Cerebrospinal fluid (CSF) leak can arise as a complication of trauma, hydrocephalus, endoscopic sinus surgery, or it may occur spontaneously without any identifiable cause. Surgical repair is recommended in patients who do not respond to the conservative management. In recent years, transnasal endoscopic approach has become the preferred method for repairing CSF leaks, and better outcomes have been reported as compared with the intracranial approaches that were previously used. The objective of this study was to analyze the outcome of transnasal endoscopic repair of CSF rhinorrhea.

This prospective study was conducted in the Department of ENT, B.J. Medical College, Ahmedabad, India, from April 2013 to July 2016. Twenty-five patients with CSF rhinorrhea were included in the study. They were diagnosed based on the clinical evaluation, computed tomography, and magnetic resonance imaging. These patients did not respond to conservative management and were operated transnasally using rigid endoscope. Patients were followed up for a mean duration of 9 months, and the outcome was analyzed.

The patients included in the study ranged in the age group of 12 to 55 years. Among the patients, 15 were females and 10 were males. The cause of CSF rhinorrhea was traumatic in 18, idiopathic or spontaneous in 7. In 12 patients, the site of leak was cribriform plate, 6 from ethmoid, 5 from sphenoid sinus, and in 2 frontal sinuses were affected. Primary surgery was successful in 23 of cases. In two cases, reexploration had to be performed. Overall success rate was 100%.

Transnasal endoscopic repair of CSF rhinorrhea is highly successful, safe, and less traumatic.

Gupta DP, Dinesh SK, Manavadaria AD. Transnasal Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea. Clin Rhinol An Int J 2017;10(2):45-48.

To determine the outcome and safety of endoscopic dacryocystorhinostomy (ENDO-DCR) with the use of silicon stents in nasolacrimal duct obstruction (NLDO).

This study was done in the Department of Otorhinolaryngology and Head and Neck Surgery, Navodaya Medical College, Raichur, from January 2013 to June 2015, with a total of 82 cases (10 cases with bilateral disease) who underwent a standardized procedure, with an endonasal approach to the lacrimal sac, surgical removal of nasal mucosa, lacrimal bone, and a fragment of the frontal process of the maxilla. The medial wall of the lacrimal sac was removed completely and canalicular silicone intubation tube was placed for 6 weeks postoperatively.

Main outcome measures were resolution of epiphora, absence of discharge, and patency of the ostium confirmed by irrigation and endoscopic evaluation of neo-ostium at 6 weeks.

The ENDO-DCR procedure with adjunctive canalicular silicone intubation tube was successful in 78 (95%) cases. No significant complications were encountered during or after the operative period.

Endoscopic dacryocystorhinostomy with canalicular silicon intubation for shorter duration (6 weeks) is a safe and successful procedure for the treatment of NLDO in adults as well as in children, with a success rate of 95%.

Chavadaki JA, Manvikar AK, Shrikrishna BH. Endoscopic Dacryocystorhinostomy: Our Experience. Clin Rhinol An Int J 2017;10(2):49-52.

To evaluate the efficacy and results of radiofrequency turbinoplasty in patients with rhinitis medicamentosa due to imidazolines like oxymetazoline and xylometazoline.

This is a prospective, single-blinded, randomized controlled study.

Study was conducted on 20 patients in a tertiary level center from January 2010 to February 2016. Patients with symptoms and signs of nasal obstruction due to rhinitis medicamentosa were selected. Patients were aged from 16 to 43 years (mean age is 24 years). Twelve were males and eight were females. The duration of use of nasal decongestant drops varied from 3 months to 5 years. The turbinoplasty was performed using the radiofrequency method. Nasal obstruction symptom evaluation (NOSE) questionnaires are used for subjective assessment and nasal endoscopy view score (NES) was used for objective assessment pre- and postoperatively. Follow-up was done at the end of 15 days and 3 months after surgery. The results were statistically analyzed by paired t-test.

The mean NOSE score before procedure was 92. At the 15th postoperative day, mean NOSE score reduced to 1.3 and it further reduced at the 3rd month to 0.5 (p < 0.001), with 99.5% reduction in subjective symptoms. The mean NES before procedure was 3.95. On the 15th day, it was 0.35 and at the end of 3rd month, it was 0 with 91.1% reduction in objective evaluation (p < 0.001). Results were same on left and right side of nose. No major postoperative complication was observed in patients.

Radiofrequency turbinoplasty technique can be recommended as an effective method in imidazoline-induced rhinitis medicamentosa. It is simple, comfortable, fast relief giving, no repeated steroids, and cost-effective, single-session treatment. Good compliance and cooperation from patients can be obtained with no major complications of the treatment. It allows patients to be managed in the office environment.

