An International Journal of Otorhinolaryngology Clinics

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2021 | September-December | Volume 13 | Issue 3

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Editors’ Speak

Bachi T Hathiram, Vicky S Khattar

Aerodigestive Tract Disorders

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:1] [Pages No:iv - iv]

   DOI: 10.5005/aijoc-13-3-iv  |  Open Access | 



Lovneesh Kumar, Sampan S Bist, Gunjan Dhasmana, Alpa Gupta, Vinish K Agarwal, Swati Pant

Clinical Profile and Predictors of Outcome in Patients with Diphtheria in a Tertiary Care Center

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:5] [Pages No:77 - 81]

Keywords: Albert stain, Antidiphtheric serum, Diphtheria, Immunization, Membrane over tonsil, Suspected diphtheria

   DOI: 10.5005/jp-journals-10003-1398  |  Open Access |  How to cite  | 


Introduction: Diphtheria, a potentially fatal upper airway infection, caused by Corynebacterium diphtheriae, still continues to be significant cause of morbidity and mortality in India, despite extensive immunization. Aims and objectives: This article aims to generate information about the clinical profile of patient of diphtheria in present times, assess association between immunization and severity of the disease and evaluate predictors that affect final outcome of the disease. Materials and methods: This is a retrospective study from June 2017 to June 2020 at a tertiary care teaching hospital. The relevant data of 33 cases who were either suspected or confirmed cases of diphtheria, were analyzed with respect to demographic details, clinical features, immunization status, treatment provided, complications, and final outcome. Results: Out of 33 cases, 72.7% were of age more than 5 years. Eighteen (55%) were nonimmunized, 10 (30%) were partially immunized, and 5 (15%) were immunized. The clinical features included fever, throat pain in all cases, membrane over tonsil in 93.7%, and bull neck in 78.1% cases. Albert stain was positive in 20 (60.6%) cases. Antidiphtheric serum (ADS) was given in 28 out of which 18 cases (64.3%) survived. Five cases did not receive ADS and out of these two (40%) survived. Case fatality rate was 55% in nonimmunized, 30% in partially immunized, and nil in immunized group. Overall, case fatality rate was 42.4%, and survival rate was 57.6%. Conclusion: As disease nowadays is affecting older children more, awareness about booster doses is required. Complete immunization, early ADS therapy irrespective of result of Albert stain, helps to decrease complications and improve survival.



Ram Shankar Renganathan, Hemalatha Palaniappan

Laryngotracheal Trauma—Etiology, Treatment, and Outcome: An Indian Scenario

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:5] [Pages No:82 - 86]

Keywords: Cotton–Myers grading, Laryngotracheal trauma, McCaffrey grading, Shiann Yann Lee procedure, tracheostomy

   DOI: 10.5005/jp-journals-10003-1388  |  Open Access |  How to cite  | 


Background: Laryngotracheal trauma is a dangerous injury that needs a very high index of suspicion and prompt intervention to increase survival and maintain aerodigestive functions. The aim of our study was to determine the incidence, airway intervention, and aerodigestive outcome among patients with laryngotracheal trauma, and factors influencing these outcomes were statistically analyzed and results derived. Materials and methods: In all, 31 patients were included in our study. The duration of the study was 2 years. In external laryngeal trauma group, patients were examined and classified according to the Schaefer–Fuhrman grading. The patient was followed up throughout the stay in hospital until decannulated or discharged. In the internal laryngeal trauma group, previous history of intubation or tracheostomy or any other causes of internal injury was noted. The stenotic segment was graded based on Cotton–Myers grading and McCaffrey grading, and the outcome was measured in terms of airway phonation and swallowing and the results were statistically analyzed. Results: Among the 31 patients, 12 patients (33.7%) were in a tracheostomy tube and the remaining were not in a tracheostomy tube (64.3%) of which 1 patient was not tracheostomized at all in the external laryngeal trauma group as she was managed conservatively. In the cutthroat group, 11 patients were successfully decannulated and 1 patient was not tracheostomized. In the stenotic segment group of 19 patients, 13 patients were in tracheostomy (68.4%) and the remaining 8 patients were successfully decannulated. Conclusion: Males outnumber females in our study. Age less than 40 years leads to a good rate of decannulation. External laryngeal trauma has good rates of decannulation when compared to internal laryngeal trauma. All cases of supraglottic stenosis in our study were attributed to corrosive acid intake. In our study, tracheal stenosis has a good rate of decannulation.



