Journal of Otorhinolaryngology and Facial Plastic Surgery

Background: Extranodal NK/T-cell lymphoma, nasal type (ENKTCL-NT) often presents with non-specific symptoms that mimic benign sinonasal conditions, leading to diagnostic delays. This challenge is amplified in post-operative patients, where symptoms can be attributed to surgical sequelae.

Case Presentation: A 43-year-old male presented with persistent nasal obstruction and discharge three months after undergoing rhinoplasty. Initial evaluation suggested post-operative inflammation. However, subsequent imaging revealed a destructive soft tissue mass with extensive bone erosion. Endoscopic biopsy and immunohistochemical analysis (positive for CD3, CD56, CD30) confirmed a diagnosis of high-grade ENKTCL-NT.

Conclusion: The patient achieved complete remission after definitive chemoradiotherapy. This case underscores that ENKTCL-NT can masquerade as routine post-surgical inflammation. Clinicians must maintain a high index of suspicion for malignancy in patients with refractory or progressive sinonasal symptoms following surgery to ensure timely diagnosis and treatment.

Background: Orbital Apex Syndrome (OAS) is an extremely rare yet significant complication following craniomaxillofacial trauma. The syndrome's clinical features predominantly involve a combination of vision loss and ophthalmoplegia. Despite the severity of its implications, there is scant literature addressing traumatic OAS without associated facial bone fractures.

Case presentation: We present the case of a young adult male who experienced traumatic OAS without facial bone fractures following a head injury from an assault. The patient exhibited ptosis, complete ophthalmoplegia in the left eye, and visual acuity impairment. Diagnostic imaging revealed comminuted fractures of the anterior sphenoid bone and slight narrowing of the optic canal, but no involvement of the intraconal region or other craniofacial injuries. The patient was managed conservatively with close monitoring. While there was some improvement in extraocular muscle movements, the visual impairment persisted.

Conclusion: A comprehensive literature search identified two studies that met the inclusion criteria for traumatic OAS without facial bone fractures or severe traumatic brain injuries. Treatment approaches ranged from observation to high-dose corticosteroids and surgical optic canal decompression. However, visual acuity remained impaired regardless of the treatment type. The variability in outcomes underscores the need for a standardized treatment protocol. Traumatic OAS without facial bone fractures presents a complex clinical challenge with variable progression and mixed treatment outcomes. Early and accurate diagnosis, individualized treatment plans, and a multidisciplinary approach are essential for improving patient prognosis. Further research is necessary to establish a unified treatment protocol for managing this rare condition.

Background: Spontaneous tonsillar hemorrhage (STH) is a rare complication of acute or chronic tonsillitis, with 63 cases reported in the literature. Despite these, no consensus exists on therapeutic pathways for STH.

Case presentation: Case 1: A 26-year-old presented with hemoptysis and a 2x3mm coagulum on the right tonsil. After admission and administration of dicynone, a significant bleed of 350ml occurred. Bleeding was controlled under general anesthesia using bipolar diathermy. CT angiography and MRI revealed a blood-filled cavity caused by erosion of the descending palatine artery. Digital subtraction angiography (DSA) confirmed this and was followed by super-selective embolization.

Case 2: A 46-year-old presented with hemoptysis and a 5x5mm coagulum on the right tonsil. The bleed was managed with bipolar diathermy. CT angiography showed a right tonsillar abscess without arterial malformations. Case 1 represents the first reported use of DSA and embolization to manage STH caused by an aberrant artery.

Conclusion: These cases and a literature review informed a diagnostic and therapeutic protocol for STH. Vascular malformations must be excluded before emergency tonsillectomy, with DSA playing a key role in identifying and managing arterial involvement.

Background: Septal mucocele is very uncommon. Those reported mostly have a prior history of trauma however; idiopathic septal mucocele is even rarer.

Case presentation: We report a case of idiopathic septal mucocele who presented with bilateral, progressive nasal obstruction. Clinical examination revealed bilateral, smooth bulge on the anterior cartilaginous septum, which on radiology indicated an expansile cystic mass. As it extended to the nasal spine superiorly, an open rhinoplasty approach was taken for its complete removal. The septal cartilage was absent inside the cyst.

