Objective: Background: Surgical management of cerebrospinal fluid (CSF) rhinorrhea can be done through a transcranial approach or endoscopically using a transnasal approach. The endoscopic technology is relatively fresh in developing countries. Keeping this in mind we conducted an audit of patients undergoing endoscopic repair of CSF leaks to review their outcome in terms of recurrence and complications and compare them with the patients had transcranial repair. The objective of the study is to review the management of patients who underwent repair of CSF rhinorrhea at Lyari General Hospital, Aga Khan University Hospital and Memon Medical Institute Hospital – 10 years experience. Study design: Cross-sectional observational study Place and duration of Study: Lyari General Hospital, Aga Khan University Hospital and Memon Medical Institute Hospital, from January 2005 to December 2014 Patients & methods: A review of patient charts having undergone surgical repair for CSF rhinorrhea in the last 10 years at our institution was conducted. Thirty eight patients meeting the inclusion criteria of having undergone a surgical procedure for the repair of CSF rhinorrhea with a minimum post operative follow up of 6 months were included in the study. Results: Skull base defects were repaired with the help of minimally invasive transnasal endoscopic approach with a success rate of 80% in comparison to transcranial repair success rate of 29%. Post-operative complications were seen in only 10% of endoscopic group and 53% of transcranial group. Conclusion: Although endoscopic management is associated with better outcomes there is room for improvement in the approach in developing countries and training programs and detailed internal audits need to be conducted to improve the situation to the level of developed countries.

This study was conducted to assess the frequency of pre-operative malnourishment in patients being treated for oral cavity squamous cell carcinoma. A retrospective chart review was carried out at the Aga Khan University Hospital, Karachi, on 62 patients. Patients were screened pre-operatively through a standard nutritional assessment tool at the time of admission to assess for malnutrition. Mean age of presentation was 48.34 +/- 13.11 years, mean height was 165 +/- 8.62cm, weight 66.09 +/- 14.98 kg and BMI of 24.09 +/- 4.84. Males were 82.3% and 17.7% were females. At the time of admission, a significant number or patients, 12 (19.4%) were prone to malnourishment, while 3 (4.8%) patients were malnourished: Assessment was done by using a standardised nutritional assessment tool.

Introduction Atypia of undetermined significance (AUS) or follicular lesion of undetermined significance (FLUS) is one of the six diagnostic categories of the Bethesda System for Reporting Thyroid Cytopathology. The prevalence of malignancy among Bethesda category III cytology is variable, ranging from 5% to 37% in the literature. Objective To determine the rate of malignancy in thyroid nodules reported as Bethesda category III. Methods A total of 495 patients underwent surgical intervention for thyroid nodules from January 2015 to December 2017. The present study included 81 cases reported as Bethesda category III, and their medical records were reviewed. Results Out of 495 fine-needle aspiration cytology samples, 81 (16.4%) samples were labeled as AUS/FLUS. Among these 81 patients, the mean age was 43.0 years (± 13.9), with only 11 (14%) patients older than 55 years of age. Most of our patients were female (n = 69; 85.2%), and the rest were male. The rate of malignancy based on the final histology was of 33.3% (n = 27). The majority were 17 cases (21%) of papillary carcinoma, followed by follicular carcinoma (n = 6) (7.4%). Conclusion The risk of malignancy can be higher than it is commonly believed, and guidelines should be based on the data from the institutions themselves for a better assessment of the outcomes.

