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http://www.webmedcentral.com/images/Header_Logo.giftext/html2013-01-02T16:08:42+01:00http://www.webmedcentral.com/Dr. Nayanna KarodpatiSuccessful Treatment of Rhinocerebral Mucormycosis with Wide Local Debridement & Nanosomal Amphotericin
http://www.webmedcentral.com/article_view/3927
Rhinocerebral mucormycosis is a frequent complication of diabetes mellitus. Advanced age predisposes to mucormycosis,however severe ketoacidosis predisposes to local spread of infection irrespective of age. Our case study describes a young patient withrhinocerebralmucormycosis.The patient was not a known diabetic but was diagnosed to have severe hyperglycaemia on admission. Aggressive treatment includes early surgical intervention along with optimum doses of amphotericin B which are pivotal in controlling the spread of mucormycosisthereby preventing the dreadfulcomplications. The surgical treatment includes wide & thorough debridement of the involved tissues. This meansan early enucleation of the eyeball to stop the spread to other eye via optic chiasma.text/html2012-04-25T12:52:47+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanHypertrophied Lingual Tonsil an Interesting Case Report and A Review of Literature
http://www.webmedcentral.com/article_view/3298
This interesting case report discusses a case of hypertrophied lingual tonsil. Commonest cause of lingual tonsil hypertrophy is compensatory enlargement following tonsillectomy, next comes GERD which is common in children. Even though such huge enlargement of lingual tonsil is rare, it can be troublesome if it occurs.text/html2012-05-19T09:50:32+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanCerebrospinal Fluid Rhinorrhoes an Overview
http://www.webmedcentral.com/article_view/3382
This article discusses etiopathogenesis, clinical features and management of cerebrospinal fluid rhinorrhoea.
Cerebrospinal fluid rhinorrhoea is the leakage of cerebrospinal fluid from the subarachnoid space into the nasal cavity due to defect in both dura and bone. Various causes of CSF rhinorrhoea include:1. Traumatic2. Iatrogenic3. Idiopathic4. Tumorstext/html2012-06-04T14:38:36+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanHuge Epiglottis Cyst Causing Upper Air way Obstruction A Case Report and Literature Review
http://www.webmedcentral.com/article_view/3445
Cystic lesions involving larynx are fairly common. They constitute about 5% of benign laryngeal lesions. Majority of cysts arise from epiglottis. Lingual surface of epiglottis is commonly involved. These cysts have the potential to cause acute upper airway obstruction. This article discusses a patient who presented with a large epiglottic cyst with acute upper airway obstruction. This case is being reported not only for its rarity but also for management challenges it provides.text/html2012-11-18T06:24:07+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanChoanal Atresia a Literature Review
http://www.webmedcentral.com/article_view/3804
Choana is also known as posterior nasal aperture. Nasal airway continues with that of posterior nares. Air from nasal cavity finds its way into the lungs via the choanal apertures. In some children the choana may be congenitally closed. This causes either total (bilateral choanal atresia) or partial (unilateral choanal atreisa) nasal obstruction. Child being obligate nasal breathers, find it rather difficult to breathe when there is bilateral choanal atresia. This is more so during the first 6 weeks of life. Hence bilateral choanal atresia should be considered as an emergency in paediatric age group. This article attempts to discuss the etiopathology and management of this condition.text/html2012-11-14T19:58:14+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanThe Art of Reducing Bleeding During Endoscopic Sinus Surgery
http://www.webmedcentral.com/article_view/3824
This article discusses the importance of anesthesia in endoscopic sinus surgery. Bloodless field is rather vital during endoscopic sinus surgical procedures. Advantages of having a bloodless field during sugery are: reduced incidence of complications, reduced operating time. Major aim of anesthetist in FESS should be to reduce blood pressure to such a level that bleeding is minimized. This article discusses the importance of anesthesia in endoscopic sinus surgery. Major aim of anesthetist in FESS should be to reduce blood pressure to such a level that bleeding is minimized. The other aspect of reducing bleeding during endoscopic sinus surgical procedure is preparation of nasal mucous membrane. Various steps that can be followed to reduce bleeding during endoscopic sinus surgery are:
1. Mucosal preparation
2. Hypotensive anaesthesia
3. Positioning of the patient
4. Good anatomical knowledge
5. Use of proper instruments text/html2013-03-05T12:29:44+01:00http://www.webmedcentral.com/Dr. Nayanna KarodpatiAdenoid Hypertrophy in Adults - A Myth or Reality
http://www.webmedcentral.com/article_view/4079
Adenoid enlargement is uncommon in adults. Usually, enlarged adenoids are misdiagnosed in adults and accordingly maltreated. In our study, 13 cases of adenoid hypertrophy were seen between the age group of 18 to 39 years. Patients came with complaints of nasal obstruction, snoring and mouth breathing. Diagnostic nasal endoscopy showed enlarged soft tissue in the nasopharynx, probably hypertrophied adenoids. Computerised tomography was done to rule out other differential diagnosis. After surgical excision the tissue was sent for histopathological examination that confirmed our diagnosis. For complete removal transnasal endoscopes were used in assistance. Patients were regularly followed up for any recurrence. At the end of the study we came to the conclusion that instead of regressing in a natural physiological way with age, adenoids can remain in the nasopharynx, sometimes getting enlarged due to infection. We should keep enlarged adenoids as differential diagnosis in adults while dealing with a nasopharyngeal lesion.text/html2013-06-28T09:53:25+01:00http://www.webmedcentral.com/Dr. Priya N ShahCysticercosis of Temporalis Muscle: A Histological Surprise
http://www.webmedcentral.com/article_view/4313
Cysticercosis, a parasitic infection caused by the larval form of the pork tapeworm, Taenia solium. Cysticercosis usually involves musculoskeletal system and CNS. Here we present an isolated involvement of right sided temporalis muscle. There was no any other system involvement including CNS. So it was very difficult to diagnose the condition. All the investigations done were not pointing to any diagnosis. The condition was diagnosed only after the excision of the cyst.Keywords – Cysticercosis, musculoskeletal swelling, tapeworm infestation, temporalis.text/html2010-09-07T20:05:53+01:00http://www.webmedcentral.com/Dr. Mohd AshrafGlomus Jugulare: A Case Of Secretory Glomus Jugulare With Review Of Literature
http://www.webmedcentral.com/article_view/552
We report a case of secretory glomus jugulare tumor in a 65 year old female who presented with hearing impairment, pulsatile tinnitus, from 3 years and difficulty in swallowing, hoarseness of voice and palpitation from last six months. Detailed history and examination with aid of investigations it turned out secretory glomus jugulare. Due to patients infirmity, she was treated with radiations and is doing well from last 4 years.text/html2010-09-26T14:43:02+01:00http://www.webmedcentral.com/Dr. Sara TorrettaBilateral Naso-sinusal Glandular Hamartoma: A Case Report
http://www.webmedcentral.com/article_view/757
Differential diagnosis of unilateral nasal mass may be a troublesome question, and also unusual conditions such as glandular hamartoma, consisting in non-neoplastic or inborn malformation, must be considered. We here describe a 78-year-old patient with an unilateral nasal mass, associated to a bilateral naso-sinusal polyposis, which was initially considered to be an inverted papilloma, (on the basis of the preliminary bioptic examination), but that actually resulted a bilateral naso-sinusal glandular hamartoma at definitive histology, after surgical excision.text/html2011-03-10T21:59:47+01:00http://www.webmedcentral.com/Mr. Oladejo OlaleyeMalignant Otitis Externa: A Review of Aetiology, Presentation, Investigations and Current Management Strategies
http://www.webmedcentral.com/article_view/1725