Discussion: Histology showed tissue lined by respiratory epithelium with mucinous glands in the stroma is confirmative of mucocele. Two months post-surgery, the septal perforation had healed well with no evidence of recurrence.

Conclusion: Although rare, septal mucocele should also be considered as differential diagnosis of long-standing septal swelling.

Background: Meningioma is the most common primary brain tumor in adults, mostly seen in middle-aged women. Magnetic resonance imaging (MRI) is the primary diagnostic and follow-up tool. Recently, radiomics have been introduced to predict prognosis in patients with brain tumors, yet studies are limited.

Aim: The aim of this study was to investigate the diagnostic value of radiomics based on MRI images before surgery in patients with meningioma.

Methods: In this cross-sectional study, meningioma patients who were operated on between 2018 and 2024 were evaluated. MR imaging of the patients were observed and Radiomics features were extracted by an expert radiologist. Finally, the images were analyzed based on radiomic algorithms.

Results: LASSO test was performed and among 851 features, 10 features with non-zero correlation were selected. The accuracy of SVM was 81.25%, Precision was 0.85 with validity of 0.814±0.052. According to findings from Logistic Regression, the accuracy of the test was 87.50%, the precision was 0.89, and the validity of the test was 0.943 ± 0.070. Random Forest algorithm was also performed on the samples and it was seen that its accuracy was 87.5%, Precision 0.89, and validity 0.889 ± 0.056. The area under the curve (AUC) for SVM, Logistic Regression, and Random Forest were 0.62, 0.75, and 0.75, respectively.

Conclusion: The use of artificial intelligence based radiomic algorithms can help radiologists diagnose meningioma more accurately, but it cannot replace it.

Background: Holes in the tympanic membranes, known as perforations, are a common ear condition often resulting from trauma, infection, or medical procedures. These perforations can lead to various degrees of hearing loss and require timely detection and treatment to prevent further damage to the middle ear.

Aim: This study aimed to investigate the correlation between the size of perforations in the tympanic membrane and the degree of hearing loss. Specifically, the study categorized the perforations into small, medium, and large sizes to assess their impact on hearing function.

Methods: The study conducted an observational analysis of 1000 patients (1230 ears) with chronic otitis media, focusing on those aged between 16 to 45 years. Patients with central perforations in the pars tensa were included, while those with squamosal chronic suppurative otitis media or wet ear were excluded. Data collection included detailed medical history, general examination, ENT examination, and assessment of perforation size using otoendoscopy. Pure-tone audiometry was utilized to measure hearing loss, categorized according to WHO standards. Statistical analysis was performed to determine the correlation between perforation size and hearing loss.

Results: Of the 1000 patients included, 23% had bilateral perforations, with varying sizes observed. The majority of patients had mild conductive hearing loss (69.9%), followed by moderate (27.6%) and severe (1.6%) loss. The analysis revealed a significant correlation between perforation size and hearing loss (p < 0.05). Smaller perforations were associated with mild hearing loss (averaging 28 dB), while larger perforations led to more severe loss (averaging 47 dB).

Conclusion: The study confirmed that the size of perforations in the tympanic membrane correlates with the degree of hearing loss, with larger perforations resulting in more significant impairment. These findings underscore the importance of early detection and appropriate management of tympanic membrane perforations to prevent further hearing deterioration. However, future research should consider additional factors such as patient age and the condition of the middle ear bones to provide a comprehensive understanding of hearing outcomes in these cases.

Background: Basal cell carcinoma, also referred to as rodent ulcer is the most common skin cancer seen worldwide. It is a slow-growing tumour that rarely metastases. Basal cell carcinoma is rarely fatal, but it can cause significant damage and disfigurement of nearby tissues if treatment is delayed. The first line of treatment is surgical excision, followed by primary repair of the defect. The face is the most commonly affected site with skin tumours. Thus, locoregional flaps are commonly used for the closure of defects due to their good texture and colour match. Skin flap techniques like transpositional flaps, advancement flaps or rotational flaps can be used to close facial defects.