Rao SVM. Radiofrequency Turbinoplasty in Imidazoline-induced Rhinitis Medicamentosa. Clin Rhinol An Int J 2017;10(2):53-57.

The aim of the study is to evaluate the age, sex, site of lesion, histopathological diagnosis, and recurrence rate of the maxillectomy patients.

A retrospective study was done in 42 patients, who underwent maxillectomy for malignant growth of the nose and paranasal sinuses from 2006 to 2015 at our center.

The most common age group is 55 to 65 years (73.8), with male predominance (66.7%). Among symptoms prevalent is nasal obstruction (47%). Maxillary sinus is the most common site of origin (61.9%). Squamous cell carcinoma is the most common histopathological diagnosis (52.4%) and recurrence rate is 16%.

Exact clearance, reconstruction, postoperative care, and perfect teamwork play a vital role. Thus, successful outcome of maxillectomy is multifactorial.

Rajasekar MK, Mariappan V, Veerasigamani N. Our Experience with Maxillectomies: A Retrospective Decade Study. Clin Rhinol An Int J 2017;10(2):58-61.

To study the efficacy of pterygopalatine fossa (PPF) block with 2% xylocaine and 1:80,000 adrenaline on bleeding during endoscopic sinus surgery (ESS).

Single-blinded prospective comparative study was conducted on patients who underwent bilateral functional endoscopic sinus surgery after obtaining written informed consent. The effect of PPF infiltration was tested by injecting 2% xylocaine with adrenaline on test side, and saline on the control side. The test and the control side were determined by block randomization technique. The surgeon was blinded as to which side the test and control drug was to be given. The surgical field was assessed and graded every 15 minutes on both sides according to Boezaart and Vander Merwe scoring system, and the results were compared and analyzed using Mann–Whitney U test.

Thirty-two patients were included in the study, of whom 59.4% were males. Ethmoidal polyposis was the most common diagnosis (50%). The median computed tomography grade and the endoscopic grade of disease in test side and control side were comparable. The mean blood loss grade on test side was 9.0 ± 3.5 and in control side was 10.9 ± 3.5, and the difference was statistically significant. Significant positive correlation was observed between preoperative endoscopic grade of the disease and blood loss during surgery. A statistically significant correlation was also observed between the vital parameters and blood loss.

Pterygopalatine fossa infiltration with 2% xylocaine and 1:80,000 adrenaline reduces bleeding during ESS.

This study is pivotal in devising an additional method for providing a clear bloodless operative field which to date is one of the major challenges faced by the otorhinolaryngologist.

Mathew R, Srinivasa C, Sathyanarayana V, Suryanarayana S, Harsha P. Role of Pterygopalatine Fossa Block in achieving Relatively Bloodless Field during Endoscopic Sinus Surgery. Clin Rhinol An Int J 2017;10(2):62-65.

The aim of this study was to evaluate all the cases of sinonasal masses based on histopathology into neoplastic and non-neoplastic lesions and to study their clinical and radiological presentations.

The present study was carried out in 42 patients coming to the outpatient and inpatient Department of ENT of Netaji Subhash Chandra Bose Medical College & Hospital with the complaint of nasal obstruction during the period of March 2015 to August 2016. Patients were subjected to thorough clinical examinations and radiological investigations, which included digital X-ray paranasal sinus (PNS) and contrast-enhanced computed tomography PNS, and diagnosis was confirmed by nasal biopsy for histopathology reports.

A total of 42 patients were studied, of which 71.43% were non-neoplastic and 28.57% were neoplastic. Nasal polyps were the commonest non-neoplastic lesions (61.91%). Most common benign neoplastic lesion was angiofibroma (11.9%), while the commonest malignant neoplastic mass was found to be squamous cell carcinoma (7.14%). There was one case of adenoid cystic carcinoma.

Patients with sinonasal masses may present with trivial complaints, but proper evaluation of all the cases will enable us to make specific diagnosis and treat them accordingly.

Sachdeva K, Naskar S. A Study of Neoplastic and Non-neoplastic Sinonasal Masses at a Tertiary Center. Clin Rhinol An Int J 2017;10(2):66-69.

To study the clinical profile of deviated nasal septum and to assess the subjective efficacy of the surgical outcome using Likert scale.

This study is a prospective, observational, single-center study from October 2013 to May 2015. The study was conducted in Sri Siddhartha Medical College, Tumkur, Karnataka, India. A detailed clinical history was taken and clinical examination of the patient was carried out. Sixty symptomatic patients were taken up. Patient scored their symptom-related severity using a Likert scale preoperatively. All patients underwent conventional septoplasty. Postoperatively, their symptoms were scored on 30th, 45th, and 90th day.

