Sandeep Bansal

Transient evoked otoacoustic emissions in hearing screening programs: protocol for developing countries.

OBJECTIVESnTo formulate a protocol for infant hearing screening in developing countries enabling it to be later incorporated into their national deafness screening programs. The screening tool should be sensitive in detecting hearing loss in infants with high specificity.nnnMETHODSn2659 infants in the age range of 0-3 months who reported to the Department of Otolaryngology were included in the study. As 537 children were lost to follow up after the first screening, the remaining 2122 infants only were considered for the statistical analysis. These were divided into 3 groups with age range between 0-1, 1-2 and 2-3 months of age. All were subjected to transient evoked otoacoustic emission (TEOAE) for hearing screening. Those who failed first screening were followed up after 1-month. Pass rate for TEOAE was calculated for each. Infants who had failed the second screening underwent Brainstem Evoked Response Audiometry (BERA). The data collected was statistically analyzed.nnnRESULTSn77.5% of infants in 0-1-month age group passed the screening test whereas 83.4% and 92.8% of infants passed the screening test in 1-2 months and 2-3 month age groups, respectively. On the first follow up, the pass percentage of the infants who had failed screening earlier rose significantly high up to age of 3 months. Those who had failed the follow up were scheduled for Brainstem Evoked Auditory testing.nnnCONCLUSIONnThe concept of this delayed hearing screening at 3 months of age would considerably decrease the number of false positive cases undergoing unnecessary investigations and wastage of resources making the universal neonatal hearing screening within 48 h of life impractical for developing countries. Combining this delayed hearing screening with the 3rd dose of universal immunization program would constitute a viable, feasible and universal hearing screening program, which can be drafted into national deafness programs of the developing countries.

Visual loss in the setting of allergic fungal sinusitis : pathophysiology and outcome

OBJECTIVEnTo hypothesise the probable pathophysiological mechanism responsible for visual loss in allergic fungal sinusitis, other than direct compression.nnnDESIGNnRetrospective, non-randomised case series. Out of 274 cases of allergic fungal sinusitis, four cases with sudden visual loss were enrolled into the study. The fourth case had visual loss on the contralateral side to bony erosion of the lateral wall of the sphenoid sinus.nnnINTERVENTIONSnAll four cases were evaluated with fungal smear, immunoglobulin (Ig) E titres, visual evoked potentials, non-contrast computed tomography and magnetic resonance imaging of the paranasal sinuses, and fundus examination. They then underwent endoscopic sinus debridement followed by intravenous methylprednisolone.nnnOUTCOME MEASURESnImprovement in vision.nnnRESULTSnAll four cases experienced an improvement in vision: full recovery in three cases and partial improvement in one case.nnnCONCLUSIONnIn view of the operative, radiological and laboratory findings for case four, with the suggestion of a hyperimmune response to fungal antigens (in the form of raised IgE titre and positive fungal serology), we suggest that a local immunological reaction to fungal antigens might be responsible for the observed visual loss in cases of allergic fungal sinusitis, in addition to mechanical compression of the optic nerve.

Evaluation and comparison of type I tympanoplasty efficacy and histopathological changes to the tympanic membrane in dry and wet ear: a prospective study.

OBJECTIVEnThis study aimed to compare the success rate of type I tympanoplasty in active (wet) and inactive (dry) mucosal chronic otitis media.nnnMETHODSnA prospective study was performed of 35 patients each with dry ear and wet ear undergoing type I tympanoplasty in the Otolaryngology Department, Postgraduate Institute of Medical Education and Research, India. All patients underwent type I tympanoplasty between January 2010 and June 2011 by the post-auricular approach. Samples of the remnant tympanic membrane were sent for histopathological examination.nnnRESULTSnAfter a minimum follow up of one year, the success rate was 88.6 per cent for dry ears and 80 per cent for wet ears. Neither the type (p = 0.526) nor the presence (p = 0.324) of discharge influenced the success rate. Histopathological examination of the tympanic membrane margins was performed for 46 patients: of these, 19 showed evidence of vascularity and 27 did not. There was no significant difference in success rate between groups (p = 0.115).nnnCONCLUSIONnThe success rate was not influenced by the presence of ear discharge at the time of surgery, and tympanic membrane vascularity did not influence graft uptake.