Aim: This study aims to outline the different categories of flaps that can be used for reconstruction after resection of facial basal cell carcinoma and their advantages and disadvantages.

Methods: We retrospectively analysed the patients who underwent surgical excision of basal cell carcinoma followed by reconstruction with different local fasciocutaneous flaps.

Results: This study describes cases of facial defects following basal cell carcinoma excision surgery closed with different flaps. All the patients were followed up for 6 months post-excision and showed acceptable functional and cosmetic results. All the flaps were healthy without any complications.

Conclusion: Based on our observations, local flaps yield acceptable outcomes for facial restoration following surgical excision of basal cell carcinoma. Depending on the area involved, different flap techniques can be used to improve cosmetic outcomes and patient satisfaction.

Background: Clonidine, an alpha-2-agonist, attenuates the sympathetic response during general anesthesia and improves intra-operative hemodynamic stability. Clonidine has been associated with certain adverse cardiopulmonary effects.

Aim: This study aimed to investigate the impact of oral clonidine, administered as premedication, on the post-operative PR interval of the electrocardiogram (ECG) in patients who underwent rhinoplasty or Functional Endoscopic Sinus Surgery (FESS).    

Methods: This study enrolled 50 patients scheduled for rhinoplasty or FESS under general anesthesia. Before arriving at the operation room, each patient received 300µg of oral clonidine 30 minutes before the standard 12-lead ECG was obtained. Induction of anesthesia was performed using the same standard protocol in all patients. Any changes in ECG monitoring during operation and in the recovery, room were registered. Six hours after clonidine administration, the standard 12-lead ECG was obtained and compared with the first ECG.

Results: The PR interval was prolonged in 23 cases (46%). In 21 cases, the prolongations were in the normal range (0.12-0.2 Sec.), and in two cases were in abnormal ranges (> 0.2 Sec.). (P value < 0.001).                                    

Conclusion: It seems that premedication with oral clonidine can prolong the PR interval.

Background: Intraoperative bleeding is a common problem encountered during endoscopic sinus surgery.

Aim: This study aimed to assess the role of pterygopalatine fossa block in reducing the intraoperative bleeding and operative time during bilateral functional endoscopic sinus surgery.

Methods: It was a prospective, comparative study. 38 patients requiring bilateral functional endoscopic sinus surgery (FESS) for chronic rhinosinusitis with nasal polyps (CRSwNP) were enrolled. Pterygopalatine fossa (PPF) block was given using 2% xylocaine and 1:2,00,000 adrenaline through greater palatine canal trans-orally on one side only based on lottery. The intraoperative bleeding was graded as per Boezaart and Van Der Merwe scale for endoscopic grading of bleeding on each side. The operative time on each side was also noted.

Results: The mean endoscopic grading of intraoperative bleeding on the side of PPF block was 2.06±0.50 and 2.50±0.47 on the contralateral side, with the difference being statistically significant (p value = 0.00). The mean operative time on the side of PPF block was 44.97±12.85 minutes and 51.47±15.35 on the side without the PPF block and the difference was statistically significance (p value – 0.04).

Conclusion: The PFF block with 2% xylocaine and 1:2,00,000 adrenaline significantly reduced both intraoperative bleeding and operative time during FESS.  It provided a comparatively better visualization of the surgical field consequently reducing the need for frequent cleaning of endoscope and nasal packing to secure hemostasis hence reducing the operative time.

Background: Computational fluid dynamics (CFD) technology has emerged as a valuable tool for studying nasal physiology.

Aim: The objective of this study was to establish a CFD analysis comparing patients with asymptomatic and symptomatic nasal septal perforations (NSP).

Methods: We applied CFD technology to examine the nasal airflow differences between 10 asymptomatic and 10 symptomatic NSP adult patients. Questionnaires (22-item Sino-Nasal Outcome Test and Nasal Obstruction Symptom Evaluation) were obtained to confirm patients' symptoms.