BACKGROUND:Re-admission following day care surgery in ENT (Ear, Nose & Throat) results in significant morbidity to patient & massive load to hospital & also raises the question on the safety of day care surgery. Only a small number of published studies emphases on return to hospital within 30 days following day care surgery in otorhinolaryngology especially from our region. This study was carried out to determine the frequency of re-admission after day care surgery in ENT.METHODS:We prospectively studied consecutive patients who underwent ENT procedures [i.e., septoplasty, tympanoplasty type I & functional endoscopic sinus surgery (FESS) for deviated nasal septum (DNS), chronic suppurative otitis media tubotympanic (CSOM TT) variety & ethmoidal nasal polyposis (ENP) respectively] as day care surgery case under general anaesthesia at the Section of Otorhinolaryngology and Head & Neck Surgery, Aga Khan University Hospital & Liaquat National Hospital, Karachi from January 2015 to December 2016. All patients aged 20- 60 years of both genders were included in the study. SPSS software version 20 was used for data compilation and analysis. p-value less than or equal to 0.05 was taken as significant.RESULTS:In the phase of 24 months, total 317 cases met the inclusion criteria & were included in the study. There were 205 males & 112 females in the study population. One hundred & twenty-two patients having DNS, 128 having CSOM TT & 67 suffering from ENP & underwent septoplasty, tympanoplasty type I & FESS respectively. Complications were observed in a total of 7 (2.2%) patients in our study group & required re-admission within 1 month of surgery. Stratification was done between re-admission & all effect modifiers, with all showing insignificant results.CONCLUSIONS:Our results demonstrate that ENT surgeries (septoplasty, tympanoplasty type I & FESS) are safe procedures which can be performed as a day care case with acceptably low readmission rates.

Introduction Critical weight loss is defined as an unintentional weight loss of ≥ 5% at 1 month or ≥ 10% at 6 months from the start of treatment. Critical weight loss leads to deterioration of the immune function and reduced tolerance to treatment (surgery ± radiochemotherapy) as well as increased complication rates. Objective Critical weight loss, defined as a weight loss of ≥ 5% after 1 month or ≥ 10% after 6 months from the start of treatment, is not uncommon in head and neck cancer patients. We aimed to assess the factors associated with critical weight loss during the treatment of oral cavity squamous cell carcinoma patients. Methods A retrospective cohort study was performed at the Aga Khan University Hospital, in Karachi, Pakistan, on 125 patients. Patients receiving adjuvant therapy were considered exposed, and the outcome was critical weight loss. Results The mean age of presentation was 46.9 ± 12.8 years in patients undergoing surgery and adjuvant therapy, with 119 (79.3%) of them being male and 31 (20.7%) female. One hundred and twelve patients (81.3%) developed critical weight loss at 6 months from the start of treatment, and the only significant variable associated with critical weight loss was the stage of the disease (p = 0.03). Conclusion A large proportion of patients with oral cancer developed critical weight loss requiring a need for intervention. The overall stage of the disease is a significant predictor of critical weight loss in patients undergoing treatment.

The paragraph where lack of cancer registry in Pakistan is mentioned, highlights the lack of a nationwide population based registry. The most apparent reasons for this are discussed in the rest of the paragraph. The Lahore based cancer registry is a commendable step and an excellent effort to kick start the process. However, data submission is not mandatory and population denominators are questionable. This makes the statistics far from a true representation of the actual cancer incidence.

Introduction: In our tertiary care hospital, we do not have a specialized ENT in-patient ward. All ENT patients are accommodated in any of the surgical wards or medical wards. In the event of any complications, we were not sure as to how adept are the nurses in all the wards to handle different situations in ENT patients. Objective: To assess whether there is difference amongst nurses in terms of knowledge of potential ENT related complications and patient care between different wards and formal ENT training. Methodology: Nursing staff involved in routine care of adult patients in general ward and special care units were included in the study. A ten-point questionnaire was used to assess knowledge of nurses in ENT patient care. Participants were approached during the working day and were asked to fill out the questionnaire ‘on the spot’. Each questionnaire was checked and evaluated by two ENT residents and rated out of 10. Result: The average scores of nurses across the wards were not same and there was significant differences (p < 0.01); it was found that in ward b1 nurses scored higher marks compared to those from other wards. Trained nurses were evenly distributed in all wards and there were no association between the distributions of trained nurses across the wards. Positive correlation was observed between the scores and experience of ENT trained nurses. Conclusion: It is advisable to have dedicated ENT and subspecialty wards and provide formal nursing training with respect to managing ENT complications to ensure ultimate patient care.

