva Subba Rao. Pakanati, **Vineeth Abraham Anchery, ***Fouzia Moidu
ABSTRACT :
INTRODUCTION :
Ankyloglossia or tongue is a congenital anomaly
Ankyloglossia commonly known as tongue tie is a
with a prevalence of 4-5% and charecterized by
congenital anomaly, characterized by abnorrnally short
abnormally short lingual frenulum. For unknown reasons
lingual frenulum. There is no uniform definition or
the abnormality is 2 times more common in males. The
grading system to describe tongue tie. The condition
pathogenesis of Ankyloglossia is not known. The authors
varies from absence of clinical significance to rare
report a family with isolated Ankyloglossia inherited as
complete Ankyloglossia, where the ventral part of tongue
an autosomal dominant trait in four consecutive
is fused to the floor of mouth.
generations. The identification of the defective gene (s)

in these patients might reveal novel information on the
Tongue tie may result in varying degree of
pathogenesis of this disorder. This case report elucidates
decreased tongue mobility. Tongue tie has been
a specific inheritance pattern of tongue tie.
suggested to cause breast feeding difficulties (sore
Keywords : Ankyloglossia, tongue tie, autosomal

dominant inheritance.
Dr. Siva Subha Rao Pakanati
nipples, poor infant weight gain, early weaning), speech

disorders (impaired articulation), and problems with
deglutition, dentition, and social issues related to limited
function of the tongue.
Management of ankyloglossia is controversial.
Dept. of ENT. Virayok Missions Medical College
There is no common opinion regarding the indications,
Karaikal, Puduchery (UT)
timing or method of surgical repair for ankyloglossia.
Tongue tie can be considered a relatively common

anomaly with a prevalence of approximately 4 5%.
For unknown reasons the abnormality seems to be more
common in males, with male to female ratio 2.5:11.
The pathogenesis of ankyloglossia is not known.
Ankyloglossia can be a part of certain rare syndromes
such as x- linked cleft palate2 and Vander woude
syndrome3. Most often Ankyloglossia is seen as an
isolated finding in an otherwise normal child. Maternal
44
*Assistant Professor, **Post-Graduate Resident, ***Asst. Graduate Resident, Dept. of E.N.T, Vinayaka Missions Medical College,
Karaikal, Puducherry (UT)
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
cocaine use is reported to increase the risk of
examined and confirmed to have Ankyloglossia. Both
Ankyloglossia to more than three fold1.
patients were treated in E.N.T. department of Vinayaka
In this case report, we describe a family with

isolated Ankyloglossia inherited as an autosomal
dominant trait. This family in which 9 individuals spread
over 4 generations have Ankyloglossia, inherited as an
autosomal dominant trait. As the exact pathogenesis is
not known yet and the limited availability of case reports,
studies regarding genetic predisposition of tongue tie,
the authors present this as an affirmative case report
for explaining genetic inheritance pattern of tongue tie.
Missions Medical College, Karaikal, by Frenotomy.

DISCUSSION :
Ankyloglossia or tongue tie is a relatively common
finding in the newborn population and represents a
significant proportion of breast feeding problems. This
anomaly is characterized by the attachment of under
surface of tongue to the floor of mouth. This condition
is the result of failure in cellular degeneration leading
to a tongue tie. For this condition treatment options
CASE REPORT:
include surgical procedures as frenotomy, frenectomy
Our cases were diagnosed in Vinayaka Missions

Medical
College,
Hospital
and frenuloplasty, though its spontaneous resolution is
Karaikal,
also possible in some cases. No widely accepted criteria
Puducherry(U.T). Two boys of 6 and 11 years each
have been established for the surgical indications and
who are brothers presented with slurring of speech and
the selection of surgical procedures.
inability to protrude the tongue. Both were diagnosed to

have tongue tie. Family history reveals the presence of
The exact pathological mechanism of ankyloglossia
Ankyloglossia in 4 consecutive generations from
remains unclear and its conclusive hereditary nature is
maternal side. Patients great grandfather, mother, 2
yet to be elucidated. In the pedigree chart of above
maternal uncles and their children have Ankyloglossia.
mentioned case there seem to be affected individuals
Except patients great grandfather all of the above were
who have passed the condition onto affected offsprings.

In the reported pedigree ankyloglossia appears to be
inherited as an autosomal dominant trait, unless all the
spouce of affected individuals in first three generations
were carriers, which is highly unlikely. This observation
is coinciding with the conclusion made by Klockars4 as
disorder.
Except for tongue tie and defect in articulation,
we didnt find any other symptoms or anomalies in our
cases. So, our report differs from previously described
cases which had fibrous bands associated with congenital
abnormality such as anencephaly, tracheo- oesophageal
Fig.I: Pedigree of patients affected with familial Ankyloglossia.
fistula or cleft palate.
45
ankyloglossia being inherited as an autosomal dominant
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
To identify the defective gene(s) causing