Results: The asymptomatic NSP group consisted of 4 males and 6 females with a mean age of 46.2 years. The symptomatic group consisted of 5 males and 5 females with a mean age of 42.1 years. The NSP etiology was before nasal surgery in most of the patients (11 cases, 55%). NSPs were considered idiopathic in 3 cases (15%). No statistically significant differences were found between groups regarding sex, age, or etiology of perforation. No statistical differences were found in perforation shape, location, axial diameters, area, nasal resistance, or volumetric flow rate shunting across the perforation between asymptomatic and symptomatic patients. Symptomatic patients had higher wall shear stress along the posterior perforation margins, although the difference was not statistically significant. 

Conclusion: NSP altered the physiology of the nasal cavity both in symptomatic and asymptomatic patients. High wall shear stress in posterior perforation regions may explain the crusting most commonly found on posterior NSP margins.

Background: The integration of artificial intelligence (AI), particularly generative large language (LLM) models like ChatGPT, promises to enhance patient education and communication in many fields, including facial plastic surgery.

Aim: We herein assess patient perceptions of AI-generated versus human surgeon preoperative and postoperative counseling for septorhinoplasty surgery.

Methods: Responses to hypothetical questions by ChatGPT and a human surgeon were evaluated by 103 blind evaluators from a general audience to assess empathy, accuracy, completeness, and overall quality. Evaluators were also asked to quantify their prior usage of AI LLMs and rate their confidence in discerning the AI and human responses.

Results: ChatGPT's responses were generally preferred, receiving significantly higher scores in accuracy (p<0.001), completeness (p<0.001), and overall quality (p<0.001). ChatGPT scored lower in empathy, but the difference was not significant (p=0.11). No significant differences were found in evaluators' trust in AI or their ability to discern between human and AI responses based on past AI LLM usage (p=0.43; p=0.25)..

Conclusion: AI, specifically ChatGPT, can supplement traditional patient education and communication methods in facial plastic surgery. Further research is necessary to understand the broader implications and optimal integration of AI in clinical practice.

Background: The most well-known side-effect of Aminoglycoside antibiotics is significant hearing loss and balance issues. For instance, Gentamicin has been widely recognized for causing hearing loss in most patients.

Aimes: This study explored the available evidence on hearing loss following Gentamicin use.

Methods: We conducted a comprehensive literature search using Web of Science and PubMed, with the keywords: "Deafness," "Hearing Loss," "Drugs," "Adverse Drug Reaction," "Ototoxicity," "Gentamicin," "Aminoglycosides," "Inner Ear," and "Audiogram." All data were independently extracted and relevant research was used to write this review article.

Results: The reviewed studies highlight the critical factors influencing the severity of Gentamicin-induced hearing loss, including the site of administration, dosage, and co-administration with other ototoxic agents like Vancomycin. The mechanisms underlying Gentamicin ototoxicity involve oxidative stress, inflammation, and apoptosis of sensory hair cells. The literature also suggests safer alternatives within the aminoglycoside class, such as apramycin and Gentamicin C1a, which could be considered for future clinical use.

Conclusion: Gentamicin has been consistently associated with significant ototoxic effects, particularly hearing loss, across various species and clinical contexts. Balancing its therapeutic benefits against potential hearing loss is essential. Developing more targeted interventions that preserve its antimicrobial efficacy while minimizing hearing loss risk may be possible.

