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Vol. 3, No. 2, Issue 2 (July - Dec.
2012) A Peer Reviewed Journal
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Prof. Anil Kumar Jha
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Prof. Toran K.C.
Managing Editor
Dr. Yogesh Neupane
Dr. Rabindra Pradhananga
Dr. Ajit Nepal
Dr. Rupesh Raj Joshi
Dr. Milan Maharjan
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Prof. P.S.N. Murthy - India
Prof. Alamgir Choudhary - Bangladesh
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Dr. Dinesh Chhetri - USA
Prof. S.C. Mishra - India
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Executive Committee of SOL Nepal

(2011-2013)
President
Prof. Anil K. Jha
Vice-President
Prof. Toran K.C.
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Dr. Milan Maharjan
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Members
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Dr. Rupa Maharjan
Nepalese Journal of ENT Head & Neck Surgery
(an official biannual publication of SOL Nepal)
EDITORIAL
Expanding Horizon in the Field of Head and Neck Surgery in Developing Countries 1
ORIGINAL ARTICLE
Sudden Sensorineural Hearing Loss: Clinical Characterization of Patients 2
Vallecular Cysts in Adult Population: Ten Year Experience 5
Linguistic Profile Test (LPT) in Nepali Language 8
Treatment Outcomes of Laryngeal and Hypopharyngeal Squamous Cell Carcinomas

in a Tertiary Care Center of Nepal 10
Clinical and Bacteriological Study of Chronic Suppurative Otitis Media by

Anaerobic Culture Methods in a Teaching Hospital 12
A Screening Picture Speech Identification Test for Nepali Speaking Children 15

CASE REPORT
An Unusual Presentation of Thyroid Gland Carcinoma: A Case Report 17
Unique Foreign Body Chest Diagnosed Incidentally 19
Primary Extracranial Meningioma of the Sphenoid Sinus: A Hidden Menace 21
MEDICAL EDUCATION
Patients Perspective on Doctors Attire 23
REVIEW ARTICLE
Endoscopic Management of Fronto Ethmoidal Sinus Mucocele 26
HOW I DO IT ?
Endoscopic Marsupialization of Fronto Ethmoidal Mucocele 29
BOOK REVIEW
Stell & Marans Text Book of Head and Neck Surgery and Oncology: Fifth Edition ` 31
INSTRUCTION FOR AUTHORS 32

Editorial
Neupane Yogesh
EXPANDING HORIZON IN THE FIELD OF HEAD AND
NECK SURGERY IN DEVELOPING COUNTRIES
The health stage of developing countries has been dominated by required, involving ENT, Head and Neck, Maxillofacial, Plastic and
communicable diseases, such as HIV infection, Malaria and TB and the reconstructive surgery, as well as radiation oncology, neurosurgical
issues of maternal and child birth. As a result Head and Neck disorder radiology, pathology and ophthalmology. For long time, Head and
have received little attention, despite being major public health Neck surgery practice in a developing countries has lagged behind
concerns. Head and neck cancer is a major problem in poorer countries the modern standards mainly due to lack of expertise in the field as
where tobacco and alcohol consumption is on the increase. Disease well as inadequate support from other specialties such as speech
often presents at a late stage and there are economic barrier to therapy, reconstructive surgery and radiation oncology.
diagnosis and treatment.
Still due to lack of Head and Neck surgeon in developing countries,
More than 50 % of worlds population resides in developing countries. Head and Neck conditions have been managed by general surgeons
Those countries also harbors the majority of cancer patients and without any specific Head and neck training. ENT surgeon still simply
predictions indicates that by 2030 it will account for 70% of newly diagnose Head and Neck malignancies and then pass patients on to
diagnosed cancers, however, it accounts for only 5% of global cancer the radiation oncologist for definitive management. These approaches
spending. Developing countries are facing cancer tsunami because has several disadvantages like there is inadequate or inappropriate
of communicable disease control improvements which resulted in assessment and management protocols, since similar conditions are
increased life expectancy, changing social habit associated with managed by different specialties. But these disadvantages can be
affluence. The cancer fatality rate is about 75% in low income countries largely overcome by establishing multidisciplinary Head and Neck
as opposed to 45 % in high income countries. surgical services.
The shortage of medical staff in developing countries is a major limiting The ideal multidisciplinary Head and Neck team will include Head and
factor for effective delivery of health care. Non-government Neck surgeons, plastic and reconstructive surgeons, maxillofacial
organizations have invested heavily in combating infectious disease surgeons, anaethesists, medical and radiation oncologists, pathologists,
such as TB, Malaria and HIV and there has been little investment in oncology nurses, nutritionists, speech and language pathologists,
non communicable disease. oncology social workers, physiotherapists and occupational therapists.
ENT community must lobby government, NGOs and World Health
Head and Neck cancers are not uncommon with approximately Organization to raise awareness and to take initiative to invest in the
6,40,000 new cases resulting in 3,50,000 deaths annually world wide. treatment of ENT related non communicable diseases.
The Head and Neck region requires special anatomical, functional and
cosmetics consideration. Therefore, a multidisciplinary approach is
............................................
Dr. Yogesh Neupane
Managing Editor
Society of Otorhinolaryngologists of Nepal (SOL Nepal) Vol. 3, No. 2, Issue 2 (July-Dec 2012) Nepalese Journal of ENT Head & Neck Surgery 1
Ori g i n a l Art i c l e
Bhatta Rishi1
Shakya Dipesh2
SUDDEN SENSORINEURAL HEARING LOSS:
KC Arun2 CLINICAL CHARACTERIZATION OF PATIENTS
Aims & Objective:
Nepalgunj Medical College, Banke, To study the clinical profile & prognostic factors in patients with sudden sensorineural hearing loss
Nepal.1 Material and Methods:
A retrospective study was carried out from patients of sudden sensineural hearing loss (SSNHL)
Department of ENT and Head Neck presenting to ENT department of T.U.Teaching hospital, a tertiary referral center of Nepal from April
Surgery, Civil Service Hospital, 2006 to June 2012. All patients were given intravenous steroids as treatment modality for 14 days and
Kathmandu, Nepal.2 pure tone audiogram was done every 3 days during hospital admission. It was followed by oral steroids
in tapering dose for further 14 days. After 1 month, audiogram was done again. After 1 month if hearing
Correspondence to: threshold was decreased by more than 50% of presenting one, then it was labeled as improved.
Dr Rishi Bhatta
Nepalgunj Medical College. Results:
email: drrishient@gmail.com Total 85 patients (87 ears) with age ranging from 6-77 years (average- 41.3 years) were included. Three
fourth were male. Presentation was 1-14days after onset of hearing loss (average- 3.7days) with pure
tone audiogram (PTA) of 38-117dB (average 83.1dB). The flat audiogram (62.3%) was most common
type. Smoking was present in 32 patients and tinnitus in 58 ears. Haemoglobin ranged from 7.3-18.7gm
%(average- 15.3gm/dl). PTA post treatment was 8-73dB (average- 56dB). Average age of improved
patient was 39.8years which was lower than non-improved patients (42.3years). In improved patients,
average PTA at presentation was 77.9dB while it was 86.6dB in non improved patients.
Conclusion:
SSNHL is more commonly seen in male patients with polycythaemia and is commonly presented in
winter season and is frequently associated with tinnitus. Young age and lower audiogram threshold
at presentation favour prognosis.
K e y w o r d s : Sudden Sensorineural Hearing Loss, Pure tone audiogram, Steroids.
INTRODUCTION:
Sudden sensorineural hearing loss (SSNHL) is an otological emergency. and hypothesis are given regarding the factors affecting disease
Idiopathic sudden sensorineural hearing loss remains a controversial course. Some factors have been well established regarding prognostic
problem with respect to its etiology and the prognostic factors.1, 2 implications. But what is the scenario of those factors in Nepal is not
There are lots of things needed to sort out about this important well established. A study over longer duration and more number of
disease. Lack of a universally accepted definition of sudden patients is required. Hence this study was designed to study the clinical
sensorineural hearing loss, insufficient knowledge of pathogenesis, profile of patients with sudden sensorineural hearing loss so that
lack of a standard method for evaluating the patients in addition to possible prognostic factors in Nepalese population can be known.
a high spontaneous recovery rate all complicate the study of
sensorineural hearing loss and the investigation of different treatment
modalities. 3, 4, 5 MATERIALS AND METHODS:
A retrospective study was carried out from patients of sudden
It is easier to recognize than to define. In fact there are various sensineural hearing loss presenting to ENT department of T.U.Teaching
definitions for this disease. Widely accepted definition is 30 dB hospital, a tertiary referral center of Nepal from April 2006 to March
sensineural loss in 3 contiguous frequencies in <3 daysgiven by 2012. Records of patient with SSNHL fulfilling Wilsons criteria and
Wilson et al in 1980. The vast majority of cases are unilateral and the who were admitted in hospital for intravenous steroid therapy were
estimated annual incidence is 20 per 100 000 persons.6 We dont have studied. Their age, sex, occupation, duration of illness, side involved
incidence rate from Nepalese population but it is frequently and date of admission were recorded. The associated complaints like
encountered entity in hospitals of Nepal. tinnitus, vertigo, history of smoking was recorded and they underwent
thorough systemic and ENT examinations. All patients underwent
Regarding its etiopathogenesis exact cause is not known in most of puretone audiogram at the time of admission. From the audiogram
the cases making idiopathic (ISSNHL) as usual prefix in diagnosis. pure tone average, threshold at 8 KHz and audiogram pattern
However known local and systemic causes that can result SSNHL are were recorded. Every patients underwent investigations for
always looked upon. Impaired cochlear blood circulation has been haematological, biochemical (including lipid profile, thyroid function
suggested to cause sudden hearing loss.7, 8 But the lack of clear test), serological (ELISA HIV, HBsAg, HCV; RA factor, ANA, VDRL) study.
relationships between SSHL and other vascular risk factors suggests
multifactorial disease profile. 8, 9 There is lack of high quality evidence All patients were given intravenous steroids in hospital for 14 days
on the effectiveness of any specific treatment. Hence there are and pure tone audiogram was done every 3 days during hospital
numerous drugs and therapies as options to use in ISSNHL. Example: admission. It was followed by oral steroids in tapering dose for further
steroid, antioxidant, vasodilators, plasma expanders, anti-coagulants, 14 days. After 1 month, audiogram was done again. After 1 month if
and carbogen inhalations, etc. Treatment outcome is measured by hearing threshold was 50% or less than the presenting one, then it
Wilsons criteria.10 According to this criteria if threshold is <10dB it is was labeled as improved.
labeled as complete recovery. If threshold improves by 50% of initial
threshold it is labeled partial recovery. If improvement is <50%, If patients had recovery before 14 days or they wanted to take their
then it is called no recovery. Approximately 50% of patient experience medications at home, then equivalent prednisolone dose was given
complete recovery in most of literatures and called for follow up after 1 month of illness. Patients with
incomplete records and patients who denied steroid treatment before
Factors governing prognosis has been defined but weightage of those recovery were excluded. Improvement percentage was calculated.
factors in context of patients of Nepal is not known well. Only 1 paper Comparison between patients with >50% improvement and those
has been published regarding this topic from Nepal so far by Nepal with less than that was done. Data were analyzed using SPSS 17.0
et al in 2007(n=46).11 It was a prospective study of 3 years duration software
(2002-2005). It is very difficult to predict recovery in sudden
sensorineural hearing loss (SSNHL) though a number of speculations
2 Society of Otorhinolaryngologists of Nepal (SOL Nepal) Vol. 3, No. 2, Issue 2 (July-Dec 2012) Nepalese Journal of ENT Head & Neck Surgery
Bhatta et al: Clinical Characterization of Patients with SSNHL
Tab. 1: Occupations of patients presented with SSNHL Tab. 3: Comparing Improved patients with non improved patients
Occupation Number of patients Features Patient with Patients with Total
Business 22 <50% improvement 50% recovery
Service 21 (n=51, ears=52) (n=34, ears=35)
Student 12
Age 39.8yrs 42.38yrs 41.35yrs
Housewife 11
Duration at 3.65days 3.76days 3.72days
Teacher 6
presentation
Retired 4
Tinnitus 31 27 58
Security Guard 3
Vertigo 9 11 20
Farmer 2
Smoking 12 20 32
Driver 2
Hb 15.0gm% 15.58gm% 15.36gm%
None 2
HTN 4 15 19
DM 3 6 9
RESULTS: Presenting 77.94dB 86.64dB 83.16dB
Total 85 patients (87 ears) with complete records and follow up at 1
month was found and they were included. The age ranged from 6-77 PTA average
years (average- 41.35 years). Three fourth were male. Presentation Type of audiogram
was 1-14days after onset of hearing loss (average- 3.72days). People Flat 21 34 55
with different occupation were involved. Most of them were involved Upsloping 5 6 11
in some sort of business or worked in an office. (Table 1) We also noted
the month of presentation (Fig. 1) and 28.2 % presented in month of Downsloping 7 7 14
January and February. There were 48 patients who had hearing loss Inverted V 0 2 2
in right ear and 35 in left. Only 2 patients had bilateral involvement shaped
at presentation. U or V 3 2 5
Fig 1: Month of presentation shaped
Month of Presentation The profile of patients who improved by more than 50% was compared
with that of those who improved by less than 50% (Table 4). Average
Jan/Feb age of improved patient was 39.8years which was lower than non-
9 8 improved patients (42.38years). In improved patients, average PTA at
24 March/April
May/June presentation was 77.94dB while it was 86.64dB in non improved
15 patients. Days of presentation were almost similar in both groups.
July/Aug
13 (Table 3)
13 Sep/Oct
Nov/Dec DISCUSSION:
Idiopathic SSNHL being idiopathic is the reason of all the
controversies and dilemma related to it. As the cause is not known,
lot of hypotheses and speculations have been formulated regarding
Audiogram showed that pure tone average (PTA) ranged from 38dB its etiopathogenesis. Multiple hypotheses lead to multiple mode of
to117dB (average 83.16dB). While threshold for 8 KHz ranged from treatment, none of which is a well established one. Diverse clinical
20dB to 110 dB with an average of 84.3dB. The pure tone audiogram conditions resulting sudden hearing loss as a symptom also helps to
pattern was mostly flat (62.3%) involving all the frequencies. increase this confusion. Most of the studies are retrospective as one
(Table 2) cant predict its onset and there is no defined high prevalence
Tab. 2: Audiogram pattern at presentation region.2,12,13, 14, 15, 16, 17 Different authors at different times have
mentioned that a well designed randomized control trial is utmost
Audiogram Pattern Number requirement.18 For carrying out such study first we need a baseline
Flat 55 scenario of demographic profile of this disease in Nepal. Only one
such study has been published from Nepal so far.11 It was 3 years
Upsloping 11 study unlike ours which was done for more than 6 years. Regarding
Downsloping 14 good sample size; we needed a center where flow of patients for
Inverted V shaped 2 otological service is maximum and that too from different parts of
U or V shaped 5 country. Same institution as in Nepal et al study was chosen so that
with similar settings and treatment modalities the outcome and profile
There were 32 patients with history of smoking and two patients had can be compared. Sample size of 85 patients in 6 years was good as
past history of SNHL in other ear. Recent history of Mumps was found compared to other studies 3, 14, 15, 19. Average age of onset (41.3yrs)
in 3 patients. Hypothyroidism was found in 2 patients one of them is comparable to Yimtae et al study (43.7yrs) and Cadoni,et al
was a known case and was under treatment. Out of 85 patients who (45.1years). We found 75.3 % male patients unlike Yimtae et al (39.3%)
underwent lab investigations 2 were having positive RA factor and and Cadoni et al (41.6%)
one had positive HBsAg. Hypertension was present in 19 patients and
9 were diabetic. There were 31 patients with fasting blood sugar ISSNHL occurred in different occupations and no clear risk group was
between 110 and 125mg/dl. Tinnitus was complained in 58 ears found. On an average people presented within 4 days of onset, but
(66.6%) while only 20 patients had vertigo or dizziness.ESR ranged this doesnt represent overall behaviour of Nepalese patients as people
from 2 to 55 mm in first hour with an average of 14.97mm in first hour. presenting after 14 days of onset were not included. Most of the
Haemoglobin estimation ranged from 7.3gm/dl to 18.7gm/dl with an patients had the disease in winter. Bilateral presentation is less common
average of 15.36gm/dl. Fourty percent of patient had haemoglobin similar to other studies as Yimtaeet al (7.1%)3 and Fetterman et al
more than 16 gm/dl. Intravenous high dose hydrocortisone therapy (1.7%).20 Bilateral simultaneous presentation was found in only 2
was taken from 3 to 14 days with an average of 9.9days. Those who patients. One of them had more than 50% improvement in both ears
didnt completed Intravenous therapy were kept in equivalent and other had less than that in both ears. Serological positive cases
prednisolone therapy. Post treatment pure tone average was 8-73dB were limited. It seemed to be incidental finding as clinical symptoms
(average- 56dB,) while for 8 KHz it was 10-110dB (average- 61dB). in other organs hadnt developed in those cases. VVascular disease
Average percentage of improvement in pure tone average was found risk factors were commonly associated like: smoking (32/85),
to be 39.25% while only 25.4% had improvement in 8 KHz frequency. hypertension (9/85) and diabetes (9/85). Though smoking was
Bhatta et al: Clinical Characterization of Patients with SSNHL
commonly found, other studies have shown that it doesnt cause sensorineural hearing loss. J Med Assoc Thai. 2001 Jan;84(1):1139
increased incidence.12,18 A community based case control study is 4. Xenellis J, Karapatsas I, Papadimitriou N et al. Idiopathic sudden
required as smoking is frequent habit in Nepalese community. Diabetes sensorineural hearing loss: prognostic factors. J Laryngol Otol.
is less common in this study when compared with Nepal et al study. 2006 Sep;120(9):718-24.
Hypertension proportion is similar to other studies.9 It was interesting 5. Lazarini PR and Camargo AC. Idiopathic sudden sensorineural
finding that most of the patients had high haemoglobin level; around hearing loss: etiopathogenic aspects. Braz J Otorhinolaryngol.
40% had hemoglobin level more than 16gm/dl. This indicates 2006 Jul-Aug;72(4):554-61
polycythaemia may be having role in etiopathogenesis and justifies 6. Stew BT, Fishpool SJ and Williams H. Sudden sensorineural hearing
use of pentoxyfylline. Tinnitus was a common aural complaint in loss. Br J Hosp Med (Lond). 2012 Feb;73(2):86-9.
Nepalese population unlike in study of Psifidis et al.13 Twenty patients 7. Yildiz Z, Ulu A, Incesulu A, Ozkaptan Y and Akar N. The importance
complained of some form of dizziness. of thrombotic risk factors in the development of idiopathic sudden
hearing loss. Clin Appl Thromb Hemost. 2008 Jul;14(3):356-9
More recent studies applying treatment protocols including 8. Ballesteros F, Alobid I, Tassies D et al. Is There an Overlap between
vasodilators, plasma expanders, anti-coagulants, and carbogen Sudden Neurosensorial Hearing Loss and Cardiovascular Risk
inhalations have shown no improvement over the rate of spontaneous Factors? Audiol Neurootol. 2008 Nov 13;14(3):139-145.
recovery without therapy. 21 Except in cases of therapy directed toward 9. Hesse G and Hesch RD. Evaluation of risk factors in various forms
known predisposing factors, there is insufficient evidence in the of inner ear hearing loss. HNO. 1986 Dec;34(12):503-7
literature to support medical treatment for SNHL, although steroid 10. Wilson WR, Byl FM and Laird N. The efficacy of steroids in the
therapy appears to be useful in selected patients. Steroid therapy is treatment of idiopathic sudden hearing loss. A double-blind clinical
most preferred method in treatment of this entity.22 Though the study.Arch Otolaryngol. 1980 Dec;106(12):772-6.
hospital protocol was to give high dose steroid in tapering dose for 11. MK Nepal, P Rayamajhi, N Thapa, H Bhattarai and RP Shrivastav
14 days; it was not fulfilled in some cases. Some cases deferred Association of systemic diseases with sudden sensorineural hearing
injectable medication and hospital stay and they were discharged loss. Journal of Institute of Medicine Vol 29, No 3 (2007)
with equivalent prednisolone dose. Some cases had rapid 12. Cadoni G, Agostino S, Scipione S et al. Sudden sensorineural
improvement and were switched to oral medication when average hearing loss: our experience in diagnosis, treatment, and outcome.
threshold went below 30dB.Many drugs have been given for SSNHL J Otolaryngol. 2005 Dec;34(6):395-401.
in different literature, but we focused on high dose steroid only. It is 13. Psifidis AD, Psillas GK and Daniilidis JCh. Sudden sensorineural
started as early as possible under supervision for possible adverse hearing loss: long-term follow-up results. Otolaryngol Head Neck
effects. Steroids are thought to help by decreasing edema over 8th Surg. 2006 May;134(5):809-15.
nerve that can be a result of viral infection, ischaemia or other 14. Kiriº M, Cankaya H, Içli M and Kutluhan A. Retrospective analysis
inflammation. of our cases with sudden hearing loss. J Otolaryngol. 2003
Dec;32(6):384-7
Improvement proportion of patient was 40.2% which is similar to 15. Zadeh MH, Storper IS and Spitzer JB. Diagnosis and treatment of
other studies.16 However few studies showed high proportion of sudden-onset sensorineural hearing loss: a study of 51 patients.
improvement which may be due to different definition of Otolaryngol Head Neck Surg. 2003 Jan;128(1):92-8.
improvement. 3,11,15, 23 The improvement proportion increases with 16. Pajor A, Durko T and Gryczyñski M. Prognostic factors in sudden
time 24 but follow up after 1 month was not documented in most of deafness. Otolaryngol Pol. 2003;57(2):271-5.
the cases. Comparing patients with 50% recovery with less than that 17. Zhao H, Zhang TY, Jing JH, Fu YY and Luo JN. Prognostic factors
revealed that average age of onset was slightly less in recovered for patients with the idiopathic sudden sensorineural hearing loss.
group. Hypertension was found in more number of patients who Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2008
didnt recover well. Vertigo is labeled as poor prognostic factor by Sep;43(9):660-4.
many authors 12, 13, 14, 16, 19 but we found almost similar proportion 18. Nakashima T, Tanabe T, Yanagita N, Wakai K and Ohno Y. Risk
in both groups. There were marginally more patients with tinnitus in factors for sudden deafness: a case-control study. Auris Nasus
improved group of patient which is correlating with other studies.14.19 Larynx. 1997 Jul;24(3):265-70
Presenting audiogram average was less in improved group. Though 19. Ben-David J, Luntz M, Podoshin L, Sabo E and Fradis M. Vertigo as
downsloping audiogram is adverse factor for good outcome 2, 4, 19, a prognostic sign in sudden sensorineural hearing loss. Int Tinnitus
25, 26, 27 but in our case such pattern was equally common. The study J. 2002;8(2):127-8.
being a secondary data analysis and having objective of evaluating 20. Fetterman BL, Luxford WM and Saunders JE. Sudden bilateral
the profile of such patients, statistical tests were not applied. Few sensorineural hearing loss. Laryngoscope. 1996 Nov;106(11):1347-
studies have shown clinical treatment within the first seven days was 50
the only statistically significantly in patients who improved hearing.28 21. Schweinfurth JM, Parnes SM and Very M. Current concepts in the
This is correlated in our study as well because average time of onset diagnosis and treatment of sudden sensorineural hearing loss.
of start of medication is early in improved groups. Eur Arch Otorhinolaryngol. 1996;253(3):117-21
22. Moskowitz D, Lee KJ and Smith HW. Steroid use in idiopathic
CONCLUSION: sudden sensorineural hearing loss.Laryngoscope. 1984 May;94(5
SSNHL is more commonly seen in male patients with polycythaemia .1):664-6.
and is commonly presented in winter season and is frequently 23. Brors D, Eickelmann AK, Gäckler A, et al. Clinical characterization
associated with tinnitus. Young age and lower audiogram threshold of patients with idiopathic sudden sensorineural hearing loss.
at presentation favour prognosis. Further studies are needed to obtain Laryngorhinootologie. 2008 Jun;87(6):400-5.
better knowledge about the etiopathogenesis of SSNHL. So that new 24. Yeo SW, Lee DH, Jun BC, Park SY and Park YS. Hearing outcome
therapeutic strategies can be considered in the treatment of this of sudden sensorineural hearing loss: long-term follow-up.
challenging ear disease. But early start of treatment is must in SSNHL Otolaryngol Head Neck Surg. 2007 Feb;136(2):221-4
as outcome improves with early treatment. Awareness should be 25. Cvoroviæ L, Deric D, Probst R and Hegemann S. Prognostic model
spread among health practitioner and general population about for predicting hearing recovery in idiopathic sudden sensorineural
urgent need of its treatment. hearing loss. Otol Neurotol. 2008 Jun;29(4):464-9.
26. Jun HJ, Chang J, Im GJ, Kwon SY, Jung H and Choi J. Analysis of
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L. Tinnitus as a prognostic sign in idiopathic sudden sensorineural 27. Mattox DE and Simmons FB. Natural history of sudden
hearing loss. Int Tinnitus J. 2001;7(1):62-4. sensorineural hearing loss. Ann Otol Rhinol Laryngol. 1977 Jul-
2. Harada H and Kato T. Prognosis for sudden sensorineural hearing Aug;86(4.1):463-80.
loss: a retrospective study using logistical regression analysis. Int 28. Penido O, Ramos HV, Barros FA, Cruz OL and Toledo RN. Clinical,
Tinnitus J. 2005;11(2):115-8. etiological and progression factors of hearing in sudden deafness.
3. Yimtae K, Srirompotong S and Kraitrakul S. Idiopathic sudden Braz J Otorhinolaryngol. 2005 Sep-Oct;71(5):633-8
Or iginal A rticle
Singhal Surinder K
Verma Hitesh
VALLECULAR CYSTS IN ADULT POPULATION:
Dass Arjun TEN YEAR EXPERIENCE
Punia Rajpal
Aims & Objective:
Department of ENT & Head Neck To compare the results of LASER and cold knife surgery for the treatment of vallecular cysts in adults.
Surgery
Government Medical College Hospital, Material & Methods:
Chandigarh, India. It was an retrospective study of 24 consecutive patients who underwent LASER and cold knife surgery
for vallecular cysts in university affiliated teaching hospital.
Correspondance to:
Dr. Surinder K Singhal Results:
Dept. of ENT & Head Neck Surgery, Three patients did not have adequate follow up & hence were excluded from the study. Patients were
Government Medical College Hospital, assessed in follow up for any recurrences. Out of 21 patients, sixteen were male and five were females.
Chandigarh, India Age ranged from 14 56 years and duration of symptoms was 1 14 months. All the patients revealed
email: singhalsks@yahoo.com a cyst in the vallecula on indirect laryngoscopic examination and plain X- ray soft tissue neck lateral
view. CT scan was done in two cases only. Tracheostomy was done in three patients for airway
management (LASER 1,Cold Knife2). Fifteen patients underwent LASER surgery where as six patients
underwent cold knife surgery. Lingual surface of epiglottis was the most common site of origin
(71%). Follow up ranged from 6 months to 48 months. Two recurrences were noted in cold knife
surgery group, whereas, no recurrence was noted in patients undergoing LASER surgery.
Conclusion:
LASER is a promising tool for treatment of vallecular cysts.
K e y w o r d s : Vallecular cysts, LASER, Tracheostomy, Epiglottic cysts
INTRODUCTION: epiglottis leaving the