OBJECTIVE To evaluate the clinical and pathological profile of young patients with squamous cell carcinoma of tongue. METHODS The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised record of patients <35 years presenting with squamous cell carcinoma of tongue between 2001 and 2011. Data was extracted from the electronic database of the hospital for site and age. Clinico-pathological variables were analysed using SPSS 20. RESULTS Of the 29 patients, 17(58.6%) were men and 12(41.3%) were women. The overall mean age at presentation was 29.6+/-4.4 years. All patients (100%) had some sort of addiction, with 15(51.7%) having more than one addiction. Of the total, 20(68.9%) patients had moderately differentiated carcinoma. At presentation, 20(68.9%) had advanced stage (III-IV) disease. Surgery was the primary modality used in all the patients (100%). Median follow-up period was 36 months (range: 1-6 years). During follow-up, 7(24.1%) patients developed recurrence. CONCLUSIONS Squamous cell carcinoma of the tongue was more commonly seen in males, and multiple addictions were a common risk factor.

Chronic suppurative otitis media (CSOM) is defined as chronic otorrhea (i.e., lasting > 6-12 weeks) through a perforated tympanic membrane. It is generally associated with some degree of conductive hearing loss. However, recurrent ear infections due to perforated eardrum result in absorption of toxins and macromolecules into the cochlea leading to sensorineural hearing loss (SNHL). We planned to determine the frequency of sensorineural hearing loss in chronic suppurative otitis media. A descriptive cross-sectional study was conducted at Aga Kgan University Hospital, Karachi, from October 2013 to March 2014. Average threshold of speech frequencies was calculated via pure tone audiogram for both diseased and normal contralateral ear.A mean of >25db in diseased ear was labelled as positive case for SNHL. SNHL was reported in 64(52%) patients and the frequency was found to increase with increasing duration. Patients with CSOM should be counselled regarding the risk of developing SNHL if left untreated.

Introduction Same-day, outpatient Sistrunk procedure is commonly performed to manage thyroglossal duct cyst anomalies and may lead to postoperative complications. Surgical drains are placed to prevent complications, but recent observations show no advantage and rather increased health care costs and patient discomfort. Objective The study evaluated if drain placement in the Sistrunk procedure offers any benefit on postoperative complications. Methods A retrospective analysis of patient records having undergone same-day, outpatient Sistrunk procedure from 2004 to 2014 was done. Of 58 (38 male and 20 female) patients included, 38 did not have drains placed and the remaining 20 had drains placed. Mean and median age of patients was 18.1 and 13.5 years, respectively. Postoperative complications of patients with drains versus those without drains were statistically analyzed. Results Overall, about 10% of patients had hematoma/seroma (H-S), with 6.9% of patients needing aspiration for H-S; 3.4% had wound infections; and 1.7% had pus formation. No statistically significant differences in Sistrunk-related complications between patient groups (with drain or without drain) were seen using Fisher exact (two-sided) test: H-S (p = 0.08); need for aspiration (p = 0.29); wound infection (p > 0.05); and pus formation (p = 0.35). Chi-square test also did not show any significant difference in the groups in terms of number of follow-ups. Conclusion Surgical placement of a drain in the Sistrunk procedure does not seem to offer any advantage in terms of reducing common postoperative complications. Same-day Sistrunk procedure without any drain placement may be a safer alternative without necessitating hospitalization. More studies with larger sample size are needed for further substantiation.

Aims: To study clinical presentation, management, and outcome of deep neck space infections (DNSI). Settings and Design: A retrospective case series was conducted in the Section of Otolaryngology of a tertiary care University Hospital from 2001 to 2011. Materials and Methods: A retrospective review of charts of the patients who were treated for deep neck space (DNSI) at our department from 2001 to 2011 was carried out. Forty-six patients fulfilled our inclusion criterion and were included in the study. A structured Performa was used for data collection and the following variables were recorded including demographics (age and gender), co-morbidities (diabetes mellitus, HIV), symptoms, etiology, infection site, bacteriology, culture growth imaging modality used, surgical intervention, and hospital stay. Results: The mean age of our patients was 30.8 years; 32 were male and 14 were female. Neck pain was the most common symptom found in 38 patients (82.60%) and most common space involved was parapharyngeal space which was seen in 20 patients (43.47%). Etiology of DNSI in majority of our patients, i.e., 18 (39%) was unknown followed by dental and tonsil problems in 12 (26%) and 10 (22%) patients, respectively. Of 46 patients, 36 underwent intervention and of these 26 cases had positive culture results. The most common organism cultured was Streptococcus seen in 8 patients (22.2%). Ten patients (21.73%) were treated medically alone. Mean hospital stay was 3.33 days with a minimum of 2 days and a maximum of 17 days stay. There was no mortality in our series of patients. Conclusions: The deep neck space infection is still a challenging disease in otolaryngology. Its presentation may be masked and bacterial culture might not be conclusive but it still needs early diagnosis and prompt management whether conservative or surgical. CT scan is a standard modality for differentiating between cellulitis and abscess. Most of the patients need surgical intervention and tracheostomy should be considered if air way protection is needed.

