MCV ENT UPDATE
Update : August - October 2005
EMERGENCIES IN ENT :
Sudden Sensorineural Hearing Loss (SSNHL)
Sudden hearing loss is a medical emergency, which can be devastating to the patients fro which definite diagnosis, and treatment is still largely unknown. It has been defined as 30dB or more hearing loss over at least three contiguous audiometric frequencies occurring within 3 days or less. Most important is this should be treated within 7 days of onset as chances of reovery of hearing is poor after one week. Those who present with vertigo and other labyrinthine symptoms do poorly as the etiological lesion has affected larger areas of inner ear.

Known reasons for SSNHL are viral infections,autoimmune disorders, trauma and vascular causes. Neural deafness is known to occur following cardio pulmonary bypass and long duration anaesthesia in older people.Hence an audiogram is reommended prior to Coronary bypass (CABG) surgery.

We do investigations to rule out diabetes, renal and cardiac problems. Audiogram in these patients has to be done by an audiologist in a well equipped sound proof enclosure. Tympanometry especially the stapidial reflex studies are helpful to localise the level of lesion .

The treatment of known aetiology is to address the underlying condition. The majority of patients do not have a clear etiology. The mainstay of treatment is steroids along with peripheral vasodilators. They used to be given as tablets or injections earlier. The Present method is to administer the drug by way of intra tympanic treatment directly to the inner ear. We use our own method to makethe drug stay in contact with round window membrane. We are present using methyl prednisolone injection for application to the round window. We have also used hyperbaric oxygen chamber at Bangalore Air force Command Hospital.

Prognosis depends on time since onset (better if treated within one week, but not more than 15 days), age (under 15 and over 60 poor results), vertigo (poor results).

Pre op CT Scan Showing left Parasellar mass lesion Per op Parasellar mass lesion

IS PRE OP CT PNS NECESSARY?

Mr. VB 30 years, non diabetic presented with severe headache of 1 ½ year duration. He had an endoscopic sinus surgery ten years ago elsewhere following which was removed after 2 days. Prior to this surgery he had only nasal complaints and no headache. No intra cranial pathology was identifiable at that time. He also had a history of visual impairment on the left side. This visual problem lasted for one month and settled with medical treatment elsewhere. His headache did not fit into the classical migraine pattern as obtained from the history. It was of temporary nature lasting less than a day or two.

A CT with contrast showed a left parasellar lesion. He underwent endoscopic debulking of lesion which was in close relation to the orbital apex and cavernous sinus As per our technique the bleeding was controlled with bipolar forceps specially made for this purpose from laproscopic instruments. No nasal pack was used and the operated area was irrigated by a cannula placed during surgery.

It is said that 98% of chronic headache patients have a negative radiology and the diagnosis is based purely on history. Whenever the history does not fit in or treatment response to medication is poor one should consider a CT or MRI with contrast.

Nasal packing with paraffin gauzes is not needed in most patients following nasal surgery. Several publications have proved the short and long term complications of nose packing. In this patient the interval between the previous endoscopic surgery and onset of headache, histopathology report of slow growing invasive mycosis seem to indicate that the origin of the problem is the nasal pack following previous surgery. Even if the fungal contamination happened during operation via the instruments, post op packing ensures establishment of infection. This may well be avoided usine saline irrigation in the immediate post op period instead of the nasal pack.