Ajoy Mathew Varghese

IgG4-related disease with sinonasal involvement: A case series.

We present the imaging findings in two cases of IgG4-related disease involving the sinonasal region in the pediatric age group. Imaging findings in IgG4-related disease affecting the nasal cavity and paranasal sinuses have been rarely reported in literature. The diagnosis is made by a combination of clinical, imaging, and histopathologic findings. Radiologists should be aware of the imaging findings of this condition to ensure early diagnosis and treatment.

Endoscopic Repair of CSF Fistulae: A Ten Year Experience

INTRODUCTION Cerebrospinal Fluid (CFF) fistulae are repaired endoscopically with varying degrees of success around the world. Large series are still uncommon, and the results varied primarily because of the different techniques by different surgeons and also because of a variation in the patient profile in each series, for example, many series deal primarily with traumatic CSF leaks where the defects are larger and outcomes poorer. AIM To analyse the surgical outcomes of Endoscopic CSF rhinorrhea closure. MATERIALS AND METHODS This is a series of 34 cases operated upon primarily by one surgeon in two different centres over a period of 10 years. RESULTS Of the 34 cases, 76% of the patients were women. Among the patients only 20.6% patients had a history of trauma preceding the CSF leak. The most common site of leak was in the fovea ethmoidalis in 19 (55.8%) followed by 10 (29.4%) in the cribriform plate. An overlay technique of placing the multiple layers of fascia and mucosa was used in 26 (76.5%) patients and underlay technique in the remaining. Postoperative lumbar drain was used in all patients. CONCLUSION Based on the treatment outcome of the 34 patients, it can be concluded that the success rate of a single endoscopic procedure in our experience is 97% and 100% following the second. Endoscopic approach for closure of CSF leak is safe with minimal complications and little morbidity.

A Randomized Controlled Trial Comparing Intranasal Midazolam and Chloral Hydrate for Procedural Sedation in Children.

Objectives To evaluate the efficacy and safety of intranasal midazolam and chloral hydrate syrup for procedural sedation in children. Study Design Prospective randomized placebo-controlled trial (double blind, double dummy). Setting Tertiary care hospital over 18 months. Subjects and Methods Eighty-two children, 1 to 6 years old, undergoing auditory brainstem response testing were randomized to receive either intranasal midazolam with oral placebo or chloral hydrate syrup with placebo nasal spray. Intranasal midazolam was delivered at 0.5 mg/kg (100 mcg per spray) and oral syrup at 50 mg/kg. Children not sedated at 30 minutes had a second dose at half the initial dose. The primary outcomes measured were safety and efficacy. Secondary outcomes were time to onset of sedation, parental separation, nature of parental separation, parental satisfaction, audiologist’s satisfaction, time to recovery, and number of attempts. Results Forty-one children were in each group, and no major adverse events were noted. The chloral hydrate group showed earlier onset of sedation (66%) compared with the intranasal midazolam group (33%). Significant difference in time to recovery was noted in the chloral hydrate group (78 minutes) versus the intranasal midazolam group (108 minutes). The parents’ and audiologist’s satisfaction was higher for chloral hydrate (95% and 75%) than for intranasal midazolam (49% and 29%, respectively). Overall, sedation was 95% with chloral hydrate versus 51% with intranasal midazolam. Both drugs maintained sedation. Conclusions Intranasal midazolam and chloral hydrate are both safe and efficacious for pediatric procedural sedation. Chloral hydrate was superior to intranasal midazolam, with an earlier time to onset of sedation, a faster recovery, better satisfaction among parents and the audiologist, and successful sedation.

TREATMENT OF OTOGENIC BRAIN ABSCESS IN PREGNANCY

Objective: Otogenic intracranial abscess complicating pregnancy has not been reported in world literature. We report the first case of cerebellar abscess secondary to chronic suppurative otitis media (CSOM) in a 23-year-old lady at 35 weeks of gestation. She was successfully treated by Caesarean section and delivery of a healthy baby, followed by combined neurosurgical and otologic procedures in the same anesthetic sitting. Study Design: Case report. Setting: Tertiary care referral center in a developing country. Conclusion: Otogenic intracranial abscess complicating pregnancy is an extremely challenging therapeutic dilemma for the attending health care provider. Concurrent surgical management by multidisciplinary intervention is safe and to be considered the treatment of choice in a tertiary referral center.

A rare case of bilateral nasolabial cysts in a postpartum lady.