ankyloglossia in the patients, linkage analysis is feasible.
REFERENCES :
1.
Harris EF, Friend GW, Tolley EA. Enhanced
Obvious candidates genes causative for non syndromic
prevalence of ankyloglossia with maternal cocaine
ankyloglossia include TB X 22 gene [a T- box
use. Cleft Palate Craniofac J 1992;29(1):72-6.
transcription factor gene] which is mutated in x- linked
2.
Moore GE, Lvens A, Chambers J, et al. Linkage
cleft palate and ankyloglossia5. LGR5 gene [an orphan
of an X-chromosome cleft palate gene. Nature.
G- protein coupled receptor gene] is found to be
1987;326(6108):91-2.
associated with neonatal lethality and ankyloglossia in

mice6.
3.
Woude syndrome in two families in China. J
CONCLUSION :
Although in this pedigree the number of patients is
Craniofac Genet Dev Biol 1987;7(4):413-8.

4.
Klockars T. Familial ankyloglossia (Tongue-tie)

int J Pediatr Otorhinolaryngol. 2007;71:1321-1324.
limited, the male predominance is established.

However, the identification of defective genes causing
Burdick AB, Ma LA, Dai ZH, Gao NN. van der
5.
Braybrook C, Doudney K, Marcano AC, Arnason
ankyloglossia might reveal novel information about
A, Bjornsson A, Patton MA, et al. The T-box
abnormal craniofacial embryogenesis and the
transcription factor gene TBX22 is mutated in X-
pathogenesis of this particular disorder.
linked cleft palate and ankyloglossia. Nat Genet

2001;29(2):179-83.
DISCLOSURES
(c) Funding - None
6.
Morrita H, Mazerbourg S, Bouley DM, Luo CW,

Kawamura K, Kuwabara Y, et al. Neonatal
lethality of LGR5 null mice is associated with
ankyloglossia and gastrointestinal distension. Mol
Cell Biol 2004;24(22):9736-43.
46
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
SECOND BRANCHIAL SINUS PRESENTING

WITH ORAL HAIR
*Charu Singh, **Jaya Gupta, ***Samiullah, ****Ranveer Singh, *****Pankaj Verma
ABSTRACT
INTRODUCTION
Branchial sinus anomalies although not rare can
Second branchial cleft anomalies are thought to
have variable presentations. We present a case of 24-
originate from the branchial apparatus that did not
year-old female with a second arch branchial pouch
completely obliterate during head and neck
presenting with a hair in the sinus internal opening. This
embryogenesis. The spectrum of developmental
case illustrates an unusual presentation of branchial
anomalies includes cysts, sinuses and fistulas and various
anomaly and also provides possible explanation for links
combinations of these anomalies. Second branchial cleft
between branchial arch anomalies and dermoids or
anomalies are the most common of the branchial
hairy polyp.
anomalies (Schoroeder et al 20071 ; Choudhary et al
Keywords: Second Branchal Sinus, Branchialarch,

Oral Hair, Anomay.
20032).The development of the second arch takes place

over a more extended time period hence anomalies in
this region are more common3. 95% of branchial cleft
Dr Jaya Gupta
Room No 604 TG Campus
anomalies originate from the second branchial cleft4.

We present a case report of a second branchial cleft
sinus with an unusual presentation and an equally unusual
treatment.
Khadra, Sitapur road,
India, Ph.: +91-9415979055

E-mail: jayaguptaent@hotmail.com
CASE REPORT
A 24-year-old woman complained of foreign body
sensation throat for 6 months. She came in the ENT
OPD giving history of hair in her mouth. On examination
there was a hair in her oropharynx coming out from a
sinus on her anterior tonsillar pillar. [Figure 1] At the
same location on the opposite side also there was a pit
with no opening. There was no history of any discharge
from the sinus. She did not have any pain or swelling in
neck suggestive of any other branchial arch anomaly.
Barium
swallow
and
pharyngoscopy
were
unremarkable.
*Associate professor and Head, **Senior resident, ****Assistant professor, *****Senior resident, ENT Department.Integral Institute of medical
sciences and research.Dasauli, Post Bas-ha, Kursi road. Lucknow, ***Associate professor Era Medical college.Sarfarazganj Lucknow, India
47
Lucknow 226003
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
Fig 1: Sinus opening on anterior tonsillar pillar with hair protruding.
The hair was pulled along with its root and the
Fig 3: Sinogram outlining the sinus tract from sinus opening in

oropharynx till hyoid.
patient got relieved of the symptoms almost

instantaneously. [Figure 2]
The patient is under follow up for past one year without

any symptoms.
DISCUSSION
Pharyngeal arches are arches of mesenchyme
derived from paraxial and lateral mesoderm and neural
cell, which appear in 4th and 5th week of development.
They are covered externally by ectoderm, which forms
successive clefts and internally lined by endoderm,
which forms pouches between arches 5. Branchial
anomalies can be lined with either respiratory or
squamous epithelium. Cysts are often lined by squamous
Fig 2: Sinus opening on left side after removal of hair and pit on left
side anterior tonsillar pillar
epithelium, whereas sinus and fistulas are more likely