Are allergic fungal rhinosinusitis and allergic bronchopulmonary aspergillosis lifelong conditions

Aspergillus fumigatus can cause several allergic disorders including Aspergillus-sensitized asthma, allergic bronchopulmonary aspergillosis (ABPA), and allergic fungal rhinosinusitis (AFRS). ABPA is an immunological pulmonary disorder caused by allergic reactions mounted against antigens of A. fumigatus colonizing the airways of patients with asthma (and cystic fibrosis). Allergic bronchopulmonary mycosis is an allergic fungal airway disease caused by thermotolerant fungi other than A. fumigatus. On the other hand, AFRS is a type of chronic rhinosinusitis that is also a result of hypersensitivity reactions to the presence of fungi that become resident in the sinuses. The pathogenesis of ABPA and AFRS share several common features, and in fact, AFRS can be considered as the upper airway counterpart of ABPA. Despite sharing similar immunopathogenetic features, the simultaneous occurrence of the two disorders is uncommon. Due to the lacuna in understanding of the causative mechanisms, and deficiencies in the diagnosis and treatment, these disorders unfortunately are lifelong illnesses. This review provides an overview of the pathogenesis, diagnosis, and long-term outcomes of both these disorders.

Audiological manifestations of allergic rhinitis.

BACKGROUNDnAllergic rhinitis is associated with excess specific immunoglobulin E. Inner ear involvement (via both cellular and humoral immunity) is poorly understood, but appears to arise from the endolymphatic sac and duct.nnnAIMSnTo assess the otological and audiological status of patients with allergic rhinitis.nnnMETHODOLOGYnThirty allergic rhinitis patients (14 men, 16 women; age 17-45 years, mean 31 years) and 20 controls (12 men, eight women; age 21-42 years, mean 27 years) underwent audiological investigation.nnnRESULTSnAll study group patients had sensorineural (rather than conductive) hearing loss, worse at high frequencies. All had abnormal transient evoked otoacoustic emissions and 27 had abnormal distortion product otoacoustic emissions. All had a statistically significantly prolonged wave I latency, and shortened absolute wave I-III and I-V interpeak latencies, compared with controls.nnnCONCLUSIONnAllergic rhinitis patients had a higher prevalence of hearing loss and otoacoustic emission abnormalities than controls. The endolymphatic sac can process antigens and produce its own local antibody response; the resulting inflammatory mediators and toxic products may interfere with hair cell function. Additional research is needed to determine the clinical value of audiometry and otoacoustic emission testing in allergic rhinitis.

Isolated sphenoid mucormycosis presenting as visual impairment: changing trends?

Mucormycosis of the paranasal sinuses represents an important cause of morbidity and mortality in patients whose host defenses have been altered by primary disease or immunosuppressive therapy. The pattern of involvement by this fungus is changing with reports of mucormycosis occurring also in immunocompetent host. The involvement of isolated sphenoid sinus is rare. In the present case, the only presenting symptom was visual impairment. These changing trends in presentation, the extent, and the area of involvement are challenging for the otorhinolaryngologist, ophthalmologist, and neurosurgeon. High index of suspicion, prompt intervention, and aggressive therapy are required to reduce the morbidity and mortality associated with this disease.

Metallic Stents for Proximal Tracheal Stenosis: Is It Worth the Risk?

Objective. To demonstrate the risk associated with blocked proximal tracheal stents when a patient presents with acute respiratory distress, with blockage of stent and what is the best management we can offer without damage to the stent and its associated complications. Case Report. A 22-yr-old, male patient, presented in severe respiratory distress. He had history of corrosive poisoning for which he was tracheotomised. A stainless steel wire mesh stent was placed in the trachea, from the subglottis, to just above the carina. One month later, he presented with a critically compromised airway with severe respiratory distress. Emergency tracheostomy was done and the metallic stent had to be cut open, in order to provide an airway. Conclusion. Management of blocked proximal stents with patient in respiratory distress remains a challenge. Formation of granulation tissue is common and fibreoptic bronchoscopic assisted intubation may not always be possible. A regular follow up of all patients with stents is essential. Placement of stents within a few centimetres of cricotracheal junction should not be encouraged for long term indications.