Nasolabial cyst, also known as Klestadts cyst is an uncommon nonodontogenic cyst. Bilateral nasolabial cysts are rarer and less than 10 cases have been reported in the literature. Diagnosis is usually clinical and they present as slow-growing swellings in the nasolabial region causing cosmetic deformity and nasal obstruction. A postpartum lady presented with bilateral swelling of the cheeks. Excision was done via a sublabial approach. She is asymptomatic one year after surgery. Nasolabial cysts are developmental but usually noticed after a trauma. There is no data relating the cysts to pregnancy.

“Post intubation Laryngeal injuries in a pediatric intensive care unit of tertiary hospital in India: A Fibreoptic endoscopic study”

STUDY OBJECTIVES To identify acute laryngeal injuries among pediatric patients intubated for more than 48hours, and to correlate these injuries with clinical variables. SETTING Pediatric Intensive Care Unit (PICU) of a tertiary level hospital in India. PATIENTS AND METHODS Prospective, observational study. Thirty-four children meeting the inclusion and exclusion criteria were recruited into the study after obtaining informed consent from the parents. A bedside, flexible, fiberoptic laryngoscopy was done within the first 24hours of extubation. Laryngeal injuries were documented and graded. Individual types of laryngeal injuries were correlated to the duration of intubation, size of the tube, the experience of the intubator and the patients demographics. A repeat endoscopy was done in the outpatient department, 3-4 weeks after extubation, and findings noted. RESULTS 97% had acute laryngeal injury, of which 88% were significant. Erythema was the most common form of injury. Duration of intubation, with a mean of 4.5 days, showed a trend towards significance (p=0.06) for association with subglottic narrowing. Laryngeal injuries were similar with both cuffed and uncuffed tubes. Age of the subject, size of the tube and skill level of the intubator did not correlate with the laryngeal injuries. 18% required intervention for post-extubation laryngeal lesions. Three (10%) children had post-extubation stridor, and of these, two needed surgical intervention (6%). CONCLUSION Post-extubation laryngeal injuries are not uncommon. Fiberoptic endoscopy is an inexpensive and cost-effective tool for bedside evaluation of post-intubation status in pediatric larynx. Early diagnosis of post-intubation laryngeal injuries in children can prevent long term sequelae. Hence, post-extubation fiberoptic laryngoscopy should be done routinely in pediatric population.

Dacryocystectomy: an uncommon indication--a case report.

Post traumatic nasolacrimal drainage obstruction is an uncommon presentation of naso-orbito-ethmoid fracture. Dacryocystorhinostomy (DCR) with or without silicon intubation is the universally accepted treatment modality. Here we report a case of recurrent lacrimal sac abscess due to post traumatic nasolacrimal drainage obstruction following naso-orbito-ethmoid fracture. The patient had previously undergone incision and drainage thrice and twice failed DCR. In the background of extensive nasal synechiae and twice failed DCR, dacryocystectomy was performed. Post operatively patient has improved and is symptom free for past 14 months. This is the first report of a successful dacryocystectomy for a post traumatic dacryocystitis.

Bilateral Simultaneous Cochlear Implantation in Children: Report of a Case and Review of Literature

The benefits of bilateral cochlear implant in adults are well established. Auditory ability in children is also substantially improved by binaural hearing. We report the first case of bilateral simultaneous paediatric cochlear implant in India and discuss the merits of bilateral implant.

ACE grading—A proposed endoscopic grading system for adenoids and its clinical correlation

OBJECTIVES To propose a novel endoscopic adenoid grading system using a rigid nasal endoscope and to study its correlation with the clinical diagnosis. METHODOLOGY Prerecorded video clips of rigid nasal endoscopy taken during endoscopic adenoidectomy were retrieved. Otolaryngology consultants blinded to the clinical diagnosis of the child were presented these videos and asked to grade the adenoid hypertrophy as per the proposed endoscopic ACE (Airway/Choana/Eustachian tube) grading system. The clinical diagnosis was correlated with the different aspects of the descriptive endoscopic grading system. RESULTS 152 video clips were presented to the otolaryngology consultants for grading. The average age was 8.6 years (SD-3.48), while the male female ratio was 3:2. The A subcomponent of the ACE grading showed significant correlation with the diagnosis of sleep disordered breathing and chronic adenotonsillitis, C subcomponent with sleep disordered breathing and the E subcomponent with the diagnosis of otitis media. CONCLUSION The proposed endoscopic grading is easily applicable and at the same time clearly describes the relation of the adenoids to the nasopharynx, choana and Eustachian tube. Different aspects of the grading system correlated differently with the clinical diagnosis emphasizing that a descriptive scoring rather than a comprehensive scoring is a more relevant clinical tool.

Congenital midnasal stenosis – A novel technique for management

Neonates are obligate nasal breathers and nasal obstruction in a neonate is an emergency. Here we report two cases of congenital mid-nasal stenosis, discuss its presentation and diagnosis with description of a novel method of management.