OBJECTIVE:To use toluidine blue intra-operatively to identify tumour involved margins after the removal of oral cavity squamous cell carcinoma, and to compare the findings with those of final histopathology.METHODS:The study was conducted at the Aga Khan University Hospital from December 1, 2009, to March 14, 2010, and comprised 56 consecutive patients with biopsy-proven squamous cell carcinoma of oral cavity regardless of grade and stage of tumour. Intra-operatively toluidine blue was used on the resected tumour margins and the staining patterns were assessed. Results were then compared with the final histopathology report.RESULTS:A total of 11(19.64%) margins were positive with toluidine blue staining out of which 8 (14.28%) were false positive. Sensitivity and specificity was found to be 100% and 84.9% respectively with a positive predictive value of 27.2%; a negative predictive value of 100%; and diagnostic accuracy of 85.71%.CONCLUSION:Toluidine blue costs only Rs25 (USD 0.30) and takes only 5 minutes for application and interpretation. It can be used with significant confidence in smaller lesions (T-l and T-II) as an alternative to frozen sections in developing countries where facilities are unavailable. Its use in larger lesions (T-lll and TIV) remains the topic of controversy and awaits a multi centre trial with a larger cohort.

BACKGROUND:Surgical excision of the primary tumor with safe margins remains the mainstay of treatment for oral cavity squamous cell carcinoma (OSCC). The standard of care for assessment of intraoperative margins is frozen section histopathology. Unfortunately the facility is not available at most centers in limited resource countries. Toluidine blue, a metachromatic dye, has been well described in clinical identification of malignant and premalignant lesion in the oral cavity. Considering this we decided to explore intraoperative use of toluidine blue staining, in comparison with frozen sections, for the assessment of tumor-free margins.METHODS:After obtaining clearance from the in-house ethical review committee, a prospective study was conducted at Aga Khan University Hospital, Karachi, from August 15, 2009 to March 14, 2010. A sample of 56 consenting patients with biopsy-proven OSCC were included in the study, giving us 280 tumor margins. Margins were analyzed using toluidine blue staining and frozen section histopathology. A receiver operator curve (ROC) was then applied to compare assessment of margin status by toluidine blue and frozen section.RESULTS:Of the 280 examined margins 11 stained positive with toluidine blue, three were positive on frozen section biopsy, and three were positive on final histopathology. Toluidine blue staining had sensitivity and specificity of 100% and 97%, respectively. The diagnostic accuracy of toluidine blue was found to be 97.1% with a positive predictive value (PPV) of 27.2% and a negative predictive value (NPV) of 100%.CONCLUSIONS:Toluidine blue can be used as an effective screening modality for the assessment of intraoperative margins in resource limited environments and reducing the number of frozen section biopsies performed. Further by providing real-time clinical information within minutes it can reduce indirect costs such as operating room time. It may also be used as an ad hoc for frozen section biopsies where frozen section facilities are available.