BackgroundMalignant otitis externa (MOE), an aggressive infection involving the external auditory canal and temporal bone was first reported in the literature by Toulmouche in 1838. In 1959 Meltzer and Kelemen identified a case of osteomyelitis of the temporal bone due to pseudomonas and malignant otitis externa was described and characterized as a unique clinic entity by Chandler in 1968. This type of otitis externa was termed malignant, due to the high mortality rate, aggressive disease progression and poor response to available treatment.Aetiology:Pseudomonas is the commonest cause of MOE1. Resistant strains of pseudomonas have been described following treatment with ciprofloxacin2,3. Staphylococcus aureus has been identified and can be methicillin-resistant staphylococcus aureus4, and rarely staphylococcus epidermidis5.Fungal MOE is mostly due to aspergillus6 and candida but some unusual organisms have been identified as a cause such as scediosporum apiospermum7, and malassezia sympodialis8. A mixed infection involving both bacterial and fungal infection is possible. Ear swabs are routinely taken and sent to microbiology in an attempt to identify the causative agent.Presentation:MOE occurs almost exclusively in diabetics and the elderly. The pathogenesis of this condition is unclear, however a number of factors are thought to contribute; microangiopathy, hypoperfusion and diminished host resistance (impaired phagocytosis, poor leukocytic response, impaired intracellular digestion of bacteria) due to diabetes. Their susceptibility to pseudomonas infection is increased by their ear wax being less acidic and having a lower lysozyme content, more favourable to pseudomonas infection. Hypotheses suggest the external otitis progresses from the external auditory canal to the temporal bone and eventually the skull base via the fissure of Santorini and the osseo-cartilaginous junction. Infection is normally introduced by minor trauma or aural irrigation.Isolated cases have been reported in a small number of non-diabetic patients, particularly in children who are immunocompromised due to malignancy, malnutrition and severe anaemia as well as in patients with HIV9. MOE has also been reported in patients who were not diabetic and not immunocompromised10 and as such a high index of suspicion is required. Malignant otitis externa is more common in males and warm, humid climates.Presenting symptoms include severe, deep seated otolgia, purulent otorrhea, hearing loss and headaches. Facial nerve palsy, swallowing problems and hoarseness may be present if cranial nerve involvement has occurred. On examination, inflammatory changes and granulations are noted in the external auditory canal, although the tympanic membrane is normal. Pain is often out of proportion to changes seen at otoscopy. In a case series of 37 patients with MOE, 51% had diabetes, 40% had facial nerve palsies and 24% had multiple cranial nerve palsies1.Skull base osteomyelitis first described in 1959, is a recognised complication of MOE and it has a high morbidity and mortality11. Atypical symptoms and findings of unilateral severe otalgia, unremitting headache, and presence of high ESR, unilateral OME, constitute diagnostic clues of skull base osteomyelitis12. Other complications of MOE include temporoparietal abscess13, multiple lower cranial nerve palsies14, 15, Cerebral abscess16, meningitis15 and involvement of the temporo-mandibular joint17.Cranial nerve involvement is due to both pseudomonas neurotoxins and inflammation occurring along the skull base as the disease progresses. The facial nerve is classically the most common and first cranial nerve involved in the disease process, at the stylomastoid foramen. Cranial nerves IX, X and XI may become affected as the jugular foramen becomes involved, as may V and VI if the petrous apex is affected. The incidence of cranial nerve palsy is decreasing with early and improved antibiotic therapy. Facial nerve paralysis does not always resolve despite full treatment of the disease and should not be used as an indicator of successful disease treatment. Other cranial nerves have good rates of recovery.Levenson’s criteria can be used to diagnose malignant otits externa. Criteria include; refractory otitis externa, severe nocturnal otalgia, purulent otorrhoea, the presence of pseudomonas and granulation tissue in the external auditory canal and diabetes or an immunocompromised state.There are a number of staging classifications for the disease and generally:Stage 1 – purulent otorrhoea, otalgia (out of proportion), granulation tissue on otoscopy.Stage 2 – disease extends to soft tissues and skull base. Involvement of CN X1 and X11 occurs.Stage 3 – intracranial extension.Intracranial complications include meningitis, brain abscess and dural sinus thrombosis. These are commonly fatal and reflect severe disease progression. Sigmoid sinus thrombosis should be considered if the disease involves the jugular foramen, likewise, cavernous sinus thrombosis should be considered if there is evidence of cranial nerve V or V11 involvement.Investigations:Base line blood tests are essential. Biochemical markers give an indication of the underlying renal function and any pre-exisitng renal dysfunction, particularly in the diabetic patient. C Reactive Protein and Erythrocyte sedimentation rate are raised in malignant otitis externa. With appropriate treatment they will start to decrease within 2 weeks and eventually return to normal. White Cell Count is often normal or only mildly raised despite the aggressive nature of this infection. All patients not known to be diabetic should be tested for this condition and the possibility of underlying immunodeficiencies.Ear swabs are essential to guide the choice of antimicrobial therapy and should ideally be taken prior to commencing antibiotics, either topical or systemic. They should be sent for culture and sensitivity. Imaging to establish the extent of disease is routine nowadays. A CT scan defines the anatomical extent of the disease and remains the initial investigation of choice. Subtle changes in bone density can be picked up, along with swelling in the nasopharynx and parapharyngeal space. Serial CT scanning helps identify the extent of soft tissue swelling, however it is not useful for monitoring resolution of skull base osteomyelitis; significant bone re-mineralization requires time.MRI scanning is useful for assessing the initial severity of the disease and is excellent at delineating the extent of soft tissue disease present and intracranial complications28. There have been some reports of serial MRI scans being used for follow up.Radioisotope scans (technetium 99 / gallium 67) have an increasing role in assessing malignant otitis externa. Gallium 67 is a very sensitive but non-specific test, detecting and binding to any cells actively dividing. A base line gallium scan is obtained for comparison followed by serial scans to monitor treatment response. Scanning the affected side and comparing to the non-affected side often improves interpretation of the scan. Gallium scans are useful for comparing radiological improvement to clinical improvement and guiding the length of antibiotic treatment required. Single Photon Emission Tomogrophy (SPET) technology has improved poor spatial resolution, an initial concern with this scan.Radioactive labelled white cell scans have a role in assessing the presence and degree of osteomyelitis. A study on the various radiological and radionuclide investigations for malignant otitis externa concluded that CT and/or MRI should be supported by routine SPECT bone imaging for initial diagnosis of malignant otitis externa. Routine SPECT bone imaging further supplemented by gallium scintigraphy should be the investigation of choice in the follow up for assessing response to treatment and disease recurrence4, 18, 19.Dual In-WBC/Tc-99m MDP bone SPECT scintigraphy provides an accurate imaging modality for diagnosis and follow-up of temporal and facial osteomyelitis when existing clinical or postoperative bone changes make it difficult to detect active osteomyelitis by computed tomographic scan31Treatment:Treatment for malignant otitis externa may take several months before complete resolution is achieved. Meticulous aural toilet of the affected ear, antibiotics both topically and systemically and strict glucose control in diabetic patients is absolutely vital for success. Analgesia is also required for the severe otalgia associated with this condition.Classically, first