Cystic lesions are common entities among the benign lesions in the epiglottic cartilage
laryngopharynx. These are usually retention cysts of the minor salivary bare. A Ryles tube was
glands and present at any age. Increase in the size of the cyst distorts inserted for feeding in
the anatomy of laryngopharynx. Although often asymptomatic in the post-operative
adults, cysts can cause stridor, dyspnea, and feeding difficulties in period. Two patients
infants and young children. Symptomatic cysts are typically treated were
by transoral marsupilization under microscopic, endoscopic, or direct tracheostomised as
visualization with cold instruments or LASER. Aims and objective of they developed
this study was to report our experience of treating cases of vallecular respiratory distress
cysts in adults as a retrospective review and compare the results of after extubation. All
LASER and cold knife surgery. the patients were
closely observed in the
MATERIAL AND METHODS: postoperative period
The retrospective study included cases of vallecular cysts who had for any respiratory
presented to outpatient department of Otolaryngology, Head and distress. They were
Neck Surgery at Government Medical College and Hospital, Chandigarh given antibiotics,
from 2000-2010. A total of 24 patients of vallecular cysts were treated steroids and anti-
during this period. The patients were offered to choose for LASER or inflammatory
cold knife surgery after explaining the advantage & disadvantage of analgesic drugs. Ryles tube was removed after 48 hours. and patient
both procedures. LASER was selected as modality of treatment as they was allowed liquids and semi solids orally. Tracheostomy which was
felt it to be new and better modality. done in two cases was closed after two weeks & there was complete
healing in four to six weeks.
All the patients underwent a detailed history and clinical examination
including indirect laryngoscopy at the time of presentation. They were In LASER surgery group patients were also taken up under general
subsequently subjected to X- ray soft tissue neck lateral view which anaesthesia. The tube was wrapped with noninflammable material
revealed a soft tissue mass in the vallecula with varying degree of as we did not have the special tubes used for LASER surgery. The cyst
epiglottic shift and narrowing of airway (Fig.1). Computerized was exposed in a similar way with help of Boyle Davis mouth. Wet
tomography was done in 2 cases as the indirect laryngoscopic findings sponges were kept in the perioral area with double protection for the
in these patients were suspicious. All patients were operated under eyes. All the instruments around the operative area were also protected
general anaesthesia. Consent for tracheostomy was taken from all the with wet sponges to prevent LASER associated complications. In few
patients. In all the cases, awake intubation was done to prevent the patients exposure was not adequate, wide mouth direct laryngoscope
laryngeal obstruction. Tracheostomy was done in three cases. In one was inserted to visualize the cyst. The laryngoscope was fixed with
case, it was done for difficult intubation and in other two cases for laryngeal suspension to keep both the hands free for instrumentation.
post-operative oedema. Fifteen patients were operated using LASER LASER beam was focused with the help of microscope, 400 mm
and six patients were done with cold knife method. objective lens & LASER power was set to 10W, continuous mode. In
patients where Boyle Davis mouth gag was used LASER was delivered
Under endotracheal general anaesthesia, Boyle Davis mouth gag was through hand applicator (Fig.2).
inserted to visualize the cyst in the vallecula. Throat packing was done
in order to prevent spillage of the contents of the cyst in case it is
ruptured. The cyst was held firmly with the help of tonsil holding
forceps and dissected from the vallecula and lingual surface of the
Singhal et al: Vallecular Cysts in Adult Population
5th and 6th decade and majority of the patients are males.4,5 The
symptoms vary depending upon the age of the patient, site of the
cyst and size of the cysts. In neonatal period the cysts have been
reported to cause noisy and labored breathing along with feeding
difficulties. The other presentation in children is failure to thrive.4,6,7,8
The other association in many of these children is laryngomalacia
which further compounds the problem. The cysts in adults are usually
asymptomatic and may be found as an incidental finding on X-ray or
at the time of intubation for some surgical procedure.9 Nearly 2/3rd
of the cysts are asymptomatic.6 The other symptoms in adults are
change in voice which is muffled, foreign body sensation, dysphagia
and choking episodes.10 Seventeen patients had a feeling of foreign
body or lump in the throat, six patients had change in voice and two
patients had choking episodes during night. Su CY and HSU JL also
reported the similar symptomatology with feeling of lump in 23
patients and change in voice in 5 patients.10 As the symptomatology
varies with the age of presentation so is the method of investigation.
In neonates and children flexible endoscopy may be required which
is confirmatory in almost all the cases where as in adults the cysts are
visible on indirect laryngoscopy. The cyst appears as shiny white mass
in the vallecula with prominent vasculature over it. In patients having
Fig.2: Photograph showing : A) Cyst in the vallecula, endotracheal a strong gag reflex, 4% Xylocaine spray usually helps. Additionally
tube also seen in picture, B) LASER hand applicator (White arrow) rigid laryngoscope & camera can be used in OPD to visualize the cyst
with focused beam (red spot) and end of Boyle Davis mouth gag and record the pictures for documentation and also for postoperative
(Blackarrow), C) Immediate postoperative view, (D) Excised cyst comparison. Unusual symptoms like dysphagia and haemoptysis has
With the hand applicator, LASER beam was used to dissect the cyst also been reported in the litrature.11 The radiological investigations
from the vallecula and lingual surface of the epiglottis as was done include plain X-ray soft tissue neck which demonstrates a soft tissue
in cold knife surgery method. In case of bigger cysts where we could mass in the vallecula. (Fig.1) It is also helpful in knowing the degree
not locate the site of origin, it was punctured with LASER beam at one of obstruction of the airway. CT scan can fairly demonstrate the mass
point and contents were sucked. After controlled decompression, one in the vallecula and helps to differentiate it from the solid tumors. We
end of the cyst wall was held with a forceps and whole cyst was did CT scan in two patients only where we were suspecting some
excised. Ryles tube was inserted for feeding in post-operative period other pathology. MRI has the best diagnostic effectiveness in
and was removed after 48 hour. demonstrating the smaller cysts but may be difficult in children &
neonates.12 The differential diagnoses include internal thyroglossal
RESULTS: duct cysts, dermoid cysts, lingual thyroid, teratomas, lymphangiomas
24 Patients were treated during a period of 10 years. Three patients and haemangiomas. The management of vallecular cysts remains a
were excluded from the study as they did not come for follow up. Out challenge both in children and adults. Fiberoptic intubation without
of 21 patients studied, sixteen were male and five females. The age any relaxant is a good proposition but sometimes due to the large
ranged from 32 to 60 years average being 46 years. The history of size of cyst and displacement of larynx it can be difficult. Direct
feeling of foreign body or lump was present in all the patients. Other laryngoscopy and intubation by an ENT surgeon can be rewarding in
symptoms were change in voice 14 (66.6%) and choking 2 (9.52%) of some cases. If this doesnt work, decompress the cyst after topical
the patients. Indirect laryngoscopy revealed a cyst in the vallecula anaesthesia and intubate the patient. In neonates and children it has
with shining surface in all the patients. Three patients were to be done carefully and quickly to avoid desaturation. However,
asymptomatic and were diagnosed as incidental finding on plain Xray tracheostomy always remains the choice when everything fails. We,
soft tissue of the neck done for other purposes. The duration of in our series, could intubate all the patients except one where we did
symptoms ranged from 1 to14 months. No patient presented with tracheostomy. Another important thing is putting a pack in the glottis
respiratory distress requiring urgent tracheostomy. so as to avoid the aspiration of cystic fluid in case the cyst ruptures.
The conventional modalities of management of cysts include
The duration of follow-up ranged from 6 months to 96 months. marsupilization, de-roofing or excision. The complete surgical removal
Recurrence was seen in 2 cases (33.3%), out of six cases treated by
cold knife method. The post-operative follow up revealed a mucosa
lined vallecula and some evidence of fibrosis at the lateral glosso-
epiglottic fold area. In cases where the cyst was arising from the lateral
free edge of the epiglottis, part of the epiglottis was excised and
resulting defect was observed in follow up examination. There was
no recurrence in cases treated by CO2 Laser.
Out of 21 cases lingual surface of the epiglottis was the commonest