Prevalence of sensitization to Aspergillus flavus in patients with allergic bronchopulmonary aspergillosis

Aspergillus fumigatus is the most common Aspergillus species worldwide; however, A. flavus has also been shown to be prevalent in North India. Herein, we investigate the prevalence of sensitization to A. flavus in subjects with allergic bronchopulmonary aspergillosis (ABPA). We also evaluate the occurrence of allergic bronchopulmonary mycosis (ABPM) due to A. flavus. Treatment-naive subjects with ABPA underwent sputum culture; and, skin testing, fungal-specific immunoglobulin E (IgE) and serum precipitation tests for A. fumigatus and A. flavus. Sensitization to A. flavus was diagnosed if any immunological test for A. flavus was positive in subjects with ABPA. ABPM was labelled as probable if sputum cultures grew A. flavus and A. flavus-specific IgE was greater than A. fumigatus-specific IgE; and, possible if only A. flavus-specific IgE was greater than A. fumigatus-specific IgE. Fifty-three subjects with a mean (SD) age of 34.2 (12.8) years were included. Sensitization to A. flavus was seen in 51 (96.2%) subjects, with overlap occurring in 49 (92.5%), 21 (39.6%), and 12 (22.6%) instances on fungal-specific IgE, skin prick test and precipitins, respectively. Sputum culture was positive in 18 (33.9%; A. flavus [n = 12], A. fumigatus [n = 6]) subjects. ABPM due to A. flavus was diagnosed in 16 (30.2%) subjects (10 probable, 6 possible). They were more likely to have high-attenuation mucus and a trend towards higher occurrence of sinusitis, compared to ABPA. We found a high occurrence of sensitization to A. flavus in subjects with ABPA. Subjects with A. flavus-related ABPM had a higher likelihood of high-attenuation mucus and probability of sinusitis. More studies are required to confirm this observation.

Analysis of differential expression of protease-activated receptors in patients with allergic fungal rhinosinusitis

Background Ever since its characterization in the 1970s, allergic fungal rhinosinusitis (AFRS) has been the subject of much controversy, especially regarding its pathogenesis. In this study, we analyzed the differential expression of genes that encode protease-activated receptors (PAR) in patients with AFRS and patients with chronic rhinosinusitis, and tried to understand the pathogenic basis of this disease. Objective To analyze the differential expression of PAR genes in patients with AFRS and in patients with chronic rhinosinusitis. Methods Mucosa from ethmoid sinuses of 51 patients (tests and controls) was biopsied and evaluated for messenger RNA expression of PAR genes by using reverse transcriptase–polymerase chain reaction. Each of the four PAR genes, i.e., par1, par2, par3 and par4 was amplified, the final gene products were run on 1.8% agarose gel and analyzed by densitometry to calculate differential expression. The significance level was determined as p ≤ 0.05. Results It was observed that the expressions of all four par genes were higher in the test samples compared with the controls, but statistical significance was achieved only for par1 (p=0.004) and par2 (p=0.05). Comparative expression of the four PAR genes was also performed within the test and control groups, and a statistically significant difference was seen between par1 and par2 (p=0.007), par1 and par3 (p=0.029), par1 and par4 (p=0.0001), par2 and par4 (p=0.002), and par3 and par4 (p=0.009) in the test group. In the control group as well, par1, par2, and par3 exhibited a higher expression compared with par4 but the difference was significant between par3 and par4 genes only. Conclusion Patients with AFRS expressed increased levels of PAR genes in their nasal mucosa, and, of the four PAR genes, a higher expression of par1, par2, and par3 was observed in both the groups compared with par4. This information contributes toward our understanding of pathogenesis and possibly treatment of AFRS.

Chronic Invasive Fungal Sinusitis Presenting as Inferior Altitudinal Visual Field Defect

ABSTRACT A young male with acute blurring of vision (6/9) complained of an inferior altitudinal field defect in right eye. Clinical ophthalmological examination was normal. Magnetic resonance imaging (MRI) of the brain revealed the expansion and mucosal thickening of right posterior ethmoid and sphenoid sinuses and opacified right maxillary sinus. Surgical intervention (transethmoidal sphenoidotomy) and histopathological examination revealed chronic invasive granulomatous fungal sinusitis. Anti-fungal therapy led to resolution of visual complaints and restoration of visual field defects.