line treatment is with antibiotics, normally, oral ciprofloxacin (a fluoroquinolone with high soft tissue and bone penetration when used orally) in the outpatient setting. However, due to the increased use of ciprofloxacin for both simple ear infections and upper respiratory tract infections there is concern pseudomonas malignant otitis externa infections are increasingly resistant to ciprofloxacin3. These patients require alternative parenteral antibiotics, but do not have an increase in mortality.If there is no resolution despite oral ciprofloxacin, intravenous antibiotics are used. Antibiotic choice depends upon hospital policy and discussion with microbiology. A number of different regimes have been documented in the literature including prolonged courses of; Meropenem, Tazocin, Ceftazidime and Gentamicin. The length of antibiotics required is determined by improvement seen on repeat imaging and clinical examination and may be continued even when imaging returns to normal.Hyperbaric oxygen has been used successfully, in conjunction with antibiotics for cases where intracranial spread has been identified or the disease appears refractory to antibiotics or is recurrent. This treatment involves placing the patient in a compression chamber and increasing the environmental pressure whilst providing 100% oxygen. This increases the oxygen supply to avascular tissue, allowing improved leukocyte function essential for infection resolution. Typical treatment courses involve 15-30sessions of about 1 – 2 hours. A Cochrane review of hyperbaric oxygen was conducted which concluded not enough data was available on suitable patient selection and oxygen dose to provide recommendations.A Cochrane Review found no clear evidence exists to demonstrate the efficacy of hyperbaric oxygen therapy when compared to treatment with antibiotics and/or surgery20. There were no randomised controlled trials identified on the use of hyperbaric oxygen in the management of MOE. No data were found to compare rates of complication between the different treatment modalities20.There are however studies that suggest hyperbaric oxygen may be useful in the treatment of MOE21. A large case series of 17 patients with MOE treated with hyperbaric oxygen concluded that although hyperbaric oxygen therapy confers minimal morbidity, its role in the management of these patients is uncertain22. Of the 17 patients, 12 were considered cured of their disease, 3 died from the disease and 2 patients had recurrent disease (with a good outcome after a second cycle of treatment) 22.Immunomodulators, such as topical tacrolimus to the affected ear have also been reported in the literature as being effective when used in combination with other treatments23, 24.Surgery in cases of MOE remains controversial. Although initially recommended by Chandler in his original report, the benefit of surgical resection is not well documented. Mastoidectomy can be performed25 but consensus is growing that this may be pointless due to its lack of efficacy against an already extensive process especially with the advent of quinolone antibiotics26. Removal of diseased bone is not recommended due to spread of the disease through fascial and vascular planes. Biopsies can be obtained and drainage of any abscess is recommended. In the presence of facial nerve palsy, decompression is not indicated. The identification and treatment of any underlying immunological deficiency is also very important.
text/html2011-03-22T20:20:33+01:00http://www.webmedcentral.com/Dr. Samuel A AdogaCadaver Temporal Bone Dissection - The JOS Experience
http://www.webmedcentral.com/article_view/1767
Background: The temporal bone is made up of nebulous complex neurovascular structure. A good grasp of this complex anatomy is necessary for the otologic surgeon in dissecting the temporal bone for various otologic surgeries and skills development.Method: The land marks for the dissections were suprameatal crest, a perpendicular line through the spine of Henle and posterior wall of the external auditory meatus of the temporal bones connected by a tangent directly overlying the mastoid antrum. Cutting burr of 6mm was used to mark out the lines above. At the juncture; the bones were deepened to expose the dural plate, sinodural angle and the posterior wall of the external meatus. Moving from one land mark to another, otologic surgeries such as mastoidectomies, facial nerve exploration and cochlear implantation were performed.Result: All the cadavers (100%) were adult males.The suprameatal crest, dural plate, aditus antrum, horizontal semi- circular canal, facial nerve canal, facial nerve, facial recess, Sigmoid plate, herald air cells, oval and round windows were present in the eighteen temporal bones. Eighteen canal wall ups and wall down mastoidectomies and cochlear implantation were performed.Spine of Henle was present in 3(16.7) %, cribrifossae,highly,moderately and poorly pneumatized, herald air cells, wide mastoid cavity, narrow mastoid cavity, tympanic membranes remnants, incus and stapes were present in 16(88.9)%, 12(66.7)%, 2(11.1)% 4(22.4)%, 13(72.2)%, 16(88.9)%, 2(11.1)%, 11(61.1)%, 12(66.7)% and 6(33.3)% respectively. Conclusion: Temporal bone dissection provides the learning curve in understanding anatomic features and the variations that pose challenge in otologic surgeries.text/html2012-04-17T12:19:22+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanPreventing Nerve Damage During Thyroid Surgeries
http://www.webmedcentral.com/article_view/3260
Thyroid sugery is a potential risk for vital nerves which include recurrent laryngeal nerve and superior laryngeal nerve. Out of these two damage to recurrent laryngeal nerve leaves the patient with a hoarse voice. Situation is more disastrous if recurrent laryngeal nerve is damaged on both sides during total thyroidectomy. This leads to bilateral abductor paralysis condeming the patient to life long tracheostomy. This article discusses various preventive steps that can be taken while performing thyroidectomies to avoid injury to recurrent laryngeal nerves.text/html2012-04-17T16:07:28+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanAtrophic Rhinitis: A Literature Review
http://www.webmedcentral.com/article_view/3261
Atrophic rhinitis is a chronic embarrassing debilitating disease involving nasal cavity and paranasal sinuses. It is characterized by foul smelling crusts (greenish) inside the nasal cavity. Nasal mucosa tends to bleed when these crusts are removed. Nasal cavity appears to be excessively roomy. Foul stench emanates from the patient. Patient is mercifully unaware of this stench because of the presence of anosmia. This article discusses the various features of this disease and the various management modalities available.text/html2012-04-18T13:15:56+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanMucoceles of Paranasal Sinuses
http://www.webmedcentral.com/article_view/3263
Mucoceles are gradually expanding lesion involving paranasal sinuses. This is usually caused due to obstruction to the normal drainage channels of paranasal sinuses leading on to pent up secretions within it. These patients classically don’t present with symptoms pertaining to nose and sinuses but with ophthalmological signs and symptoms. They invariably present to the opthalmologist before finding their way to an otolaryngologist.text/html2012-04-18T13:15:34+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanTests for Malingering
http://www.webmedcentral.com/article_view/3265
Malingering is common these days with liberal workmen compensation act. Lots of concessions are given to physically challenged these days. It is our duty to ensure that these incentives reach the deserving. In order to identify the beneficiaries we should weed out malingerers. Fortunately there are various tests which can be performed to weed them out. This article is a treatise of how to identify malingerers. It enumerates various bed side tests, tuning fork tests and objective tests to identify non organic hearing loss.text/html2012-04-19T16:47:09+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanRhinosporidiosis Personal Experience and Review of Literature
http://www.webmedcentral.com/article_view/3268