site of origin in13 (61.9%) cases. This was followed by aryepiglottic
fold 5 (23.8%), base of tongue 2 (9.5%) and 1 (4.7%) from lateral wall
of vallecula. Histopathological examination (Fig.3) showed mucus
retention cyst in 17 cases (80.9%), lymphoepithelial cyst two cases
and myxolipoma and squamous cell carcinoma in one each
DISCUSSION:
Vallecular cyst also known as epiglottic cyst or mucus retention cyst
is classified as ductal cyst as a result of obstruction of the ducts of sub
mucosal glands. They constitute about 5% of benign lesions of the
larynx.1 Of the laryngeal cyst, vallecular cysts accounts for 10.5% to
20.1% of all laryngeal cysts.2 The most common location of epiglottic
cyst is lingual surface of the epiglottis. DeSanto et al reviewed 238
cases of laryngeal cysts over a period of 10 years and found that 134
(52%) were arising from the epiglottis3. These cysts gradually increase Fig: 3: Photomicrograph showing a vallecular cyst lined by cuboidal
in size and fill up the vallecula. Literature review reveals that there is to columnar epithelium with mucous glands and lymphoid tissue
bimodal age of presentation. The peak incidence in adults is seen in in its wall. (HE X 100)
Singhal et al: Vallecular Cysts in Adult Population
with laryngeal cold instrument is time consuming and difficult. We 3. DeSanto LW, Devine KD, Werland LH (1970). Cyst of Larynx.
have observed in our patient that with cold instruments the tissue Classification. Laryngoscope,80:397-400.
oedema is more because of the tissue handling and two of our 4. Gutiérrez JP, Berkowitz RG, Robertson CF. Vallecular cysts in
patients required tracheostomy after extubation. The complete newborns and young infants. Pediatric Pulmonology.
removal of cyst is proposed by most authors because simple aspiration 1999;27(4):282285.
of the content of the cyst is likely to results in recurrence12,13,14.
Marsupilization and excision of cysts by LASER is new treatment 5. Arens C, Glanz H, Kleinsasser O. Clinical and morphological aspects
modality. This technique allows excellent depth perception and good of laryngeal cysts. European Archives of Oto-Rhino-Laryngology.
magnification, and permits more accurate assessment of the level of 1997;254(9-10):430436).
resection. It has the advantages of superior surgical precision, control 6. Berger G, Averbuch E, Zilka K, Berger R, Ophir D. Adult vallecular
and lower incidence of postoperative edema and pain15. However, cyst: thirteen-year experience. Otolaryngology. 2008;138
we, in our series, have removed the cysts in toto including the lining (3):321327.
over the lingual surface of the epiglottis so as to reduce the chances 7. Tuncer U, Aydogan LB, Soylu L. Vallecular cyst: a cause of failure
of recurrence. In one of the case we resected part of the epiglottis as to thrive in an infant. Int J Pediatr Otorhinolaryngol. 2002 Sep
it was not looking like a typical cyst but was firm, attached to the 2;65(2): 133-5.
epiglottis & filling the vallecula. The biopsy in this case was myxolipoma.
Histopatholgical reports in our series revealed majority of the lesions 8. KuAS. Vallecular cyst: report of four cases -one with co-existing
to be mucus retention cyst in 17 cases apart from two lymphoepithelial laryngomalacia. J. Laryngol Otol. March 2000; 114(3): 224-6.)
cyst, one each myxolipoma, and squamous cell carcinoma. This patient 9. Kamble VA, Lilly RB, Gross JB. Unanticipated difficult intubation
was subjected to radiotherapy and is without any recurrence till date. as a result of an asymptomatic vallecular cyst. Anaesthesiology
There was no recurrence in our series in patients treated with LASER 1999; 3:872-3.
where as two cases recurred in cold knife group. Simple aspiration of 10. Su CY, Hsu JL. Transoral LASERmarsupialization of epiglottic cysts.
the cyst is associated with high recurrence.16 Suzuki et al reported Laryngoscope. 2007 Jul; 117 (7):1153-4.
one recurrence in 39 cases after marsupilization.13 On searching the 11. Alsaleh SA, Al-Ammar AY.Haemoptysis: a rare presentation of
Pubmed, we could not come across any study comparing the vallecular cyst. Saudi Med J. 2008 Oct; 29(10):1497-500)
recurrence rates with Cold instruments and LASER. Su et al reported
28 patients where they did transoral LASER marsupilization of the 12. Suzuki J, Hashimoto S, Watanabe K, Takahashi KCongenital
vallecular cyst and did not find even a single recurrence.11 However vallecular cyst in an infant: case report and review of 52 recent
the literature is silent about the recurrence following the conventional cases. J Laryngol Otol. 2011 Jun 14:1-5..
surgery. 13. Dahn MC, Panning B, Lenarz T. Acute apnoea cuased by an
epiglottic cyst. Int.J Pediatr otorhinolarngol 1998:42;271-276,
CONCLUSIONS: 14. Fang TJ, Cheng KS, Li HY. A huge epiglottic cyst causing airway
LASER excision is the promising tool for the treatment of vallecular obstruction in an adult. Chan Gung Med J 2002:25; 275-278.
cyst. 15. Van de, Water FW. Laryngeal cysts: their surgical management.
Laryngoscope 1973;83:1185-1194.
REFERENCES:
16. Chi Ying Su et al Transoral LASERmarsupialization of Epiglottic
1. Newman BH, Taxy JB, Laker HI. Laryngeal cysts in adults: a
Cysts. Laryngoscope117:1153-1154, 2007.
clinicopathologic study of 20 cases. Am J Clin Pathol. 1984
17. Mitchell D, Irwin B, Bailey C et al. Cysts of the Infant larynx . J
Jun;81(6):715-20.
Laryngol Otol 1987:101;833-7
2. Romak JJ, Olsen SM, Koch CA, Ekbom DC. Bilateral vallecular cysts
as a cause of Dysphagia: case report and literature review. Int J
Otolaryngol. 2010;2010: 697583 Epub 2010 Dec 12.
Karna Sureshwar Lal1
Karantha Pratibha2
LINGUISTIC PROFILE TEST (LPT) IN NEPALI
Khanal Kabiraj1 LANGUAGE
Ganesh Man Singh Memorial Aims & Objective:
Academy of ENT - Head & Neck To construct the Linguistic Profile Test (LPT) in Nepali and to standardize the test.
Studies, Institute of Medicine(IOM)
Maharajgunj, Kathmandu, Nepal.1 Material & Methods :
LPT in Nepali language has 3 major sections-Phonology, Syntax and Semantics to assess the subjects
47, Hutchins Road 2nd Cross, ability to distinguish between basic features of the phonological system, ability to pronounce the
Cooke Town(Sarvanja Nagar), different phonemes, to understand the grammatical complexities and knowledge regarding the
Bangalore 560084, Karnataka, meaning or concept associated with words. Total number of 40 healthy normal adults from different
India.2 regions of nepal were included for the study during July 2006 to March 2007 in speech and hearing
unit of TU Teaching Hospital, Kathmandu, Nepal. The subjects responses were scored and tabulated.
Correspondence to :
Sureshwar Lal Karna Results :
Audiology and Speech-Hearing Unit The mean and S.D. on all the three sections of test were calculated. The data were also analysed based
Department of ENT-HNS on sex and native & non-native speaker of language. Data analysis revealed total mean score ranged
Ganesh Man Singh Bhawan, from 281.50 to 296.00 with the mean value of 288.98 and S.D. 3.82
TU Teaching Hospital
Institute of Medicine, Kathmandu, Conclusion :
Nepal Overall findings indicated that there is no need of separate normative data for native and non-native
email: sureshwarlal21@hotmail.com speaker of Nepali. LPT in Nepali can be very useful tool in identifying language disorders and their area
of deficits as well as post therapy progress and residual problem evaluation.
K e y w o r d s : LPT, Phonology, Syntax, Semantics
INTRODUCTION : regions of Nepal. The total number of subjects were 40 in the age
Linguistics may be defined as the description of language of the earth, range of 20 to 39 years with one male and one female subjects in each
and about the ways in which human beings use their language to age were included for the study during July 2006 to March 2007 in
communicate with each other. Language involves a system of symbols speech and hearing unit of TU Teaching Hospital, Kathmandu, Nepal.
that conveys meanings. The ways in which sounds combine to form All the subjects were under graduate level/ post-graduate level student.
words and words combine to form sentences are determined by a Among the total subjects, 20 subjects were native speakers of Nepali;
system of rules. In the construction of words, such rules specify which Nepali as mother tongue and 20 subjects were non-native speakers
sounds can combine with one another and which sounds cannot be of Nepal; Nepali as a second language. The non-native speakers were
combined. For example, in English, a word cannot consist of only presumed to be equally competent in Nepali language, as from pre-
consonants but must also include a vowel, etc. Based on definition of school/school age they formally learn Nepali compulsorily.
language, it is possible to identify 3 major components of language The construction of the test in Nepali language was based on Hindi
content, form and use. The content of language is the linguistic version of LPT (Karanth, 1986) in consultation with Nepali linguists.
representation of what persons know about the objects. Form can be This test had 3 major sections (1) Phonology (2) Syntax (3) Semantics.
described in terms of phonology, morphology, and syntax. Thus, Section -I (Phonology) -
the integration of content/form/use makes up language competence. Designed in order to elicit all the basic features in the phonological
Children learn language as they use language. What is to be expected system of Nepali Language. It contains two sub-sections. Section I-A
with chronological age; we discuss here about language tests. tested subjects ability to distinguish between basic features of the
A test is basically a tool available for objective measurements and aids phonological system in his/her reception. Covering all the features in
the clinician in arriving at an accurate diagnosis and in successful the phonemic system of Nepali language, possible number of minimal
rehabilitation of the clients. Some tests are designed especially to test pairs was developed based on familiarity and pictureability. The
language and its acquisition in pre-schoolers and some tests are to subjects were asked to point out to two pictures out of a set of four,
test language and its disorders in school going children. Some tests on hearing the minimal pairs. The features covered were grouped
are administered only for the adult population and then there are under following categories - a)Vowels and b)Consonant. Section I-B
tests which are efficient in testing all the age groups. The description tested subjects ability to pronounce the different phonemes of Nepali
available from an appropriate combination of tests, reveal the childs language in different word position and combinations by asking the
abilities and disabilities within his language system. Tests also help subjects to repeat words after the interviewer. If the subject was
in seeking the aspects of language code and its processing that might unable to repeat the words, the picture cards were presented to him
be disturbed after brain injury, to account for the patterns of language or her and were asked to name the object pictured. Section I-B was
in terms of what is lost. Nepal is a small country with enormous number further divided into 3 sub-sections Section I-B (i) consisted of number
of languages being spoken. It is not possible to have a common test of words containing target phonemes either in the initial, medial or
for all the languages, and that indicates the need for tests to be made final position and subjects were asked to repeat the words after the
in different languages. Nepali is National language of Nepal in which tester. Section I-B (ii) sampled the subjects performance with
there is no standardized test for assessing language in children and consonantal clusters. Section I-B (iii) consisted of free reading passage
adults with norms. So attempt has been made to develop and covering the entire range of phonemes in Nepali. The subjects were
standardize the LPT in Nepali language. This test will be useful in initially asked to repeat this passage after the examiner. Later he/she
identifying the children and adults with language deficits and also was asked to read on his/her own.
the area of deficits.
Section II - dealt with syntax to check the subjects ability to understand
The objective of this study was to construct the Linguistic Profile Test the grammatical complexities of heard speech. If the subject was
in Nepali and standardize the test. unable to understand the verbal command or statement, his ability
MATERIAL & METHODS : to follow it in print/graphically was checked. There were 11 sub-
The subjects for this study were healthy normal adults speakers of sections in the syntax section: a) Morphophonemic structures, b) Plural
Nepali language with no physical or sensory disabilities from different forms, c) Tenses, d) PNG marker, e) Case markers, f) Transitives,
Intransitives and Causatives, g) Sentence types, h) Predicates, i)
Karna et al: Linguistic Profile Test (Lpt) in Nepali Language
Conjunctions, Quantities and Comparatives, j) Conditional causes and Tab. No.2 : Sex wise Mean and S.D. of total subjects.
k) Participial constructions. The item was first presented verbally and
the subject was asked to respond either verbally or through gestures. Phonology Syntax Semantics Total scores
If the subject was unable to follow verbal instructions, the instruction Male Female Male Female Male Female Male Female
and the test items were given in the written form. The subjects were Min. score 93.25 94.00 86.00 85.00 92.50 93.00 282.25 281.50
asked to judge whether the given sentences are grammatically correct Max. score 100.00 100.00 98.50 97.50 100.00 100.00 294.00 296.00
or wrong. Mean 97.87 97.57 93.36 92.66 98.87 97.60 290.11 287.84
Section III - dealt with semantics to check whether the subject knew S.D. 1.83 1.71 2.70 3.07 1.77 2.01 3.38 3.96
the meaning or concept associated with words and the relationship The values given in Table No.2 reveal that the mean for male in all the
between words, and ability to express this knowledge in speech. 3 sections of LPT and the combined mean value calculated for both
Instruction was given verbally and/or graphically. The subject was male and female (as mentioned in Table No.1) are almost same. Even
expected to respond verbally, graphically or through pointing to though mean value for female in all the sections of test was slightly
particular object or the correct response word among alternatives. less than the combined mean value calculated for both sex (as
This section was further subdivided into 2 major sub-sections - (a) mentioned in Table No.1), the difference was minimal. The separate
Semantic discrimination (b) Semantic expression. In Section III A Mean and S.D. value of all the 3 sections of LPT for native speaker (NS)
(Semantic discrimination) : discrimination of colors, furniture and body and non-native speakers (NNS) are given in Table No.3.
parts were tested. The subjects were asked to point the color, furniture,
or body parts named. In Section III B (Semantic Expression) : expression Tab.3 : Mean and S.D. value of LPT sections for native and non-native
ability was tested under these tasks : Naming, Lexical category, speaker.
Synonymy, Homonymy, Polar questions, Semantic anomaly, Phonology Syntax Semantics Total scores
Paradigmatic relations, Syntagmatic relations, Semantic contiguity, NS NNS NS NNS NS NNS NS NNS
Semantic similarity and Discourse Conversation, Description of Min. score 94.00 93.25 90.00 85.00 94.00 92.50 284.50 281.50
picture and Narration. The instruction for each task was given differently
based upon the type of expressive ability being tested. Example items Max.score 100.0 100.00 98.50 96.50 100.0 100.00 296.00 294.00
were repeated whenever required. Whenever subject chose wrong Mean 97.77 97.67 94.06 91.97 98.35 98.12 290.18 287.77
illustration or gave an incorrect verbal response, response was noted S.D. 1.55 1.98 2.28 3.08 1.92 2.07 3.24 4.05
down. However prior to proceeding to the next item, investigator The values given in Table No.3 reveal that, even though the mean
explained why it was wrong and gave expected response. Subjects value of native and non-native speakers of Nepali in phonology and
response for each item administered was recorded on the individual semantic sections were almost same, the mean value for non-native
response score sheets. A stimulus word was pronounced more than speaker in syntax section was slightly poorer than native speaker for
once by the examiner, either upon request, or as per requirement. the same. The overall total score of test for NNS was also slightly less
The subject was asked to study all alternatives carefully before making than NS.
a choice. The total score of the each section separately such as DISCUSSION:
Phonology, Syntax and Semantic section was 100. For all categories The findings in the present study were similar to the findings of earlier
except Plural forms under Part-II Syntax, and Lexical items and studies by Suchitra & Karanth (1990), Monika, S. (1995), Asha, M.M.
Paradigmatic relations under Part III semantics, the following scoring (1997), who observed that the mean score in phonology section was
procedures is adopted. Response on each item was given a full assigned higher than syntax. However the subjects of present study scored
score for the correct response, ½ of the assigned score for a correct highest mean value in semantics section compared to phonology and
response which is not mentioned in the list of expected response and syntax. The mean of syntax score and total test score for non-native
0 for wrong or no response. In case of Lexical category if the subject speaker indicate a minimal difference in language abilities in
responds with all the five names, a score of 1 is given. If the subject comparison to native speaker. As there is no test in regional languages
responds with two or more but less than five names, then a score of of Nepal (mother tongue of non-native speaker of Nepali subjects)
½ is given. For no response/incorrect response or a single name this Nepali version of LPT can be used to evaluate non-native speaker
response a score of 0 is given. Paradigmatic Relations -A score of 1 too until separate language tests in subjects mother tongue is available.
is given for identification of all the 4 pictures belonging to the specified
group. Identification of less than 4 pictures is scored as 0. Plural CONCLUSION :
Forms: if the subject identifies plural form correctly, the score of 1 is Overall findings indicate no need of separate normative data for native
given. A score of 0 is given for any other response. The subjects and non-native speaker of Nepali. LPT in Nepali can be very useful
responses were scored and tabulated. The mean and standard tool in identifying language disorders and their area of deficits as well
deviation of LPT scores for each age group under each section was as post therapy progress and residual problem evaluation.
computed. These scores are tentative normative scores and are only
of a suggestive nature considering the limited sample size. REFERENCES :
1. Asha, M.M. (1997). Linguistic Profile Test(LPT in Malayalam)
RESULTS : Normative data for children in Grades I to X. Unpublished masters
Scores are calculated for (i) Phonology, Syntax, and Semantics, (ii) dissertation, University of Mysore, Mysore.
Total Cumulative score, (iii) Sex wise values ( Male/ Female), (iv) 2. Karanth, P. (1980). A comparative analysis of aphasics and
Speaker wise value (Native speaker/Nonnative speaker). The data schizophrenic language. Doctoral thesis, University of Mysore,
obtained was subjected to the Mean and Standard deviation(S.D.) Mysore.
statistical analysis. The Mean and S.D. on all the 3 sections of test was 3. Karanth, P. (1981). Linguistics, The Evaluation and Remediation of
calculated and details are given in Table 1. Language in Aphasics, Indian Linguistics Journal of the Linguistic
Society of India. 41(3-4)181-187.
Tab.1: Mean & S.D. of LPT Scores 4. Karanth, P. (1990). Evaluation of Language Disorders ib Adults. In
Min. Max. Mean S.D. SK Kacker and V. Basavraj(eds.) Indian Speech, Language and
Phonology 93.25 100.00 97.72 1.75 Hearing Teststhe ISHA Battery1990 (223 231).
5. Monica, S. (1995). Linguistic Profile Test(LPT in Hindi) Normative
Syntax 85.00 98.50 93.01 2.87 data for children in Grades I to X. Unpublished masters dissertation,
Semantics 92.50 100.00 98.23 1.98 University of Mysore, Mysore.
Total Score 281.50 296.00 288.98 3.82 6. Pokharel, M.P. (1989). Experimental Analysis of Nepali Sound
System. Doctoral thesis, Deccan College of Pune, Pune.
Note : Max. score for each section is 100 and total score is 300 7. Pokharel, M.P. (2000). Nepali Phonology. Kathmandu : Royal Nepal
Among all the 3 sections of Nepali LPT, the range was maximum and Academy
Mean value was least for Syntax section compared to other two 8. Suchitra, M.G. and Karanth, P (1990). Linguistic Profile Test(LPT in
sections. The range and Mean for phonology and semantics were Kannada) Normative data for children in Grades I to V. Journal
almost similar. The general pattern noticed was, highest total score of the All India Institute of Speech & Hearing, 21,14-27.
in semantics followed by phonology and then syntax respectively. 9. Suchitra, N. and Karanth, P (1993). Linguistic Profile of aphasia
The mean value of semantics section was highest. The mean and S.D. sub types. Unpublished masters dissertation, University of Mysore,
separately for males and females are given in Table No.2. Mysore.
Sinha Pallavi
Sinha Bimal Kumar
TREATMENT OUTCOMES OF LARYNGEAL AND
Baskota Dharma Kanta HYPOPHARYNGEAL SQUAMOUS CELL CARCINOMAS
Neupane Yogesh IN A TERTIARY CARE CENTER OF NEPAL
Acharya Kunjan Aims And Objectives:
To analyze the treatment outcomes in patients with laryngeal and hypopharyngeal cancers using locally
Ganesh Man Singh Memorial recurrent or residual disease as an outcome measure.
Academy of ENT - Head & Neck
Studies, Tribhuvan University Teaching M at e r i a l s A n d M e t h o d s :
Hospital, Institute of Medicine, Data for the observational study was obtained from the Cancer Registration Forms and Register of the
Kathmandu, Nepal. Department of E.N.T. and Head Neck Surgery of T.U. Teaching Hospital, Maharajgunj. Patients with
histopathologically proven squamous cell carcinomas of larynx and hypopharyx with a minimum follow
Correspondence to: up duration of 6 months were included in the study. Treatment outcomes were assessed as patients
Dr Pallavi Sinha having recurrent/ residual disease or not. Data was analysed using percentages.
Department of ENT - HNS Results:
Ganesh Man Singh Bhawan Of the 74 patients included in the study 12% were females and 88% were males. The mean age was
TU Teaching Hospital, 60.82 years. The mean follow up duration was 37.7 months. Majority, 38% had carcinoma glottis. 59.5%
Kathmandu, Nepal. of the patients were detected in the advanced stage of disease. Overall, recurrenct/ residual tumour
email: dr_pallavi@hotmail.com was seen in 13.3% of the early stage disease group whereas recurrent or residual disease was seen in
25% of the advanced stage tumour group. Recurrent/ residual disease was found in 31.8% of the
patients that were treated with CT/RT as their primary treatment modality.
Conclusion:
Recurrence rate for squamous cell carcinomas of the larynx and hypopharynx in early as well as advanced
stages was found to be higher in the current study as compared to the data available from other parts
of the world. The rate was observed to be higher in those treated with chemoradiation as their primary
treatment modality. This leads to the question as to whether treatment modalities other than
chemoradiotherapy should be adopted especially in the treatment of early laryngeal and hypopharyngeal
cancers. Conservative endolaryngeal surgery may be a good alternative to radiotherapy for the treatment
of early laryngeal cancers. However, a larger multicentric study needs to be conducted.
K e y w o r d s : Squamous cell carcinoma, Chemoradiation, Recurrence.
INTRODUCTION: Tumour staging was done as per TNM staging of UICC 2009. T1 and
Head and Neck malignancies are fairly common globally. They are the T2 stages were taken as early stage disease and T3 and T4 were taken
sixth leading cause of cancer-related mortality worldwide1. Incidence as advanced stage disease.
of head and neck cancer varies with geography with high rates being
reported in France, India, South America and Eastern Europe2,3. In the Treatment outcomes were assessed as patients having recurrent/
Indian subcontinent more than 45% of all cancers arise in the head residual disease or not having recurrent/ residual disease after at least
and neck4. Among the malignancies arising in the head and neck 6 months of completion of the primary treatment modality. If after 6
region more than 90% are squamous cell type. In most regions of the months of completion, a suspicious lesion was noticed then biopsy
world majority of cancers arise in the larynx1,2. The treatment of was taken. If the lesion was histopathologically positive for squamous
laryngeal cancers requires a multidisciplinary approach and depends cell carcinoma then it was labeled as recurrent or residual tumour.
on various factors like patient factors, tumour factors and the healthcare Data was analysed using percentages.
facilities available. For example the general health condition of the
patient, the patients pulmonary reserve, the site and stage of the RESULTS:
tumour, the expertise of the treating surgeon, the radiotherapy and Records of 131 patients of squamous carcinomas of larynx and
rehabilitation facilities available, all play a vital role in the decision- hypopharynx were available. However, only 74 fulfilled the inclusion
making process for the treatment of laryngeal and hypopharyngeal criteria and were included in the study. There were 12% (9) females
cancers. The modalities of treatment currently available in our set-up and 88% (65) males. The patients included in the study were in the
are chemoradiotherapy, surgery or combined therapy. Patients with age range of 41-80 years with a mean age 60.82 years.
early low volume tumours are referred for radiotherapy with organ The minimum follow up duration was 6 months and the maximum
preservation as one of the main objectives. Patients with advanced 192 months. Mean follow up duration was 37.7 months.
but operable tumours undergo surgery which may or may not be Among the patients included, majority (38%) were diagnosed as
followed by chemoradiotherapy depending upon the post-operative carcinoma glottis whereas trans-glottic carcinoma was the least
histopathology report. Patients with advanced stage tumours which common being found in only 17% of the cases.
are not operable are referred for palliative chemoradiotherapy.
The aims and objectives of this study were to analyze the treatment Fig. 1: Distribution according diagnosis
outcomes in patients with laryngeal and hypopharyngeal cancers
using locally recurrent or residual disease as an outcome measure Diagnosis
and also to note in locally recurrent or residual tumours, the primary
treatment modality and the stage of tumour prior to treatment.
Such a study has not been carried out in Nepal and it can be used as 22% 23% PFS
a platform for future research. The results obtained from this study
can be compared with the data available from other parts of the world. Glottis
MATERIALS AND METHODS: 17%
The data for this observational study was obtained from the Cancer 38% Transglottis
Registration Forms and Register of the Department of E.N.T. and Head
Neck Surgery of T.U. Teaching Hospital, Maharajgunj, Kathmandu, Supraglottis
Nepal. Patients attending the Ganesh Man Singh Memorial Academy
for ENT and Head Neck Studies, in as well as out patient clinics with
histopathologically proven squamous cell carcinomas of larynx were
included in this study. A minimum follow up duration of 6 months Maximum number of patients (40/74) that is 54% were diagnosed at
was required for inclusion. Those patients whose records were not T3 stage of tumour whereas minimum (4/74) i.e. 5.4% number of
complete or those who had not followed up after being diagnosed patients were diagnosed at T4 stage. 59.5% of the patients were
were excluded from the study.
Sinha et al: Treatment Outcomes of Laryngeal and
Hypopharyngeal Squamous Cell Carcinomas
detected in the advanced stage of disease i.e. T 3 and T 4 . carcinoma of the glottis is the most common among the subsites of
Out of the total 11 patients with T1 stage of disease, recurrence was the larynx found in 45% of the patients5. Head and neck cancer patients
seen in 3 that is 27.3% of the patients. Out of the total 19 patients usually present with late-stage, locally advanced disease. 59.5% of
with T2 stage of disease, recurrence was seen in 2 that is 10.5% of the the patients presented at an advanced stage of disease which is similar
patients. Out of the total 40 patients with T3 stage of disease, recurrence to the results in the study by Awada and Castro in which around 75%
was seen in 10 that is 25% of the patients. Out of the total 4 patients of patients were diagnosed with stage IIIIV1. Disease recurrence was
with T4 stage of disease, recurrence was seen in 1 that is 25% of the found in 27.3% of the patients with T1 stage of tumour which is high
patients. Overall, recurrenct/ residual tumour was seen in 13.3% of as compared to the results of 75-100% locoregional control obtained
the early stage disease group whereas recurrent or residual disease by Dickens et al7. 25% disease recurrence/ residual disease found in
was seen in 25% of the advanced stage tumour group. advanced stage disease which is high as compared to 2-12% primary
recurrence found in study by Wolf et al8. The rate of recurrent or
Fig. 2: Presence or absence of recurrent/ residual tumour based on residual tumours was found to be highest among those who
pre-treatment T stage underwent chemoradiotherapy. The results obtained in the current
study are inferior to those from other parts of the world especially in
Outcome based on T stage of tumour the treatment outcome of T1 tumours. Many radiotherapy cohort
studies report excellent success rates for early laryngeal cancer9. On
examining the literature endoscopic laryngeal surgery and
40 radiotherapy seem to have very similar cure rates10,11. From the results
it can be also be stated that surgery in this set-up provides a better
Number of patients
35
30 30 control rate for disease as compared to chemoradiotherapy. There
No are no randomized controlled trials (RCT) comparing different surgical
25
20 treatments for advanced laryngeal cancer, but the Veterans
Yes Administration Trial and text books such as Weinstein et al recommend
15 17
total laryngectomy with voice rehabilitation for T4 tumours and
10 8 10 are in clinical equipoise between laryngectomy and radiotherapy
5 3 2 3 for T3 tumours8,12.
0 1
1 2 3 4 CONCLUSION:
T stage Recurrence rate for squamous cell carcinomas of the larynx and
hypopharynx in early as well as advanced stages was found to be
higher in the current study as compared to the data available from
Recurrent/ residual disease was found in 14 patients that is 31.8% of other parts of the world. The rate was observed to be higher in those
the patients that were treated with CT/RT as their primary treatment treated with chemoradiation as their primary treatment modality.
modality. There was no recurrent/ residual disease in patients treated This leads to the question as to whether treatment modalities other
with Surgery alone as their treatment modality. There was found to than chemoradiotherapy should be adopted especially in the
be recurrent/ residual disease in 13.3% of patients treated with surgery treatment of early laryngeal and hypopharyngeal cancers. Conservative
along with adjuvant chemoradiotherapy endolaryngeal surgery may be a good alternative to radiotherapy for
the treatment of early laryngeal cancers. However a larger multicentric
Fig. 3: Presence or absence of recurrent/ residual disease based on study needs to be conducted.
primary treatment modality
REFERENCES:
Recurrent/Residual Disease 1. Awada A, Castro GD. Head and neck cancer emerging strategies:
advances and new challenges. Current Opinion in Oncology 2009,
21:1913
50 2. Johnson NW. Oral cancer: a worldwide problem. FDI World 1997;
Number of patients
6: 19-21.
40 3. Moore SR, Johnson NW, Pierce AM, Wilson DF. The epidemiology
30 30
No of mouth cancer: a review of global incidence. Oral Diseases 2000;
20 6: 65-74
14 15 13 Yes 4. Sankarnarayanan R. Oral cancer in India: a clinical and
10 epidemiological review. Oral Surgery, Oral Medicine and Oral
0 0 2 Pathology 1990; 69: 325-30
CT/RT Surgery Surgery + CT/RT 5. C a n c e r Research UK website. 2009.
http://info.cancerresearchuk.org/cancerstats/types/larynx/acces
Primary Treatment Modality sed October 5, 2009.
6. Mackenzie K, Mehanna H. Larynx. Stell and Marans Textbook of
DISCUSSION: Head and Neck Surgery and Oncology. 5th ed. Hodder Arnold
We frequently come across patients with laryngeal and 2012. 645-60.
hypopharyngeal cancers in our day to day practice and we manage 7. Dickens WJ, Cassisi NJ, Million RR et al. Treatment results of early
patients based on the international norms set. However, an analysis vocal cord carcinoma: A comparison of apples and oranges.
of the treatment outcomes in our set-up has never been carried out. Laryngoscope 1983; 93: 216-219.
With such an analysis we can find out whether there is any room for 8. The Department of Veterans Affair Cancer Study Group. Induction
improvement in our methods of treatment of laryngeal and chemotherapy plus radiation compared with surgery plus radiation
hypopharyngeal cancers and whether there are any modifications in patients with advanced laryngeal cancer. N Engl J Med 1991;
that we need to make. In the current study, patients with a minimum 324: 1685-90
follow up duration of 6 months after completion of their primary 9. Inoue T, Inoue T, Ikeda H, Teshima T, Yamazaki H, Murayama S,
treatment modality were included. An interval of 6 months was allowed Othani M, Ozeki S. Comparison of early glottic and supraglottic
for post-operative or post radiotherapy changes to settle down as at carcinoma treated with conventional fractionation of radiotherapy.
times it is very difficult to differentiate between post radiotherapy Strahlenther Onkol. 1993 Oct;169(10):584-9
changes and recurrent disease. More number of males were found to 10. Moreau PR. Treatment of laryngeal carcinomas by laser endoscopic
be suffering from laryngeal and hypopharyngeal cancers as compared microsurgery. Laryngoscope 2000;110: 1000-6
to females. This is similar to results obtained in U.K. in 2009 5. The 11. Ambrosch P, Kron M, Steiner W. Carbon dioxide laser microsurgery
mean age of patients in this study was 60.82 years which is in for early supraglottic carcinoma. Annals of Otology, Rhinology
accordance with other data available which states that laryngeal and and Laryngology 1998; 107: 680-8
hypopharyngeal cancers are rare before the age of 40 years and the 12. Weinstein GS, Brasnu 0, Laccourreye H. Organ preservation
incidence is strongly associated with age6. 38% of the patients were surgery of the larynx. California: Singular Press.
diagnosed as carcinoma glottis. According to U.K. cancer data
Kumar .S.A. Jagdish1
Hima Bindu P2
CLINICAL AND BACTERIOLOGICAL STUDY OF
CHRONIC SUPPURATIVE OTITIS MEDIA BY
Department of ENT
Katuri Medical College and Hospital ANAEROBIC CULTURE METHODS IN A TEACHING
Guntur (Ap), India.1 HOSPITAL
Aims & Objective:
Department of ENT To observe the types of organisms grown in CSOM both Tubotympanic (TT) and Atticoantral (AA) type
Mamata Medical College and
Hospital,Khammam(Ap), India.2 Material and Methods:
This was a prospective study conducted between October 2009 to June 2011 in tertiary referral center
Corresopndence: in India.120 chronic and actively discharging ears of 100 pateints were included in study.
Prof. Jagdish Kumar .S.A.
Department of ENT Results:
Katuri Medical College and Hospital, Majority of patients were in age range 26 to 35 years. 69 % of patients were from low socioeconomic
Guntur (Ap), India group. CSOM-TT was found in 81.67% and CSOM-AA in 18.88% cases. Out of 120 swabs only 113 swabs
email: mmcmsupdt9@gmail.com grew bacteria. Out of 120 swabs, 48.35% swabs grew monomicrobial isolates and 48.83% swabs grew
jsunkum@hotmail.com polymicobial isolates. Aerobic growth was seen in 48.33 anaerobic growth was seen in 2.5 % and mixed
flora was seen in 43.34% and no growth was seen in 5.83%. In COSM-TT commonest anaerobic was
prevotella whereas peptostreptococcus was common in CSOM-AA.
Conclusion:
In COSM-TT commonest anaerobic was prevotella whereas peptostreptococcus was common in CSOM-
AA.
K e y w o r d s : Bacteriological Study, Chronic Suppurative Otitis Media, Culture
INTRODUCTION: were in age range between 26 and 35 years were more in number
Chronic suppurative otitis media (CSOM) is a common condition in (42), followed by 16 - 25 years age group (22). Least common age
developing nations and it is being managed by general practitioners. range was 56 65 years(3) as shown in Table I. There was almost equal
The patients turn to ENT specialists only when it causes significant distribution of disease between both the sexes (1.08:1).Majority of
hearing loss or persistant otorrhoea or some complications. The them belonged to low socioeconomic group , mainly labourers (69%)
organisms found in CSOM is many times a mixed flora of aerobes and as shown in Table II. Symptoms of ear discharge was less than 5 years
anaerobes. The foetid discharge seen in CSOM is due to anaerobes. in 69 ears (57.5%), 5 -10 years in 40 ears(33.33%), more than 10 years
This study was mainly conducted to investigate the types of organisms in 11 ears (9.2%) as shown in Table III. Most common type of CSOM
both aerobic and anearobic, in CSOM cases both Tubo tympanic (T was T T in 98 ears (81.67%) and remaining 22 ears (18.88%) were A
T )and Atticoantral (A A) types and ascertain the sensitivity patterns A type. Central perforation was seen in 98 ears(81.7%), attic perforation
of aerobes to commonly used antibiotics in a tertiary referral center in 13 ears (10.8 %) and marginal in 9 ears (7.5%) as shown in Table IV.
which is a 1000 beds medical college teaching hospital in an urban Out of 120 ear swabs, 113 swabs grew bacteria and the remaining 7
setting which draws patients from mostly rural areas , tribal areas and (5.83%) swabs were sterile. Of the 113 swabs that grew bacteria, 58
semi urban populations. (48.35%) swabs grew monomicrobial isolates and the remaining 55
(48.83%) swabs grew polymicrobial isolates [Table V, VI ]. Only aerobic
MATERIALS AND METHODS: growth was seen in 58 ears (48.33%), only anaerobic growth in 3 ears
This was a prospective study done between oct 2009 and june 2011as (2.5%), mixed flora in 52 ears (43.34%) and no growth in 7 ears (5.83%).
part of the dissertation of the second author submitted to NTRUHS The mixed flora obtained contained both aerobic and anaerobic