Ashwin G Vedhapoodi, Nitin R Ankle, Jyoti Nagmoti

Microbial Pattern of Tracheal Aspirate in Tracheostomized Patients in a Tertiary Care Center and Its Clinical Implications

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:8] [Pages No:87 - 94]

Keywords: Colonization, Pseudomonas aeruginosa, Staphylococcus aureus, Tracheal aspirate, Tracheostomy

   DOI: 10.5005/jp-journals-10003-1393  |  Open Access |  How to cite  | 


Background: The frequent use of invasive procedures in intensive care units (ICUs), such as tracheostomy, is associated with increased risk of nosocomial infections of the lower respiratory tract with increase in incidence of antibiotic resistant bacteria. There is inadequate published information regarding the lower respiratory tract bacterial pathogens and their resistance patterns in Indian clinical setting. Hence we endeavor to determine the pattern of colonization of tracheal aspirate and their antimicrobial sensitivity. Materials and methods: The study was conducted in the Department of Otorhinolaryngology at a Tertiary Care Center at Belagavi from January 2012 to December 2012. The tracheal aspirate was collected intraoperatively on day 1 and on day 8 during tube change using 10F suction catheter under direct vision. The sample was immediately transferred to fluid Thioglycollate medium and transported to the Microbiology laboratory. The aerobic culture and sensitivity and anaerobic culture were done. Results: In this study, on day 1, 26 (87%) patients showed growth in tracheal aspirate as compared to 28 (93%) on day 8 following tracheostomy. The most common organism isolated in day 1 and day 8 aspirate was Pseudomonas aeruginosa which was present in 11 (40%) and 13 (45%) of isolates, respectively. The antimicrobial sensitivity of the organisms in the aspirate decreased as the duration of tracheostomy increased probably due to the development of hospital-acquired resistance and/or infection. Anaerobic organisms were also isolated; however, they were insignificant. Conclusion: The observation of the varying pattern of the organisms and antimicrobial susceptibility will definitely prove fruitful in the treatment of infections of the lower respiratory tract under our clinical settings. The regular surveillance culture of aspirates is of prime importance in patients suspected of having infection such as tracheobronchitis and pneumonia.


Original Article

MC Trupthi, Roshna Rose Paul, Sramana Mukhopadhyay, Meera Thomas, Rita Ruby Anbuselvi

Effect of Smoking on Vocal Fold Polyp: A Comparative Histopathological Study

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:6] [Pages No:95 - 100]

Keywords: Dysplasia, Microlaryngoscopy, Polyp, Smoking

   DOI: 10.5005/jp-journals-10003-1387  |  Open Access |  How to cite  | 


Vocal fold polyp is a benign condition of the vocal fold, which requires surgical excision under general anesthesia. We intend to look for any early premalignant changes among smokers with vocal polyp as it is a well-known carcinogen. Aim and objective: To study the (1) impact of smoking on the histopathology of vocal fold polyps and (2) serum IgE levels in patients with vocal cord polyps. Materials and methods: All patients above 18 years diagnosed with vocal polyp fitting into our inclusion criteria were included in the study. The study group was divided into group A—smokers with vocal polyp and group B—nonsmokers with vocal polyp. Serum IgE levels were assessed in all patients with vocal polyps. All patients underwent microlaryngoscopy and excision biopsy under general anesthesia. The surgical specimen was sent for histopathological examination. The pathologists were blinded to the smoking-related history. Results: In all, 70 patients diagnosed with vocal polyp were enrolled in the study with a smoker to nonsmoker ratio of 1:1. Voice abuse was seen in 85% of smokers and 74% of nonsmokers. There was an in increase in thickness of the basement membrane and fibrosis of vocal polyp in smokers on histopathological examination. Among the 70 patients we studied, dysplasia was seen in 10% of vocal polyps irrespective of smoking, which was statistically significant (p-value <0.001). Serum IgE was elevated in both smokers and nonsmokers (60%). Conclusion: Conflicting reports regarding the histopathological examination of vocal fold polyps suggest further multicentric studies. Histopathological evidence of dysplasia in statistically significant numbers in both groups suggests a mandatory early surgical excision.