Rhinosporidiosis has been defined as a chronic granulomatous disease characterised by production of polyps and other manifestations of hyperplasia of nasal mucosa. The etiological agent is Rhinosporidium seeberi.[1]Rhinosporidium seeberi: was initially believed to be a sporozoan, but it is now considered to be a fungus and has been provisionally placed under the family Olipidiaceae, [5] order chritridiales of phycomyetes by Ashworth. More recent classification puts it under DRIP’S clade. Even after extensive studies there is no consensus on where Rhinosporidium must be placed in the Taxonomic classification. It has not been possible to demonstrate fungal proteins in Rhinosporidium even after performing sensitive tests like Polymerase chain reactions [2].This article is a description of author's experience with the disease and a literature review. Unfortunately since this disease is most prevalent in South Asian countries very little attention has been focussed on it by western medical literature.text/html2012-04-19T16:46:55+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanCarhart\'s Notch Its Implications
http://www.webmedcentral.com/article_view/3273
Carhart’s notch is classically seen as a dip centered around 2 kHz range of bone conduction curve audiometery. This feature is seen in patients with otosclerosis. This article attempts to discuss why this dip is caused in the bone conduction audiometry curve in these patients.text/html2012-04-19T16:46:41+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanNovel Use of Tissue Glue in Repair of Rent in Thyrohyoid Membrane After Excision of External Laryngocele
http://www.webmedcentral.com/article_view/3276
This paper narrates our experience of using tissue glue to seal the rent in thyrohyoid membrane following excision of external laryngocele. Thyrohyoid membrane is highly elastic, and this elasticity makes suturing the rent in the membrane very difficult. We used tissue glue with success to seal the rent.text/html2012-04-21T11:09:21+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanCystic Fibrosis Otolaryngologist Perspective
http://www.webmedcentral.com/article_view/3278
Cystic fibrosis is an autosomal recessive disorder affecting the exocrine glands. It causes the secretions from these glands to become thick and viscous. There is a tendency to involve multiple organ systems. This article discusses the etiopathogenesis, clinical features and management of this problem. This article is written from otolaryngologist's perspective. One component of cystic fibrosis happens to be recurrent nasal polyposis which seems to be resistant to various management modalities. Hence this article focusses on this unique problem.text/html2012-04-21T11:08:38+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanTuning Fork Tests
http://www.webmedcentral.com/article_view/3279
This article reviews the history of tuning fork tests, its current status as a clinical examination tool. All the commonly performed tuning fork tests are discussed in detail. The three commonly performed tuning fork tests include: Rinne test, weber test and Absolute bone conduction test.text/html2012-04-28T11:09:04+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanHyperbaric Oxygen therapy Concepts and Myths
http://www.webmedcentral.com/article_view/3309
Hyperbaric oxygen therapy is defined as administration of 100% oxygen to a patient placed inside a chamber pressurised to greater than 1 atmosphere at sea level 1. Local application of oxygen under high pressure without completely enclosing the patient is not considered to be hyperbaric oxygen therapy.text/html2012-05-01T17:03:25+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanMucocele of Middle Turbinate an Interesting Case Report and Literature Review
http://www.webmedcentral.com/article_view/3318
Concha involving middle turbinate is a common occurence [1]. Review of literature puts the incidence anywhere between 14 – 40%. This is an interesting case report of mucocele involving middle turbinate concha. Pneumatization of middle turbinate is known as concha bullosa [4]. Concha bullosa actually is a radiological diagnosis [2]. Mucoceles can technically arise from a concha bullosa if its outflow channel is obstructed. This is ofcourse rather rare. This case report discusses a case of mucocele involving a pneumatized middle turbinate.text/html2012-05-04T18:04:30+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanBlow Out Fracture Orbit Endoscopic Reduction a Novel Management Modality
http://www.webmedcentral.com/article_view/3329
Blow out fracture of orbit involves fracture of orbital floor without fracture of infraorbital rim. This injury is common from frontal blow to orbit. Frontal blow to orbit causes increased intraorbital tension causing fracture of floor of the orbit (weak point) with prolapse of orbital content into the maxillary sinus cavity. This causes enophthalmos and diplopia. Infraorbital rim is not involved in pure blow out fracture, it is also involved then it should be considered as an impure blow out fracture [3]. Entrapment of inferior rectus muscle between the fracture fragments will cause diplopia in these patients. This article discusses a novel endoscopic internal reduction of fractured fragments. Main advantage of endoscopic approach is the lack of facial skin incision. It is cosmetically acceptable.text/html2012-05-07T16:23:54+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanHuge rhinolith nasal cavity an interesting case report and a review of literature
http://www.webmedcentral.com/article_view/3335
Rhinoliths are calcareous deposits (stone like) inside the nasal cavity. These stone like structures are highly friable and may crumble when crushed. This interesting case report discusses a patient with a huge rhinolith inside the nasal cavity. Rhinoliths since they crumble easily can be removed after crushing with a luc's forceps via the nasal cavity. Since the rhinolith in this patient was very large extending up to the choana it was removed via lateral rhinotomy approach in order to avoid excessive injury to nasal mucosa during the process of removal.text/html2012-05-11T14:09:32+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanDeviated Nasal Septum and its management. A Straight Nasal Septum is rather rare
http://www.webmedcentral.com/article_view/3359
This article discusses various causes of deviation of nasal septum. A review of literature suggests that a midline septum is rather rare. A midline nasal septum could actually be a clinical curiosity. Mild deviations involvng nasal septum are asymptomatic and are incidental finding. Gross deviations involving nasal septum may cause deformities involving dorsum of nose, nasal obstruction, pain due to nerve entrapment and sinusitis due to obstruction at the level of middle meatus. This article discusses this topic in a systematic manner highlighting the various management modalities available.text/html2012-05-25T17:28:41+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanFrontoethmoidal Mucocele with Intracranial Extension an Interesting Case Report and Review of Literature
http://www.webmedcentral.com/article_view/3409
Mucoceles are gradually expanding lesion involving paranasal sinuses [1]. This is usually caused due to obstruction to the normal drainage channels of paranasal sinuses leading on to pent up secretions within it. These patients classically don’t present with symptoms pertaining to nose and sinuses but with ophthalmological signs and symptoms. They invariably present to the opthalmologist before finding their way to an otolaryngologist. This interesting case report describes a patient with a large frontoethmoidal mucocele who presented with extensive proptosis and intracranial extension of the lesion. This case is reported to stress the importance of endoscopic approach in managing these lesions.text/html2012-11-05T13:18:54+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanDentigerous Cyst from Supernumerary Teeth an Interesting Case Report
http://www.webmedcentral.com/article_view/3801
Dentigerous cysts are the most common developmental odontogenic cysts. They are usually derived from the epithelial remnants of tooth forming organs. These cysts increase in size gradually. There may also be associated bone resorption. Managing these lesions creates problems in children. It is always better to be conservative in managing this problem in children because dentition is yet to complete in them. This article reviews this topic with specific focus on Dentigerous cyst arising from unerupted supernumerary tooth.text/html2012-11-16T13:41:04+01:00http://www.webmedcentral.com/Dr. Balasubramanian ThiagarajanDrug Induced Gingival Overgrowth
