Subhash Chandra Mishra

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.

The problems of denture impaction

The retrospective study of 50 cases revealed the commonest site of denture impaction to be just below the cricopharynx and usually successful procedure for extraction was per endoscopy. Two cases necessitated transcervical oesophagotomy, another two required transthoracic oesophagotomy while eight dentures passed out per via naturalis. Denture impaction was commonest among the males and rural counterparts. The accidental denture swallowing appears to be the reflection on poor training of dentists and the crude method of denture manufacture. The prevalence of impaction amongst the smokers is perhaps due to nicotine induced poor mucosal sensations.

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.

Current molecular profile of juvenile nasopharyngeal angiofibroma: First comprehensive study from India

An attempt is made to analyze the molecular behavior of juvenile nasopharyngeal angiofibroma (JNA).

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.

Anterior septal chondroma

The cartilaginous tumours of the nasal septum are very rare and almost always arise from the posterior part. Considering the extremely rare occurrence of chondroma arising from anterior part of septum we report such a case. The tumour was well defined, homogenous in appearance and was widely excised through lateral rhinotomy approach. The least accepted traumatic etiology seems to be most appropriate for the oncogenesis in this case. We advocate a thorough histopathological examination of the tumour in to-to in order to appreciate early sarcomatous changes. This report also reviews the relevant literature

Clinical correlation of molecular (VEGF, FGF, PDGF, c-Myc, c-Kit, Ras, p53) expression in juvenile nasopharyngeal angiofibroma

BackgroundA molecular surrogate may exist for the clinical behaviour of juvenile nasopharyngeal angiofibroma (JNA).MethodsIn 9–14 cases, a ‘correlation’ of clinical behaviour with molecular expression (m-RNA expression through RT-PCR) of VEGF, FGF, PDGF, Ras, c-Myc, c-Kit and p53 was undertaken.ResultsA comparison of the two extremes of expressions characterized some specific clinical phenotypes for every marker except c-Myc. A higher FGF was associated with post-adolescent presentation, smaller tumour size, enhanced haemorrhage and recurrence. A higher c-Kit was associated with adolescents, rapid growth, skull base involvement and recurrence. Enhanced Ras was associated with post-adolescence, smaller tumour size, skull base involvement and recurrence. Enhanced p53 and PDGF were associated with adolescents, early presentation and rapid progression. Higher VEGF expression was associated with skull base involvement and enhanced haemorrhage.ConclusionThis study is currently the only evidence revealing a clinical molecular association in JNA and larger multicentric studies need to be performed to show a statistical significance.