Original Article

Shiva Priya Jeyabalakrishnan, Sanjeev Mohanty

Management of Supraglottic Stenosis: An Institutional Experience

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:5] [Pages No:101 - 105]

Keywords: FOL, Harmonic scalpel, Management, Stenosis, Stenting, Supraglottis

   DOI: 10.5005/jp-journals-10003-1389  |  Open Access |  How to cite  | 


Introduction: Supraglottic stenosis is an unusual subset of laryngotracheal stenosis that has distinctly different causes, associated symptoms, and treatment options, some of which are novel. This is a case series of patients with supraglottic stenosis and the individual treatment options used for each of these patients, and the outcome over a period of 8 years (2010–2017) is analyzed. Materials and methods: Fourteen patients of supraglottic stenosis due to different causes were identified. Quantum of surgery involved release of stenotic segment and placement of stent. All patients underwent CT neck for assessment of the site and extent of stenosis. Endoscopic assisted excision of stenotic segment was performed in 12 patients. Laryngofissure approach was used in two patients as a surgical approach. Periodic assessment of airway was done to ascertain the patency postoperatively. Results: Successful decannulation was possible in 12 out of 14 patients. Stent was removed for all patients. Eleven of the 14 patients are phonating and swallowing well. Other three patients were advised modified swallowing techniques. These patients had esophageal stricture which was released at the same sitting. Conclusion: Trauma was the most common cause of supraglottic stenosis. Endoscopic approach using laser was the most common procedure used to treat supraglottic stenosis with 85.7% success rate in experienced hands.


Original Article

Manaswita Roy, NN Mathur

Role of Videostroboscopy and Electroglottography during Therapeutic Intervention in Voice Disorders

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:4] [Pages No:106 - 109]

Keywords: Contact quotient, Dysphonia, Electroglottography, Videostroboscopy

   DOI: 10.5005/jp-journals-10003-1390  |  Open Access |  How to cite  | 


Aims and objectives: Videostroboscopy (VSS) and electroglottography (EGG) are widely accepted essential tools in diagnosis and management of dysphonia. Larynx can also be examined by indirect mirror, rigid, or flexible laryngoscopy, but VSS provides superior visualization and recording of the vocal fold mucosal lesions producing dysphonia. The present study was conducted in order to determine the role of VSS and EGG to analyze vocal fold lesions before and 3 months after therapeutic intervention. Materials and methods: This was a prospective observational study conducted over a period of 1.5 years. Thirty patients were enrolled after fulfilling the inclusion criteria. Results: This study showed that the most common etiology of benign vocal cord lesions was acute laryngitis (26.7%). Mucosal waves were normalized after intervention for both right (n = 1, 3.3%) and left (n = 2, 6.7%) true vocal cord (TVC). Complete glottic closure was seen in 93.3% (n = 28) cases after intervention as compared to 40% (n = 12) cases during initial examination (p <0.01). Mean contact quotient was improved after therapeutic intervention, and the difference was statistically significant (p = 0.015). Discussion and conclusion: Laryngeal lesions causing dysphonia are multifactorial. Early vocal fold lesions causing dysphonia may not be evident by conventional methods of laryngeal assessment including indirect and direct laryngoscopy. This study demonstrated that VSS and EGG provide comprehensive information regarding vocal fold pathology for both diagnosis and follow-up of patients having voice disorders.