to be lined with ciliated columnar epithelium6.
The patient was given intravenous antibiotics for

three days to reduce any infection, adhesion or
granulation around the tract to demonstrate entire course

of fistula. The sinus was then cannulated with venflon
cannula no 26 from oropharynx as no external opening
was present. Iohexol was injected into the sinus and
patient was radiographed. The radiological image
depicted the sinus tract going up to the hyoid and ending
in a pouch. [Figure 3] CT scan of the neck did not
In the present case the ectoderm seems to be lining

the sinus tract and giving rise to hair. The histological
examination did not show any variation from normal
skin hair unlike those reported by Farazaneh AgahHosseini7, Miles8, and Baughman9. In all these cases
the etiology was not clear; however in our case the hair
is an ectodermal derivate, which seems to be embedded
in the cervical sinus during embryogenesis.
demonstrate any other ectodermal or mesodermal
Other cases in literature where such hair have
elements in association with the tract. The patient being
been reported along with branchial arch anomalies
asymptomatic the surgical intervention is not indicated.
are hairy polyp.10,11 In these cases the authors have
48
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
suggested that hairy polyps are developmental
lies in the simplicity and avoidance of extensive
malformations of branchial anomalies. In a case
dissection. However it is a blind procedure with high
reported by Burns, patient had a hairy polyp attached
risk of injury to surrounding vital structures, hence it is
to the upper pole of tonsil with second arch branchial
not widely practiced. This technique requires a complete
sinus opening at the junction of upper 2/3 and lower 1/
fistula, which are very rare.
hairy polyp attached to the palate with a discharging

first arch sinus. The presence of these hairy polyps or
dermoids in oropharynx in these patients with branchial
arch anomalies could also be a coincidential finding.
However in our case the ectodermal tissue element was
Pull through technique described by Talaat15 in

which the pharyngeal portion of the fistula is approached
per orally after tonsillectomy. The fistula is freed from
the surrounding structures and delivered through mouth.
In this technique the patient should at least have an
found in ororpharynx coming out of branchial pouch
external opening from where the dissection can be
sinus. This serves as a connecting link between dermoids
commenced.
or hairy polyps and branchial arch anomalies. Our case
Fistulectomy technique described by Takehito
adds further weight to the above theory that dermoids
Oshio16 using nylon thread as a guide wire and traction
in oropharynx represents developmental anomalies of
on the gauze ball at one end of the fistula. In this method
branchial arches.
also at least one external opening is required.
Another rare finding in our case was distinct
Attempts have been made to treat the fistula by
opening of the sinus on the anterior tonsillar pillar. This
injecting sclerosing agents (Bailey H) 17 and
is the first case in the world literature in which an
trichloroactetic acid (Kim et al)18 electrocautery (Jordan
isolated 2nd arch branchial pouch sinus is reported. The

location of inner opening of 2nd arch branchial pouch
sinus has only been found to lie in close association with
tonsillar fossa as per the methylene blue dye tests. The
tract may end in the upper half of the posterior tonsillar
pillar, supratonsillar fossa or directly on to the tonsillar
surface12. In the presenting case not only is the opening
clearly visible, but also its location is rare. Here we
suggest a classification for the inner opening of second
arch sinus/fistula A- posterior tonsillar pillar, B tonsillar
fossa or supratonsillar cleft, C Anterior tonsillar pillar.
et al)19 endoscopic diathermy using uretheral diathermy

wire (PA Rhea)20 All these methods carry a definite
risk of damage to important nearby structures and
pharyngeal perforation. The clinical results achieved
by the above authors are encouraging but there is a
possibility of recurrence of infection due to distal parts
of the sinus tract.
CONCLUSION
Though second branchial arch anomalies are a not
uncommon presentation in ENT OPD. However
Due to this rare presentation and no external
complete second arch fistulae are rare and comprise
opening it would be challenging to remove this sinus
2% of all branchial anomalies.12 This is the first case of
completely. In the literature many techniques have been
branchial pouch sinus with a hair that has been reported
described for treatment of such branchial anomalies.
in world literature (to our knowledge). Not only is this
Taylor and Bicknell13 and Lee and Krishanan14 have
an exclusive presentation but also it helps to fill the
described stripping of branchial fistula by passing a
missing gaps between the dermoids or hairy polyp and
stripper inside the tract. The advantage of this method
branchial arch anomalies. It also reminds us that the

49
3.In another case reported by Vaughman, patient had a
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
anatomy and embryogenesis of neck is complex and
10. Burns BV, Axon PV, Pahade A. Hairy
some of its presentations and treatment still eludes us.
polyp with an ipsilateral branchial sinus:evidence
DISCLOSURES
that hairy polyp is a second branchial arch

malformation. J laryngol Otol. 2001; 115:145-8.

(c) Funding - None
REFERENCES
1.
Schroeder J.W, Mohyuddin N, Maddalozzo J.