Andhra Pradesh, India.120 chronic and actively discharging ears of bacteria. A total no. of 173 (115 aerobic and 58 anaerobic) bacteria
100 patients afflicted with both TT and AA types of CSOM who were isolated from 120 ear discharge specimens. Most common
attended the ENT OPD, were included in the study. Exclusion criteria anaerobic bacterium was Peptostreptococcus (20 i.e, 34.5%) followed
included Children with age less than 5 years , patients who received by Prevotella (16 i.e, 27.6%),porphyromonas (11 i.e,19%), Bacteroides
antibiotics 15 days prior , in any form either systemic / topical any
febrile illness, patients on renal dialysis, recent ear surgery , aural Tab. I: Showing Age /Sex Distribution Of Patients
polyp and pregnancy. After taking informed consent, the external
auditory canal was cleaned with betadine swab . Fresh specimen of Age in Years No and % of patients Sex No
middle ear effusion was obtained by suction with siegles pneumatic 5-15 13 Male 52
speculum. Two thin sterile cotton wool swabs were used to collect 16-25 22 Female 48
the pus for bacteriological study from the deeper part of the canal.
One swab was inoculated in Cary- Blair transport medium for anaerobic 26-35 42
culture and both the swabs were taken immediately after the 36-45 14
collection, to the department of Microbiology which is situated within 46-55 6
the same building, one floor below ,without any delay. In the 56-65 3
department of Microbiology,the swab sent in Cary-Blair medium was Total 100
subcultured onto blood agar and Thioglycollate medium and were
incubated at 370C for 48-72 hours in Gaspak jar . In cases where the
transport medium could not be used, the swab was inoculated directly Tab. II : Occupation Of Patients
into Robertson cooked meat medium from which it was subcultured Occupation No. and Percentage of patients
on to blood agar and incubated anaerobically in Mc Intosh Fildes jar
and Gaspak jar. Labourer 69
Student 19
RESULTS:
Clinical evaluation of the patients revealed that , age range started House wife 6
from 5 years to 65 years, with a mean age of 29 years. Patients who Others 6
S.A. e t a l : C l i n i c a l a n d B a c t e r i o l o g i c a l S t u d y o f C h r o n i c
S u p p u r at i v e O t i t i s M e d i a
Tab. III: Duration Of Ear Discharge et al6.The difficulty to treat comes from the fact that most of the times
the treatment is inadequate and there is failure of compliance. This
Duration No. of ears Percentage lead to the emergence of resistant organisms. Out of 100 cases (120
< 5 years 69 57.5 ears) studied, mono-microbial growth was obtained from 58 (48.35%)
ears, poly-microbial growth was seen in 55 (45.38%) ears and no
5 10 years 40 33.33 growth in 7 (5.83%) ears [Table V and VI]. A combination of the different
>10 years 11 9.17 aerobes and anaerobes varied and there was no consistent pattern
Total 120 100 of combinations. Only 3 ears showed pure anaerobic culture (5.17%),
out of which 2 were peptostreptococci and one was Peptococcus.
Tab. IV: Type Of Perforation Most of the anaerobic organisms isolated were in combination with
aerobes (94.82%), the most common was Peptostreptococcus (34.49%)
Type of perforation No of ears Percentage followed by Prevotella (27.58%), Porphyromonas (18.96%), Bacteroides
Central 98 81.67 (12.06%) and Peptococcus (6.89%). These results were similar to
Marginal 9 7.5 Jonsson et al9. who observed that Peptostreptococci (55%) were
common as compared to Bacteroides (33%). Anaerobes have been
Attic 13 10.83 isolated in a few studies. 61% of patients in the study by Erken et al
Total 120 100 in 1994 showed anaerobes10. Improved bacteriological methods may
Tab. V: Type Of Bacterial Culture be said to be the reason for this high yield. In the study as above by
the principal author11, Anaerobes were grown in 46.66% (14 out of
Type No. of ears Percentage 30) ear swabs. The sample may be less and hence difficult to comment.
Monomicrobial 58 48.35 Also, in the same study11, it was observed the importance of transport
Polymicrobial 55 45.83 medium for anaerobic bacteriological study. Out of 60 samples of ear
No growth 7 5.83 swabs,15 were sent through CARY-BLAIR transport medium, in which
Total 120 100 12 out of 15 (80%) were positive, where as 45 samples were sent
directly, but inoculated within a few minutes, into Robertsons cooked
Tab.VI : Incidence Of Monomicrobial Vs Polybacterial Growths- meat medium, in which only 9 out of 45 (20%) swabs were positive
Various Studies for anaerobes. Hence it is important to use transport medium for
Nature of Loy Srivastava HaiderA VK Poorey Present Jagdish anaerobic cultures. Anaerobes were not significant pathogens in their
growth (2002) (2010) (2002) (2002) study(2011) (1984) study according to Srivastava 4 (2010) and Loy3 (2002). In classical
text books, it is described that anerobes are seen mostly in CSOM (A
Monomi A) type. But in our study we found that they were seen in both types.
crobial 63.3% 80.7% 80.7% 82% 48.35% 88% Among anaerobes, Prevotella was common in T T disease (32.50%)
Polymi and Peptostreptococcus in A A disease (50%) [Table VII]. There was
crobial 34.4% 19.3% 3.3% 10% 45.38% 5.6% no significant data in the literature describing the commonest
anaerobic organisms in both types of CSOM.
No
growth 2.2% NIL 16% 8% 5.83% 6.4% CONCLUSION:
In this study, age of the patients ranged from 5 65 years. Majority
Tab. VII: Anaerobic Organisms Isolated were in 26-35 years age group. Male: Female ratio was 1.08:1. Labourers
(low income group) were found to be affected more. 69 % had ear
No. of (%) No. of (%) No.of (%) discharge for less than 5 years, 40% had discharge between 5-10 years
Organism isolates in
isolates isolates and 11 % had discharge for more than10 years. The present study is
CSOM(TT) in CSOM one of the extensive reports on aerobic and anaerobic bacteria. In
98 ears (AA) 22 ears this study, bacteria from the ear discharge in chronic suppurative
Peptostreptococcus 20 34.48 11 27.50 9 50.00 otitis media were grown, obtained from the middle ear aspirate.
Peptostreptococci followed by Prevotella were the most frequently
Prevotella 16 27.59 13 32.50 3 16.67
isolated anaerobic organisms as compared to previous studies.
Porphyromonas 11 18.97 8 20.00 3 16.67 Anaerobes were seen equally in both T T and A A types of CSOM,
Bacteroides 7 12.07 7 17.50 0 0 contrary to common belief that anaerobes are seen mostly in CSOM
Peptococcus 4 6.89 1 2.50 3 16.67 (A A) type.
Total 58 100 40 100 18 100
(7 i.e,12%) and Peptococcus (4 i.e,7%)[ Table VII]. Amongst anerobes, REFERENCES:
Prevotella (32.50%) was common in TT type of CSOM. In AA type, 1. Bluestone CD, Gates GA, Klein JO et al. Definitions, terminology
Peptostreptococcus (50%) was commonest Table VII and classification of otitis media. Annals of Otology, Rhinology
and Laryngology.2002; 111: 8-18.
DISCUSSION: 2. Healy GB, Rosbe KW. Otitis media and middle ear effusions. In :
CSOM and its complications are among the most common conditions Snow, Ballenger JJ, Editors. Ballengers Otolaryngology Head Neck
seen by the otologist, paediatrician and the general practioner. Surgery. ( 16th ed). BC Decker INC; 2003: 249-60
Anaerobes are commonly implicated in otogenic brain abscess cases. 3. Loy AHC et al , Microbiology of Chronic Suppurative Otitis Media
It was observed from the present study that majority of the patients in Singapore; Singapore Med J 2002; Vol 43(6): 296-299.
belonged to the age group of 26-35 years (42%) [Table I] with an 4. Srivastava.A, Singh.R.K.et al, Microbiological evaluation of active
overall increase in incidence between 11 to 45 years. These findings tubotympanic type of chronic suppurative otits media,Nepalese
were consistent with the findings of Loy et al3 and Srivastava et al4. Journal of ENT Head & Neck Surgery.(2010)Vol1 No.2Issue2:14-16
The basis for delayed presentation may be due to the ignorance of 5. Poorey VK, Arati Iyer. Study of bacterial flora in CSOM and its
and / or the economic restraints on the patients with regard to their clinical significance; Indian Journal of Otolaryngology and Head
seeking health services at an early stage of the complaint and general and Neck Surgery, 2002, vol.54; No.2, 91-95
poverty. Incidence of CSOM was almost same in males as compared 6. Asif Alam gul, Liaqat ali, Ejaz Rahim, Shakeel Ahmed(2007): Chronic
to females (M: F- 1.08:1) [Table I]. A similar conclusion was made by suppurative otitis media; frequency of pseudomonas aeruginosa
Loy et al3. Who found an almost equal distribution between both in patients and its sensitivity to various antibiotics. Professional
sexes. Duration of ear discharge was <5 yrs in 58%, 5-10 yrs in 33%, medical J; 14(3): 411-415.
and > 10 yrs in 9% [Table-III ] Type of perforation was central in 81.67% 7. Ahira Mansoor, Mohammed Ayub Musani, Gulnaz Khalid, Mustafa
, marginal and attic types in 18.33% ears in this study. CSOM was seen Kamal. Pseudomonas aeruginosa in chronic suppurative otitis
to be more common in labourers (69%) [Table-III] who belong to low media: Sensitivity spectrum against various antibiotics in Karachi.
socioeconomic group and indulge in outdoor work. These findings J Ayub Med Coll Abbottabad 2009; 21(2) 120-3
were in accordance with other researchers like Poorey et al and Gul 8. B M Ahmad, M T Kudi, Chronic suppurative otitis media in Gombe,
Nigeria;The Nigerian Journal of Surgical Research(2003)Vol 5:3-4
S.A. e t a l : C l i n i c a l a n d B a c t e r i o l o g i c a l S t u d y o f C h r o n i c
S u p p u r at i v e O t i t i s M e d i a
9. Jonsson L, Schwan A, Thomander L, Fabain P. Aerobic and Annals Otol Rhinol Laryngol ; 1994; vol 103 771-774.
anaerobic bacteria in chronic suppurative otitis media. A 11. Jagdish kumar S.A., A comparative bacteriological study in ASOM
quantitative study. Acta Otolaryngol. 1986 :102(5-6):410-4. and CSOM Dissertation submitted to Bangalore university (1984)
10. Erkan et al : Bacteriology of Chronic suppurative otitis media ; unpublished data
Or iginal A rticle
Khanal Kabi Raj1
Dattatreya T2 A SCREENING PICTURE SPEECH IDENTIFICATION
Karna Sureshwar Lal1 TEST FOR NEPALI SPEAKING CHILDREN
Speech and Hearing Unit Aims & Objective:
Ganesh Man Singh Memorial The objective of the present study was to develop screening monosyllabic picture speech identification
Academy of ENT- Head & Neck test for the children speaking Nepali language.
Studies, Institute of Medicine,
Maharajgunj, Kathmandu, Nepal.1 Material and Methods:
A prospective study was conducted in speech and hearing unit, Ganesh Man Singh Memorial Academy
Institute of Health Sciences of ENT and Head and Neck Studies, Institute of Medicine, Maharajgunj, Kathmandu, Nepal from feb
College of Speech and Hearing, 2006 to august 2006. 30 Nepali speaking children of age group 5-6 years were chosen for the study.
Mangalore, India.2 A list of CVC monosyllabic Nepali words were constructed in which words were selected within the
vocabulary of 5 to 6 years old children. A commercial artist drew the black and white pictures of each
Correspondence to: word in consultation with the author. After construction of the material, monosyllabic words were
Kabi Raj Khanal presented through the audiometer at 40 dB. The study was conducted in a sound treated two room
Department of ENT-HNS, setup.
Speech and Hearing Unit
Ganesh Man Singh Bhawan, Results:
TU Teaching Hospital A picture speech identification test was constructed for assessing hearing ability of the children of age
Institute of Medicine, Kathmandu, 5-6 years.
Nepal
e-mail: kabiraj_k@yahoo.com Conclusion:
At present, no test material is available for assessing speech identification in children of 5-6years age
in Nepali. A picture speech identification test was constructed using phonemically balanced monosyllabic
words. A criterion measurement cut-off point of 95 % was considered, to make the pass-fail decision.
This test can be used to evaluate hearing ability of the children for early identification and rehabilitation.
K e y w o r d s : Monosyllabic, Speech identification test.
INTRODUCTION: to august 2006. Prior to the study, a familiarization of the words and
Hearing is an act of perceiving sound present in the environment. pictures was done in 15 subjects of age 5-6 years to determine whether
Hearing, in children is most important because the ability to develop the selected items were within the recognition vocabulary of the
and use oral language is closely related to their ability to process children and pictorial representations were adequate. 100 monosyllabic
speech through hearing. Erber (1982) pointed that hearing is the words were selected from the book meant for children. Each subject
avenue for communication and majority of what we learn throughout was tested individually during the words and picture familiarity test.
our lives, occurs through hearing and speech. The crucial role of The subjects were either asked to name the pictures or point to the
hearing in spoken language development is indicated by the language picture named by the examiner. For speech identification test, the
delay observed among children with bilateral hearing loss (Lach and words were retained only if 95 percent of the children could name
Ling, 1976). Therefore it is the essential duty of an audiologist to the picture and identify the picture correctly.
identify, evaluate and rehabilitate aurally handicapped individuals.
Elliot (1963) pointed that hearing assessment through pure tones All the subjects included in study were native speakers of Nepali
provides information regarding the sensitivity of an individuals hearing Language residing in urban area having normal speech and language
ability but not on the receptive auditory ability. Giolas and Epstein development, within age range of 5-6 years. They had normal hearing
(1963) stated that speech audiometry measures listeners and had no history of otological, neurological, psychological and
understanding of speech and also gives information for planning and ophthalmologic problem. After the familiarity check was done, the
management of aurally handicapped. present study was carried out in two stages. Stage one: construction
of the test material and stage two: obtaining normative data.
A number of studies have been carried out towards developing pictures
speech identification test in western as well as Indian scenario in Stage one: Construction of test materials
different Indian languages to assess the hearing ability of the children. The test pictures were selected after familiarization of words and
Abrol B.M. (1971) developed a picture speech identification test for pictures . Test items were selected according to the frequency of their
children in Tamil. Hemalatha R. (1981) developed Picture speech occurrence in Nepali language. The phonemes, which were having a
Reception threshold for children in Kannada. The study was conducted high frequency of occurrence, were selected and those phonemes,
for the children of age range 4-8 years using closed set 20 polysyllabic which were having low frequency of occurrence, were not included
words in Kannada. Prakash (1999) developed a picture speech while constructing test materials. Out of 100 monosyllabic words, 80
identification test for children in Tamil using phonemically balanced words were found to be familiar to the children. Among the 80 words,
monosyllable, bisyllable and trisyllable words in closed set format. 25 words were used as test items and rest were used as distracters.
Chaudhari B.K. (2003) developed picture speech identification test for The pictures were arranged in 25 sets where each set consisted of 4
Hindi speaking children using 50 phonetic and phonemically balanced pictures out of which one being the target word and 3 were distracters.
monosyllabic words in closed set format. However, to assess the Either the initial or final sounds of the test item were similar to the
children speaking Nepali, no screening picture speech identification distracters words.
test has been developed yet. Hence, the present study has been taken
up, to fulfill the need. Thus the aim of present study is to develop a Stage Two: Obtaining Normative Data
screening speech identification test in Nepali language to evaluate 30 subjects were chosen for the present study. They met the same
the hearing ability of the children for early identification and criteria as the subjects involved during familiarization check. These
rehabilitation. children were taken from different culture and socioeconomic
background. A two channel calibrated diagnostic audiometer (Elkon
MATERIAL AND METHODS: 3N3) was used. Study was conducted in a sound treated two-room
A prospective study was conducted in speech and hearing unit, Ganesh set up. The test items were presented through earphone at 40 dB SL.
Man Singh Memorial Academy of ENT and Head and Neck Studies, Subjects were instructed to point to the appropriate picture
Institute of Medicine, Maharajgunj, Kathmandu, Nepal from feb 2006
Khanal e t a l : A S c r e e n i n g P i c t u r e S p e e c h I d e n t i f i c a t i o n T e s t
for Nepali Speaking Children
corresponding to the target word which they heard. Prior to test loss. Therefore, the developed monosyllabic material can be used for
administration, puretone audiometric evaluation (attaining 20 dB HL speech identification for Nepali speaking children with the age range
or less at 0.5, 1, 2, 4, and 8 KHz) and familiarization of test materials of 5 to 6 years for hearing screening purposes. The test materials can
was done for each subject. Three practice items (monosyllabic words) also be used for auditory training or prescribing the amplification
were used for a familiarization of test materials before administering devices as well.
the test items.
CONCLUSION:
The response was recorded on a score sheet. A correct response was Speech identification test is a challenging part of audiological test
marked as one and incorrect was marked as zero. The data obtained battery. By assessing speech identification ability, well be able to
were subjected to statistical analysis to find out the Mean score, S.D obtain valuable information about childs use of audition. The present
and confidence level and to judge the pass- fail criteria. study appears to be a potentially valuable clinical tool in pediatric
A criterion measurement cut off point of 95% was involved, to make audiology. Therefore, it should be routinely included in pediatric
the pass fail decision. The children falling below the criteria were audiological evaluation.
suspected to have the hearing impairment and further suitable referral
were made for comprehensive diagnostic evaluation. Recommendation: The screening test should be standardized on a
large population, clinical validation of the screening test should be
RESULTS: done. We can include more tests and can develop a diagnostic test
Test scores reveal that out of 30 subjects, 11 subjects got 96 % and in future.
19 subject could score 100%. The data obtained were subjected to
statistical analysis to find out the mean score, SD and confidence level REFERENCES:
and to judge the pass- fail criteria. 1 . Abrol, B.M. (1971). A picture speech identification test for children
Tab.1: Description of Mean score, S.D and confidence level. In Tamil. Unpublished Masters Dissertation, Mysore: University
Presentation Age Measure 95% Maximum Minimum
of Mysore.
Level confidentialInterval score score 2. ASHA (1997) American Speech Language and Hearing Association
for mean committee on Audiometric evaluation guidelines for determining
Mean S.D Lower Upper threshold level for speech. ASHA, 19, 241- 243.
Bound Bound 3. ASHA (1978) American Speech Language and Hearing Association
committee on Audiometric evaluation guidelines for determining
40 dB SL 5-6 Yrs. 24.6333 0.49013 24.4503 24.8164 25 24
threshold level for speech. ASHA, 19, 241- 243.
4. Chaudhari, B. K. (2003). Picture speech identification test for Hindi
Table 1 shows description of mean score, S.D and confidence level. speaking children. Unpublished Masters Independent project,
The above table explains about the total mean scores, S.D., and University of Mysore, Mysore.
confidence level for all subjects. The total mean score was found to 5. Devaraj, A. (1983). Effects of word familiarity on speech
be 24.6333 and S.D. was 0.4901. A 95% confidence interval for mean discrimination score. Unpublished Masters dissertation, University
was found and under that the lower bound was 24.4503 and upper of Mysore, Mysore. Elliott, L.L. (1963). Prediction of speech
bound was 24.8164. In the scores obtained from all the subjects, the discrimination scores from other test information.. Journal of
minimum score obtained was 24 where as maximum score was 25. Auditory Research, 3, 35-45.
6. Erber, N. P. (1982). Auditory training (PP. 29-46). Alexander Gram
Tab.2: Comparision of score between Males and Females. Bell Association for the Deaf. Washington: DC.iolas, T.G., Epstein,
Sex Total A. (1963). Comparative intelligibility of word lists and continuous
discourage. Journal of Speech and Hearing Disorders, 6, 649-359.
Male Female 7. Hemalatha, R. (1981). Picture speech reception threshold test for
Score 24(96%) 4(26.7 %) 7(46.7%) 11(37.7%) children in Kannada. Unpublished masters Independent project.
25(100%) 11(73.3%) 8(53.3%) 19(63.3%) University of Mysore, Mysore.
8. Lach, R.D. , Ling, D. (1976). Early speech development in deaf
infants. American Annals of the Deaf, 115, 522-526.
Total 15(100.0%) 15(100.0%) 30(100.0%) 9. Prakash, B. (1999). A picture speech identification test for children
in Tamil. Unpublished Masters Independent Project, University
Table 2 shows comparision of score between males and females. of Mysore, Mysore.
P= .256 NS (not significant). Table 2 also explains gender wise
comparison of scores obtained from the total of 30 subjects (15 males,
and 15 females). Among the 30 subjects, 11 (36.7%) scored 24 which
represent 96% scores and 19 (63.3%) have the total scores of 25 which
represents 100% scores. Among 15 males, 4(26.7%) males got 24/25
score and 11(73.3%)could score 25/25,where as among female group,
7 females (46.7%) scored 24/25 and 8(53.3%) could score 25/25. Overall
data reveal that even though the number of male subjects scoring
25/25 was more than the female group, this difference was not
statistically significant (p>0.05).
DISCUSSION:
The results of picture speech identification test show that the normal
hearing children of age range 5-6 years obtained 95% correct response
on the PB monosyllabic test stimuli. The children obtaining scores
below the cut-off criteria were further evaluated for suspected hearing
Case Report
Shrestha Kundan Kumar
Jha Anil Kumar
AN UNUSUAL PRESENTATION OF THYROID GLAND
Joshi Rupesh Raj CARCINOMA: A CASE REPORT
Rijal Anupama Shah
ABSTRACT
Dhungana Anup Thyroid disorder is a common clinical presentation in our day to day Otolaryngology and Head and
Regmi S Neck Surgery (ENT and HNS) practice. Papillary thyroid carcinoma (PTC) and medullary thyroid
Amatya A carcinoma (MTC) have always been considered different from each other; in their incidence, their cell
origin and their histopathological features. The simultaneous occurrence of PTC and MTC in the
Department of Otolaryngology & Head same thyroid gland is rather rare. We are presenting a case of a 75 year old gentleman from
and Neck Surgery Sinhupalchowk who came with history of swelling in front of neck for 20 years. Computer Tomography
Nepal Medical College Teaching (CT) scan of the neck showed features consistent with huge colloid goiter without local invasion.
Hospital,Kathmandu, Nepal Fine needle aspiration cytology (FNAC) showed features of mixed papillary and medullary carcinoma.
Near total thyroidectomy was performed. Post operative histopathological examination (HPE) showed
Correspondence to: poorly differentiated carcinoma with features of papillary and medullary carcinoma.
Dr. Kundan Kumar Shrestha
Department of Otolaryngology & Head K e y w o r d s : Thyroid, Papillary carcinoma, Medullary carcinoma, Collision tumor.
and Neck Surgery
Nepal Medical College Teaching
Hospital, Attarkhel, Jorpati, Kathmandu,
Nepal;
email: kundanshrestha9@hotmail.com
INTRODUCTION:
Thyroid cancer is the most common endocrine tumor with an incidence
ranging from 1.2-3.8/100,000 cases per year in the UK. It has a
favourable outlook in comparison to most other solid tumors, and
accounts for less than 0.5% of the cancer deaths1. PTC accounts for
around 81 percent of all thyroid cancers whereas medullary cancer
accounts for around 5 percent. Concurrent occurrence of both PTC
and MTC is rare. We present a case of such unusual presentation of
thyroid cancer that came to ENT and HNS outpatient department
(OPD) of Nepal Medical College Teaching Hospital (NMCTH).
CASE REPORT:
A 75 year old gentleman from Sindhupalchowk came to ENT OPD of
NMCTH with swelling in front of the neck for 20 years. It was insidious
in onset and
g r a d u a l l y Fig. 2: CT scan of the patient Fig. 3: CT scan of the patient
progressive. It was (Saggital view) (Axial view)
associated with
pain in the neck above and omohyoid muscle below), each measuring 3x2 cm , firm
while walking and in consistency and mobile laterally.
difficulty in
breathing in The patient was worked up in NMCTH. Thyroid function tests were
supine position for normal. Ultrasound neck showed a large hypoechoic lesion. CT scan
past 2 months. of the neck was done which showed a large swelling in the anterior
There was no neck without evidence of local invasion and right cervical
history suggestive lymphadenopathy (Fig. 2 and 3). FNAC was consistent with malignant
of hyper or tumor with mixed features of medullary and papillary carcinoma of
hypothyroidism. thyroid.
On examination of Total thyroidectomy with excision of level III & VI lymph nodes was
neck, there was a done (Fig. 4 and 5). Post operative period was uneventful. Biopsy
single, smooth, report suggested poorly differentiated carcinoma with features of
globular mass papillary and medullary carcinoma. In view of the HPE report, patient
around 20x15cm, was advised for further neck dissection but refused. The patient was
firm to hard in then advised for chemoradiotherapy and discharged on day 10.
consistency,
extending laterally DISCUSSION:
to the anterior Papillary thyroid carcinoma (PTC) and medullary thyroid carcinoma
border of sternocleidomastoid on both sides, superiorly to body of (MTC) are two different thyroid neoplasia. The former originates from
the mandible and inferiorly to the clavicle on both sides (Fig 1) which thyroglobulin-producing follicular cells, whereas the latter arises from
moved with deglutition. There were two cervical lymph nodes on calcitonin-producing cells. MTC is a rare tumor that arises from neural
right side, corresponding to level III (between the carotid bifurcation crest-derived parafollicular C cells. The coexistence of PTC and MTC
has been reported in the literature. Tumors showing both features
Shrestha et al: An Unusual Presentation of Thyroid Gland Carcinoma
CONCLUSION:
The concomitant occurrence of papillary thyroid carcinoma and
medullary thyroid carcinoma and the exact diagnosis of this
uncommon event are important. Whenever encountered, even in
older age group, surgical thyroidectomy should be considered. Age
itself should not be a contraindication to surgery when indicated on
clinical backgrounds.
.
REFERENCES:
1. Ramsden J, Watkinson JC .Thyroid Cancer. In: Gleeson M, editors.
Scott-Browns Otorhinolaryngology, Head and Neck Surgery. 7th
edition. Great Britain. Hodder Arnold; 2008: 2663-2701.
2. Rossi S, Fugazzola L, De Pasquale L, Braidotti P, Cirello V, Beck-
Fig. 4: Patient undergoing total Peccoz P, Bosari S, Bastagli A:Medullary and papillary carcinoma
Fig. 5: Post surgery
thyroidectomy with excision of specimen of the thyroid gland occurring as a collision tumour: report of
level III and VI nodes three cases with molecular analysis and review of the literature.
Endocr Relat Cancer2005,12:281-289.
are rare and represent less than 1% of all thyroid malignancies.2 They 3. Gero MJ, Lipper S, Chernys AE, Silver L:ÊMedullary and papillary
have different patterns of clinical presentation and biological behavior.
The simultaneous occurrence of MTC and PTC in the same thyroid is carcinomas occurring as a collision tumor: report of a case. Clin
a rare phenomenon that can be observed in two main settings: a Nucl Med1989,14:171-174.
mixed tumor showing dual differentiation or a collision tumor (that 4. Kim WG, Gong G, Kim EY, Kim TY, Hong SJ, Kim WB, Shong YK:
is, a tumor with two separate and different components).2,3 These Concurrent occurrence of medullary thyroid carcinoma and
tumors occurred together more frequently in women, presented with papillary thyroid carcinoma in the same thyroid should be
a palpable neck mass, and were treated with surgery. In our case, considered as coincidental. Clin Endocrinol (Oxf). 2010 Feb;
however, the patient was an elderly male. Kim et al4 have compared 72(2):256-63.
the concurrent occurrence rate of PTC in MTC patients with that in 5. Grogan RH, Mitmaker EJ, Hwang J, et al. A population based
Graves disease (GD) and follicular thyroid carcinoma (FTC) patients prospective cohort study of complications after thyroidectomy in
and have concluded that the simultaneous occurrence of MTC/PTC
is generally a simple reflection of incidental papillary microcarcinoma. the elderly. J Clin Endocrinol Metab. 2012; 97: 1645-53.
Older patients tend to have more aggressive thyroid cancers so surgical 6. Lin JD, Chao TC, Chen ST, et al. A Characteristics of thyroid
thyroidectomy should not be delayed. Age itself should not be a carcinomas in aging patients. A Eur J Clin Invest. 2000; 30: 147-53.
contraindication to surgery when indicated on clinical backgrounds.5
Lin et al6 conducted a retrospective analysis of 204 thyroid cancer
patients aged 60 years and older, however, they have not commented
upon the simultaneous occurrence of papillary and medullary thyroid
carcinoma in their study.
Case R eport
Wahid I Fazal
Khan Muhammad Riaz
UNIQUE FOREIGN BODY CHEST DIAGNOSED
Khan Adil INCIDENTALLY
Ahmad Iftikhar
Abstract
Department of ENT, Head and Neck Foreign Body (F.B) inhalation is a common problem in children but is an uncommon occurrence in
surgery, Postgraduate Medical adults. Risk factors of F.B inhalation in adults are advanced age, altered state of consciousness due to
Institute, Lady Reading Hospital, drugs intoxication, poor dentition and neurological deficit. Sometime accurate diagnosis of F.B inhalation
Peshawar, Pakistan. may be missed even by an experienced clinician either the initial choking episode is not witnessed or
the delayed symptoms may mimic other clinical condition like asthma, pneumonia, recurrent upper
Correspondence to: respiratory tract infection and persistent cough. We present such a unique long standing F.B (tooth)
Fazal-I-Wahid in right main bronchus in an old lady which is diagnosed incidentally and was removed with rigid
Department of ENT, Head and Neck bronchoscope successfully, although F.B is a rare incidence in adults but it must be kept in mind while
Surgery, Postgraduate Medical dealing the patient with chronic cough.
Institute(PGMI), Lady Reading
Hospital(LRH), Peshawar Khyber K e y W o r d s : Foreign body, Tracheobronchial tree, Rigid bronchoscopy.
Pakhtunkhwa, Pakistan.
email: drfazal 58@yahoo.com
INTRODUCTION: Fig. 1: CXR of the patient with F.B in right main bronchus.
Foreign Body (F.B) inhalation is a common problem in children but is
an uncommon occurrence in adults. Its occurrence in children less
than 15 years is about 80 percent. F.B aspiration may give rise to life-
threatening emergency if it is enough large causing complete occlusion
of the airway1. Risk factors of F.B inhalation in adults are advanced
age, altered state of consciousness due to drugs intoxication, poor
dentition and neurological deficit. The major issues involve in F.B
aspiration include accurate and timely diagnosis and prompt and safe
retrieval of FB. Sometime accurate diagnosis of F.B inhalation may be
missed even by an experienced clinician either the initial choking
episode is not witnessed or the delayed symptoms may mimic other
clinical condition like asthma, pneumonia, recurrent upper respiratory
tract infection and persistent cough2. F.B aspiration had a wide
spectrum of presentation ranging from typical choking to
asymptomatic long standing F.B. Occult F.B may remain undetected
for months to years thats why a high index of suspicion is necessary
for diagnosing trachea-bronchial F.B.3. In majority of cases F.B can be
diagnosed clinically; however radiological investigation may help4.
Bronchoscopy is the gold standard technique for removal of F.B and
in some cases open surgical procedure may be adopted for removal
of F.B. If F.B are not diagnosed and removed timely, they will result in
increased morbidity and mortality5.
CASE REPORT:
We present a rare case of F.B inhalation by an old lady of 45 years age.
The main complaint of this lady was episodic dry cough lasting for 4
years. She had no definitive history of FB inhalation. She had visited anesthesia and F.B was localized in right main bronchus and removed
various general practitioners for the same complaint and took various successfully with uneventful recovery of the patient. Patient was put
medications advised by doctors. The patient had temporary relief with on injectable antibiotic post operatively. Post operative X-Ray chest
the use of medication prescribed by general practitioners but no was carried out. The F.B was a rusted tooth. The patient was discharged
significant improvement. Then she was put on anti tuberculosis therapy on 5th day.
by physician. She completed 8 months course of anti tuberculosis
therapy but she was not cured. Then the patient consulted DISCUSSION:
pulmonologist for the same complaint. After proper evaluation fiber F.B aspiration is an emergency seen in children with highest incidence
optic bronchoscopy was performed by pulmonologist and he found of morbidity and mortality. However F.B aspiration by adults is an
that a foreign body looked like tooth was lodged in right main bronchus uncommon incidence especially when there is no typical symptom6.
although the CXR revealed no pathology. Pulmonologist attempted Likewise in this case patient age was 45 years old but there was no
on removal but was difficult and patient was referred to clear-cut history of F.B aspiration. In adults F.B aspiration may be due
otorhinolaryngologist for removal of F.B with rigid bronchoscope. to overdose of sedative drugs, unconsciousness or poor dentition.
This patient was admitted into ENT, Head and Neck surgery However in this case no such cause was found. This case is also at
department. Base line investigations were performed prior to variance from other studies where F.B aspiration is more common in
bronchoscopy. Rigid bronchoscopy was performed under general male population as they are more prone to such incidence. F.B
Wahid et al: Unique Foreign Body Chest Diagnosed Incidentall y
Fig. 2: F.B removed from right main bronchus. F.B inhalation9. The success rate of fiber optic bronchoscopic retrieval
of F.B airway in adults is from 60 to 90%. The procedure is performed
under local anesthesia and is associated with risks because the fiber
optic forceps had less grasping power of a F.B as compared to rigid
bronchoscopy forceps10. In this case although F.B airway was first
diagnosed with fiber optic bronchoscopy but it was retrieved with
help of rigid bronchoscopy under general anesthesia. Bronchoscopy
may have some complication and in this case there was no
complication as the patient recovered from procedure uneventfully
and she was discharged on 3rd day.
CONCLUSION:
It is concluded that although F.B is a rare incidence in adults but it
must be kept in mind while dealing the patient with chronic cough.
Moreover patients should not be subjected to long course of
medication without having justified evidence. Rigid bronchoscopy
has to be adopted for removal of F.B in airway.
REFERENCES:
1. Ngoo Ks, Ramzisham ARM, Joanna OSM and Zamrin DM. Foreign
Body Aspiration in an Adult: The Great Mimic. Med J Malaysia
2008; 63: 61-62.
2. Mahmoud M, Imam S, Patel H and King M. Foreign Body Aspiration
of a Dental Bridge in the Left main Stem Bronchus. Case Reports
aspiration has some association with geo-cultural differences7. F.Bs in Medicine 2012; 1-4 doi: 10.1155/2012/798163.
could be either organic or inorganic. Organic F.B includes seeds, nuts, 3. Dhanasekar T, Rajendran A, Rao KU and Thomas PK. Usual and
vegetables and bones while inorganic F.B includes wood, metallic Unusual Case of Foreign Body in the Bronchus. Int. J. Med. Public
and plastic items. Peanut is the commonest F.B aspiration universally. Health. 2011; 1(2): 37-40.
In children the triad of wheeze, cough and diminished air entry creates 4. Beyan AKZ, Al-Hassani FAA, Kareen DR. Sharp pin inhalation in
high index of suspicion. F.B can get lodge at any site of the respiratory Tracheo-Bronchial tree in women wearing Hijab. J Postgrad Med
tract but right side main bronchus is the dominant site for lodgment Ins 2012; 26(2) 201-5.
as it is wider and straight than left side. Similarly in our patient the F.B 5. Bist SS, Varshney S, Kumar R and Saxena RK. Neglected Bronchial
was found in right main bronchus. Presentation of F.B aspiration in Foreign Body in an Adult. JK SCIENCE 2006; 8(4) 222-24.
adults has a wide range from completely asymptomatic to the 6. Boyd M, Chatterjee A, Chiles C and Chin R Jr. Tracheobronchial
complication of aspiration as compared to children. Unlike those who foreign body aspiration in adults. South Med J. 2009; 102(2); 171-
present with sudden respiratory distress or witnessed by other, F.B 4.
aspiration in adults may remained unnoticed for years, or it may give 7. Aissaoui A, Salem NH and Chadly A. Unusual foreign body
rise to non-specific symptom like chronic cough, haemoptysis and aspiration as a cause of asphyxia in adults: an autopsy case report.
dyspnea8. In this case the main presentation of the patient was long Am J Forensic Med Pathol. 2012; 33(3):284-5.
standing episodic cough. Most of the time F.B airway can be diagnosed 8. Rusydi WZA, Asma A and Goh BS. Hidden foreign body in
clinically, nonetheless Chest X-ray is usually the first line of investigation unexplained asthma. Bangladish J Otorhinolaryngol 2012;
but 6 to 80% of radiographs have negative findings. In this case Chest 18(2):200-202.
X-ray was not helpful in diagnosing F.B as it was radiolucent. Removal 9. Karapolat S. Foreign-body aspiration inadult. Can J Surg.2008;
of F.B is an old concept. Louis removed F.B airway via bronchotomy 51(5):411.
first in 1759 while first endoscopic removal of F.B airway is recorded 10. Asif M, Shah SA, Khan F and Ghani R. Analysis of Tracheobronchial
in1897 and since then bronchoscopy is the gold standard technique foreign bodies with respect to sex, age type and presentation. J
for evaluation of the patient with high index of clinical suspicion of Ayub Med Coll Abbotabad 2007; 19(1): 13-15.
Case R eport
Maliha Kazi
Mubasher Ikram
PRIMARY EXTRACRANIAL MENINGIOMA OF THE
Ramiz Mumtaz SPHENOID SINUS: A HIDDEN MENACE
Sadaf Qadeer
Department of Otolaryngology-Head Abstract:

and Neck Surgery, Extracranial meningioma are infrequent tumours. Here we are discussing a case of 40 years old male
Aga Khan University Hospital, patient who came with chief complain of gradually increasing nasal obstruction for 5 years. Right sided
Karachi, Pakistan facial swelling, anosmia and post nasal drip for 2 years. MRI and CT scan showed soft tissue mass
occupying sphenoid sinus, maxilla and infratemporal fossa. Preoprative biopsy was consistent with
Correspondence to: meningioma. Mass was removed via combine (external and endoscopic) approach. On follow up 6
Maliha Kazi month postoperatively, patient was disease free.
Department of Otolaryngology-Head
and Neck Surgery, K e y W o r d s : Meningioma, Extracranial, Sphenoid sinus
Aga Khan University Hospital
Karachi 75500, Pakistan
email:maliha_kazi@hotmail.com
INTRODUCTION: operatively right total

Tumors of the central nervous system (CNS) are infrequent, but maxillectomy was performed,
meningioma is the one tumor which is encountered most frequently. along with removed of the tissue
Arising from the arachnoid cells of the meninges, they make upto 13- from the right infra-temporal
18% of all intracranial tumors.1 Ectopic meningiomas have been found fossa. Sphenoid disease was
at various anatomic sites. In the head and neck, they have been removed using rigid nasal
reported in the floor of the mouth, nose and paranasal sinuses, as endoscopes. The residual disease
well as in the lungs, retro-peritoneum and thigh.2 It is believed that in and around the sinus was
the arachnoid cells along the peripheral nerves are responsible for removed under microscope to
the origin in these cases.3 In the following section, we describe the ensure adequate and safe
hospital course of a patient who presented with an extracranial excision. The whole cavity was
meningioma involving the sphenoid sinus. then packed with a BIPP (Bismuth
iodoform paraffin paste) soaked
CASE REPORT: ribbon gauze. Post-operatively
A 40 years old male presented in our out-patient department, with a vision was intact. He remained
history of persistent nasal obstruction for a period of 5 years, right vitally stable, the BIPP pack was
sided facial swelling, gradually increasing in size for the past 2 years. removed 48hours after the
He, further on, complained of anosmia and post-nasal drip for the surgery and patient was discharged the next day. On his follow up a
past 2 years. A previous biopsy performed 2 years back was week later, he was stable and 2 months down the road, an MRI scan
inconclusive. On clinical examination, the individual had no lesion or of the paranasal sinuses was carried out, which did showed only mild
mass visible on anterior rhinoscopy or on a rigid nasal endoscopic soft tissue thickening (Fig II). On his recent follow up 6 months later,
examination. There was right sided non-tender facial swelling. Vision patient is free of disease.
and extra-ocular movements were intact. Rest of the ear, nose and
throat examination was un-remarkable. He had a magnetic resonance DISCUSSION:
image performed of his paranasal sinuses which showed a mass Meningiomas are benign tumors representing 13 to 18% of all primary
involving the sphenoid sinus (Fig 1). The patient underwent an intracranial neoplasia. 1 Primary extracranial meningiomas are
endoscopic biopsy from the sphenoid sinus under general anesthesia. histologically identical to intracranial meningiomas. The aetio-
Frozen section favored a pathogenesis is considered to be due to the migration of arachnoid
diagnosis of neoplasm and the cells, derived from the neural crest cells. Apart from that different
final histopathology came out to mechanisms have also been proposed such as; originating from
be Grade I meningioma. The arachnoid cells of nerve sheaths emerging from skull foramina, from
patient was advised surgery in pacchionian bodies possibly displaced or entrapped in an extracranial
collaboration with neurosurgery. location during embryologic development, by trauma or cerebral
He was lost to follow up for 6 hypertension displacing arachnoid islets or,deriving from
months. After 6 months he undifferentiated mesenchymal cells.4
returned with increase in facial
swelling and a computed They usually occur in 40 to 60-year-old patients and are rare in the
tomographic scan showed pediatric age group. Primary extracranial meningiomas represent 1
extension of the disease in the to 2% of all meningiomas.5 Meningioma of the nose and paranasal
maxilla as well as in infra-temporal sinuses may occur as a secondary extension of a primary tumor in the
fossa region. He underwent cranial cavity or primarily in the nose and paranasal sinuses de novo.
surgical excision via a Weber- Fig. I: Disease involving primarily the
Fergusson approach. Intra- sphenoid sinus
Maliha et al: Primary Extracranial Meningioma of the Sphenoid Sinus
The symptoms for involvement of paranasal sinuses are non-specific is a rare entity which requires an adequate diagnosis. This relies almost
and are similar to the symptoms of sinusitis and the involvement of completely on tissue biopsy. Once identified, complete surgical excision
adjacent structures. The most common complaints are nasal discharge, is the curative treatment with a good prognosis and an acceptable
nasal mass and epistaxis. Nasal obstruction, anosmia, headaches and disease free survival. It is, therefore, essential to have basic knowledge
proptosis are also frequent complaints.6 This creates a problem to regarding this pathology.
diagnose based on clinical examination. The differential diagnosis
would then include epithelial neoplasms (carcinoma), melanoma, REFERENCES:
olfactory neuroblastoma and nasopharyngeal angiofibroma. 7 1. Bayar MA, Iplikçioglu C, Kökes F, Gökçek C. Intra-Extracranial
Meningioma. Turkish Neurosurgery 1993; 4: 170 172
The roentgenographic findings are usually nonspecific and include 2. Gökduman CA, Iplikcioglu AC, Kuzdere M, Bek S, Cosar M. Primary
clouding or opacification of the sinuses, bony sclerosis, and focal meningioma of the paranasal sinus. J Clin Neurosci 2005; 12: 832-
destruction of the surrounding sinusoidal or nasal cavity bony tissues.8 834
Despite that, computed tomography helps in demonstrating intra- 3. Deshmukh SD, Rokade VV, Pathak GS, Nemade SV, Ashturkar AV.
tumoral calcification and homogenous contrast enhancement. Primary extra-cranial meningioma in the rightsubmandibular
Magnetic resonance imaging compliments the findings on CT scan region of an 18-year-old woman:a case report. Journal of Medical
imaging by providing relevant information regarding involvement of Case Reports 2011; 5:271
surrounding structures and invasion into the orbit or intracranially.9 4. Serry P, Rombaux PH, Ledeghen S, et al. Extracranial sinonasal
For follow up imaging, either modality can be adopted. On biopsies tract meningioma: a case report. Acta Otorhinolaryngol Bel 2004;58:
taken, histologic features can easily help in differentiating these 151-5
entities from other lesions common in the paranasal sinuses. Where 5. Kainuma K, Takumi Y, Uehara T, Usami S. Meningioma of the
queries regarding differentiating between carcinomas and melanomas paranasal sinus: a case report. Auris Nasus Larynx2007; 34: 397-
arise, immune-histochemical stains prove beneficial. 400
6. Thompson LDR, Gyure KA. Extracranial sinonasal tract
Owing to the proclivity for local permeation through suture lines and meningiomas. Am J Surg Pathol 2000; 24: 640-650
skull foramina, it is easy for meningiomas to spread from one sinus 7. Haber DM, Maniglia MP, Schiavetto RR, Molina FD et al. Primary
to another as well as into the brain. It is still worth mentioning that Meningioma of the Paranasal Sinuses: Case Report. Intl. Arch.
clinical and radiological features cannot predict the nature of these Otorhinolaryngol, 2007;11: 70-73
lesions. 8. Moulin G, Coatrieux A, Gillot JC, et al. Plaque-like meningioma
involving the temporal bone, sinonasal cavities and both
Treatment of primary extracranial meningioma is via a surgical excision parapharyngeal spaces: CT and MRI. Neuroradiology 1994; 36:
as meningiomas are known to be radio resistant. Recurrence is very 62931
rare following adequate surgical resection.10 Most meningiomas are 9. Filho JR, Floriano VH, Felipe LF et al. Clinical-Radiological Aspects
benign with no tendency to metastasize and malignant change is Of Primary Extracranial Meningioma Of The Ethmoid Sinus In A
rare. In general, the prognosis of primary meningioma of the sinonasal Child. Arq Neuropsiquiatr 2008; 66:274-275
tract appears to be excellent.11 Recurrence of disease is usually at the 10. Mair R, Morris K, Scott I, Carroll TA. Radiotherapy for atypical
same anatomical site as the site previously operated for the disease. meningiomas. Neurosurg 2011; 115: 811-819
This, therefore, denotes the presence of residual disease rather than 11. Marzin FA, Carmona GL, Florez MA, Garcia PF. Extracranial
recurrence of the same. Studies have reported little difference in the meningioma of the paranasal sinuses. Acta Otorrinolaringol Esp.
5 year and 10year disease free survivals. Rushing et al reported the 5 2010;61:238-240
year and 10 year disease free survivals to be 91.2% and 90.1% 12. Rushing EJ, Bouffard JP etal. Primary Extracranial Meningiomas:
respectively, thus indicating that once the patients survive disease An Analysis of 146 Cases. Head and Neck Pathol2009; 3 :116130
free for 5 years, they are unlikely to die secondary to it. 12
CONCLUSION:
Primary extracranial meningioma originating from the sphenoid sinus
Medical ed ucation
Shrestha Abha1
Shrestha Bikash2
PATIENTS PERSPECTIVE ON DOCTORS ATTIRE
Amatya Ram Chaya2 Aims & Objective:
Chawla C D1 The main aim of this study is to observe the patients perspective on doctors attire.
Materials and Method:
Department of Obstetrics and This study was carried out among four hundred patients in both department of Gynaecology and
Gynecology, Kathmandu University obstetrics, and otorhinolaryngology in Kathmandu university hospital, Dhulikhel from 1st June to 1st
School of Medical Sciences, Dhulikhel, July 2012. Questionnaires were prepared which contains the demographic data and patients answers
Kavre, Nepal.1 of yes or no to the questions asked. All data were analyzed using SPSS 16.0 software with frequency
and percentage.
Department of ENT-HNS, Results:
Kathmandu University School of About 343(85.8%) patients are below 45 years. The male to female ratio is 0.8:1. About 205(51.2%)
Medical Sciences, Dhulikhel, Kavre, patients had education level of primary/ high school, whereas only 19(4.8%) patients had master degree.
Nepal.2 About 329(82.3%) patients want their doctors to wear white coat. 208(52%) patients think that white
coat is required for identification, whereas 143(35.7%) patients think that it is required for preventing
Correspondence to: infection. All our patients think that nametag is required for identification of the doctor. 290(72.6%)
Dr. Abha Shrestha. patients think that it is required for doctors to wear stethoscope. Most of our patients explained that
Department of Obstetrics and stethoscope is required for patient examination. Similarly, out of 110 patients, 79(71.9%) patients
Gynecology, Kathmadu University explained that the stethoscope may not be required for all doctors.
School of Medical Sciences, Dhulikhel,
Kavre, Nepal. Conclusion:
email: phuche_001@yahoo.com Patient prefers doctors to wear white coat, nametag and stethoscope as these attire gives doctor more
professional look and also easy to identify the treating doctors.
K e y w o r d s : Attire, Nametag, Patients perspective, Stethoscope
INTRODUCTION:
The physicians dress up is one of the important means to increase accomplishing the questionnaires. These records were collected and
patient comfort level during examination, which is vital for high quality analyzed by simple manual analysis using frequencies and percentages
care. Hippocrates believed that physicians must be clean, well-dressed with SPSS 16.0 version
and meet their patients with good mood.1 There had been several
studies regarding patients first impression on physician competence RESULTS:
by their physical appearance.2-4 The study performed by Gooden et The age distribution of patient is as shown in table 1. About 343(85.8%)
al5 showed that the patient feel more confident and better to patients are below 45 years. The mean age of patient was 46.5+/-8.6
communicate with physician who wear white coats. Similarly study (range= 15-78 years)
performed in Maneham and Shvartzman 6 and Anvik7 showed that
the majority of patients prefer physicians to wear white coats. Tab. 1: Age distribution (n=400)
One study conducted by Dunn et al8 showed that 65% of the patients
wanted to see their physician in white coat. Likewise another study Age No. of patients(%)
showed that the name tag were very important for physician attire,9 15-30 238(59.5%)
whereas other study showed that the attire of physician had no
influence on choice of family physician10 or satisfaction.6 Although 31-45 105(26.3%)
there is debate regarding doctors attire and also the patients 46-60 38(9.5%)
perspective on dress code has not been extensively investigated. So, >60 19(4.7%)
this study is conducted.
The male to female ratio is 0.8:1 as shown in tab.2.
The purpose of our study is to observe the patients perspective on
doctors attire. To the best of our knowledge, this is the first study of Tab.2: Sex distribution (n=400)
its kind being carried out in Nepal.
Sex No. of patients(%)
MATERIALS AND METHOD: Male 188(47%)
This cross-sectional study was carried out among four hundred patients Female 212(53%)
who attended the out patient department of both Gynecology and
obstetrics, and otorhinolaryngology in Kathmandu university hospital, About 205(51.2%) patients had education level of primary/ high school
Dhulikhel from 1st June to 1st July 2012 after taking informed consent whereas only 19(4.8%) patients had master degree as shown in tab.3.
from patients. The study was performed in following phases.
Questionnaire were framed, inspired and based on the study Tab. 3: Educational level of patients(n=400)
performed by Douse et al11 and Hathorn et al.12 Regarding the validity
and reliability of the questionnaire, consultation was done with Level of education No. of patients(%)
statistician and the department of community medicine. The survey Primary/High School 205(51.2%)
questionnaires were framed in English and translated into native Certificate 90(22.5%)
Nepali. The questionnaires covered the demographic data and patients
answers of yes or no to the questions of should doctors wear white Baccalaureate 86(21.5%)
coat? Patients were also given the opportunity to qualify the answer Masters 19(4.8%)
by agreeing or disagreeing the suggestions given. Patients were also
asked to answer yes, no or to give their own reason to the questions The tab. 4 showed that about 329(82.3%) patients want their doctors
regarding should doctors wear nametag and stethoscope. Patients to wear white coat.
verbal consent were taken and then instructed clearly before answering
the questionnaire. Uneducated patients were assisted in
Shrestha et al: Patients Perspective on Doctors Attire
Tab. 4: Patients answers regarding the requirement of wearing the Tab. 10: Patients reasons regarding not wearing of stethoscope by
white coat by doctors. (n=400) doctors (n=110)
Level of education Yes(%) No(%) Level of education Cross-infection Not required for all doctors
Primary/High School 150(37.5%) 55(13.7%) Primary/High School 8(7.3%) 40(36.4%)
Certificate 80(20%) 10(2.5%) Certificate 11(10%) 22(20%)
Baccalaureate 80(20%) 6(1.5%) Baccalaureate 12(10.8%) 17(15.5%)
Masters 19(4.8%) 0(0%) Masters 0(0%) 0(0%)
The table 5 showed that 208(52%) patients think that white coat is DISCUSSION:
required for identification whereas 143(35.7%) patients think that it Doctors attire has known to impact patients trust and confidence
is required for preventing infection. for better clinical practice. So, it is important for the doctors to wear
Tab. 5: Patients reasons regarding wearing of white coat by proper dress as careful consideration of attire and labeling forms helps
doctor. (n=400) to improve the patient- doctors relationship. Regarding the age
Level of education Tradition Identification Prevent Professional distribution, most of our patients are within 45 years which is similar
infection look
to study performed by Najafi et al13 and McKinsty and Wang.4
Likewise the distribution of sex and educational status is similar to
Primary/High School 10(2.5%) 134(33.5%) 56(14%) 5(1.2%) study performed by Najafi et al.13 Regarding the wearing of white
Certificate 5(1.2%) 45(11.3%) 35(8.7%) 5(1.2%) coat by doctor, 82.5% of our patients answered that the doctors should
Baccalaureate 0(0%) 29(7.2%) 43(10.7%) 14(3.5%) wear white coat which was similar to study performed by Najafi et
Masters 0(0%) 0(0%) 9(2.3%) 10(2.5%)
al13 and Ikusaka et al.14 Whereas it was differ from the study performed
by Douse et al11 which showed only 56% of patients favoured doctors
The tab. 6 showed that all the patients wanted their doctors to wear wearing white coats. Our study also differ from other different study
nametag. performed at different places.5,8,12,15-17 This vast difference in patient
perspective could be because in our hospital most of patient came
Tab. 6: Patients answers regarding wearing nametag or not by from village areas and they think that doctors should wear white coat.
doctors.(n=400) While asking the patient regarding reasons for wearing white coat,
Level of education Yes No 87.7% of our patients replied that its for identification and to prevent
Primary/High School 205(51.2%) 0(0%) infection which is similar to study performed by Douse et al11, but
several other studies showed that white coats and nurses uniforms
Certificate 90(22.5%) 0(0%) suggest potential risk of bacterial contamination.18-21 The variation
Baccalaureate 86(21.5%) 0(0%) in results could be because patient doesnt know the core risk of
Masters 19(4.8%) 0(0%) contamination of white coat by different organisms while examining
the patients. Similarly, 8.7% of our patients replied that wearing of
All our patients think that nametag is required for identification as white coats provide professional look which is similar to study
shown in tab. 7. performed by Gooden et al5 but differ from the study performed by
Palazzo and Hocken22 which showed 93% of patients replied as
Tab.7: Patients reasons regarding wearing of nametag by professional look. The difference could be because of different opinions
doctors (n=400) of patients in different countries, time period of study and also
Level of education Identification educational status of patients.
Primary/High School 205(51.2%)
Regarding the wearing of nametag, all our patients answered that
Certificate 90(22.5%) the doctors should wear name tag and all of them answered that it
Baccalaureate 86(21.5%) is required for identification. Results of our study somehow similar to
Masters 19(4.8%) that performed by Keenum et al23 and Najafi et al13. The reason could
be because our patients are very curious in knowing the treating
As shown in the table 8 290(72.6%) patients think that it is required physian name. Regarding the wearing of stethoscope, 72.6% of our
for doctors to wear stethoscope. patients, mainly well educated, replied that doctors should wear
Tab. 8: Patients answer regarding the requirement of wearing the stethoscope which is similar to study performed by Keenum et al23
stethoscope by doctor. (n=400) 79.3% of our patients, who were mostly well educated, gave the
reason that it is required for patients examination while rest replied
Level of education Yes No that it is required for identification. Reasons regarding not wearing
Primary/High School 157(39.3%) 48(12%) stethoscope, our patients replied that it causes cross infection and it
Certificate 57(14.3%) 33(8.2%) may not be required for all the doctors. This differ in results could be
because of study conducted in 2 different deparments where in one
Baccalaureate 57(14.3%) 29(7.2%) department stethoscope is frequently used and in other department
Masters 19(4.7%) 0(0%) it is not. The size of our study group is well enough to provide a good
cross-section and sufficient power to make small differences. Even
Out of 290 patients, 230(79.3%) patients explained that stethoscope then the limitation of our study is that, this finding could not be
is required for patient examination as shown in table 9. generalised to all OPD patients and also In patients. So, it is require
Tab. 9: Patients reasons regarding wearing of stethescope by to perform study in all Out patients and in patient departments of
doctors(n=290) hospital.
Level of education Identification Patient
CONCLUSION:
examination Patient prefers doctors to wear white coat, nametag and stethescope
Primary/High School 50(17.3%) 107(36.9%) as these attire gives doctor more profesional look and also easy to
Certificate 7(2.4%) 50(17.3%) identify the treating doctors.
Baccalaureate 2(0.7%) 55(18.9%) REFERENCES:
Masters 1(0.3%) 18(6.2%) 1. Hippocrates, Harvard University Press, Cambridge.Massachusetts
1923; 2: 311-12.
Similarly, out of 110 patients,79(71.9%) patients explained that the 2. Taylor PG. Does the way housestaff physicians dress influence the
stethoscope may not be required for all doctors as shown in table 10.
way parents initially perceive their competence? Paediatr notes
1985;9:1.
Shrestha et al: Patients Perspective on Doctors Attire
3. Dunn JJ,Lee TH,Percelay JM,Fitz JG,Goldman L. Patient and house

14. Ikusaka M, Kamegai M, Sunaga T, Narita N, Kobayashi H,
officer attitudes on physician attire and etiquette. JAMA
YonenamiK, et al. Patients attitude toward consultations by
1987;257:65-68.
physician without a white coat in Japan. Intern Med 1999; 38: 533-
4. McKinstry B, Wang JX. Putting on the style: what patients think of
6.
the way their doctor dresses. Br J Gen Pract 1991;41:270,275-278
15. Harnett PR. Should doctors wear white coats? Med J Aust
5. Gooden BR, Smith MJ, Tattersall SJ , Stockler MR. Hospitalised
2001;174:3434.
patients views on doctors and white coats. Med J Aust 2001; 175:
16. Tiwari A, Abeysinghe N, Hall A, et al. Should doctors wear white
219-22.
coats? The patients perspective. J Eval Clin Pract 2001;7:3435.
6. Maneham S, Shvartzman P. Is our appearance important to our
17. Dover S. Glasgow patients attitude to doctors dress and
patients? Fam Pract 1998;15:391-97.
appearance. Health Bull (Edinb), 1991;49:2936.
7. Anvik T. Doctors in a white coat: what do patients think and what
18. Babb JR, Davies JG, Ayliffe GA. Contamination of protective clothing
do doctors do? Scand J Prim Health Care 1990;8:91-94.
and nurses uniforms in an isolation ward. J Hosp Infect
8. Dunn JJ, Lee TH, Percelay JM, Fitz JG, Goldman L. Patient and
1983;4:14957.
house officer attitudes on physician attire and etiquette. JAMA
19. Grys E, Pawlaczyk M. Does a physicians apron protect against
1987; 257: 65-8.
nosocomial infection? Ginekol Pol 1996;67:30912.
9. Gjerdingen DK, Simpson DE. Physicians attitude about their
20. Loh W, Ng W, Holton J. Bacterial flora on the white coats of medical
professional appearance. Fam Pract Res J 1989; 9: 57-64.
students. J Hosp Infect 2000;45:658.
10. Gjerdingen DK, Simpson DE, Titus SL. Patients and physicians
21. Wong D, Nye K, Hollis P. Microbial flora on doctors white coats.
attitudes regarding the physicians professional appearance. Arch
BMJ 1991;303:16024.
Intern Med 1987; 147:1209-12.
22. Palazzo S,Hocken DB. Patients perspectives on how doctors dress.
11. Douse J,Derrett-Smith E,Dheda K,Dilworth JP. Should doctors wear
J Hosp Infect. 2010 Jan;74(1):30-4.
white coats? Postgrad Med J2004 May;80(943):284-6.
23. Keenum AJ, Wallace LS, Stevens LR. Patients attitudes regarding
12. Hathorn IF, Ross SK, Cain AJ. Ties and white coats , to wear or not
physical characteristics of family practice physicians. South Med
to wear? patients attitude to doctors appearance in the
J 2003; 96: 1190-4.
otolaryngology outpatient clinic. Clinic Otolaryngol 2008;33:505-
506.
13. Najafi M, Khoshdel A, Kheiri S. Preferences of Iranian patients
about style of labeling and calling of their physicians. J Pak Med
Assoc 2012;62: 668-71.
Revie w Art i c l e
Neupane Yogesh1
Basnet Meenakshi2
ENDOSCOPIC MANAGEMENT OF
Pradhan Bibhu1 FRONTO-ETHMOIDAL SINUS MUCOCELE
Ganesh Man Singh Memorial
Academy of ENT-Head & Neck Aims & Objective:
Studies, Tribhuvan University Teaching The aim of this study was to present the efficacy of endoscopic sinus surgery for management of fronto-
Hospital, Institute of Medicine, ethmoidal sinus mucocele.
Kathmandu, Nepal.1
Material and Methods:
Nobel Medical College A prospective, longitudinal, observational study of seven patients with clinical and radiological evidence
Biratnagar, Nepal.2 of mucocele of fronto-ethmoidal area from June 2008 to June 2009 and who underwent endoscopic
wide marsupialization of mucocele cavity with or without fronto-ethmiodectomy were included in the
Correspondence to: study.
Dr Yogesh Neupane, Department of
ENT - Head & Neck Surgery Results:
Ganesh Man Singh Bhawan Duration of symptoms ranged from 25 days to 1 year. Most common symptoms were swelling in
TU Teaching Hospital, Kathmandu, supero-nasal, medial canthal region, infero-lateral eye displacement. Majority of patients had soft to
Nepal. hard swelling in periorbital region and non axial proptosis. One patient had lid ptosis and two patients
email: yogeshneupane@hotmail.com still complained of diplopia after surgery. Postoperative endoscopy revealed widely opened sinus cavity
with epithelisation of mucosa without sign of recurrence in all the cases.
Conclusion:
Endoscopic marsupialization with drainage through nasosinusal approach proved to be safe and
efficient procedure in therapeutic approach of frontoethmoidal mucocele.
K e y w o r d s : Mucocele, Endoscopic, Marsupialization, Frontoethmoidal
INTRODUCTION: with involvement of paranasal sinus other than fronto-ethmoidal

