Anupam Mishra

Olfaction and its alteration by nasal obstruction, rhinitis, and rhinosinusitis.

The sense of smell has been largely ignored by otorhinolaryngologists, even though 1) its medical stewardship falls within their specialtys purview, 2) olfactory dysfunction is not uncommon in the general population, and 3) disorders of olfaction have significant quality of life, nutritional, and safety consequences. This report provides a succinct overview of the major intranasal neural systems present in humans (namely, cranial nerves O, I, and V, and the nonfunctional accessory [vomeronasal] organ system), along with a summary of notable findings resulting from the application of modern olfactory tests to patient populations, emphasizing diseases of the nose. Such tests have led to the discovery of significant influences of age, gender, smoking, toxic exposure, and genetics on the ability to smell. Within the field of otorhinolaryngology, they have revealed that 1) surgical and medical interventions in patients with rhinosinusitis do not, on average, lead to complete recovery of olfactory function, despite common beliefs to the contrary, and 2) associations are generally lacking between measures of airway patency and olfactory function in such cases. These findings have thrown into question the dogma that olfactory loss in rhinosinusitis is attributable primarily to blockage of airflow to the receptors and have led to histopathological studies demonstrating significant olfactory epithelial compromise in sinonasal syndromes.

Changing trends in the incidence of juvenile nasopharyngeal angiofibroma: seven decades of experience at King George's Medical University, Lucknow, India.

BACKGROUND The occurrence of juvenile nasopharyngeal angiofibroma is reportedly higher in India than in some other parts of the world, and our centre has seen a four-fold increase in its occurrence across seven decades. METHODS This paper reports a retrospective archival analysis of 701 juvenile nasopharyngeal angiofibroma cases from 1958 to 2013, and considers probable environmental factors in an Indian context that may affect its biology and the global distribution, as reported in the literature. RESULTS A continuously progressive increase in occurrence was evident, but the rapid rise observed in the current decade was alarming. The world map of juvenile nasopharyngeal angiofibroma incidence does not reflect true global distribution given the paucity of reporting. Our centre has dealt with approximately 400 cases in the last 24 years. CONCLUSION With the alarming increase in juvenile nasopharyngeal angiofibroma incidence, there is a need for a registry to define its epidemiology. The world literature needs to reflect the status of juvenile nasopharyngeal angiofibroma incidence in the third world as well. Environmental factors known for hormone disruptive actions may influence its occurrence. Such aspects need to be considered to plan specific prevention policies.

Time trends in recurrence of juvenile nasopharyngeal angiofibroma: Experience of the past 4 decades ☆

BACKGROUND An analysis of time distribution of juvenile nasopharyngeal angiofibroma (JNA) from the last 4 decades is presented. METHODS Sixty recurrences were analyzed as per actuarial survival. SPSS software was used to generate Kaplan-Meier (KM) curves and time distributions were compared by Log-rank, Breslow and Tarone-Ware test. RESULTS The overall recurrence rate was 17.59%. Majority underwent open transpalatal approach(es) without embolization. The probability of detecting a recurrence was 95% in first 24months and comparison of KM curves of 4 different time periods was not significant. CONCLUSION This is the first and largest series to address the time-distribution. The required follow up period is 2years. Our recurrence is just half of the largest series (reported so far) suggesting the superiority of transpalatal techniques. The similarity of curves suggests less likelihood for recent technical advances to influence the recurrence that as per our hypothesis is more likely to reflect tumor biology per se.

Prevalence of hearing impairement in the district of Lucknow, India

A multi-cluster study (survey) was carried out by department of ENT KG Medical University, Lucknow from July 2003 to August 2004 in rural and urban population of Lucknow district to estimate prevalence and causes of hearing impairment in the community. Data included audiological profile and basic ear examination that was analysed through EARFORM software program of WHO. Overall hearing impairment was seen in 15.14% of rural as opposed to 5.9% of urban population. A higher prevalence of disabling hearing impairment (DHI) in elderly and deafness in 0-10 years age group was seen. The prevalence of sensorineural deafness necessitating hearing aids was 20% in rural and 50% in urban areas respectively. The presence of DHI was seen in 1/2 urban subjects and 1/3rd of rural counterparts. The incidence of cerumen / debris was very common in both types of population and the need of surgery was much more amongst rural subjects indicating more advanced / dangerous ear disease.

In defence of transpalatal, transpalatal-circumaxillary (transpterygopalatine) and transpalatal-circumaxillary-sublabial approaches to lateral extensions of juvenile nasopharyngeal angiofibroma.

