An International Journal Clinical Rhinology

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2009 | September-December | Volume 2 | Issue 3


C Ekambar E Reddy, Trevor Teemul, Sucha Hampal, Krishna TV Reddy

Alar Batten Grafts for Non-iatrogenic Nasal Valve Area/Alar Collapse

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:1 - 4]

Keywords: Rhinoplasty,nasal valve collapse,cartilage graft

   DOI: 10.5005/jp-journals-10013-1001  |  Open Access |  How to cite  | 



We present our 3 years experience with alar batten grafts, using a modified technique, for non-iatrogenic nasal valve/alar collapse.


Retrospective (Oct. 2005 to Apr. 2008) and prospective study (Apr. 2008 to Dec. 2008) of 16 consecutive patients undergoing alar batten grafts for alar collapse causing nasal obstruction. The graft was inserted through a rim incision and placed across as well as superficial to the lower lateral cartilage. The main outcome measures were subjective improvement in nasal obstruction and absence of alar collapse at examination.


Alar collapse was bilateral (n = 8), right sided (n = 4) and left sided (n = 4) giving 24 operated sides (s = 24). Deviated nasal septum (n = 9), synechiae (n = 1) and drooping tip (n = 1) were also present. Donor sites for the graft were septal cartilage (n = 10), conchal cartilage (n = 4) or both septal and conchal cartilages (n = 2). The median follow-up was 4 months (range 1 month to 3 years). Subjective nasal obstruction had worsened in 0%, was unchanged in 16.6% (s = 4), had improved in 16.6% (s = 4) and 66.6% (s = 16) were completely free of obstruction. Two of the improved cases worsened at 10 and 3 years giving overall failure in 25% (s = 6). Significant alar collapse was present in all failed cases and absence of collapse was documented in improved cases (s = 13). In failed cases the graft size width was 5 to 8 mm and in successful cases it was 10 to 15 mm. Lengths of the grafts in all cases was between 18 and 24 mm. One complication of graft extrusion through skin occurred.


Our technique of alar batten graft insertion appears to be as effective as other techniques described in the literature. We suggest a minimum graft size of 10 mm width and 18 mm length to improve success rate.


Nasopharyngeal Angiofibroma - Staging and Selecting a Surgical Approach: Changing Trends

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:6] [Pages No:5 - 10]

Keywords: Angiofibroma,nasopharyngeal tumors,endoscopic excision,maxillofacial development

   DOI: 10.5005/jp-journals-10013-1002  |  Open Access |  How to cite  | 



The purpose of this study was to propose a new staging system which would allow for an accurate preoperative tumor assessment, appropriate surgical planning and to look for any changing trends in the surgical management of JNA.

Study design and methods

Retrospective chart review of 91 patients operated between Jan.1998 to Dec. 2007 at the Postgraduate Institute of Medical Education and Research, Chandigarh. The tumor location and extent was based on preoperative imaging reports and operative notes to review the staging system and surgical approaches.


All patients were initially staged according to the modified sessions staging system. The revised staging system led to the reclassification of 36 (39.6%) in stage I A, I B and II A in the old staging system to stage I according to the new staging. Before 2003, none of the patients had undergone an endoscopic excision of the JNA, whereas 32 (35%) of patients underwent an endoscopic excision in group II (after 2002) with acceptable recurrence rates.


The choice of the surgical approach should be based on precise tumor location and in young patients the approach should be tailored to minimize potential for facial growth retardation. We recommend endoscopic resection for tumors confined to nasopharynx, nasal cavities, sinuses and minimal extension to PMF. Excision via lateral rhinotomy and its extensions and modifications is recommended for tumors having significant involvement of pterygomaxillary fossa, infratemporal fossa, cavernous sinus or minimal intracranial extension according to the surgeon's comfort and expertise.


Rahul Gupta, Ranjan G Aiyer, Jayman Raval

Endoscopic Septoplasty: A Novel Technique- A Case Series of 19 Cases

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:11 - 14]

Keywords: Endoscopic septoplasty,FESS,DCR

   DOI: 10.5005/jp-journals-10013-1003  |  Open Access |  How to cite  | 


Endoscopic septoplasty is a rapidly evolving substitute to the customary “headlight” septoplasty. The primary advantage of the technique is the ability to reduce morbidity and postoperative swelling in isolated septal deviations by limiting the dissection to the area of the deviation. Other advantages include improved visualization, particularly in posterior septal deformities; improved surgical transition between septoplasty and sinus surgery and its use as an effective teaching tool. We present our experience with endoscopic septoplasty in a series of 19 patients.


AK Agarwal, JC Passey, JM Kaul

Anatomical Analysis of the Frontal Recess Cells in Endoscopic Sinus Surgery-An Indian Perspective

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:6] [Pages No:15 - 20]

Keywords: Frontal recess,frontal recess cells,FESS,agger nasi cells,supraorbital ethmoidal cells,intersinus septal cell

   DOI: 10.5005/jp-journals-10013-1004  |  Open Access |  How to cite  | 


Surgery of the frontal sinus has gone a full circle from intranasal procedures to destructive and disfiguring external operations and now back to intranasal procedures but with endoscopes. Endoscopic surgery of the frontal sinus has always been a challenging experience because of the narrowness of the area, poor visibility, variable anatomy and encroachment by accessory cells such as agger nasi, frontal, intersinus septal cells on the drainage pathway. With the developments in optical aids such as endoscopes, which provide an angled view, better and brighter illumination, sophistication in the designs of instrumentation and development of imaging techniques, a renewed interest has been created in this area, but the knowledge of anatomy of this area is poor and does not meet the demands of the present day endoscopic surgeon. Moreover, no studies are available on Indian subjects.

Our main interest in the present study was to study the various air cells which encroach the area of frontal recess and would need surgical removal to provide a good drainage and ventilation.


Kapil Dua, H Chopra, Neha Chopra, Sanjeev Puri, Vikrant Mittal

Invasive Fungal Rhinosinusitis: Our Experience

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:6] [Pages No:21 - 26]

Keywords: Immunocompromised,mucormycosis,aspergillosis

   DOI: 10.5005/jp-journals-10013-1005  |  Open Access |  How to cite  | 


Opportunistic fungal infections in immunocompromised patients are associated with a high mortality rate. Endemic mycoses are often asymptomatic, but in appropriate hosts, fungi can cause severe and even fatal infection. Facial pain in an immunocompromised patient may signify invasive fungal sinusitis. Treatment with antifungal agents needs to be individualized according to factors such as the type of fungus, presence of renal failure, or pregnancy. Combining antifungal agents or addition of other approaches, such as surgical debridement or steps to control intracranial pressure, may be needed for adequate treatment of certain types of fungal infections.


Zareen A Lynrah, Gopika Kalsotra

Invasive Sino-aspergillosis in Immunocompetent Individuals: Atypical Presentations

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:6] [Pages No:27 - 32]

Keywords: Invasive aspergillosis,isolated sinus involvement,Voriconazole

   DOI: 10.5005/jp-journals-10013-1006  |  Open Access |  How to cite  | 



To describe the demographic, clinical and radiological findings of invasive aspergillosis of the orbit and paranasal sinuses in immunocompetent individuals that presented without any nasal symptoms and to review the role of voriconazole in such cases.

Materials and methods

A series of 13 cases is being reported with review of literature. All these cases except one underwent complete surgical debridement of the disease at the time of biopsy. On histopathological confirmation of invasive aspergillosis, the cases with sphenoid sinus involvement were given 2.5 gm of intravenous Amphotericin B (1 mg/kg/day) followed by oral itraconazole in a dose of 10 mg/kg/day for 6 months. The cases where there were lesser chances of intracranial involvement or the cases that refused for intravenous Amphotericin B were started on voriconazole 200 mg twice a day for six to twelve months. All these cases were followed up with the help of radiology, clinical improvement in symptoms and signs and fungal serology.


We found isolated sphenoid sinus involvement in 10 (76.92%) cases, isolated maxillary sinus involvement 2 (15.38%) cases and isolated orbital involvement 1 (7.69%). Our protocol was successful in 11 (84.61%) cases, one patient was lost to follow-up while one died due to intracranial complications during the third week of therapy.


This study showcased the atypical presentations of invasive aspergillosis in immunocompetent individuals and the high degree of suspicion required to diagnose this entity. An aggressive, effective and optimal management protocol has been suggested and the role of voriconazole has been highlighted.


Alok Thakar, Gaurav Gupta, Mohnish Grover

Nasomaxillary Swing - A Novel Approach for Bilateral Angiofibroma

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:33 - 36]

Keywords: Angiofibroma,maxilla,swing

   DOI: 10.5005/jp-journals-10013-1007  |  Open Access |  How to cite  | 


Juvenile nasopharyngeal angiofibroma (JNA) is a high-risk tumor of adolescent males. Choice of the approach should be based on the stage and site of the lesion. For complete removal of tumor, surgical exposure must be adequate. We here present a case of nasopharyngeal angiofibroma with intracranial and bilateral infratemporal fossa extension in which tumor was completely excised by nasomaxillary swing approach.


Daisy Sahni, Rupa Mehta, Anjali Aggarwal

Towards the Understanding of Sinonasal Anatomical Variations - A Cadaveric Study

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:6] [Pages No:37 - 42]

Keywords: Endoscopic sinus surgery,paranasal sinus anatomy,orbit

   DOI: 10.5005/jp-journals-10013-1008  |  Open Access |  How to cite  | 


A thorough understanding of the sinonasal anatomy is required for the performance of a safe and successful surgery. With the aim to identify the variations in sinonasal anatomy in north Indian population twenty fresh cadaveric heads were dissected by messerklinger technique to identify various sinonasal anatomic variations in north Indian population. The variations in the key landmarks of nose and paranasal sinuses during endoscopic sinus surgery were noted and compared with other studies. Identification and differentiation of the normal and the abnormal sinonasal anatomic variations helps in preventing complications and giving optimum surgical results.


Sandip Jain, Devinder Pal Singh, Ashwani Jindal

Epistaxis: Management Protocol As Per Etiology

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:43 - 46]

Keywords: Epistaxis,management,protocol,hypertension

   DOI: 10.5005/jp-journals-10013-1009  |  Open Access |  How to cite  | 



To underline a management protocol for epistaxis as per etiology so as to reduce associated morbidity of repeated packing, procedures and hospitalization.

Materials and methods

This was a prospective study carried out over a period of 2 years from January 2007 till December 2008 wherein all the cases that presented with a symptom of acute epistaxis to the emergency department of Fortis Hospital, Mohali were, enrolled into the study. These cases were evaluated for the brief history (a detailed history was taken after the primary management in majority of the cases), physical examination, diagnostic nasal endoscopy, radiology (if needed), hematological and biochemical profile and cross match (if needed). All these patients were hospitalized and were grouped into two groups on the basis of the age with group A having cases under 14 years of age and group B having cases more than 14 years of age. These cases were managed by a definitive management protocol stated in detail. Following this protocol for the management, we studied the duration of hospitalization for it and the frequency of repeated packing that patient had to undergo.


A total of 97 cases were studied in this study with 26 cases in group A and 71 cases in group B. There was a male predominance with 20 males in group A and 52 males in group B. The most common etiology in group A was decrease in platelet count secondary to ITP (Idiopathic thrombocytopenic purpura) and in group B was accelerated hypertension. There was only anterior bleeding in only 10 of these cases and 81 cases had anterior and posterior bleeding. The cases were managed as per etiology following a management protocol and by this we could reduce hospitalization as in highlighted in the tables.


There is no defined management protocol for the management of epistaxis as per the etiology though there are many studies on different treatment options used and its results. We here could follow a management protocol for different etiologies.


The management protocol as per etiology for hypertension if used can reduce the hospitalization and also associated morbidity of repeated packing considerably.


Mahesh Kumar, MG Rajiniganth, Usha R Kim

Coexistent Optic Neuritis and Isolated Acute Sphenoid Sinusitis

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:47 - 50]

Keywords: Sphenoid sinus,optic canal,visual acuity

   DOI: 10.5005/jp-journals-10013-1010  |  Open Access |  How to cite  | 


We report two cases of optic neuritis associated with isolated acute sphenoid sinusitis. This is the first report of isolated sphenoid sinusitis with dehiscent optic canal with exposed nerve presented with optic neuritis without any orbital inflammation. In both cases visual acuity deteriorated with steroid therapy, CT scan showed air fluid in the sphenoid sinus with dehiscent optic canal. Antibiotic, sphenoidotomy and later steroid course had a partial recovery in vision.


Satyawati Mohindra, Amanjit K Bal, Jagvir Yadav

Osteosarcoma of the Maxilla Masquerading as Maxillary Mucocele on CT Scan: A Case Report

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:51 - 54]

Keywords: Osteosarcoma,maxilla,mucocele

   DOI: 10.5005/jp-journals-10013-1011  |  Open Access |  How to cite  | 



The authors intend to present a case of osteosarcoma of the maxilla which presented like a mucocele, a previously unreported phenomenon.

Patients and methods

Clinical features, radiology, histopathological findings and endoscopically managed osteosarcoma of the maxilla are presented. Diagnostic difficulties and previously reported diagnostic dilemmas related to osteosarcomas of the maxillary sinus are discussed.


The patient has been on regular follow-up for the past 10 months, and is free from any local or systemic disease.


Though osteosarcoma of the maxilla is a rare tumor about 6.5% of all osteosarcomas1, patients tend to be in the late-third to mid-fourth decades of life, a high index of suspicion and aggressive management can reduce the morbidity that goes with the management of this condition.


Jaimanti Bakshi, Roshan K Verma

Recurrent Massive Malignant Fibrous Histiocytoma of Maxilla-A Rare Case

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:4] [Pages No:55 - 58]

Keywords: Recurrent,massive,malignant fibrous histiocytoma of maxilla

   DOI: 10.5005/jp-journals-10013-1012  |  Open Access |  How to cite  | 


We present a case of recurrent extensive malignant fibrous histiocytoma of maxilla. The case is unusual because of its massive extent at presentation even after primary surgery and full course of radiotherapy and chemotherapy. Even such massive tumor can be excised successfully. Primary malignant histiocytoma is rare; and such huge tumor at presentation is also rare and favorable outcome even rarer.


Shashidhar S Suligavi, MK Darade, SH Chandrashekharayya, SS Chougule

Bony Hemangioma of Maxillary Sinus-A Rare Presentation

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:2] [Pages No:59 - 60]

Keywords: Hemangioma,maxillary sinus,medial maxillectomy

   DOI: 10.5005/jp-journals-10013-1013  |  Open Access |  How to cite  | 


Hemangioma of maxillary sinus is a rare entity. We present a case with an inconclusive preoperative diagnosis which was treated by excision of entire tumor by medial maxillectomy through lateral rhinotomy approach. There is no recurrence after two years. The literature on the topic is reviewed.


S Bhargava, M Grover, PC Verma

Blue Nevus: A Rare Pigmented Lesion of Sinonasal Tract

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:2] [Pages No:61 - 62]

Keywords: Sinonasal,melanocyte,blue nevus

   DOI: 10.5005/jp-journals-10013-1014  |  Open Access |  How to cite  | 


Blue nevi are uncommon lesions of skin and mucosa. Most of these occur in skin. Only occasionally they are seen to involve mucosa. Sinonasal mucosa is one of the rarest of the sites for these lesions to occur. Only four such cases have been reported in international literature till date. We report here one such case which we came across.


Ravi Meher, Pankaj Vats, Deepti Vats, Subash Dadeya

Endoscopic Management of Optic Nerve Sheath Meningocele

[Year:2009] [Month:September-December] [Volume:2] [Number:3] [Pages:3] [Pages No:63 - 65]

Keywords: optic nerve meningocele,optic nerve cyst,CSF

   DOI: 10.5005/jp-journals-10013-1015  |  Open Access |  How to cite  | 


Optic nerve sheath dilatation forming a cyst containing cerebrospinal fliud (CSF) is a rare condition. It is actually an enlargement and dilation of primarily the optic nerve sheath. There is an expansion of the cerebrospinal fliud space around the optic nerve with no associated inflammation, orbital or cerebral neoplasm at the apex of the orbit. It is a very rare condition and only few cases have been reported in the literature. We describe a case of optic nerve meningocele which was successfully managed surgically through intranasal route. A brief review of the existing literature is also presented.

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