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The histological and electron-microscopic (EM) characteristics of juvenile nasopharyngeal angiofibroma (JNA) have been described but no study has compared them with one another or with clinical features. The objective is to compare ultrastructural characteristics of JNA with clinical parameters. This prospective study included histology of 21 samples of which only 13 underwent transmission-EM. Four clinical parameters (age, duration, epistaxis, recurrence), three radiological-staging, 13 histological and 15 EM characteristics were considered. A descriptive analysis for association of these characteristics and also with clinical parameters was attempted. Furthermore statistical analysis of clinical and radiological categories with respect to frequencies of ultrastructural characteristics was also undertaken. Dense-intranuclear-inclusions (DNI) and peripheral-nuclear-irregularities were universally encountered while other very prominent features were nuclear-blebs-and-pockets, myoid-features, thin-vessel-wall (TnVW), irregular-vascular-contour (IVC) and fibrous-stroma (FS). Statistical significance was obtained between recurrence with histology (p = 0.04) and Fisch staging with EM (p = 0.001). While muscle-in-vessel-wall, thick-vessel-wall, mast-cells, stellate-stromal-cells and cellular-stroma predominated in recurrent cases, the upfront disease showed predominance of scar-like-stroma, fusiform-stromal-cells, IVC, TnVW, FS, organised-collagen-bundles and less-cellular-stroma. A very unique Rod-like-structures were appreciated in the cytoplasm of the fibroblast for the first time. While histological parameters of recurrence need further validation, a larger sample may better define histopathological surrogate for predicting intracellular dynamics that may further correlate with underlying cellular stresses. Hence an ‘ultrastructural staging’ may better customise treatment protocol and prognosis. Furthermore ‘characteristic’ unique rods need to be further investigated along with validation of viral aetiology for DNI.

Objective To assess olfactory and clinical morbidity in primary (idiopathic)–type atrophic rhinitis and its course following treatment. Study Design Prospective nonrandomized controlled cohort study with follow-up. Setting Department of Otorhinolaryngology and Head and Neck Surgery of a university hospital (tertiary heath care center). Methods Sixty-one patients with atrophic rhinitis underwent assessment of clinical severity with baseline olfaction with the Brief Smell Identification test, while the improvement of their status following surgical versus nonsurgical treatment was further assessed. Results Olfaction was universally deranged with bimodal age presentation and female predominance (61%). Clinical improvement was significantly associated with surgical treatment but did not reveal any relation with up-front severity of disease. A near-significant association of age with severity did not reveal significance when stratified by age group. Baseline olfaction or its change following treatment did not reveal any significance with severity of disease or clinical improvement. Radiologic atrophy also did not reveal any significant relation with severity criteria. Conclusions Olfactory functions as compared with clinical parameters provided better reflection of underlying (systemic) pathology with environmental interaction, while later it mainly signified localized condition. Accordingly, olfaction was affected early and recovered slowly (or not at all), independent of clinical morbidity, which in turn is affected rather late but recovers early. Olfactory dysfunction at the initial stage may be a surrogate marker of potential worsening clinical condition, since bacteria often superinfect underlying susceptible nasal environment. While surgery mainly improved clinical parameters without affecting olfaction directly, a true improvement would include recovery of both.

Background:Molecular categorisation may explain the wide variation in the clinical characteristics of juvenile nasopharyngeal angiofibroma.Methods:Variations in molecular markers in juvenile nasopharyngeal angiofibroma in an Indian population were investigated and compared with global reports.Results:Variable molecular marker expression was demonstrated at the regional and global levels. A wide variation in molecular characteristics is evident. Molecular data have been reported for only 11 countries, indicating a clear geographical bias. Only 58 markers have been studied, and most are yet to be validated.Conclusion:Research into the molecular epidemiology of juvenile nasopharyngeal angiofibroma is still in its infancy. Although the molecular variation is not well understood, data obtained so far have prompted important research questions. Hence, multicentre collaborative molecular studies are needed to establish the aetiopathogenesis and establish molecular surrogates for clinical characteristics.