http://www.webmedcentral.com/article_view/3829
Gingival hyperplasia / hypertrophy is a rather common condition. This article reviews literature pertaining only to gingival overgrowth following drug ingestion. A wide range of causes have been attributed to gingival overgrowth. Drug induced overgrowth commonly occurs following medications prescribed for non dental causes. Pathogenesis of gingival overgrowth following ingestion of certain drugs is still unsure. Certain high risk co existant factors like presence of gingivitis has been implicated. Management of this condition should take into consideration the condition for which the offending drug has been prescribed. Physicians should be aware of drugs that could cause gingival overgrowth in order to identify and manage this problem.text/html2013-07-15T11:58:39+01:00http://www.webmedcentral.com/Dr. Gundappa MahajanNasal Angiofibroma - A Rare Presentation
http://www.webmedcentral.com/article_view/4337
Angiofibroma is a fibrous and vascular tumour that commonly occurs in adolescent males and involves the nasopharynx. Hence the name juvenile nasopharyngeal angiofibroma. The incidence of juvenile angiofibroma is less than 0.5% of head and neck tumours. Radiological evidence, drawn from over 20yrs, reveals the probable origin of this tumour to be the recess behind the pterygopalatine ganglion at the exit aperture of the pterygoid canal. It develops almost exclusively in adolescent males, though there are reports of this tumour being found in children, the elderly and pregnant women. We report a rare presentation of a middle aged female patient who came with right sided nasal mass which was found arising from nasal septum and was diagnosed as angiofibroma on postoperative histopathological evaluation.text/html2016-12-27T07:48:47+01:00http://www.webmedcentral.com/Dr. Nuno D CostaSudden Unilateral Hearing Loss After non-Otologic Surgery
http://www.webmedcentral.com/article_view/5247
A 61-year-old woman presented with sudden right-sided hearing loss with tinnitus, immediately after of laparoscopic oophorectomy. The patient is blind due to congenital retinitis pigmentosa. Physical examination revealed a normal otoscopy with tuning fork test compatible with right-sided sensorineural hearing loss. Pure tone audiograms (PTA) demonstrated right-sided sensorineural hearing loss affecting the frequencies between 250 and 1000 Hz and normal left-sided hearing. MRI of the ear and brain was normal. Treatment consisted in high-dose oral prednisolone followed by progressive withdrawal and hyperbaric oxygen therapy. PTA was repeated after the treatment and showed a partial improvement in hearing threshold, but with persistence of the tinnitus. Sudden onset sensorineural hearing loss (SSNHL) following non-otologic surgery is a rare event with frightening consequences, especially when the patient is blind.text/html2017-01-04T05:24:33+01:00http://www.webmedcentral.com/Dr. Nuno D CostaUnilateral Hearing Loss Following Carbon Monoxide Poisoning
http://www.webmedcentral.com/article_view/5250
The ototoxicity associated wih carbon monoxide is rare and is usually associated with chronic exposure. The pathophysiological mechanisms include hypoxia due to decreased import of oxygen and free radical damage to the cochlea, auditory nerve, and central nervous system.
We present a case of a 49-year-old man admitted to our emergency department after acute voluntary intoxication by carbon monoxide. Due to psychomotor restlessness, the patient was admitted in intensive care for surveillance and early treatment with hyperbaric oxygen therapy. On the 7th day, sedoanalgesia was suspended. At this point refers decreased hearing acuity of the right ear associated with tinnitus. The audiogram showed a severe right-sided sensorineural hearing loss from 500 to 8000 Hz. Systemic corticosteroid therapy was initiated associated with hyperbaric oxygen therapy. After three months the audiogram shows a partial recovery of hearing loss in his right ear.text/html2017-08-31T07:32:23+01:00http://www.webmedcentral.com/Mrs. Ines F GambôaIntraosseous cavernous hemangioma: A rare nasal tumour
http://www.webmedcentral.com/article_view/5316
The nasal cavity harbors a wide variety of benign and malignant neoplasms. Benign neoplasms include those arising in epitelial and soft tissues. Hemangioma is an infrequent neoplasm of the nasal cavity, mostly arising in the mucosa and rarely in the bone. We report a case of an intraosseous cavernous hemangioma arising from the nasal floor in a 51 years old woman.text/html2018-06-15T04:55:51+01:00http://www.webmedcentral.com/Dr. Kang ChengModeling Working Mechanisms of Human Cochlea
http://www.webmedcentral.com/article_view/5480
To keep healthy people from auditory dysfunction such as hearing loss, tinnitus et al, it is significant to understand the working mechanisms of the cochlea. Bekesy discovered the physical mechanism of stimulation within the cochlea about 70 years ago. Since then, many topics of the researches have been continued experimentally and theoretically. Most of them are involved in: how do sound waves travel in the cochlea? Do they propagate along the basilar membrane as slow waves or through biological fluids as fast and compressional ones (similar to the sound speed in water)? To the best of our knowledge, such questions have not been fully answered and the working mechanisms of the cochleae, otoacoustic reception and emission are still unclear today, in a perspective of biomedical and biochemical infophysics.
In this study, based on Newton's laws, Shannon information theory and our previous published mathematical model relating the characteristic/natural frequencies (in time domain) and the spiral angles of human cochlea, we further develop biomedical and biochemical infophysics models to investigate working mechanisms how a human cochlea filters sound waves to obtain and transmit the signals, for both normal auditory senses and abnormal hearings, such as tinnitus, aural response obstruction or aural hindrance (loss).
We believe our models of biomedical and biochemical infophysics will help us to prevent healthy people from, or to assistant the patients to recover from the diseases, or to improve the patients’ hearing ability or quality as well as to understand the working mechanisms.text/html2020-08-17T07:57:01+01:00http://www.webmedcentral.com/Dr. Deepak GuptaN99 Neck Masks for Neck Breathers
http://www.webmedcentral.com/article_view/5620
Neck breathers may have air movement across tracheoesophageal puncture/fistula or laryngopharynx during vocalization leading to aerosols exiting via nasopharynx and oropharynx [1]. Therefore, neck breathers wear facemasks during COVID-19 pandemic as depicted by masked mannequin (Figure 1: pink arrowheads). However, neck mask is also needed for neck breathers to contain aerosols exiting via neck tracheal access. If the Kelley Circuit is unavailable [2], hospitalized neck breathers should be offered N99 neck masks with N99 bacterial/viral filter’s 15mmID attachment to tracheal access cannula (Figure 1: A) or fiber-optic bronchoscope swivel adapter plus N99 bacterial/viral filter combo allowing almost-closed suctioning of tracheal secretions (Figure 1: B) via flexible diaphragm-sealed cap (Figure 1: red arrowhead) snugly fitting tracheal suction catheter (Figure 1: green arrowhead) [3]. The oxygen supplementation via tracheostomy mask or T-piece and self-inflating bag-valve resuscitation can be performed across N99 bacterial/viral filter’s 22mmID (Figure 1: yellow arrowheads). The additional benefit of attaching swivel adapter is that, to avoid barotrauma by clogged N99 bacterial/viral filter, hard-plug (Figure 1: blue arrowhead) or soft-cap (Figure 1: red arrowhead) can be emergently unplugged or uncapped while inadvertently tight-fitted N99 bacterial/viral filter is being replaced. Few considerations regarding these N99 neck masks are that (a) with them, cuffless tracheal access may get a little less aerosol-containment than cuffed tracheal access; (b) to contain accidental tracheal decannulation, patients must themselves be able to snug-fit (not too tight-fit) and detach them easily, as-and-when needed; and (c) to contain the costs, it must be investigated whether they can have extended use or limited reuse at home if they are allowed to dry in regular sunlight or be sanitized with ultraviolet-C sanitizers.