Mucocele first described by langenbeck in 1818, is an epithelial lined, region, coexisting other pathology like polyp and with history of
mucous containing sac completely filling the sinus and capable of previous surgery for mucocele were excluded from study. All patient
expansion.1 A clinically significant mucocele most commonly originates underwent endoscopic wide marsupialization of mucocele cavity with
in the frontoethmoidal sinus.2 Frontoethmoidal areas are most or without fronto-ethmiodectomy by single surgeon. No stent were
susceptible to mucocele formation due to complexity of its drainage kept in all the cases. The aspirated fluid was send for culture and lining
as compared to sphenoid and maxillary sinuses. Mucocele are usually mucosa for histopathological examination. Postoperatively all patients
unilateral but in five percent cases they are bilateral and/or were given oral cefexime according to body weight and were advised
multiloculated. In at least a third of cases they occur without an to douche the nasal cavity with normal saline twice daily both for two
obvious predisposing factor but in remaining cases predisposing weeks. Patients were evaluated at 2 weeks, 2 months and 6 months
factors are infection, polyps, trauma and allergic rhinitis.3 There are following surgery. Study variable noted were age, sex, sinus/side
conflicts among author concerning the etiology of mucocele. 2,4 Some involved, duration of symptoms, past history, physical finding,
suggest they develop from obstruction of sinus ostium whereas other proptosis, intracranial extension, postoperative complication and
believe that mucocele formation occurs when there is obstruction of follow-up endoscopic finding.
duct of minor salivary glands located within the lining of paranasal
sinus.4 Either mechanism they result as a consequence of obstruction RESULTS:
plus inflammation. Total of seven patients were included in the study. There were five
male and two female. Age of patient ranged from 24 years to 70 years.
The diagnosis of mucocele is based on the history, physical examination Out of seven patients with mucocele, four were frontoethmoidal, two
and radiological findings. Fronto-ethmoidal mucocele usually present were ethmoidal and one was frontal sinus mucocele. In five patients
with orbital symptoms of infero-lateral eye displacement, lid edema, right side and in two patients left side sinus were involved. Duration
swelling in supero-nasal and medial canthal region, diplopia, proptosis, of symptoms ranged from 25 days to 1 year ( Table 1).Most common
ptosis, palpable mass, reduced vision, orbital pain and headache.1 symptoms swelling in supero-nasal, medial canthal region, infero-
Computed tomography (CT) scan and magnetic resonance imaging lateral eye displacement, increased lacrimation, headache, blurring
(MRI) are effective in detecting the lesion and in demonstrating any of vision in decreasing frequency respectively. No nasal symptoms
intracranial extension.5 Several treatment options are available and were noted in any of the patients. Majority of patients had soft to
choice depends on the degree of extension6 and may range from hard swelling in periorbital region. Similarly five patients had non
functional endoscopic sinus surgery to external approach, craniotomy axial proptosis and two had no orbital displacement. CT scan showed
and craniofacial exposure with or without obliteration of the sinus. 7 radiological finding compatible with mucocele in all cases. Culture of
The current tendency is to conduct functional, minimal invasive and aspirated fluid showed no microorganism or fungi. Histopathological
low morbidity procedure with nasosinusal endoscopic surgery with examination was suggestive of mucocele in all patients. Mean follow-
marsupialization and abundant drainage of the lesion, preserving the up time was 4.5 months. Table 2 shows that one patient had history
epithelium.9 The aim of this study was to present the efficacy of of trauma two years prior to symptoms. One patient still had lid ptosis
endoscopic sinus surgery for management of fronto-ethmoidal sinus four month post surgery. Two patients still complained of diplopia
mucocele. six month after surgery. Postoperative endoscopy revealed widely
opened sinus cavity with epithelisation of mucosa without sign of
MATERIAL AND METHODS: recurrence in all the cases. (Table 2)
A prospective, longitudinal, observational study was conducted at
Department of ENT- Head and Neck surgery of Ganesh Man Singh DISCUSSION:
Memorial Academy of ENT- Head and Neck Studies, Tribhuvan A mucocele is an epithelial lined mucous containing sac completely
University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal filling the sinus and is capable of expansion. They tend to expand,
from June 2008 to June 2009. We included patient with clinical and remodel and reabsorb bone wall of affected paranasal sinus, changing
radiological evidence of mucocele of fronto-ethmoidal area. Patient their integrity and occasionally affecting the neighbouring structure
Neupane et al: Endoscopic Management of Fronto-ethmoidal
Sinus Mucocele
Tab. 1: Showing age, sex, site and sinus involved, duration of Tab. 2: Showing past history, operative finding,
symptoms, finding, proptosis, and IC extension post operative complication and follow up endoscopy
SN Age/Sex Sinus/Site Duration Finding Proptosis IC S.N. Past Operative finding Postoperative Follow up
of Extension history complication endoscopic
symptoms finding
1 41/M Right 1 year 3x3 cm Non axial Absent 1. None Edematous ethmoidal Lid ptosis Widely opened
Frontal Swelling air cell mucosa. Thick sinus cavity with
over Rt dark fluid in frontal epithelization
upper lid sinus.
2 70/F Right 6 months 1x1 cm None Absent 2. None Thick straw colored fluid None Widely opened
Fronto- swelling in frontal and ethmoid sinus cavity with
over Rt sinus. Kuhns type I frontal epithelization
ethmoid supraorbital cell present
region
3 24/M Right 3 months None None Absent 3. None Thick amber colored fluid None Widely opened
in ethmoid sinus. Middle sinus cavity with
Ethmoid epithelization
turbinate and uncinate
4 60/M left 1 year 5x4 cm Non axial Present absent
Fronto- swelling
ethmoid over Lt
supraorbital 4. Trauma Thick tenacious green- Diplopia Widely opened
region 2 years yellowish fluid in ethmoid sinus cavity with
back and frontal sinus. Posterior epithelization
5 30/M Right 25 days 5x.5 cm Non axial Absent wall of frontal sinus
dehiscent , dura intact
Fronto- swelling
ethmoid over Rt 5. None Thick grayish fluid Diplopia Widely opened
medial sinus cavity with
canthal in frontal and
ethmoid sinus epithelization
region
6. None Dark Greenish None Widely opened

6 37/M Left 2 months None Non axial Absent tenacious fluid in sinus cavity with
Ethmoid ethmoid sinus epithelization
7 30/M Right 9 months 2x2 cm Non axial Absent