Branchial anomalies in pediatric population.
Otolaryngol. Head Neck Surg. 2007;137:289-295.
2.
Chaudhary N, Gupta A, Motwani G et al. Fistula

of the fourth branchial pouch. Am. J. Otolaryngol.
2003; 24:250-252.
3.
Munoz-Fernandez N, Mallea-Canizares I,
Fernandez-Julian E. et al Double second branchial
cleft anomaly. Acta Otorrinolaringol Esp
11. Vaughan C, Prowse SJ, Knight LC. Hairy polyp

of oropharynx in association with first branchial
sinus. J Laryngol Otol.2012; 126.12 1302-4.
12. Burton MG. Second branchial cleft cyst and
fistulae Am J Radiol. 1980; 134: 1067-69.
13. Taylor PH, Bicknell PG. Stripper of branchial
fistula. A new technique. J Laryngol Otol. 1977;
91:141-9.
14. Lee STS , Krishnan MMS. Branchial fistule a
review. Singapore Med J. 1991;32:50-2.
15. Talaat M. Pull-through branchial fistulectomy: a
technique for the otolaryngologist .Ann Otol Rhinol
Laryngol 1992 June101(6) 501-2.
2011;62:68-70.
16. Oshio T, Nakamizo H, Yoshikawa K et al. A new
4.
Mitroi M, Dumitrescu D, Simionescu C et al.

Management of second branchial cleft anomalies.
fistulectomy method for the second pharyngeal

arch remnants. J Ped Surg .2005;40:1784 87.
Rom J Morphol Embryol 2008;49:69-74.

17. Bailey H. The clinical aspects of branchial fistula.
5.
Chandler R, Mitchell B. Branchial cleft cysts,
Br J Surg 1933;21:173 82.
sinuses,and fistulas. Otolaryngol Clin N Am

1981;14:175-86.
18. Kim KH, Sung MW, Roh Jl et al. Sclerotherapy

for congenital lesions of head and neck. Otolaryngol
6.
Stephanie P, Acierno J, Waldhausen HT.
Head Neck Surg.2004;131:307-16.
Congenital cervical cysts, sinuses, and fistulae.

Otolaryngol Clin N Am 2007;40:161-76
19. Jordan JA, Graves JE, Manning SC et al.
Endoscopic cauterization for treatment of fourth

7.
Agah-Hosseini F, Etesam F, Rohani B. A boy with

oral hair:Case report. Med Oral Pathol oral cir
branchial cleft sinuses. Arch Otolaryngol Head

Neck Surg. 1998;124:1021-4.
Bucal 2007; 12:E 357-9.

20. Rea PA, Hartley BE, Bailey CM. Third and fourth
8.
Miles AEW. A Hair Follicle in human Cheek.

Proc R Soc Med1960;53:527-8.
9.
Baughman R.A, Paul D, Heidreich JR et al. The

oral hair: An extremely rare phenomenon.Oral
Surg Oral Med Oral pathol 1980;49:530-1.
50
branchial pouch anomalies. J laryngol Otol

2004;118:19-24.
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
BILATERAL ANTROCHOANAL POLYP IN

AN ELDERLY MALE A RARITY
*Sandesh Chodankar **Markandeya Tiwari ***Nicola Barreto ****Ehrlson de Sousa
INTRODUCTION
ABSTRACT:
Antro-choanal polyps are generally recognized
Antro-Choanal Polyps are benign, solitary lesions
all nasal
which arise from the mucosa of the Maxillary
polyps and are more prevalent in the pediatric
sinus. The mucosa usually prolapses through the
to represent approximately
4-6%
of
population. Bilateral antro-chonal polyps are a rarity.
maxillary ostium and may protrude through the
We report a case of bilateral antro-chonal polyp in
accessory ostium, if present. They increase in size
an elderly male.
and gradually progress towards the choana and
Keywords: Antrochoanal polyp, Bilateral AC

polyp.
nasopharynx and typically appear as a smooth, pale

or bluish solitary mass on anterior or posterior
rhinoscopy.
An antrochonal polyp usually has 3 parts to it
Dr. Ehrlson de Sousa
i.e antral, nasal and choanal part. Antro-choanal
Junior Resident Department of ENT
polyps are generally recognized to represent
Goa Medical College Bambolim

Goa- 403202
Mob: 9822920729
Email: ehrl218@gmail.com
approximately 4-6% of all nasal polyps and are

more prevalent in the pediatric population.1 Killian
was the first to describe this entity in 1906.2 It is
nearly always unilateral and bilateral. Antro-Choanal
Polyp is an extremely rare entity and seldom found
in literature.4,5,6
was in a 24-year-old female while post-operative