In the interim, as schematically demonstrated in Supplementary video file (Video 1), spontaneously breathing and even mechanically ventilated neck breathers can be "masked" in perioperative areas so that, during suctioning of airway secretions, there is less spill into atmosphere and, in the absence of suctioning needs, neck breathers can have their own N99 masks during their perioperative stay. For cost-efficiency, the same N99 bacterial/viral filters used intraoperatively within anesthesia circuits for neck breathers can be carried over to recovery areas for postoperative use as well. It is not clear if thicker heat and moisture exchanger filters will have more resistance for spontaneously breathing neck breathers as compared to thinner N99 bacterial/viral filters demonstrated in Figure 1 and Video 1 [4-5]. If perioperative teams find it logistically difficult to use N99 masks in perioperative areas, they can alternately use non-N99 medical grade or non-medical grade masks/cloth coverings among spontaneously breathing neck breathers by dual-masking them with face-mask plus neck-mask.
In summary, neck masks among neck breathers are for here to stay even after when COVID-19 pandemic will be over.
"Bacterial/Viral Filter Based (A) N99 Trach Mask With (B) Almost-Closed Suction Catheter Assembly"
text/html2020-12-27T08:18:05+01:00http://www.webmedcentral.com/Dr. Deepak GuptaCan Audiometry/Tympanometry Unravel If Our Masks Not Allowing Our Ear Drums To Vibrate Freely?
http://www.webmedcentral.com/article_view/5674
It happens to be a chance real observation and a chance theoretical interpretation. It is just an amusing tell-tale that what people are saying and what we are hearing is not exactly the same when they or we especially when they and we are wearing masks. So, the question arises how the masks are affecting our hearing [1]. Are the masks interfering in their sound production and transmission under the masks? Or are the masks interfering in our sound reception and perception under the masks? Or both? We cannot check them. Therefore, we have been considering checking our own selves for some time.
The thought to investigate is simple. Are our masks allowing our ear drums to vibrate freely? The underlying theory is that if eustachian tubes get blocked, our hearing changes [2]. The underlying theory is that if air pressures in our aural apparatus change, our hearing changes. Thus, the primary question is whether our masks are blocking our eustachian tubes from freely opening. The primary question is whether our masks are changing the air pressures in our aural apparatus [3-6]. The secondary question is whether our masks induced hot and humid micro-climate is facilitating the opening of eustachian tubes to counter the changed air pressure induced secretions resulting blockade of our eustachian tubes [7].
Herein comes the difficulty to investigate in the times of COVID-19 pandemic even when it seems more likely than ever to share scientific investigations and the results therein with the rapidly adapting biomedical world and eagerly listening general population.
Is it easy to pursue internal review board review and approval for something as meager as hearing impairment under the masks in the times when COVID-19 pandemic is warranting and mandating all to wear the masks to save lives?
Is it dangerous to ask ourselves to remove our masks while asking others to investigate our ear drums only for the sake of research investigation into our chance observation?
Is it medicolegally liable for others to conduct research investigation into our chance observation without ruling out COVID-19 test status of all involved during this research investigation?
Is it logical to expose oneself to the eventuality of testing, tracing, quarantining and isolating in case things go south during the research investigation for our chance observation in the midst of surging resurging pandemic?
Can hearing impairment quantification while wearing masks be a temptation for self-experimentation to inspire future and formal research investigation?
Essentially, we have been hearing about hearing impairment caused by masks. Now is the time to investigate how true this is. The option is either to self-experiment or to pursue formal research. As self-experiment may not be publishable and formal research may not be feasible [8], we are just sharing our envisaged protocol which resourceful investigators around the world can consider worth exploring as formal research.text/html2021-01-31T05:35:02+01:00http://www.webmedcentral.com/Dr. Deepak GuptaInvestigate In-Mask Temperature As A Surrogate Indicator Of Potentially \"Therapeutic\" Nasopharyngeal Temperature Denoting Masks\' Therapeutic Efficiency To Complement Masks\' Filtration Efficiency Against SARS-CoV-2 And Its Variants
http://www.webmedcentral.com/article_view/5692
Abundance of information leading to abundance of interpretation leads to abundance of misunderstanding thus creating a double jeopardy preventing the true understanding of information. Herein, I am sharing my interpretation hoping to correct the misunderstanding unless my understanding of the ever-changing situation may eventually be misunderstood considering the double jeopardy of too many informing harmlessly and too many interpreting harmlessly while harmful misunderstanding still persisting amidst the soaring pandemic.
When the world wonders about deaths after COVID-19 vaccinations [1], the world forgets that, in Vaccine Adverse Event Reporting System (VAERS) since 1990 [2], Centers for Disease Control and Prevention (CDC) receive reports of deaths presumed to be after any vaccination and these reports number in thousands although it is NOT clear how rarely the suspected vaccines are actually confirmed to be the actual cause of those deaths after thorough investigations by public health officials. The reassuring fact is that compared to millions vaccinated with billions of all vaccine doses over the last three decades as tracked by CDC/VAERS, the COVID-19 vaccinations are happening at the rates of millions being vaccinated per day with target to vaccinate billions in months ahead. Therefore, the reports of presumed deaths after COVID-19 vaccinations may NOT turn out to be an absolute zero especially when the COVID-19 data from across the world is getting updated in real-time globally under the public eye of masses and media who are seeking reassurances to overcome vaccine hesitancy. Moreover, the mitigation of pandemic further starts appearing harder when reports of new SARS-CoV-2 variants surface with proven data for high transmissibility and/or high virulence to raise the concerns about evolving resistance of SARS-CoV-2 variants to currently approved vaccines warranting the need to adjust the newly invented COVID-19 vaccines [3-4]. Although too many moving pieces of real-time scientific information make the global population dizzy amidst the pandemic, some harmless theories go unnoticed and turn harmfully stale [5-7].