BACKGROUND Juvenile nasopharyngeal angiofibroma often presents with lateral extensions. In countries with limited resources, selection of a cost-effective and least morbid surgical approach for complete excision is challenging. METHODS Sixty-three patients with juvenile nasopharyngeal angiofibroma, with lateral extensions, underwent transpalatal, transpalatal-circumaxillary (transpterygopalatine) or transpalatal-circumaxillary-sublabial approaches for resection. Clinico-radiological characteristics, tumour volume and intra-operative bleeding were recorded. RESULTS The transpalatal approach was suitable for extensions involving medial part of pterygopalatine fossa; transpalatal-circumaxillary for extensions involving complete pterygopalatine fossa, with or without partial infratemporal fossa; and transpalatal-circumaxillary-sublabial for extensions involving complete infratemporal fossa, even cheek or temporal fossa up to zygomatic arch. Haemorrhage was greatest with the transpalatal-circumaxillary-sublabial approach, followed by transpalatal approach and transpalatal-circumaxillary approach (1212, 950 and 777 ml respectively). Tumour size (volume) was greatest with the transpalatal-circumaxillary approach, followed by transpalatal-circumaxillary-sublabial approach and transpalatal approach (40, 34 and 29 mm3). There was recurrence in three cases and residual disease in two cases. Long-term morbidity included small palatal perforation (n = 1), trismus (n = 1) and atrophic rhinitis (n = 2). CONCLUSION These modified techniques, performed with endoscopic assistance under hypotensive anaesthesia, without embolisation, offer a superior option over other open procedures with regard to morbidity and recurrences.

A Rare Case of Jugular Foramen Chordoma With an Unusual Extension

Chordomas are midline tumors of notochordal origin, occurring anywhere from the skull base to the coccyx. Although one-third of chordomas occur in the sphenooccipital region, to our knowledge only 1 case of jugular foramen chordoma with unusual extension into the neck has been reported in the literature to date. A 21-yearold woman presented with a 3-year history of a large neck mass and partly compensated lower cranial nerve symptoms of insidious onset. Imaging revealed a tumor involving the posterior cranial fossa and carotid space, with widening and erosion of the jugular foramen. Characteristic histopathologic findings and immunohistochemical staining confirmed the diagnosis. The tumor was removed by a combined retrosigmoid and lateral cervical approach. The patient was disease free 18 months after treatment.

Olfactory Dysfunction in Leprosy

Leprosy (Hansens disease) is associated with a high incidence of nasal pathology. Despite this fact, the influence of this disorder on the sense of smell is poorly understood. In this study, we administered a standardized 12‐item odor identification test to 77 patients with three types of leprosy: tuberculoid (n = 9), borderline (n = 42), and lepromatous (n = 26). All three types exhibited significantly lower test scores than their respective age‐, sex‐, and smoking–habit‐matched controls. Patients with lepromatous leprosy exhibited significantly lower test scores than those with the other two types. Only patients with lepromatous leprosy exhibited meaningful improvement in smell function after treatment. No association between disease duration, per se, and the severity of the olfactory deficit was present. Overall, 100% of the patients exhibited olfactory dysfunction, suggesting that earlier prevalence estimates based on nonstandardized olfactory testing have underestimated the prevalence of this problem.

Variable expression of molecular markers in juvenile nasopharyngeal angiofibroma

BACKGROUND Molecular categorisation may explain the wide variation in the clinical characteristics of juvenile nasopharyngeal angiofibroma. METHODS Variations in molecular markers in juvenile nasopharyngeal angiofibroma in an Indian population were investigated and compared with global reports. RESULTS Variable molecular marker expression was demonstrated at the regional and global levels. A wide variation in molecular characteristics is evident. Molecular data have been reported for only 11 countries, indicating a clear geographical bias. Only 58 markers have been studied, and most are yet to be validated. CONCLUSION Research into the molecular epidemiology of juvenile nasopharyngeal angiofibroma is still in its infancy. Although the molecular variation is not well understood, data obtained so far have prompted important research questions. Hence, multicentre collaborative molecular studies are needed to establish the aetiopathogenesis and establish molecular surrogates for clinical characteristics.

Current status and clinical association of beta-catenin with juvenile nasopharyngeal angiofibroma

OBJECTIVE A possible role of the APC/beta-catenin pathway in the pathogenesis of sporadic juvenile nasopharyngeal angiofibroma has been suggested. This paper presents its current status and clinical association in our patients. METHOD A prospective observational study was conducted at King George Medical University and Central Drug Research Institute, in Lucknow, India. Western blot analysis was undertaken in 16 cases to examine beta-catenin expression. The clinical details were recorded along with follow up observations, to determine associations. RESULTS Up-regulation of beta-catenin expression was seen in 69 per cent of cases. The clinical variables did not reveal significant differences between patients with extremes of expression (extreme under- vs over-expression). However, absent expression was shown exclusively in young adults aged over 18 years, while enhanced expression was associated with an altered facial profile. CONCLUSION Although a beta-catenin association was seen in a subset of our sporadic juvenile nasopharyngeal angiofibroma cases, its expression was not homogeneous. This is in contrast to the Western literature that suggests a universal (homogenous) enhanced expression in the majority. Hence, further research is required to better define its molecular cascade.

Isolated acute sphenoid sinusitis presenting with hemicranial headache and ipsilateral abducens nerve palsy

Isolated sphenoid sinusitis is a rare disorder and may present with complications due to its anatomical location and proximity to the intracranial and orbital contents. It is frequently misdiagnosed, because the sphenoid sinus is not visualised adequately with routine sinus radiographs and is not accessible to direct clinical examination. We report a case who presented with hemicranial headache and ipsilateral abducens nerve palsy as the presenting feature of sphenoid sinusitis. The symptoms disappeared within a week of conservative treatment. Sphenoid sinusitis should be kept in the differential diagnosis of isolated sixth cranial nerve palsy, especially in the presence of headache, and all patients should be investigated with CT/MRI brain. Prompt diagnosis and management before intracranial extension can prevent devastating complications.