bilateral ACP was documented emerging from
previously performed inferior meatus antrostomies
in a 45-year-old female.
CASE REPORT
A 57-year-old known hypertensive male
presented to ENT OPD with history of bilateral
progressive nasal blockade for the last three years.
*Associate Professor, **Assistant Professor, ***Senior Resident, ****Junior Resident, Department of ENT, Goa Medical College,
Goa
51
The oldest report of primary bilateral ACP
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
There was increase in intensity of symptoms for the
CT scans revealed both maxillary sinuses filled
last 3 months. There was no history of pain, itching,
with hypo-dense soft tissue densities extending into
sneezing, nasal bleeding or any nasal discharge.
the corresponding nasal cavities and posteriorly upto
There was no history of associated
the choana. Osteomeatal complex was widened and
asthma or
allergy.
General physical examination was within normal
limits.
Anterior rhinoscopy revealed smooth, pale,
polypoidal masses filling up both nasal cavities.
Posterior rhinoscopy revealed the same polypoidal
masses at both choana.
Routine blood investigations were within normal
limits. Xray of the nose and paranasal sinuses
showed opacification/haziness of both maxillary
antrum and nasal cavities.
blocked on both sides.

The patient underwent Endoscopic sinus surgery
with bilateral uncinectomy, middle meatal antrostomy
and bilateral polypectomy under general anaesthesia
. The polyps were pale fleshy and had a glossy
surface. The gross appearance showed that the
polyps had 3 parts: Antral, nasal and choanal.
The histopathologic report confirmed it to be
benign inflammatory nasal polyps.
DISCUSSION
Antrochoanal polyps (ACP) are thought to
represent hypertrophic maxillary sinus mucosa
prolapsing into the nasal cavity through the natural
or accessory ostium. Although the natural history
and site of origin of ACP was first reported by
Killian in 1906 , the first description of ACP was
made by Palfyn in 1753. Antro-choanal polyps are
almost always unilateral and bilateral antrochoanal
polyps are extremely rare. Only 3 cases were found
in literature3,6 with only one reported case in an
adult.
Fig 1: CT findings
The common clinical presentation of AntroChoanal Polyp is nasal obstruction, and it usually
presents as a hypo-attenuating mass occupying the
maxillary sinus on CT scans, which distinctly reveals

its extension.
No definite etiological factor has been found
but chronic sinusitis, cystic fibrosis and allergy may
have roles in its development. Look et al. postulated
that 24% of ACP had the aspirin-sensitive asthma
triad.
The treatment is surgical. The aim of surgery
Fig 2: Intra operative picture of Bilateral AC polyp
52
is to remove both the nasal and antral parts of the
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
polyp as it tends to recur after simple avulsion.

The maxillary antrum should always be carefully
REFERENCES
1.
inspected.
Chen
JM,
Schloss
MD,
Azouz
ME.
Antrochoanal polyp: a 10 year retrospective
Different approaches are recommended for this
study in the paediatric population with a review
purpose, from the classical Caldwell-Luc approach
of the literature. J Otolaryngol. 1989 June;
to the modified Caldwell-Luc approach (intranasal
18(4):168-72.
antrostomy with resection of anterior part of inferior
2.
turbinate) and functional endoscopic sinus surgery
Fosini P, Picarella G, De Campora E.

Antrochoanal polyp: analysis of 200 cases. Acta
(FESS). The Caldwell-Luc procedure may have
OtolaryngologicaItalica. 2009 Feb; 29(1):21-26.
possible side-effects including both anaesthesia and

swelling of the cheek and also carries risks to the
3.
Basu SK, Bandyopadhyay SN, Bora H. Bilateral

Antrochoanal polyps. J Laryngol Otol. 2001Jul;
developing teeth in children.
115 (7): 561-2.

At present FESS is a very popular technique
and if properly performed there is no recurrence
4.
in children. Acta Med Croatica. 1999;
and very few complications. Antro-choanal polyps
53(2):97-99.
originating from the anterolateral wall can be

removed by a combined endoscopic and trans-canine
5.
polyp. Am J Rhinol. 2002 Mar-Apr;16(2):71-76.
CONCLUSION
occurrence and seen mostly in children and

adolescents . Bilateral occurrence of antrochoanal
polyps in an adult is a very rare occurrence.
Chung SK, Chang BC, Dhong HJ. Surgical,

radiologic and histologic findings of Antrochoanal
approach.
Antrochoanal polyps are generally unilateral in
Markov D, Drajina Z, Pole G. Nasal polyps
6.
Yilmaz YF, Titiz A, Ozcan M, Tezer MS,

Ozlugedik S, Unal A. Bilateral antrochoanal
polyps in an adult: a case report. B-ENT.2007;
3(2):97-9.
DISCLOSURES
(c) Funding - None
53
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
DIAGNOSTIC DILEMMAS LEADING TO FATALITY IN