7. None Thick grayish fluid in None Widely opened
Fronto- swelling sinus cavity with
ethmoid above and frontal and ethmoid sinus
epithelization
medial to
Lt
medial epithelium. Intranasal marsupialization of mucocele was reported as
canthus early as 1921 by Howarth, who stated that by removing the floor of
extending mucocele, one practically makes the mucocele a part of roof of nose.15
to frontal Endoscopic marsupialization of frontal sinus mucocele was first
sinus reported by Kennedy et al. in 1989.14 In our study also we found no
sign of recurrence of mucocele during our follow up period. Kennedy
NB. IC= intracranial et al. in a series of 18 mucocele found endoscopic surgical technique
such as the orbit and intracranial cavity.10 Mucocele expands in the successful with no recurrence. Similarly Har-EI G17 in their study of
direction of least resistance, frontal and ethmoidal mucocele tends 103 with 108 paranasal sinus mucocele treated with wide endoscopic
to erode the thin bone of superior and medial orbital wall extending marsupialization found a very low recurrence rate of 0.9% after mean
into orbit displacing the globe infero-laterally.11 Vicente et al,12 found follow up of 4.6 years. Khong et al.18 in their study of 41 patients with
that disease has equivalent incidence in men and women but in our mucocele found that long term results of modified endoscopic Lothrop
study we had more male patients which may be due to small sample procedure and endoscopic marsupialization were similar. Lund8 in a
size. In our study we found age of patients ranged from 24-70 years series of 48 patients found the recurrence rate to be 0% in the
with mean age being 41.71 years. Vicente et al,12 found mucocele endoscopic group and 11% in the combined endoscopic and external
normally affects people on their 3rd and 4th decade but James et al,11 group during mean follow up of 39 months. Kennedy et al.14 in a
found highest incidences in 4th to 7th decade of life. Patients with series of 15 case treated by endoscopic fontoethmoidectomy found
mucocele in frontoethmoidal region present with orbital symptoms13 0% recurrence during follow up period of 3-42 months.
similar to our study. Considerable time lag between the initiating Complications of endoscopic surgery for mucocele are minimal.
factor and the clinical presentation of mucocele occur, in the case of Though there is potential risk of haemorrhage, CSF leak, and/or orbital
surgery or trauma this is an average of 23 years3. In one of our case damage but in practice this has not been reported. In our study we
it occurred 2 years after trauma. found one case of lid edema and two cases of persistence of diplopia
postoperatively. As these were persistence of symptoms they were
Treatment of mucocele is surgical. There are two modes of operative not taken as complication of surgery. The advantage of endoscopic
treatment; external and endonasal. External approach in made through procedure is the preservation of bony framework of sinus involved,
Lynch-Howarth external fronto-ethmiodectomy with or without decrease operative time, no external incisions, decrease hospitalization
placement of stent or by osteoplastic flap with or without frontal sinus and thus the surgical cost. With this approach the mucosal lining and
obliteration and total excision of mucosa. These procedures have function of the sinus are preserved and following surgery direct
significant surgical morbidities including scarring, cosmetic deformities endoscopic visualization of the area enables accurate follow up.
and paresthesia.14 Furthermore, obliterative procedure may make Patients with mucocele require long term follow up since recurrence
follow up difficult because of the inability to visualize the cavity of mucocele may occur even years after surgery.
endoscopically and difficultly in imaging recurrent disease14. Second
approach is endonasal approach with marsupialization and abundant CONCLUSION:
drainage by creation of new drainage pathway and preserving the Functional endoscopic surgery affords the potential for dramatically
reducing operative morbidity of surgery for paranasal sinus mucocele
by offering a minimal invasive approach and also direct endoscopic
visualization of the area enables accurate follow up. There is increasing
evidence in the literature that endoscopic management of sinus
Neupane et al: Endoscopic Management of Fronto-ethmoidal
Sinus Mucocele
mucocele is successful, with low morbidity rates and recurrence. 9. Bussaba NY, Salman SB, Maxillary sinus mucoceles: clinical
Endoscopic marsupialization with drainage through nasosinusal presentation and long term results of endoscopic surgical
approach proved to be safe and efficient procedure in therapeutic treatment. laryngoscocpe. 1999: 1446-9
approach of frontoethmoidal mucocele. Otorhinolaryngologist 10. Lund VJ, Henderson B, Jong Y. Involvement of cytokines and
should consider the endoscopic approach as the surgical procedure vascular adhesion receptors in the pathology of fronto-ethmoidal
of choice for management of frontoethmoid mucocele. . mucocele. Acta Otollaryngol. 1998; 113; 540-5
11. ames E, Dutta A, Swami H, Ramakrishnan R. Frontal mucocele
REFERENCES: causing unilateral proptosis. MJAFI. 2009;65:73-74
1. Natvig K, Larsen TE. Mucocele of paranasal sinuses. Journal of 12. Vicente AO, Chaves AG, Takahashi EN, Akaki F, Sampaio AA,
Laryngology and otology.1978; 92: 1075-082. Matsuyama C. Frontoethmoidal mucocele: a case report and
2. Stiernberg CM, Bailey BI, Calhoun KH, Quinn FB. Management of literature review. Rev Bras Otorrinolaringol.2004; 70(6)
invasive frontoethmoidal sinus mucoceles. Arch Otolaryngol Head 13. Lund VJ, Rolfe ME. Ophthalmic consideration in frontoethmoidal
Neck surg. 1986; 112: 1060-3 mucoceles. J of Laryngology and otology.1989;103:667-9
3. Lund VJ. Anatomical consideration in the aetiology of fronto- 14. Kennedy DW, Josephson JS, Zinreich SJ, Matrox DE, Goldsmith
ethmoidal mucoceles. Rhinology. 1987; 25: 83-8 MM. Endoscopic sinus surgery for mucoceles. Laryngoscope
4. Aydin E, Akkuzu G, Akkuzu B. Frontal mucocele with an .1989;99:885-95
accompanying orbital abscess mimicking a fronto-orbital 15. Stamberger H. Functional endoscopic sinus surgery. Philadelphia.
mucocele: a case report. BMC Ear Nose and Throat Disord 2006; Pa:B.C. Decker, 1991: 365-7
6:6 16. Moriyama H, Nakajima T, Honda Y. Studies on mucoceles of
5. Cansiz H, Yener M, Giveny MG, Canbaz B. Gaint frontoethmoid ethmoid and sphenoid sinuses: analysis of 47 cases. Laryngol Otol.
mucocele with intracranial extension: case report. Ear Nose Throat 1992;106: 23-27
J.2003; 82: 50-2 17. Har-EI G. Endoscopic management of 108 mucocele. Laryngoscope
6. Koike Y, Takara K. Chiha Y, Suzuki SI, Mlirai M, Ita H. Intracranial . 2000; 111:2131-4
extension of paranasal sinus mucocele: two case reports. Surg 18. Khong JJ, Malhotra R, Selva D, Wormald PJ. Efficacy of endoscopic
neurol J.1996; 45: 44-8. sinus surgery for paranasal sinus mucocele including modified
7. Weitzel EK, Haller LH, Calzada G, Manalids S. Single stage endoscopic Lothrop procedure for frontal sinus mucocele. Journal
management of complex fronto-orbital mucocele. J craniofac of larynology and otology. 2004; 118: 352-6
Surg. 2002; 13: 739-45
8. Lund VJ. Endoscopic management of paranasal sinus mucoceles.
Journal of Laryngology and otology.1998;112:36-40
How I D o it ?
Pradhan Bibhu
ENDOSCOPIC MARSUPIALIZATION OF FRONTO
Ganesh Man Singh Memorial
Academy of ENT - Head & Neck
ETHMOIDAL MUCOCELE
Studies, Tribhuvan University
Teaching Hospital, Institute of
Medicine, Kathmandu, Nepal.
Abstract:
Correspondence to: Mucocele is a chronic, expansile, benign cystic lesion of the mucosa of the paranasal sinuses, with thick
Prof. Bibhu Pradhan translucent mucous sectretions. Although considered a benign lesion, the expansile character of the
Unit chief, Rhinology & Allergy Unit mucocele promotes slow erosion of the adjacent bone due to compression and consequent bone
Department of ENT-HNS absorption.Fronto ethmoidal mucoceles are ideal cases for endoscopic marsupialization. Sharing here
Ganesh Man Singh Bhawan is the experience of 15 cases of endoscopic marsupialization of fronto ethmoidal mucocele without use
T.U.Teaching Hospital of stent.
Kathmandu, Nepal
email: bibhuduga@yahoo.com K e y w o r d s : Fronto ethmoid mucocele, Endoscopic marsupialization.
Mucocele is a chronic ,expansile,benign cystic lesion of the mucosa may cause a cosmetic defect. Nose was packed with BIIP pack.
of the paranasal sinuses with thick translucent mucus secretion. It is Antibiotics was continued for 10 days. Patient went home on 3rd POD.
believed that this disease is secondary to obstruction to sinus drainage Patient was evaluated in ENT OPD after 1 week to check the patency
leading to stagnation of the secretion within the cavity. The of the sinuses. After that ,they were asked to follow up after 1 month,
predisposing factors can be fractures , mucosal oedema, polyps,tumors, 3months,1 year,16 months to check the patency of the sinus opening.
surgical trauma and chronic sinusitis. Mucocele are classified according
to the sinus of origin.The frontal sinus is the most common site,
followed by the ethmoid , maxillary and sphenoid sinus. Fronto 15 patients of fronto ethmoidal mucocele diagnosed clinically and
ethmoid and sphenoid sinus mucoceles are ideal cases for endoscopic confirmed by CT Scan underwent endoscopic marsupialization. All 14
marsupialization. Mucocele accessible with the endoscope should be patients did well till 16 months of follow up. Only 1 patient who had
opened as widely as possible using through cut forceps, inorder to extensive frontal sinus involvement with complete erosion of anterior
minimize the amount of scar tissue that forms around the edges and table of frontal sinus had two times recurrence after endoscopic
which might lead to recurrences. Coronal CT Scan is helpful to show marsupialization, so that cases was stented after second operation.
whether the lesion can be approched via the nasal cavity and also to
know whether the lesion is uni or multilocular. In the frontal sinus, The majority of the mucocele can be marsupialized endoscopically
lateral extension of the mucocele may be difficult to access by with minimal morbidity and with long term result that are as good as
endoscopic alone and may need combined approach. done by the conventional external approach. Mohammadi et al had
performed endoscopic marsupialization of fronto ethmoidal mucocele
Except for few patients ,most of the patients were referred from the in 18 patients and had no recurrence till 17 months of follow up.
department of Ophthalmology as they presented with proptosis. Khang. et al performed marsupialization of 41 mucocele and had no
Thorough clinical examination including endoscopic examination of recurrence till 41 months of follow up. The wider the mucocele is
the nasal cavity was done. All patients underwent CT Scan evaluation marsupialized the better is the result. Extensive mucocele like extensive
by both coronal and axial sections. This helped us to know the exact destruction of frontal bone or laterally extended frontal sinus mucocele
location and extension and the bony erosion by the mucocele like may require combined approach both by endoscopic and external
lamina papyracea, roof of the frontal sinus or lateral extension into approach and may need stenting.
the frontal sinus. Patients were admitted one day prior to operation
and intravenous antibiotic was started. Surgery was performed under So, endoscopic marsupialization is the treatment of choice for fronto
general anesthesia. 2% xylocaine with adrenaline was injected at the ethmoidal mucocele, as it is simple procedure causing less morbidity,
axilla of the middle turbinate and on the ethmoid bulla . Adrenaline short hospital stay, without external scar and without stenting which
pack was kept in the middle meatus. Initially 0 degree endoscope is very unpleasant for the patient as the stent needs to be kept for 4
was used. Uncinectomy was done using backbiting forceps and middle weeks.
meatal antrostomy was performed. Bulla was opened inferomedially,
proper anterior ethmoidectomy was performed.Basal lamella of the REFERENCES:
middle tubinate identified and punctured to enter the posterior 1. Balwant Singh Gendeh. Extended applications of Endoscopic
ethmoidal cells. Then the frontal recess was opened.The endoscope sinus surgery and its reference to cranial base and pituitary
was changed to 70 degree. Frontal sinus was located with the help fossa.Indian Journal of otoaryngology and Head & Neck
of frontal curette and the ostium was enlarged with frontal mushroom surgery.2010; 62: 264-276.
and giraffe. The wider the mucocele is marsupialized the better is 2. Kennedy DW,Josephson JS, Zinreich SJ,Mattox DE, Goldsmith MM
the result. After adequate marsupialization the sinus cavity was washed (1989) Endoscopic Sinus Surgry for mucocele : A variable
with Betadine. No stenting was used required. Once the frontal and alternative.Laryngscope 99; 885 889.
or ethmoid mucocele has been marsupialized, the expanded shellof 3. Natvig K ,Larsen TE .Mucocele ofthe paranasal sinuses .Journal of
bone was pushed manually in order to correct any bony swelling that laryngology and otoogy. 1978; 92: 1075 -1082.
Pradhan : Endoscopic Marsupialization of Fronto Ethmoidal Mucocele
4. Mohammadi G.Sayyah Meli MR.Naderpour M. Endoscopic surgical the pathogenesis of fronto ethmoid mucocele. Acta Otolaryngol.
treatment of paranasal sinus mucocele.Medical journal Malaysia 1988; 106: 145- 151.
2008;63: 39 - 40. 9 Lund VJ.Anatomical considerations in the etiology of the fronto
5 Kama IG,Kim SJ, Jun JH,Paik JY, Woo JH, Cho HE, Chi MJ, Jin SM ethmoid mucocele.Rhinology 1987; 25: 83 88.
.Effect of Endoscopic marsupialization of paranasal sinus mucocele 10 Koike Y, Takara K.Chiha Y, Suzuki SI, Mlirai M, Ita H. Intracranial
involving orbit. Europian Arch.Otorhinolaryngol 2013; 5:43-46. extension of paranasal sinus mucocele: Two case report. Surg.
6. Khung.JJ, Malhotra R, WarmaldPJ. Efficacy of Endoscopic sinus Neurol J 1996; 45: 44 48.
surgery for paranasal sinus mucocele including modified 11 Weitzel EK, Haller LH, Calzada G,Manalids S. Single stage
endoscopic Lothrop procedure for frontal sinus. Journal of Laryngol management of complex fronto orbito mucocele. J craniofac
otol 2004; 118(5):352- 326. Surg. 2002; 13:739 - 745.
7. Chih Chen Tseng, Ching yin Ho,Shu- Ching Kao. Ophthalmic
manisfestation of paranasal sinus mucocele.Journal of Chinese
Medical Association.2005: 68 (6); 260 264.
8 Lund VJ , Harvey W, Meghji S,Harris M.Prostaglandin synthesis in
Book Review
Baskota Dharma Kanta
STELL & MARANS TEXT BOOK OF HEAD AND NECK
SURGERY AND ONCOLOGY: FIFTH EDITION
In 2012, fifth-edition of Stell and Marans Text book of Head and Neck The fundamental part of this book is, it targets to update professionals
Surgery and Oncology arrived in the medical community of the world on recent development in molecular biology, new methods in
after 40 years of its inception and 10 years of its previous edition, pathological diagnosis, advances in chemo-radiation, minimally
which fulfilled the long waited desire of specialists, working in this invasive surgeries and new techniques in reconstruction in Head and
field. No doubt, this is a comprehensive book of Head and Neck Neck region providing aesthetic value in depressed cancer patients.
Surgery and Oncology where 116 well renowned specialists of the It is important to mention it here that A personal prospective written
world, working in this field contributed. It has got six parts; each part by living martyrs of this field; Arnold Maran, is one of the unique and
is edited by a separate section editor and contains 1156 pages. important topics which reflects the difficulties and struggles done by
our seniors to establish this subspecialty in the field of medical sciences
The important part of this book is, it is an illustrated book containing and to bring this subspecialty at this stage. Both of the editors of this
original photographs of the patients, reports of investigations, book are also well known clinical practitioners and researchers of this
procedures and outcomes of the provided treatment. Each topic is field, whose contributions along with contributions of other scholars,
full of information with its history, practices in the past, recent advances professionals and experts are reflected in every topic of this book due
in this field and future prospective too. At the end of each topic, to which this book became a comprehensive book of Head and Neck
information is summarized in a separate box which in fact is very easy Surgery and Oncology.
to grapes the information provided in the entire text. Two important
topics like endocrinology and reconstructions are added in this edition,
which are also quite beneficial for the overall management of Head
and Neck Cancer Patients including their quality of life.
I nst ru c t i o n fo r A u t h o r s
INSTRUCTION FOR AUTHORS
Nepalese Journal of ENT Head and Neck Surgery (Nepalese J ENT Head Review Board waived the need for informed consent. Before your
Neck Surg) is a biannual official publication of Society of submission can be sent out for peer review, it is necessary that you
Otolaryngologists of Nepal. address this issue of institutional review approval. This is in accordance
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Submit paper in accordance with these instructions for a quick requirements for manuscripts submitted to biomedical journals. Please
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ENT Head Neck Surg. section confirming approval by the Institutional Animal Care and Use
The manuscript is reviewed for publication in the Nepalese J ENT committee and that the care and handling of the animals were in
Head Neck Surg on the understanding that it has not been submitted accord with National Institutes of health Guidelines or another
simultaneously to another journal, has not been accepted for appropriate internationally recognized guidline for ethical animal
publication elsewhere or has not already been published. On treatment.
acceptance, a manuscript becomes the copyright of the Nepalese J
ENT Head Neck Surg. Manuscripts are subjected to peer review (two MANUSCRIPTS MUST BE SUPPLIED AS FOLLOWS:
anonymous peer reviewers) but the Editor-in-chief reserves the right The articles should adhere to the following format; text should be in
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this time. The Nepalese J ENT Head Neck Surg accepts the criteria for
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to biomedical journals" as published by International Committee of at www.solnepal.org.np
Medical Journal Editors (ICMJE) www.icmje.org. or email your article at yogeshneupane@hotmail.com
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P Adhikari. Pattern of ear diseases in rural school children: Experiences
of free health camps in Nepal. Int J Paediatric Otorhinolaryngol 2009;
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Weymuller EA, Gal TJ. Neoplasm, In Cummings CW editor.
Otolaryngology Head and Neck Surgery. (4th ed). Pennsylvania: Elsevier
Mosby 2005: 1212.
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Vol. 3, No. 2, Issue 2 (July - Dec.

2012) A Peer Reviewed Journal

Editorial Advisory Board

International Advisory Board

Executive Committee of SOL Nepal

Sudden Sensorineural Hearing Loss: Clinical Characterization of Patients 2

Vallecular Cysts in Adult Population: Ten Year Experience 5

Linguistic Profile Test (LPT) in Nepali Language 8

Treatment Outcomes of Laryngeal and Hypopharyngeal Squamous Cell Carcinomas

Clinical and Bacteriological Study of Chronic Suppurative Otitis Media by

A Screening Picture Speech Identification Test for Nepali Speaking Children 15

An Unusual Presentation of Thyroid Gland Carcinoma: A Case Report 17

Unique Foreign Body Chest Diagnosed Incidentally 19

Primary Extracranial Meningioma of the Sphenoid Sinus: A Hidden Menace 21

Patients Perspective on Doctors Attire 23

Endoscopic Management of Fronto Ethmoidal Sinus Mucocele 26

Endoscopic Marsupialization of Fronto Ethmoidal Mucocele 29

INSTRUCTION FOR AUTHORS 32

K e y w o r d s : Sudden Sensorineural Hearing Loss, Pure tone audiogram, Steroids.

K e y w o r d s : Vallecular cysts, LASER, Tracheostomy, Epiglottic cysts

INTRODUCTION: epiglottis leaving the

Out of 21 cases lingual surface of the epiglottis was the commonest

K e y w o r d s : LPT, Phonology, Syntax, Semantics

K e y w o r d s : Bacteriological Study, Chronic Suppurative Otitis Media, Culture

Department of Otolaryngology-Head Abstract:

INTRODUCTION: operatively right total

3. Dunn JJ,Lee TH,Percelay JM,Fitz JG,Goldman L. Patient and house

K e y w o r d s : Mucocele, Endoscopic, Marsupialization, Frontoethmoidal

INTRODUCTION: with involvement of paranasal sinus other than fronto-ethmoidal

6. None Dark Greenish None Widely opened

7 30/M Right 9 months 2x2 cm Non axial Absent

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Patients Perspective on Doctors Attire 23

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