Original Article

Prisca M Thomas, Srikanth Nayak, Usha Devadas

Prevalence and Voice Characteristics in an Indian Treatment-seeking Population for Voice Disorders

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:8] [Pages No:110 - 117]

Keywords: Epidemiology, Laryngeal pathology, Prevalence, Voice disorder

   DOI: 10.5005/jp-journals-10003-1391  |  Open Access |  How to cite  | 


Objective: The purpose of this study was to describe the characteristics of a treatment-seeking population visiting the voice clinic of the Speech and Hearing department in a tertiary care hospital. Study design: Retrospective study. Methods: The study included patient's data who visited the voice clinic from January 2015 to January 2020. The retrospective data related to laryngeal pathology, age, gender, occupation, overall grade (G score of GRBAS), maximum phonation duration, S/Z ratio, and acoustic parameters (F0, jitter, shimmer, noise-to-harmonic ratio) were tabulated and analyzed. Results: The study results were analyzed and reported from 524 patient records. The frequency of organic/structural vocal pathology was observed to be higher (n = 468; 89.3%) than functional/nonstructural pathologies (n = 38; 7.3%). Vocal nodules (28.1%), vocal fold paralysis/paresis (15.5%), vocal fold edema (13.7%), sulcus vocalis (7.3%), and vocal polyps (6.1%) were the most common (those occurred in more than 5% of the patients) diagnosis observed for the overall sample. Male dysphonic patients (n = 283; 54%) outnumbered the females (n = 241; 46%). The majority of patients consulting the voice clinic for dysphonia were between 25 and 64 years. The most common occupations seeking help for voice problems were homemaker, student, teacher, business, farmer, retired, singer, and laborer. The overall perceived hoarseness was significantly higher in males compared to females. Conclusion: The present study results allowed a better understanding of characteristics of treatment-seeking population for voice disorders visiting voice clinic. Identification of characteristics and diagnosis of individuals seeking treatment for voice disorders help the speech language pathologists to increase the awareness among the general population about preventive voice care strategies.


Original Article

Shimelis Seid, Efrem Fenta

Assessments of the Practice and Knowledge of Health Professionals toward Tracheostomy for Patients Admitted to ICU in Ethiopian Hospitals

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:6] [Pages No:118 - 123]

Keywords: Acute respiratory failure, Artificial airway, Intensive care, Mechanical ventilation, Tracheostomy

   DOI: 10.5005/jp-journals-10003-1392  |  Open Access |  How to cite  | 


Background: Tracheostomy is a surgical procedure commonly done in intensive care unit patients to facilitate weaning and to fasten the recovery process. More than 10% of mechanically ventilated patients require tracheostomy. The practice and knowledge of health professionals toward tracheostomy are left undisclosed and not well stated in Ethiopia. Materials and methods: This descriptive multicenter cross-sectional study was conducted with chart review and prospective evaluation of ICU health professionals’ knowledge regarding the practice of tracheostomy. This study was collected after distributing 24-item standard questionnaires to all health professionals who were working in surgical and medical intensive care units of Amhara regional comprehensive specialized hospitals (CSHs). All the data were entered and analyzed with SPSS version 25. Descriptive statistics, figures, and tables were used to present the data. Result: A total of 625 tracheostomies were done in our 3-year retrospective studies of 10 intensive care units of Amhara regional CSHs. We found that surgical tracheostomy was the commonest technique practiced currently in our setup. The majority of tracheostomy procedures were performed in the operation theater. Conclusion: Percutaneous tracheostomy was under-practiced in Amhara regional CSHs. The decision time to proceed with a tracheostomy was late, which was after 14 days of postintubation, in most cases. The knowledge of health professionals, who were working in intensive care units, regarding tracheostomy, was poor. Clinical significance: This study is one of the important areas in addressing peculiar gaps in the tracheostomy practice for mechanically ventilated patients in ICU, especially in low-income countries where tracheostomy-related complication is high. Knowing the practice and health professional's knowledge toward tracheostomy is among the most important area of ICU care in medicine, and there is no previous published work within this regard in Ethiopia and in Africa.