Hearing loss, an increasing problem across the globe, results in an important solution in the form of cochlear implants, highlighting the critical need for effective interventions. This review involves analyzing 46 relevant publications via databases such as PubMed and Google Scholar, providing current insights into pre-operative issues. Studies through databases such as PubMed and Google Scholar, ensuring contemporary insights into the pre-operative considerations. The pre-operative evaluation encompasses medical history, covering prenatal events and immediate post-natal health, along with physical examinations and complete audiometric assessments. High-Resolution Computed Tomography (HRCT) and Magnetic Resonance Imaging (MRI) emerge as crucial imaging techniques, guiding surgical planning and electrode placement. Brainstem Evoked Response Audiometry (BERA) supplements inconclusive MRI data, while vestibular screening aids in candidate selection. Cochlear duct length determination, often assessed through imaging techniques, contributes to optimal electrode array selection. Models in cochlear implant research, spanning computational, animal, tissue engineering, and physical models, further enhance our understanding and refinement of cochlear implant designs. In conclusion, this comprehensive pre-operative workup plays a significant role in assessing patient health, identifying causes of deafness, and contributing to the overall success of cochlear implantation, a transformative solution for profound hearing impairment.

Background: Extracorporeal Shockwave Therapy (ESWT) involves the application of impulse acoustic waves in a focused pattern to facilitate healing. While ESWT machines, classified as Class II medical devices, are widely used in urology and sometimes physical therapy, they produce impulse noise averaging 88 dB, raising concerns about potential auditory hazards for operators and clients. There is limited research and inconsistent recommendations regarding the need for hearing protection during ESWT.

Aim: This literature review aims to investigate the available evidence on the auditory impacts of ESWT-associated noise for both operators and clients, assessing the necessity for hearing protection.

Methods: A systematic search of studies on ESWT-associated noise was conducted, yielding 906 studies. After removing 131 duplicates and screening out 768 studies based on inclusion criteria, seven studies published in English were included in the review. The studies analyzed noise levels, hearing function outcomes, and recommendations for hearing protection.

Results: The findings on ESWT-associated noise and its auditory impacts were mixed. Four studies reported no significant detrimental effects on hearing function, while three studies indicated hazardous sound levels with potential risks for hearing loss. Operating manuals for ESWT devices reviewed recommend hearing protection for both operators and clients, although reported sound levels were often within regulatory safety limits.

Conclusions: There is inconsistent evidence regarding the auditory risks of ESWT-associated noise, with some studies identifying potential hazards, especially for operators exposed over extended periods. Operating manuals generally advise hearing protection, indicating a precautionary approach. Further research, such as randomized controlled trials, is needed to clarify the risks and develop evidence-based guidelines.

Background: Sensorineural hearing loss is a prevalent condition that affects many and results from damage to cochlear hair cells and spiral ganglion neurons. Current treatments offer partial auditory restoration but fail to address the underlying cellular damage. Cell-based therapies have emerged as a potential strategy for regenerating damaged auditory structures.

Aim: This review examines the recent progress and ongoing challenges in the application of cell therapy for hearing loss.

Methods: A comprehensive review of the literature was conducted searching through PubMed, Scopus, and Google Scholar with a focus on publications between 2000 and 2023. Studies were included if they addressed the use of stem cell-based therapies in hearing loss, involving both preclinical models and human trials. Data were collected on the used cell types, mechanisms of action, outcomes, and barriers to clinical application.

Results: ESCs, iPSCs, MSCs, and NPCs have been explored for hearing loss therapy. ESCs and iPSCs demonstrated the ability to differentiate into auditory hair cells and SGNs, showing potential for direct auditory repair. While preclinical studies in animal models showed partial restoration of auditory function, challenges such as limited cell survival, maturation, and integration persist. Initial clinical trials using MSCs have demonstrated safety, with mild improvements in hearing function, though significant functional recovery is not yet definitive.

Conclusion: Cell therapy offers a novel approach for treating SNHL, but further research is necessary to optimize cell survival, delivery, and integration. Future clinical trials and advancements in stem cell technology will be critical to translating these findings into viable treatments.

Meniere's disease is an inner ear pathology characterized by recurrent episodes of vertigo, sensorineural hearing loss, a sensation of fullness in the ear, and tinnitus. It is estimated to occur at a rate of 15 individuals per 100,000 globally. Several recommendations exist for treating the disease, but there is no exact guideline to approach its management. In this study, we reviewed a decade of studies on the intratympanic approach to treating Meniere's disease which compared corticosteroids and antibiotics used on the condition. We found that the available data present conflicting evidence, and studies that investigated intratympanic gentamicin or dexamethasone did not demonstrate conclusive improvement in patient outcomes.