Hereafter, unless SARS-CoV-2 learns to evolve into a variant that does NOT like to reside and proliferate in cold secluded vestiges of human nasopharyngeal areas [8-12], it may be high time that we explore the consistent therapeutic efficiency of masks rather than focusing on their variable filtering efficiency considering that we may be able to use in-mask temperatures as surrogate indicators for nasopharyngeal temperatures which can be easily proven by concurrently and continuously measuring in-mask temperatures and nasopharyngeal temperatures among volunteers wearing various types of masks for varied durations of times. Alternatively, if planning a volunteer study seems too arduous amidst the pandemic, the nasopharyngeal swabs’ tissue samples’ temperatures can be measured by infra-red no-touch thermometer or thermal imaging camera at the time of testing for SARS-CoV-2 among asymptomatic population to gauge if the nasopharyngeal swabs’ tissue samples’ temperatures of those testing positive for SARS-CoV-2 turn out to be in vivo lower than nasopharyngeal swabs’ tissue samples’ temperatures of those testing negative for SARS-CoV-2 considering that in vitro temperature affecting SARS-CoV-2 testing has been demonstrated [13-15]. It may be ironic that the utility of masks discovered during pandemic may remain relevant even after the pandemic is over when filtration-cum-therapeutic efficiency of masks may continue to decrease surgical site infections among perioperative patients, hospital acquired infections among hospitalized patients and acute exacerbations among chronic obstructive pulmonary disease patients as long as patients, caregivers and healthcare providers continue to appropriately and religiously wear masks even after the pandemic is over [16-21].
Essentially, it has been long overdue to recognize the pathophysiological importance of our nosy noses [22-24], unless we need evidence from neck-only breathers to scientifically and experimentally prove to us all the things they and their noses miss due to the absence of rhythmic airflow happening across their noses when rhythmic breathing is happening only and only across their tracheal stomas in their necks [25-28]. Ironically, the long-term changes in the functioning of noses among neck-only breathers may potentially make them more tolerant to masks covering their mouths and noses considering that such masks may potentially neither induce increased in-mask temperatures nor induce increased nasopharyngeal temperatures among them when they have become used to absent rhythmic-coolant-airflow across their non-breathing noses. Interestingly, the investigation of concurrently and continuously measuring in-mask temperatures and nasopharyngeal temperatures among neck-only breather-subgroup of volunteers wearing various types of masks covering their mouths and noses for varied durations of times along with or without neck-masks covering their tracheal stomas may confirm or refute the consequences on local tissue temperatures within the noses of neck-only breathers with implications therein for nasopharyngeal swabs’ tissue samples’ temperatures among neck-only breathers.text/html2021-04-06T03:21:27+01:00http://www.webmedcentral.com/Dr. Deepak GuptaWorth Investigating The Changes (If Any) In The Misnomer \"Wind-Chill\" Effect Of Noses Among Masked Workers, Intubated Patients and Laryngectomy Patients
http://www.webmedcentral.com/article_view/5698
As elicited in my opinion [1] for the resourceful readers to consider researching and exploring the theorized and envisaged pathophysiological phenomena, I am sharing my thoughts on how to investigate nasopharyngeal temperatures changing among masked workers, intubated patients and laryngectomy patients to validate or refute if human noses are providing the misnomer “wind-chill” effect [2] on to the airs they (the humans) exhale while warming what they (the humans) inhale [3] and on the brains they (the noses) cool with changes in the nasopharyngeal temperatures providing the indication that this brain-cooling and exhalation-cooling (inhalation-warming) effects of noses may be attenuated when humans wear masks, or are intubated, or have undergone laryngectomy. text/html2021-04-06T03:19:59+01:00http://www.webmedcentral.com/Dr. Deepak GuptaPersonal journey of in-mask nasopharyngeal temperature: Is it time to investigate whether one-year of pandemic mitigation measures has induced nasopharyngeal cellular changes detectable by narrow-band imaging and/or contact endoscopy?
http://www.webmedcentral.com/article_view/5700
Unlike rare personalities who are able to do what they say [1], I am just like any other biological/non-biological algorithm-bound living thing who despite being physically free [2], will always be a prisoner of my thoughts. I used to sympathize with those who can't or won't wear masks during pandemic. Now I envy them because it is becoming difficult for me to let go my masks and take them off despite vaccination. I am chained to my thought of masks' potential therapeutic role secondary to masks creating non-physiological hot and humid micro-environments. For the last one year or so, I have been feeling that my masks are not just passive bystanders by preventing SARS-CoV-2 infection in me but actively fighting against SARS-CoV-2 by heated humidity in my breathing environment. Moreover, besides always masked when at work or if out-of-home, indoor temperatures at my home have gotten dialed up from pre-pandemic 68-70 F to 77-78 F since the pandemic to avoid normal vasomotor physiology [3-4] of nose misrepresenting itself as pandemic era pathology. Now the questions arise how, when, and why I may have to let go my hot and humid micro-environments in due course of time very soon [5].
The question of how is very simple. I will have to change as per updated guidelines of experts and authorities to take my masks off [6]. The question of when is simple too. Once I have mustered enough courage, I will set my nose free from the shackles of "therapeutic" masks [7]. The question of why is a little complicated as it is mostly unanswered why I started wearing masks despite not liking them and why I have to stop wearing them despite being afraid to take them off. Some explorative questions may help in allaying my fear to take them off although my thought about their therapeutic role may remain permanently imprinted on to my core.
Should the world explore whether nose-mouth inhalation-exhalation pattern might have been better than mouth-mouth inhalation-exhalation pattern under the masks to keep nasopharynx cooler with maybe brain cooler too even though it might have been difficult-to-follow tedious, exhausting and noisy nose-mouth inhalation-exhalation pattern day-in-day-out under the flow-resistive masks [8-12] which induce breathing resistance considering that hotter nasopharynx with mouth-mouth inhalation-exhalation pattern might have been better for potential "therapeutic" role of masks?
Should the world explore whether in-mask hot and humid micro-environments with mouth-mouth inhalation-exhalation pattern may have correspondingly created hot and humid nasal and nasopharyngeal cavities which being non-physiological for those cavities may have the potential to induce cellular changes therein mimicking the disuse atrophy or other patterns observed in these cavities among the laryngectomy patients [13] who have almost no air current flowing through their noses?
Should the world explore whether non-physiological hot and humid nasal and nasopharyngeal environments may have forced them to go into overdrive as heat-exchangers with reversal of their role from warming and humidifying the colder and drier ambient inhalations to potentially cooling and dehumidifying the hotter and wetter in-mask inhalations considering that absolute/specific humidity under the masks and correspondingly within nasal and nasopharyngeal cavities increase to discomforting supra-normal levels thus making the physiologically present 100%-saturated relative humidity within the nasopharynx pathologically irrelevant [14-15]?
Should the world explore whether non-physiological trapped heat and humidity within the masks and correspondingly within nasal and nasopharyngeal cavities may lead envisioning the long term effects as cellular changes therein as similar to hot and humid geographical climate related distribution of cellular changes in the nasopharynx especially when there is a discordance between the nasal and nasopharyngeal anatomy that had evolved to survive in cold-dry climate and the seasons-pandemics which are forcing those evolved populations to live in hot-humid ambient or in-mask climate [16-18]?
Should the world explore whether hot and humid micro-environment may erroneously feel "soothing" to the oral cavity and its swollen structures like tonsils, if any, especially if mouth-mouth inhalation-exhalation pattern may appear warming but dehumidifying the oral mucosa and the swollen structures therein when mouth tries but fails miserably to mimic nose's heat-exchanging and humidity-holding mechanisms as demonstrated by collection of exhaled breath condensate during non-humidity holding oral breathing when compared to humidity-holding nasal breathing [19-27]?