Henrique Rodrigues Teixeira, Mariana Branco Lopes, Lília Ferraria, Maria Helena Rosa, Luis Antunes

Isolated Laryngeal Syphilis with Bilateral Vocal Fold Immobility: A Rare Clinical Presentation

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:2] [Pages No:124 - 125]

Keywords: Airway obstruction, Infectious diseases, Laryngology, Syphilis, Vocal fold paralysis

   DOI: 10.5005/jp-journals-10003-1385  |  Open Access |  How to cite  | 


Aim: Report a case of a very rare clinical presentation of syphilis, manifesting exclusively in the larynx. Background: Syphilis is a sexually transmitted disease, usually with multisystemic involvement, that has seen an increase in incidence over the past two decades. The disease can present in four different stages and can mimic many other diseases. Laryngeal manifestations are rare and can result from different mechanisms, such as direct damage to the larynx, vagal neuropathy, and central nervous system dysfunction. Syphilis can affect the larynx along its course, but an isolated manifestation of syphilis in the larynx is extremely rare, with only few cases reported in the literature. Case description: We present a case of a 45-year-old man who initially presented with an isolated lesion in the aryepiglottic fold which was biopsied and diagnosed as a syphilitic lesion. Despite adequate medical treatment, he progressively developed a bilateral vocal fold immobility requiring tracheostomy, and subsequently a laser posterior cordectomy for definitive treatment. Conclusion and clinical significance: The global incidence of syphilis is increasing, and although it can have laryngeal manifestations, an isolated presentation of syphilis in the larynx is extremely rare. Therefore, a high index of suspicion is needed by otorhinolaryngologists for a timely diagnosis and treatment in order to prevent the sequelae of this disease.



Cosimo Galletti, Galletti Bruno, Francesco Ciodaro, Francesco Galletti

Recurrent Laryngeal Papillomatosis: A Laser CO2 Surgery and Bevacizumab Intralesional Injection as Adjuvant Therapy

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:3] [Pages No:126 - 128]

Keywords: Airway obstruction, Bevacizumab, HPV, Laryngology, Laser, Oncology, Surgery

   DOI: 10.5005/jp-journals-10003-1386  |  Open Access |  How to cite  | 


We present a case of recurrent respiratory papillomatosis (RRP) transformed in a lobular intraepithelial neoplasia LIN 2 vocal fold lesion treated with a microdirect laryngoscope with 10,600-nm laser CO2, in addition, adjuvant therapy is performed which consists of an intralesional bevacizumab injection on surgical site. Adjuvant therapy involves a cycle of four intralesional bevacizumab injections. The RRP is characterized as a long-life condition of the respiratory epithelium caused by the human papilloma virus (HPV), HPV 6 and 11 genotypes in most of all cases. Airway obstruction or voice correlated symptoms are the most common way of presentation, which can be variated from a low–mild form to severe which can represent, in rare cases, a situation that requires prompt treatment. This study aims to evaluate the efficacy and safety of the use of intralesional bevacizumab as adjuvant therapy in the treatment of RRP.



Vasilios Chalkiadakis, Sofia Stamataki, Theodoros Pantazopoulos

A Delayed Diagnosis of a Retropharyngeal Abscess in a 38-day-old Neonate: A Case Report and Review of the Literature

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:4] [Pages No:129 - 132]

Keywords: Retropharyngeal abscess, Neonate, Complications

   DOI: 10.5005/jp-journals-10003-1395  |  Open Access |  How to cite  | 


Objectives: Retropharyngeal abscess is very rare in neonates. Its clinical presentation, severity, and management may share different characteristics when compared to young children or adults. Precise physical examination can be difficult and imaging may be required. Management of this clinical entity includes both intravenous antibiotic therapy and surgical drainage. The aim of this case report is to evaluate clinical presentation and management of retropharyngeal abscesses in neonates. Methods: We report the case of a delayed diagnosis of a retropharyngeal abscess in a 38-day-old neonate that was admitted to the emergency department of our hospital. Results: Interestingly, our patient had not been diagnosed at the first examination due to insidious clinical symptoms. This reminds us the importance of accurate history and detailed clinical examination. His condition deteriorated gradually. Although surgical drainage of the abscess was performed as soon as it was diagnosed, postoperative complications were not avoided. Conclusion: A retropharyngeal abscess remains a life-threating condition, with high mortality and morbidity. In neonates, diagnosis is challenging due to the variety of symptoms. Given the higher incidence of airway obstruction in these patients, early surgical intervention is usually essential. When complications are present, a multidisciplinary approach is required.



Monika Sood, Sarita Negi, Ramesh K Azad, Jagdeep S Thakur

Laryngeal Carcinoma Masquerading as Tubercular Deep Neck Abscess

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:3] [Pages No:133 - 135]

Keywords: Abscess, Cancer, Larynx, Neck, Tuberculosis

   DOI: 10.5005/jp-journals-10003-1396  |  Open Access |  How to cite  | 


Aim: A rare case presentation with important clinical lesson. Background: Laryngeal carcinoma and tuberculosis have common clinical features that can mislead the management. Deep neck abscess is rare in laryngeal cancer, while it is common in tuberculosis. Case description: A 54-year-old male presented with painful swelling in the neck with odynophagia and fever for last 20 days. Clinical examination and radiological investigations favored laryngeal tuberculosis; however, laryngoscopic biopsy found squamous cell carcinoma. Conclusion: All cases of deep neck abscess with laryngeal involvement should be subjected for direct laryngoscopic examination and biopsy to rule out any hidden malignancy.



Sashikanth Jonnalgadda, Amjad Khan

An Open Safety Pin in an 8-month-old Child: A Rare Delayed and Unusual Presentation of This Dangerous Foreign Body

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:3] [Pages No:136 - 138]

Keywords: Child, Esophagoscopy, Esophagus, Foreign body esophagus, Neck, Unusual presentation, X-ray neck

   DOI: 10.5005/jp-journals-10003-1394  |  Open Access |  How to cite  | 


Introduction: Foreign bodies (FBs) are common in young children aged 3 months to 6 years, and FBs in the esophagus can present with a wide variety of symptoms. We present an extremely rare case of chronic open safety pin (SP) in an 8-month-old child who was asymptomatic for 8 weeks and then presented with cough and neck spasms. Case history: An 8-month-old baby girl presented to us referred from a pediatrician with an incidental finding of open SP in the esophagus when a chest X-ray was performed to diagnose nonresponding cough. Patient had constant neck deviation towards right side without any other symptoms for 8 weeks, when X-ray diagnosed the FB. Flexible and rigid endoscopical removal were unsuccessful since the sharp end of the pin was buried in the luminal wall with granulation tissue surrounding it. Open neck exploration with esophagostomy and extraction of the SP under general anesthesia had to be done. The child is now asymptomatic with normal neck posture postprocedure. Conclusion: Open SP can have delayed presentation, and a high index of suspicion is required to diagnose the presence of an FB. Chronic FBs can penetrate the luminal wall of the esophagus resulting in granulation tissue, and this further leads to fixation of the FB making it extremely difficult to remove endoscopically. We advocate open neck exploration and esophagostomy for safe removal of chronic sharp FB like open SP.



Naresh Kumar Panda, Manjul Muraleedharan

A Combined Rigid Endoscopic Approach for Zenker's Diverticulum

[Year:2021] [Month:September-December] [Volume:13] [Number:3] [Pages:3] [Pages No:139 - 141]

Keywords: Combined approach, Endoscopic, Endo-stapler, Harmonic, Zenker's diverticulum

   DOI: 10.5005/jp-journals-10003-1397  |  Open Access |  How to cite  | 


From open excision of the pouch to the flexible endoscopy and division of cricopharyngeus, there are multiple options for the division of wall between esophagus and Zenker's diverticulum (ZD) depending on its size, availability of resources, and their side effects. Hereby, we report a case of 43-year-old female who presented with complaints of progressive dysphagia, regurgitation of food particles, gurgling sound on taking liquids, and dyspnea on lying down. Barium swallow and esophagogastroduodenoscopy helped in diagnosing it to be ZD. One-stage endoscopic diverticulotomy using stapler and harmonic scalpel leads to significant improvement in symptoms with no complaints even after 1 year postsurgery. Thereby, a combination of stapler and harmonic scalpel can be used for one-stage endoscopic diverticulotomy without any major complication making it a good alternative to modalities like LASER. Key messages: A combination of stapler and harmonic scalpel can be used for one-stage endoscopic diverticulotomy for ZD without any major complication making it a good alternative to modalities like LASER.


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