Background: The healing process is one of the main issues for the medical and general population. Studies have shown that vitamin C can accelerate this process, in this study, we aimed to review the effects of vitamin C on wound healing.

Methods: We searched PubMed, MEDLINE, and Elsevier databases for studies with the keywords “vitamin C” OR “ascorbic acid” AND “wound healing” OR “wound repair.” Studies from the start of 2013 to the end of 2023 were reviewed.

Results: Few studies have evaluated the effects of Vitamin C on wound healing. Six studies were assessed, which found that vitamin C significantly improves wound healing, closure, post-healing appearance, decreased bacterial load, and inflammatory markers.

Conclusion: Given that only a few studies have confirmed the effects of Vitamin C on wound healing, further studies are required to appropriately confirm the association.

Background: Hormonal changes during pregnancy significantly affect various physiological systems, including the respiratory tract, contributing to the onset and progression of sinusitis and rhinitis. These conditions can impact the quality of life of pregnant women and pose potential risks to maternal and fetal health.

Aim: To explore the prevalence, risk factors, pathophysiology, clinical manifestations, diagnostic challenges, and management strategies for sinusitis and rhinitis during pregnancy, emphasizing the role of hormonal fluctuations.

Methods:
A narrative review was conducted by analyzing and synthesizing data from relevant studies, focusing on the impact of pregnancy-related hormonal changes on the nasal and sinus mucosa. Peer-reviewed articles published in reputable medical journals were reviewed, emphasizing prevalence, pathophysiology, clinical challenges, and treatment options.

Results: Pregnancy-associated rhinitis affects approximately 10% of pregnant women, with nasal obstruction, rhinorrhea, and sneezing being common symptoms. Elevated estrogen and progesterone levels contribute to increased vascular permeability, mucosal edema, and immune modulation, predisposing women to sinus inflammation and infection. These hormonal changes complicate the differentiation between physiological nasal changes and pathological conditions, creating diagnostic and management challenges. Most cases are mild, but complications such as obstructive sleep apnea and adverse fetal outcomes have been reported.

Conclusions: Hormonal fluctuations during pregnancy play a pivotal role in the development and progression of sinusitis and rhinitis. Management strategies focus on conservative approaches, such as saline nasal sprays and humidification, to ensure safety for both mother and fetus. Pharmacological interventions are considered only when necessary and must have established safety profiles. Further research is needed to understand long-term outcomes and optimize treatment approaches for these conditions.

Background: Background: Fungal rhino-sinusitis is a rare, rapidly progressing, life-threatening opportunistic infection, primarily affecting immunocompromised patients, such as those with diabetes and lung diseases, recently observed in post-COVID pneumonia cases. Clinically, it presents with partial neurological dysfunction and progressive necrosis secondary to blood vessel invasion and thrombosis, potentially involving the cranium, increasing morbidity and mortality. First-line treatment includes antifungal therapy, followed by surgical intervention.

Aim: To emphasize the significance of timely diagnosis and treatment strategies for Rhino-orbital-cerebral Mucormycosis and Aspergillosis.

Methods: Since the coronavirus outbreak in India, our hospital has treated thousands of patients, including nine confirmed cases of invasive fungal rhino-sinusitis from April to July 2021. We collected data from electronic records to ensure accuracy, with diagnoses based on clinical presentation, nasal endoscopy, imaging, KOH mount, fungal culture, and histopathology. Our team provided tailored medical and surgical management to meet each patient’s needs, demonstrating our commitment to high-quality care during this challenging time.

Results: Five out of nine patients survived our treatment; the mortality rate was reported as 37.5%, with one patient lost to follow-up.

Conclusion: Timely surgical intervention, effective debridement, and appropriate antifungal therapy can significantly reduce mortality and morbidity in patients with Rhino-orbital-cerebral Mucormycosis and Aspergillosis.