Preoperative and Postoperative values were analyzed. Statistically significant improvement was observed in the entire population: Nasal obstruction (p<0.001), headache (p<0.001), nasal discharge (p<0.001), facial pain (p<0.001), and hyposmia (p<0.001). Patient satisfaction was high and they used fewer nasal medications.

After surgical correction of the septum and analysis of the subjective scale, i.e., Likert scale showed improvement in all symptoms. The principal benefits of septal surgery relate to improvement in nasal symptoms.

Mogarnad M, Mohta V. A Study on Clinical Profile of Deviated Nasal Septum and to determine the Efficacy of the Surgery. Clin Rhinol An Int J 2017;10(2):70-73.

Adenoid hypertrophy is known as the most common cause of nasal obstruction in children; thus, adenoidectomy is one of the most commonly performed surgical procedures in the pediatric population. We performed both conventional and endoscopic-assisted adenoidectomies in 54 patients. Our objectives were to compare the efficacy of both methods in terms of subjective and objective relief of symptoms, safety, recurrence, and postoperative morbidity.

Fifty-four patients were studied and were diagnosed depending upon clinical examination and radiological investigation. The patients were operated by either conventional or endoscopic-assisted adenoidectomy (EAA). Intraoperative and postoperative complications were looked for. After discharge from the hospital, the patients were called for follow-up on 1st week, 3rd week, 2nd and 4th month, and patients were asked for relief of symptoms and examined for nasal disease and for recurrence.

Adenoid hypertrophy was seen commonly in children and the most common presenting complaints were nasal obstruction, mouth breathing, and snoring. The patients were diagnosed to have chronic adenoiditis, chronic adenotonsillitis, with or without chronic suppurative otitis media. More number of patients became symptom free with EAA as compared with conventional adenoidectomy.

Conventional adenoidectomy and EAA both have comparable success rates. Endoscopic-assisted adenoidectomy allows complete removal of adenoid tissue, thereby reducing the chances of developing recurrent adenoid obstructive symptoms and reducing the bacterial reservoir in the nasopharynx.

Goel AK. Adenoidectomy: Conventional or Endoscopic Assisted? Clin Rhinol An Int J 2017;10(2):74-77.

Chronic sinusitis affects more than 30 million people each year worldwide. Computed tomography (CT) has become a standard diagnostic tool in the evaluation of paranasal sinuses (PNS), but medical literature lacks studies correlating preoperative CT and intraoperative findings of functional endoscopic sinus surgery (FESS). The aim of our study was to evaluate ostiomeatal unit on multidetector CT (MDCT) and correlate findings of MDCT with intraoperative findings during FESS in patients with chronic sinusitis and hence check for its usefulness during surgery.

Prospective clinical study.

Forty-nine patients with chronic sinusitis who visited the Lok Nayak Hospital, Delhi, India, between October 2010 and February 2012 were included in the study. All such patients underwent preoperative CT scan of PNS before surgery, i.e., FESS with or without septoplasty under general anesthesia.

Maxillary sinus was found to be the most common sinus involved in chronic sinusitis. Preoperative CT findings correlated well with intraoperative findings for all sinuses except left maxillary sinus.

Multiplanar CT of nose and PNS helps to deli­neate the anatomy of nose and PNS, and drainage pathways of sinuses preoperatively. Therefore, the operating surgeon should be well versed with it. Progress of endoscopic sinus surgery can be partially attributed to revolution in imaging modalities.

Tandon S, Rathore PK, Raj A, Prakash A, Wadhwa V. Correlation of Computed Tomographic Findings and Intraoperative Findings in Patients with Chronic Sinusitis. Clin Rhinol An Int J 2017;10(2):78-85.

To compare the results of conventional nasal endoscopic dacryocystorhinostomy (DCR) and inferior nasal endoscopic DCR in Study cases of idiopathic chronic dacryocystitis.

Forty patients diagnosed with idiopathic chronic dacryocystitis were divided into two groups alternately. After relevant investigations, they were subjected for endoscopic DCR by two techniques. Twenty patients underwent conventional endoscopic DCR and 20 underwent inferior endoscopic DCR under transoral pterygopalatine block and topical lignocaine (4%) with adrenaline 1:2,000. After 3 months of follow-up in the outpatient department, nasal endoscopy along with fluorescein dye disappearance test (FDDT) at 10 minutes was done.

Ninety-five percent (19/20) of patients undergoing conventional endoscopic DCR and 90% (18/20) of patients undergoing inferior endoscopic DCR were found to have patent anatomical fistula. On FDDT, nasal endoscopy after 10 minutes revealed 84% (16/19) in group I and 94.4% (17/18) in group II with fluorescein in nasal cavity.

Present study concludes the importance of bony, tendinous, and muscular support of lacrimal sac in physiological lacrimal pump functioning and advantage of relatively new technique of inferior endoscopic DCR. Inferior endoscopic DCR is associated with less operative time as well as less local complications.

Thakur K, Kashyap A, Negi S, Chauhan PL. Anatomical and Functional Evaluation of Conventional vs Inferior Endoscopic Dacryocystorhinostomy in Study Cases of Idiopathic Chronic Dacryocystitis. Clin Rhinol An Int J 2017;10(2):86-90.

To highlight canaliculitis masquerading as chronic dacryocystitis that may mislead a rhinologist.

Canaliculitis is an inflammation of the lacrimal canaliculi caused by infection or as a complication of punctal plug insertion. It is often misdiagnosed, leading to a delay in diagnosis.

We report a case of a 20-year-old female patient who presented with complaints of watering from left eye since 1 year and was referred to the Department of Ear, Nose, and Throat for endoscopic dacryocystorhinostomy (DCR). She had a history of silicone punctal plug insertion in the same eye for “dry eye” following an attack of herpes zoster 12 years earlier. She was asymptomatic for 10 years following punctal plug insertion, but started complaining of epiphora since the last 2 years. Punctal plug was removed 1 year back by an ophthalmologist but the epiphora persisted. Regurgitation of purulent discharge on pressure over lacrimal sac area made it look like dacryocystitis. Syringing through lower punctum was blocked while through the upper punctum it was patent. Thus, possibility of nasolacrimal duct block was ruled out. An occuloplasty opinion was sought and a diagnosis of lower canaliculitis with possibility of retained plug was made.

Canaliculitis should be considered as a differential diagnosis in cases presenting with epiphora as canaliculitis is a close masquerade of dacryocystitis.

As more and more rhinologists are getting direct referrals of cases needing endoscopic DCRs, it is important for them to be well aware of other associated pathologies of proximal lacrimal system. This will help them to reach a correct diagnosis before going ahead with endoscopic DCR.

Gupta N, Das S, Chawla N. Canaliculitis masquerading as Dacryocystitis: Rhinologist's Dilemma. Clin Rhinol An Int J 2017;10(2):91-92.

Nasal masses are common finding in the ear, nose, and throat outpatient department. Most patients present with complaints of nasal obstruction. A sinonasal mass can have various differential diagnoses. They may be congenital, inflammatory, neoplastic (benign or malignant), or traumatic in nature. A careful histopathological examination is necessary to decide the nature of any particular lesion.

The retrospective study was carried out between January 2011 and December 2013. A total of 185 cases diagnosed with masses of the nasal cavity, paranasal sinuses, and nasopharynx were included. Data from histopathological records were retrieved to confirm the diagnosis.

Among 185 cases, 75% were non-neoplastic and 25% were neoplastic. Among neoplastic masses, 57% were benign and 43% were malignant. The age of presentation ranged from first to eighth decade of life (mean age 37.74 years). The lesions had a stronger predilection for males (1.68:1). Among non-neoplastic lesions, nasal polyp was the commonest lesion followed by ethmoidal mucocele (1.44%) and lupus vulgaris (0.72%). Among benign lesions, inverted papilloma (30.77%) and nasopharyngeal angiofibroma (30.77%) were the commonest followed by capillary hemangioma (15.38%), osteoma (7.68%), nasopharyngeal lymphoepithelioma (3.85%), chondroma (3.85%), pleomorphic adenoma (3.85%), and schwannoma (3.85%). Squamous cell carcinoma (40%) was the commonest malignant neoplastic lesion observed followed by adenoid cystic carcinoma (20%), malignant melanoma (15%), nasopharyngeal carcinoma (10%), esthesioneuroblastoma (10%), and non-Hodgkin lymphoma (5%).

Among the noninflammatory lesion, nasal polyp is the commonest lesion. Nasal polyps are more common in hilly area may be due to exposure to pine pollens. There is no difference in the histopathological profile of benign and malignant lesions.

Guleria TC, Mohindroo S, Mohindroo NK, Azad RK, Kumar A. Histopathological Profile of Nasal Cavity, Paranasal Sinuses, and Nasopharyngeal Masses in Hill State of Himachal Pradesh, India. Clin Rhinol An Int J 2017;10(2):93-98.

Kaur N, Tiwana H, Sawhney S, Gupta AK. Malignancy mimicking Juvenile Nasopharyngeal Angiofibroma. Clin Rhinol An Int J 2017;10(2):99-102.