RATIONALE, AIMS AND OBJECTIVES Surgical sub-specialization has been considered to be a major factor in improving cancer surgery-related outcomes in terms of 5-year survival and disease-free intervals. In this article we have looked at the evidence supporting the improvement in colorectal cancer outcomes with 'colorectal specialists' performing colon and rectal surgery. METHODS A literature review was carried out using search engines such as Pubmed, Ovid and Cochrane Databases. Only studies looking at colorectal cancer outcome related to surgery were included in our review. RESULTS Specialist surgeons performing a high volume of colorectal cancer surgery demonstrated better 5-year survival rates in patients, with less local recurrence. This was most evident in surgery for rectal cancer, where an association with increased sphincter saving surgery was also seen. Total mesorectal excision is now the accepted treatment for rectal cancer and has markedly improved survival rates and decreased local recurrence. CONCLUSION The outcomes in colorectal surgery continue to steadily improve. The training of specialized colorectal surgeons is a major contributing factor towards this improvement.

Tuberculosis (TB) accounts for the highest number of mortalities among infectious diseases worldwide. Laryngeal TB is an extremely rare presentation of TB. It has many similarities to laryngeal carcinoma, one of the three most common cancers among males in the city, with an age standardized rate of 8.6. The associated risk factors of laryngeal carcinoma i.e. smoking, paan, betel nut usage and alcohol use also tend to be concentrated in the same demographic background as that of TB, creating a diagnostic dilemma. We present a case of granulomatous laryngeal TB, in a 40 year old male, with characteristic presenting features of laryngeal carcinoma i.e. persistent hoarseness and weight loss. He had no associated symptoms of fever, night sweats, cough or dysphagia, nor did he have any history of tobacco or irritant use. There was no history of tuberculosis (TB) contact. He was initially worked up for laryngeal carcinoma; however laryngoscopic biopsy revealed laryngeal TB. We present this case to emphasize the point that although primary laryngeal tuberculosis is a rarity, it must not be overlooked as a possibility when evaluating dysphonia and/or considering laryngeal carcinoma.

Tuberculosis (TB) accounts for the highest number of mortalities among infectious diseases worldwide. Laryngeal TB is an extremely rare presentation of TB. It has many similarities to laryngeal carcinoma, one of the three most common cancers among males in the city, with an age standardized rate of 8.6. The associated risk factors of laryngeal carcinoma i.e. smoking, paan, betel nut usage and alcohol use also tend to be concentrated in the same demographic background as that of TB, creating a diagnostic dilemma. We present a case of granulomatous laryngeal TB, in a 40 year old male, with characteristic presenting features of laryngeal carcinoma i.e. persistent hoarseness and weight loss. He had no associated symptoms of fever, night sweats, cough or dysphagia, nor did he have any history of tobacco or irritant use. There was no history of tuberculosis (TB) contact. He was initially worked up for laryngeal carcinoma; however laryngoscopic biopsy revealed laryngeal TB. We present this case to emphasize the point that although primary laryngeal tuberculosis is a rarity, it must not be overlooked as a possibility when evaluating dysphonia and/or considering laryngeal carcinoma.

Mucoepidermoid carcinomas are thought to arise from the reserve cells of salivary gland ducts. Minor salivary glands are located all around the oral cavity and base of the tongue; however few cases of MEC of the base of the tongue have been reported in literature and no guidelines are available for its management. Here we would like to present the case of a 71 year old male with mucoepidermoid carcinoma of the base of the tongue successfully treated with surgical excision and neck dissection. Regular clinical follow up showed no signs of recurrence at 9 months post excision.

In patients with allergic fungal sinusitis, the mainstay of treatment remains surgical removal of allergic mucin and fungal debris. But as a single modality, surgery is associated with high rates of recurrence, so a number of adjunctive medical modalities have been tried, including postoperative corticosteroid therapy. We conducted a study of 63 patients with allergic fungal sinusitis who underwent endoscopic sinus surgery with or without postoperative steroid therapy. A group of 30 patients who had been treated prior to January 2000 had undergone surgery only; their cases were reviewed retrospectively, and they served as historical controls. Another 33 patients who were treated after June 2000 underwent surgery plus oral and nasal steroid therapy. All patients were followed for a minimum of 2 years. Recurrences were seen in 50.0% (15/30) of the no-steroid group and 15.2% (5/33) of the steroid group-a statistically significant difference (p = 0.008). The results of our study strongly support the use of steroids to control allergic fungal sinusitis and prevent its recurrence, and we recommend further study to identify the optimal dosage and duration of therapy.