MUCOSAL MALIGNANT MELANOMA OF HARD PALATE:
A RARE CLINICAL PRESENTATION
*Mohammad Shakeel, **Gaurav kumar, ***Iram khan, ****Ritu Sharma
ABSTRACT
INTRODUCTION
We report a case of hard palate mucosal malignant
There are several subtypes of melanoma, but
melanoma with progressively enlarging swelling on the
mucosal malignant melanoma, also referred to as oral
right side of the upper neck in 60 year old female for
malignant melanoma, primarily affects the oral cavity
which she had taken treatment from many local
and is an extremely rare phenomenon. Oral malignant
practitioners. Detailed history of the patient was taken.
melanoma (OMM) was first described by Weber in
Investigations carried out are Computed tomography of
18591. OMM has an estimated incidence of 1.2 cases
maxillary region and neck, Fine Needle Aspiration
per 10 million persons per year2. Primary oral malignant
Cytology of right cervical lymphnode and incisional
melanoma is rare disease represent only 0.28% of all
biopsy of the tissue from hard palate sent for
melanomas3. Mucosal malignant melanoma, arising
histopathology then final diagnosis of mucosal malignant
from the uncontrolled growth of melanocytes is a
melanoma was arrived. Thus to emphasize that early
potentially aggressive tumor of melanocytic origin
diagnosis and to maintain high index of suspicion for
present as a black macule, later it may develop as a
those pigmented lesions occurring in the oral cavity could
nodule or ulceration, with asymmetry and irregular
have improve the prognosis of patient.
borders. Mucosal melanoma is more frequent among
Key words: Mucosal malignant melanoma,

Cervical lymph node, Computed tomography, Hard
palate, Metastasis.
Japanese people and can occur in hard palate, maxillary

gingival, labial and buccal mucosa of oral cavity4.
The incidence of melanoma has been steadily
increasing in the past several decades with an annual
increase of 3-8% worldwide5. It occurs slightly more
Dr. Gaurav Kumar
often in males6,14, 2.8:1 male to female ratio and the
H/No. 1404, HIG , SECTOR-I,
age range is from. 20-83 years worth an average age of
LDA COLONY KANPUR ROAD,
56 years6. Oral malignant melanoma frequently exhibits
LUCKNOW, U.P, INDIA.
an extremely aggressive behavior, high index of
Email: kumargaurav.1014@gmail.com,
metastasis and has poor prognosis7. Surgery, either alone
Ph. : 9559815295
or in association with radiotherapy, is the preferred

treatment modality. Prognosis is poor with a 5-year
survival rate varying from 0 to 55%3.
54
*Associate Professor, Deptt. of ENT, ELMC, Lucknow, India, **Junior Resident, Deptt. of ENT, ELMC, Lucknow, India, ***Associate Professor, Deptt. of Forensic MED. & Toxicology, HIMS,
Lucknow, India, **** Junior Resident, Deptt. of Pathology, MGMCH, Jaipur, India
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
revealed solitary right upper cervical lymph node
CASE REPORT:
A 60 year old female reported to Department of
Otolaryngology, Eras Lucknow Medical College,
Lucknow with a complaint of a painless, pigmented
patch on right side of anterior hard palate from last one
year which was progressively increasing and bleeds on
touch. She took treatment from many local practitioners
but was not relieved. Later on she developed
progressively enlarging swelling on the right side of the
upper neck to the present state of about lemon size
palpable about 3.0 2.0 cm in size, which was freely

mobile, firm and non-tender [Figure1(a)]. Computed
tomography (CT) of maxillary region and neck revealed
irregular lobulated lesion of soft tissue density arising
from hard palate opposite right maxillary incisor to first
pre molar teeth and not crossing the midline, measuring
approximately 30 10 22 mm size and no bony
erosion[Figure 2 (a, b)]. There is also evidence of a
large necrotic right level 2 cervical lymphadenopathy
measuring 32 21 mm [Fig.2 (c)]. An incisional biopsy
[Fig.1(a)]. She gave no other history of any systemic
of the lesion was performed and histopathological
illness or trauma to the head and neck region. Her
section [Fig. 3] shows parakeratinized stratified
general physical examination was insignificant and her
squamous epithelium with atypical melanocytes along
vital signs were under normal limits. Intra oral
with melanin pigmentation throughout the stroma
examination showed non tender non ulcerated nodular
proving the diagnosis of mucosal malignant melanoma.
soft tissue swelling of bluish-black pigmentation
Fine Needle Aspiration Cytology of right cervical
measuring 3.0 2.5 cm in dimension. It extended from
lymphnode [Fig. 4] shows dispersed population of
right maxillary incisor to first premolar teeth not
melanin containing highly pleomorphic cells having high
crossing the midline and on palpation borders are not
N/C ratio, anisokaryosis and prominent nucleoli with
well defined [Figure 1(b)]. Extra oral examination
abundant extracellular pigment. Melanin pigment was
Fig 2 (a)
Fig 1 (a)
Fig 2 (b)
Fig 3:
Fig 2 (c)
Fig 4 (a)
Fig 1 (a)
Fig 4 (b)
55
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
confirmed by Masson Fontana silver stain which
recognition and subsequent delayed treatment leading
confirmed it as metastatic node of mucosal malignant
to further worsening the prognosis.
melanoma. Work for distant metastases (CT scan of

chest, brain and abdomen) was negative.
Histopathologic examination of the lesion remains

the most accurate diagnostic tool. Adjunctive radiologic
Based on the clinical examination, radiologic and
diagnostic methods such as CT, MRI and Positron
histopathologic features a final diagnosis of mucosal
emission tomography are sometimes useful. The
malignant melanoma was arrived. Medical information
histologic appearance of the tumor is an invasive pattern
was provided to the patient and her family regarding
of growth, with the tumor cells often appearing as
the diagnosis, staging, therapeutic options and prognosis.
densely packed epithelioid or sometimes sarcomatoid
The patient was referred to a cancer institute with
cells with eosinophilic cytoplasm. Varying degrees of
facility of Radio-Chemotherapy and was called for
cellular pleomorphism, tumor invasion of blood vessels
regular follow up. According to her attended she died
and lymphatics are seen. The special stains (Fontana
due to complication of metastasis with in one month of
silver stain and the Prussian blue stain) are accurate in
starting chemotherapy after referral.
only about 75% of the cases. Demonstration of the

neuronal specific S-100 protein is a useful diagnostic
DISCUSSION:
indicator, especially if the tumor is of amelanotic type.

Primary oral mucosal malignant melanoma is a
rare neoplasm, demonstrate significant heterogenecity
in morphological features, developmental process and
biological behavior that could render the clinical
More recently, the application of monoclonal antibody

techniques HMB-45 and Mart-1 (Melan A) 13 has
increased the specificity of immunohistochemical
diagnosis13.
diagnosis extremely difficult and represents 0.5% of

all oral malignancies2,8. Blacks, Japanese and Asian
patients tend to be disproportionately more affected than
Radical surgery is the treatment of choice for oral

melanoma. Elective neck dissection has also been
advocated along with surgery. Radical surgery in
Whites2.
combination with radiotherapy and chemotherapy or

The differential diagnosis includes melanotic
macule, smoking associated with melanosis, postinflammatory
pigmentation,
melanoplakia,
melanoacanthoma, nevi, Addisons disease, Peutz-
Jeghur syndrome, amalgam tattoo, Kaposis sarcoma9.
radiotherapy alone is preferred in inoperable tumors or

in the elderly7. Immunochemotherapy has been shown
to be useful as an adjuvant to surgical resection7.
Chemotherapy is generally reserved for proven
metastatic disease. Morton et al 11 demonstrated
Oral melanoma presents as a dark brown, bluish
temporary tumor regression following the intralesional
black mucosal discoloration. The lesions may be solitary
injection of cutaneous melanoma with BCG vaccine.
or multiple, flat and/or elevated, borders are usually
Kirkwood et al12 reported that melanoma is one of the
irregular, and no clear demarcation exists between the
human cancers which respond to interferon anti-tumor
tumor and the adjacent tissues. Rarely, melanoma may
therapy. The future promise of tumor-directed
present itself without clinical evidence of pigmentation,
antibodies labeled with cytotoxic drugs may offer hope
10
in which case it is termed as amelanotic melanoma .
for improved survival. Malignant melanoma generally
These lesions are fatal because they have delayed
has been considered a poorly radiosensitive malignancy.
56
DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
Primary radiotherapy appeared to be more effective
pigmented lesion from last twelve month was under
than surgical treatment when the 5-year cumulative
treatment of many practitioners. Earlier investigation
survival rates were compared. Postoperative
and confirmation of diagnosis could have improved the
radiotherapy could be of some use; postoperative
prognosis of our patient. Vigilant comprehensive
radiotherapy using fractions of 6 Gy twice a week for a
analysis of published cases and recognition of new ones
13
may be helpful in establishing definite classification and
total dose of 30 Gy has to be given .

Five-year survival for oral melanoma is very poor
with a median survival about 2 years14. Gingival location
carries better prognosis compared to palatal (median
proposing clinical features that would facilitate its early

diagnosis, as a prerequisite for timely treatment and
better prognosis of this rare pathology.
survival 46 vs. 22 months)14. Involvement of lymph nodes
Hence, the purpose of this study is to emphasize
affects survival considerably, with a median survival
on early diagnosis and to maintain high index of suspicion
being 46 months, when lymph nodes are not involved,
for those pigmented lesions for oral malignant melanoma
14
and 18 months when they are involved . As in our case

patient presented with hard palate lesion along with
occurring in the high risk sites such as palate.

DISCLOSURES
secondarys neck which has worse prognosis. Apart

from late presentation of patients with locally advanced
disease, rich vascularity and lymphatic drainage of the
mouth favors earlier metastatic spread to regional lymph
(c) Funding - None
nodes and to distant sites such as the lungs and vertebral
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Ullah H, Vahiker S, Singh M, Baig M. Primary
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age of the patients, all pigmented lesions in the oral
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Tanaka N, Amagasa T, Iwaki H, Shioda S, Takeda

M, Ohashi K, Reck SF. Oral malignant melanoma
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M, Shah JP, Huvos AG, et al. Prognostic factors
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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1
INSTRUCTIONS TO AUTHORS
The Odisha Journal of otolaryngology and Head & Neck
Surgery is a half yearly medical journal [Internationally
(Index Copernicus international plc, Poland: http: //
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All articles are reviewed by one or more experts to

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Address the manuscript to :

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the investigation.
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reader, who is unfamillar with this line of investigation.
on a separate sheet of paper. The legends of micro-photographs

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60
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in parentheses.
Examples: Sheaj.j., Sanabria, Fand Smyth, G.D.L. (1962)

Teflon piston operation for otosclerosis. Archives of
Otolaryngology 78.516.
Boies, L.R. (1954): Fundamentals or Otolaryngology,

Philadelphia, W.B. Saunders Co, 376-385.
The Bibliography should be titled References and the

quoted articles should be listed in the surname of the first
authors.
Charges Payable: According to the decision of the AOI,

Orissa State Branch contributors of the articles are to
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over 2 diagrams or 2 tables or 1 diagram and 1 table is
charged extra at the rate of Rs. 250/- for each diagram/
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the name of Orissa Journal of Otolaryngology & HNS
Payable at any bank in Cuttack, Odisha.
Authors are requested to send their articles and clinical

report addressed to:Dr. K. C. Mallik
Associate Editor
Plot. No. 1195/C-27, Sector -6, CDA, Cuttack,
Odisha, India, PIN-753014, Cell- 09437092087
E-mail: editorodishaentjournal@gmail.com

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DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

(An Internationally & Nationally Indexed Journal)

NATIONAL ADVISORY BORAD

INTERNATIONAL ADVISORY BOARD

Prof. K. K. Ramalingam, Chennai

Dr. James P. Thomas, USA

Prof. T.V. Krishna Rao, Hyderabad

Dr. Asutosh Kacker, USA

Prof. M. Kameswaran, Chennai

Dr. Arun Gadre, USA

Prof. R. Jaya Kumar, Trivandrum

Dr. Ludwig Moser, Germany

Prof. Ahin Saha, Kolkata

Dr. Sylvester Femandes, Australia

Prof. Bachi Hathiram, Mumbai

Dr. Sharat Mohan, U.K.

Prof. Achal Gulati, New Delhi

Dr. Ullas Raghavan, U.K.

Prof. Vikas Sinha, Jamnagar, Gujarat

Dr. Ravinder Ahluwalia, U.K.

Prof. P.S. N. Murthy, Vijayawada

Dr. Naishadh Patil, U.K.

Dr. Madan Kapre, Nagpur

Prof. Andree A. Sultan, France

Prof. B. vishwanatha, Bangalore

Prof. Prepageran Narayanan, Malayasia

Prof. T.S. Anand, New Delhi

Prof. Peter Catalano, U.S.A.

Vol.-9, Issue-I, Jan-June - 2015

STATEMENT OF OWNERSHIP & OTHER PARTICULARS OF ODISHA JOURNAL OF

Owner of the Journal

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

ORISSA JOURNAL OF OTORHINOLARYNGOLOGY AND HEAD & NECK SURGERY

Sl.No Tittle and authors

Role of Ultrasonography in Thyroid Swellings

DSouza Caren, Vaidyanathan Vinay, M B Sandeep

Nudrat Parvez Kamal, Vivek V. Harkare, Nitin V. Deosthale,

Importance of Pre-operative HRCT Temporal Bone in Chronic Suppurative Otitis Media

Sunita M, A.P. Sambandan

Tissue Myringoplasty: A Simple & Cost Effective Technique

Rupam Borgohain, Swagata Khanna

Paediatric Bronchoscopy- An Overview

V. J. Vikram, S. K. Jha, D. Roy, B. Chowdhury, G. C. Sahoo

Dipak Ranjan Nayak, Asheesh Dora, Ranjani Kudva, Shekar Patil

Solitary Parotid Mass Presenting as Sarcoidosis: Unusual Presentation

V. V. Rokade, N. A. Pathak, S. V. Nemade

Nasal Glioma in 18 Month Child

D Kumar, A Agrawal, N Shree, C Gupta, AP Verma

Congenital Choanal Atresia

C. S. Ray, Rabindra Kumar Khatua

Familial Ankyloglossia [Tongue-Tie] - A Rare Case Report

Siva Subba Rao Pakanati, Vineeth Abraham Anchery, Fouzia Moidu

Second Branchial Sinus Presenting with Oral Hair

Charu Singh, Jaya Gupta, Samiullah, Ranveer Singh, Pankaj Verma

Bilateral Antrochoanal Polyp in an Elderly Male - A Rarity

Sandesh Chodankar, Markandeya Tiwari, Nicola Barreto, Ehrlson de Sousa

Vol.-9, Issue-I, Jan-June - 2015

Diagnostic Dilemmas Leading to Fatality in Mucosal Malignant Melanoma of Hard Palate:

Mohammad Shakeel, Gaurav kumar, Iram Khan, Ritu Sharma

DOI No.: 10.21176/ ojolhns.0974-5262.2015.09.1

Vol.-9, Issue-I, Jan-June - 2015