The extranasopharyngeal angiofibroma is a separate clinical entity but those involving infratemporal fossa and cheek resemble juvenile nasopharyngeal angiofibroma (JNA) and hence have been labelled as juvenile perinasal angiofibroma (JPA) in this paper. This paper presents a 7th case of JPA and attempts to review the world literature on JPA, along with a proposal of staging the disease. A 16 year male presented with a painless compressible facial swelling since 7 months without any epistaxis or nasal obstruction. Initially a vascular lesion was suspected but JNA without nasal extension was strongly suspected on imaging. A deep trucut biopsy confirmed the histopathology. The vascular enhancement was significant and the tumour was excised through open approach (Weber Fergusson). JPA that can be regarded as a variant of JNA that fails to extend medially. Imaging demonstrates classical JNA findings with a clear nose/nasopharynx. A deep trucut biopsy under control in inpatient settings may sometimes help. JPA presents most commonly in Stage II where an open facial approach preferably following selective preoperative embolization is indicated. Hence with painless compressible (or non-compressible) cheek swelling suspected to be of a vascular etiology, a high degree of clinical suspicion for JPA needs to maintained in order to prevent a misdiagnosis.

To study the pattern of olfactory dysfunction/recovery in juvenile nasopharyngeal angiofibroma (JNA).Olfactory assessment was undertaken in 30 patients (category1) both pre-post-operatively and in another 18 (category 2) only postoperative. All patients underwent transpalatal excision and variables of interest included age, radiological stage/parameterstumor size.Objective olfactory dysfunction was seen in 60% while involvement of olfactory strip was suggested in 50%. Despite some marginal trends only noted between size/age with change of olfaction, Pearson's correlation test did not reveal any significance amongst multiple variables. However a better recovery of olfaction following surgery was evident in Category-2 where Chi-Square test (p 0.05) significantly revealed this to be a function of postoperative duration. This regenerative course in JNA suggests an optimum period of 4 years for full recovery after surgery.In this first study of olfaction in JNA many new trends have been appreciated. In general, deteriorations of olfaction were seen due to 'vascular-concussion' effect in early postoperative phase where post-surgical clearance of airway showed minimal effect in terms of improvement. The hypervascularity of olfactory epithelium with possible hormonal effects may be responsible for the unique pattern of olfactory function and recovery in JNA.

Background An analysis of time distribution of juvenile nasopharyngeal angiofibroma (JNA) from the last 4 decades is presented. Methods Sixty recurrences were analyzed as per actuarial survival. SPSS software was used to generate Kaplan–Meier (KM) curves and time distributions were compared by Log-rank, Breslow and Tarone–Ware test. Results The overall recurrence rate was 17.59%. Majority underwent open transpalatal approach(es) without embolization. The probability of detecting a recurrence was 95% in first 24 months and comparison of KM curves of 4 different time periods was not significant. Conclusion This is the first and largest series to address the time-distribution. The required follow up period is 2 years. Our recurrence is just half of the largest series (reported so far) suggesting the superiority of transpalatal techniques. The similarity of curves suggests less likelihood for recent technical advances to influence the recurrence that as per our hypothesis is more likely to reflect tumor biology per se.

Background:Juvenile nasopharyngeal angiofibroma often presents with lateral extensions. In countries with limited resources, selection of a cost-effective and least morbid surgical approach for complete excision is challenging.Methods:Sixty-three patients with juvenile nasopharyngeal angiofibroma, with lateral extensions, underwent transpalatal, transpalatal-circumaxillary (transpterygopalatine) or transpalatal-circumaxillary-sublabial approaches for resection. Clinico-radiological characteristics, tumour volume and intra-operative bleeding were recorded.Results:The transpalatal approach was suitable for extensions involving medial part of pterygopalatine fossa; transpalatal-circumaxillary for extensions involving complete pterygopalatine fossa, with or without partial infratemporal fossa; and transpalatal-circumaxillary-sublabial for extensions involving complete infratemporal fossa, even cheek or temporal fossa up to zygomatic arch. Haemorrhage was greatest with the transpalatal-circumaxillary-sublabial approach, followed by transpalatal approach and transpalatal-circumaxillary approach (1212, 950 and 777 ml respectively). Tumour size (volume) was greatest with the transpalatal-circumaxillary approach, followed by transpalatal-circumaxillary-sublabial approach and transpalatal approach (40, 34 and 29 mm3). There was recurrence in three cases and residual disease in two cases. Long-term morbidity included small palatal perforation (n = 1), trismus (n = 1) and atrophic rhinitis (n = 2).Conclusion:These modified techniques, performed with endoscopic assistance under hypotensive anaesthesia, without embolisation, offer a superior option over other open procedures with regard to morbidity and recurrences.

Background:The occurrence of juvenile nasopharyngeal angiofibroma is reportedly higher in India than in some other parts of the world, and our centre has seen a four-fold increase in its occurrence across seven decades.Methods:This paper reports a retrospective archival analysis of 701 juvenile nasopharyngeal angiofibroma cases from 1958 to 2013, and considers probable environmental factors in an Indian context that may affect its biology and the global distribution, as reported in the literature.Results:A continuously progressive increase in occurrence was evident, but the rapid rise observed in the current decade was alarming. The world map of juvenile nasopharyngeal angiofibroma incidence does not reflect true global distribution given the paucity of reporting. Our centre has dealt with approximately 400 cases in the last 24 years.Conclusion:With the alarming increase in juvenile nasopharyngeal angiofibroma incidence, there is a need for a registry to define its epidemiology. The world literature needs to reflect the status of juvenile nasopharyngeal angiofibroma incidence in the third world as well. Environmental factors known for hormone disruptive actions may influence its occurrence. Such aspects need to be considered to plan specific prevention policies.

Objective:A possible role of the APC/beta-catenin pathway in the pathogenesis of sporadic juvenile nasopharyngeal angiofibroma has been suggested. This paper presents its current status and clinical association in our patients.Method:A prospective observational study was conducted at King George Medical University and Central Drug Research Institute, in Lucknow, India. Western blot analysis was undertaken in 16 cases to examine beta-catenin expression. The clinical details were recorded along with follow up observations, to determine associations.Results:Up-regulation of beta-catenin expression was seen in 69 per cent of cases. The clinical variables did not reveal significant differences between patients with extremes of expression (extreme under-vsover-expression). However, absent expression was shown exclusively in young adults aged over 18 years, while enhanced expression was associated with an altered facial profile.Conclusion:Although a beta-catenin association was seen in a subset of our sporadic juvenile nasopharyngeal angiofibroma cases, its expression was not homogeneous. This is in contrast to the Western literature that suggests a universal (homogenous) enhanced expression in the majority. Hence, further research is required to better define its molecular cascade.

Aural swabs were collected from 250 patients with chronic suppurative otitis media (CSOM) (tubotympanic disease). Duration of ear discharge was more than 6 months for culture and sensitivity test. The disease was unilateral in 178(71.2%)and bilateral in 72 (28.8%) patients. From a total of 322 aural swab cultures, 324 organisms were isolated with predominance of Pseudomonas aerugimosa (36.4%) followed by Staphylococcus aureus (30.2%). All the isolated Gram-negative organisms showed in vitro sensitivity to ciprofloxacin, amikacin, ofloxacin, and gentamycin whereas cloxacillin, ofloxacin, erythromycin, ciprofloxacin, gentamicin and tetracycline were more effective against Gram-positive isolates. Most isolates were resistant to amoxycillin. It is concluded that ciprofloxacin is preferred to aminoglycosides as an important tool in the treatment of CSOM because of its lower cost, lack of ototoxicity and availability astopical oral preparations.