Should the world explore whether hot and humid nasopharyngeal cavities of healthcare workers wearing N95 respirators day-in-day-out during pandemic need to be formally investigated for cellular changes by narrow-band imaging and/or contact endoscopy [28-30] to see if there are any long term cellular consequences of mask-wearing on their nasopharynx because it is not clear whether it is the calculated changes in diet to avoid high-salty dishes or it is the eased provisions for controlled air-conditioning providing cooler and drier living conditions which have brought down the incidence of nasopharyngeal cellular changes in populations who had been at-risk for nasopharyngeal oncogeny [31-39]?
The bottom line is that there is so much which the world needs to explore and document. I am just sharing the changes in my nasopharyngeal temperature. Figure 1 demonstrates my right-sided nasopharyngeal temperature having a roller coaster ride under masks worn in various combinations with head coverings and face shields while a second temperature probe just outside my left nostril keeping a track of the temperature of air being inhaled while wearing or not wearing mask/head covering/face shield.
Vertical Zones within Figure 1 represent what the combination of mask/head covering/face shield was:
Vertical Zone A: No mask/head covering/face shield
Vertical Zone B: Bouffant cap
Vertical Zone C: Bouffant cap + Simple mask
Vertical Zone D: Bouffant cap + N95 respirator
Vertical Zone E: Bouffant cap + N95 respirator + Simple mask
Vertical Zone F: Bouffant cap + N95 respirator + Simple mask + Face shield
Vertical Zone G: No mask/head covering/face shield
Vertical Zone H: Thick woolen hat
Vertical Zone I: Transitioning period
Vertical Zone J: Bouffant cap + Cotton mask + Bandana + Surgical mask + Face shield
Vertical Zone K: Bouffant cap + N95 respirator + Bandana + Surgical mask + Face shield
Vertical Zone L: No mask/head covering/face shield
Vertical Zone M: Thick woolen hat
During vertical zones A-H, only nasal breathing was happening. During vertical zones I-M, only oral breathing was happening.
Few interesting observations were unraveled. Thick woolen hat (vertical zones H and M in Figure 1) and not bouffant cap (vertical zone B in Figure 1) somewhat increased nasopharyngeal temperatures. Irrespective of mask/head covering/face shield, nasopharyngeal temperatures were higher during oral breathing (vertical zones I-M in Figure 1) as compared to during nasal breathing (vertical zones A-H in Figure 1), most likely due to the lost cooling effect of moving air which was not moving across the nasopharynx during oral breathing. Simultaneously, irrespective of mask/head covering/face shield, oral breathing related exhaled breaths seemed to warm the ambient air environment to be inhaled as demonstrated by higher temperatures outside left nostril during oral breathing (vertical zones I-M in Figure 1) as compared to during nasal breathing (vertical zones A-H in Figure 1); this exaggerated warming induced by exhaled breaths exiting mouth seemed to be secondary to the absence of cooling effect of nose on them during oral breathing because the cooling effect of nose during nasal breathing can even try to maintain nasopharyngeal temperatures below in-mask environment temperatures (vertical zones E-F in Figure 1) which can overshoot due to the trapped heat under the masks with/without head covering and/or face shield. It will be interesting to see in future if nasopharyngeal temperatures remain higher and/or increase further when duration of nasal and/or oral breathing is prolonged irrespective of mask/head covering/face shield thereby simulating healthcare workers wearing mask/head covering/face shield for many work-hours per workday because doffing the masks (vertical zones G and L in Figure 1) decreases nasopharyngeal temperatures rapidly although baseline nasopharyngeal temperatures may remain higher during oral breathing (vertical zone L in Figure 1) as compared to during nasal breathing (vertical zone G in Figure 1). Although, during this short duration ~1-hour graphing of nasopharyngeal temperatures at 1-minute intervals in Figure 1 the fluctuations with each breath were not recorded as similar to septal mucosal surface temperature recorded by others [40-41], it appeared that nasopharyngeal temperatures on the temperature monitor screen were fluctuating more often over a range with each breath in the absence of masks but not in the presence of masks making the case for exhaled breaths’ heat trapped under masks reaching an equilibrium under masks thus potentially preventing the nasopharyngeal temperatures to fluctuate with each breath under masks. Similar thoughts can be investigated to make or break the case for more fluctuations in windy cold outdoor environments as compared to controlled temperature indoor climates or during rapid shallow breathing as compared to slow deep breathing (nasopharyngeal temperatures in Figure 1 were graphed with slow deep breathing in indoor environment controlled at 77 F temperature).
Although heat/humidity reducing masks with exhalation valves are no longer recommended to use and heat/humidity adsorbent/absorbent material-based non-valved masks are yet to be developed, the heat trapped under masks is surely raising nasopharyngeal temperature, more so during oral breathing, making the case for a heated microenvironment getting created within nasopharynx while wearing masks with or without wearing head covering and face shield concurrently. Herein, Figure 2 of ~2-hours graphing left nasopharyngeal and right nostril temperature combination demonstrates that nose-nose inhalation-exhalation pattern (rectangular curve A in Figure 2) and nose-mouth inhalation-exhalation pattern (rectangular curve C in Figure 2) ends up with nose reversing its warming the nasal inhalation role during cooler ambient climate to cooling the nasal inhalation role during warmer in-mask climate thus preventing too much rise in nasopharyngeal temperature while mouth-mouth inhalation-exhalation pattern (rectangular curve D in Figure 2) much more than mouth-nose inhalation-exhalation pattern (rectangular curve B in Figure 2) turns up the heat within the nasopharynx in the absence of heat-exchanging nasal inhalations. Interestingly for me, nose-nose inhalation-exhalation pattern has been natural during ambient living condition and mouth-mouth inhalation-exhalation pattern has been essential during in-mask living condition while nose-mouth inhalation-exhalation pattern has been exhausting during in-mask living condition despite being the coolest for nasopharynx and mouth-nose inhalation-exhalation pattern has been unnatural during any living condition.
It will be only time and future biomedical research that may prove or disprove if heated microenvironment in nasopharynx is going to be detrimental to cold viruses like SARS-CoV-2 [42] by inactivating them thus imparting masks a therapeutic role therein because, although it remains to be seen if 100% relative humidity constantly maintained within nasopharynx physiologically [15] means that absolute humidity during hotter nasopharyngeal temperatures will be more than during colder nasopharyngeal temperatures or whether nasal and nasopharyngeal cavities are equally effective in cooling the hotter ambient air as they are in heating the colder ambient air, warm mist inhalation (and NOT cool mist inhalation) that may raise nasopharyngeal temperature to higher level even during nasal breathing (Figure 3 of ~30-minutes graphing left nasopharyngeal and right nostril temperature combination) may not be always possible and certainly not feasible during many work-hours per workday and mouth breathing may not be always feasible or advisable over nasal breathing [43-47]. Hereafter, it will be very futuristic to investigate if there will be a trade off by nasopharyngeal heat inactivating viruses for now vs. nasopharyngeal heat activating oncogeny for later or a win-win by nasopharyngeal heat not only inactivating viruses but also oncogeny as well [48-53].
Fig 1:
Fig 2:
Fig 3: