OTO-RHINO-LARYNGOLOGY (ENT)

Department of ENT has an exclusive Outpatient clinic situated in the second floor of the Main block with OPD & Ward in the 2nd floor of the Main block and exclusive Laminar airflow operation theatre complex in the 5th floor and Surgical ICU for ENT with 6 beds with all life saving necessary equipments.

NEWLY ADDED MICROSCOPES

• Out patient clinic also offers various sub-speciality services like Neuro-otology clinics for vertigo patients like BPPV, Vestibular labyrnthitis, Meniere’s disease and other peripheral causes of vertigo
• Allergy clinics for diagnosing and treating allergic rhinosinusitis, cancer screening clinics for suspicious nasal, nasopharyngeal, oral, oropharyngeal, laryngeal and hypopharyngeal lesions and OSA clinic to diagnose sleep apnoea.
• The above sub-speciality clinics are monitored regularly by Head of the Department and an exclusive Assistant Professor for each clinics
• Patients with quality of life affected with snoring are evaluated with nasal endoscopy ,videolaryngoscopy and radiological imaging and are managed successfully accordingly.
• We have dedicated team for audiology services with wide range of audiological tests like PTA,OAE,BERA and Impedance Audiometry. We are furnished with special diagnostic facility, VNG one of its kind when compared to nearby institutions. We also provide excellent speech therapy; Department of ENT holds the privilege of catering hearing aids to the beneficiaries in and around Thiruvallur district.
• The Newborn OAE Screening Program is integrated with the District Early Intervention Centre (DEIC) under Rashtriya Bal Swasthya Karyakram (RBSK). All babies delivered in our institutionare screened within 48 hrs of delivery for congenital hearing loss through OAE ensuring early detection. The DEIC also conducts routine hearing assessments in children less than 5 years ,thereby identifying suitable candidates for cochlear implant surgery.
• In co-ordination with DEIC, we are conducting regular camps for screening hearing disability children and identifying suitable candidature for cochlear implant surgeries. In near future we are starting Cochlear implant surgeries at our own hospital for which we have procured high end instruments.
• The Department of Otorhinolaryngology at Govt Medical College Hospital, Thiruvallur, is committed to delivering quality ENT care, advancing research, and training future Otorhinolaryngologists. Establishing an MS (Otorhinolaryngology) postgraduate course will further enhance patient care, provide hands-on surgical training, and strengthen community ENT services, ensuring better hearing for the population.

Department of ENT facilities teaching of

• Undergraduate MBBS students
• C.R.M.I from Foreign Medical graduates
• District Residency Program Post graduates from various Government and Private medical colleges and Institutions
• Nursing students and Allied Health students.

Undergraduate MBBS teaching programs

• Our Department of ENT conducts theory and practical demonstration classes for final year and Pre final year MBBS Students as per NMC Medical education unit guidelines.
• Our Government Thiruvallur Medical College, Thiruvallur has 100 Undergraduate seats each academic year starting from 2021. At present we are having First year, Second year and pre final year and final year students in our college.
• In the morning, In OPD, Wards and Operation theatre we are facilitating Early Clinical exposure as per NMC guidelines for Second year and prefinal year students

• As per COMPETENCY BASED UNDERGRADUATE CURRICULUM we provide
• education and clinical skill knowledge through various means from first year to final year Early Clinical Exposure (ECE) is a learning tool that provides medical students with
• practical experience in a healthcare setting early in their studies.
• Competency-based curriculum: The curriculum is designed to help students develop competencies in working in a healthcare team, practicing medicine, and more
• 2 weeks Clinical classes are held in final and prefinal year where proper schedule is based on Curriculum including case discussion, DOAP , self directed learning and small group teaching.
• A summative assessment is made at the end of session testing their competency skills which helps in strengthening their weak areas
• Theory classes were held regularly every month for prefinal years based on CBME curriculum that includes ENT & procedural skills, AETCOM modules , Alignment and Integration topics.

C.R.M.I. from Foreign Medical Graduates

• In our Government Medical College and Hospital, CRMI from Foreign Medical Graduates are posted after completing their Foreign Medical Graduate Examination for past 2 years with each academic year approximately 100 CRMI graduates.
• We are teaching basic clinical exposure and hands on training to all the posted CRMIs to enable them to diagnose and treat common ENT ailments.
• All the posted CRMIs are allowed to assist in
• Comprehensive ENT examination
• Deafness screening
• Learning audiogram and hearing aid prescription
• Attend to ENT emergencies at TAEI
• Observation of major and minor surgeries
• Basic ENT procedures like syringing,FB removal,ear lobe repair and Endoscopy techniques
• CRMIs are allotted topics for case presentation and symposium during their postings. For all CRMIs, evaluation of their knowledge and clinical skills is done at the bedside periodically and at the end

District Residency Program Post graduates

• As per Post Graduate Medical Education Regulations 2000 (PGMER-2000) vide notification dated 16.09.2020, Post graduate students in various Government and Private Medical Colleges in their second year are posted in New Medical colleges, District Headquarters Government Hospitals and Taluk Hospitals.
• In our Government Medical College and Hospital, Thiruvallur, District Residency Program Post Graduates are regularly posted for the past two years from various Government and Private Medical Colleges.
• All the DRP Post graduates posted in our Department are trained under subject specific learning objectives. This will be dealt with under the following headings:
• Theoretical knowledge (Cognitive domain)
• Practical and clinical skills (psychomotor domain)
• Attitudes including communication skills (Affective domain)
• Writing thesis / Reviewing Research activities (Scholarly activity)
• Training in Research Methodology (Practice based learning, Evidence based practice)
• Professionalism
• Teaching skills
• All the DRP PGs are involved in the following academic activities
• Case Presentation- Once a week in the ward and in Outpatient department
• Seminars- Once a week on every Friday
• Journal club- Once a week on every Saturday
• Academic grand ward rounds- Twice a week presentation of cases by residents and clinically applicable discussions
• Quality of training are monitored by log books, supportive supervision and continuous assessment of performance.

42/M Patient came with H/o self inflicted, cut throat Diagnosed -Self inflicted cut injury /zone-1 and 2 neck injury . Presented with severe bleeding, hypovolumic shock .Airway secured and fluids started . Pt was shifted to emergency OT and resuscitation started and stabilized by our anesthesia team. Patient underwent Emergency exploration of neck and bleeding IJV was ligated and ryles tube inserted .There were two penetrating wounds in neck , one in zone 1 which was exposed and Tracheostomy done. In zone 2, there was complete transection of thyroid cartilage and epiglottis, completely separated and tear went upto pyriform mucosa. Cartilage repair and mucosa repair done . It is first of its kind , cut throat injury with vessel bleed and pt revived in almost arrested stage and successfully surgical repair done .

Papillary Carcinoma Within Thyroglossal Duct Cyst: A Rare case report

• A 50-year-old male coming from Andhra Pradesh came to ENT OPD with complaints of swelling in the anterior aspect of neck for 2 years.
• On inspection, swelling of size 4x4x3 cm present over the anterior aspect of neck, extending between two anterior borders of Sternocleidomastoid, from thyroid to hyoid cartilage, moves with deglutition and protrusion of tongue.
• CT neck showed: -? thyroglossal cyst with malignant changes.
• MRI neck showed: A well-defined t2 hyperintense, t1 hypointense predominantly cystic lesion measuring 4.5x3.5x3cm. Both thyroid lobes seen separately from the lesion - likely thyroglossal cyst with haemorrhage and malignant transformation- suggested HPE correlation
• USG neck: B/L thyroid lobes appears normal. A well-defined anechoic cystic lesion measuring 2.9x3.9x3.3 cm, THYROGLOSSAL CYST suggested FNAC
• USG guided FNAC not conclusive, hence a diagnosis of thyroglossal cyst was made and surgery was proceeded- SISTRUNK OPERATION:

Impression: Features of thyroglossal cyst with Papillary Carcinoma thyroid

• HISTOPATHOLOGICAL EXAMINATION: Thyroglossal duct cysts are the most common congenital neck cystic anomaly during thyroid gland development. They are commonly seen in adult population with a prevalence of 7%. Most of these cystic lesions are benign and approximately 1% of cases are malignant.
• Till date, about 250 cases of TDC carcinoma were reported worldwide with most being papillary carcinoma. In India, around 30 cases of TDC carcinoma were reported.
• This is a very rare case reported to our hospital with features suggestive of thyroglossal cyst for which sistrunk procedure was done and to our surprise HPE proved it to be thyroglossal cyst with papillary carcinoma thyroid.
• Clinical examination, ultrasound, FNA, and CT findings can help to make a preoperative diagnosis, but most carcinomas are not discovered until surgery and anatomical pathology are performed. FNA cytological examination only diagnoses papillary carcinoma within TDC in two-thirds of the cases.
• In most cases, papillary carcinoma within TDC is treated with the Sistrunk procedure. Sistrunk procedure should include en bloc removal of the cyst, part of the hyoid bone, and thyroglossal duct remnants until the tongue base. Thyroidectomy should not be performed unless palpable abnormalities in the gland are observed ,or if inadequate follow-up is predicted. If routine performed, thyroidectomy does not seem to have a significant impact on the treatment outcome. This type of carcinoma usually has an excellent prognosis.

CONCLUSION:

TDC is the most common congenital anomaly related to the thyroid gland. In a TDC, papillary carcinomas typically present as swellings along the midline of the neck, which move with deglutition and tongue projection. Less than 1% lof all TDC cases present with papillary carcinomas. This type of pathology has a good prognosis and can be successfully managed with cyst removal (Sistrunk procedure) and careful follow-up. Thyroidectomy, neck lymph node dissection, or adjuvant treatments are not required in most cases.

• 60-year-old male, ent-cme-hailing from Andhra Pradesh came to ENT OPD with complaints of watery nasal discharge for 3 months and increased on bending forward, from right nasal cavity.
• Unable to sniff back and Handkerchief test was positive. Nasal endoscopy showed spontaneous clear fluid collected in nasopharynx.
• CT Cisternogram was Positive for CSF leak and was identified from the lateral wall of right sphenoid sinus with contrast extravasation into right nasal cavity.
• Leak was closed by trans nasal endoscopic closure by Composite graft placement consisting of fat, surgicel, fascia lata, tissue glue, gelfoam. Post operatively patient recovered well and was discharged on 10th postoperative day. Unnecessary trans cranial surgery was avoided and this is the first of its kind of surgery performed in Thiruvallur district.

WHEN BENIGN BECOMES BOTHERSOME A CASE OF RECURRENT INVERTED PAPILLOMA

Dr M.Kumar MS(ENT)
Associate Professor
Government Medical College And Hospital, Tiruvallur.

A 75 years old male from Tiruvallur who is a farmer by occupation came to ENT OPD with C/O nasal obstruction left side for 2 months

• C/O nasal obstruction on left side which is insidious in onset, progressive in nature, with no specific aggravating or relieving factors.
• C/O blood stained nasal discharge from left nasal cavity on and off for 2 months
• H/O reduced smell sensation for 2 months
• H/O voice change (hyponasal voice) for 2 months
• Chronic smoker and alcoholic for past 30 years

LOCAL EXAMINATION

EXAMINATION OF NOSE

• External nasal contour – normal
• Anterior nasal Rhinoscopy septum deviated to right
• Left nasal cavity- A pinkish polypoidal mass seen obliterating the entire nasal cavity
• Right nasal cavity- minimal secretion

Posterior nasal Rhinoscopy

• posterior end of septum- normal
• roof of nasopharynx- free/ no mass

Airway patency test

• cotton wool test- reduced movement on left side
• cold spatula test- reduced fogging on left side
• cottle’s test- no improvement on the left side

Paranasal sinus examination: tenderness over left maxillary, ethmoidal sinus region.

Left nasal cavity: A pinkish proliferative polypoidal friable mass arising from the roof reaching till the floor seen obliterating the entire left nasal cavity, able to probe around medial, lateral and floor of the nasal cavity except roof of the nasal cavity. Scope could not be passed further. bleeds on touch+

Right nasal cavity: post op changes. mucopurulent secretion noted +

SURGICAL PROCEDURE –

• We proceeded with endoscopic medial maxillectomy and excision of the mass with high ended micro debrider. Procedure was uneventful and patient recovered well post operatively.

HISTOPATHOLOGY REPORT-

• HPE proved as inverted papilloma

DISCUSSION

• A Benign epithelial neoplasm arising from Schneiderian membrane of nose and paranasal sinuses.
• The mucosal lining of nose and paranasal sinuses is known as Schneiderian membrane .
• Papillomas arising from this membrane is very unique in that they are found to be growing inwardly and hence the term inverted papilloma.
• Inverted Papilloma behave like neoplasms, arising from reserve / replacement cells located at the basement membrane of the mucosa due to UNKNOWN stimulus .
• The resulting thickening of the epithelium assumes an inverting, fungiform or combination growth pattern