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   Table of Contents - Current issue
July-December 2022
Volume 10 | Issue 2
Page Nos. 117-189

Online since Thursday, December 15, 2022

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Artificial intelligence and machine learning in head and neck oncology Highly accessed article p. 117
Krishnakumar Thankappan
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Inequality in the use of microvascular versus pedicled flaps in oral cancer reconstruction across India: Can we bridge the gap? Highly accessed article p. 121
Abhishek Vaidya
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Approach to T4b oral cancers – A surgeon's perspective p. 127
Abhinav Thaduri, Achyuth Panuganti, Dileep Dungala Maharaj, Pallvi Kaul, Kinjal Shankar Majumdar, Shahab Ali Usmani, Pankaj Kumar Garg
T4b oral cancers are considered unresectable tumors according to most of the standard treatment guidelines. However, from a head-and-neck surgeon's perspective number of factors has to be considered before labeling a T4b cancer as unresectable. This narrative review aims to emphasize various aspects of decision-making in treating a T4b oral cancer, in particular tumors involving infratemporal fossa (ITF). We conducted a literature search in PubMed for articles published between January 1990 and December 2021 using the following key terms: Oral cancer, advanced oral cancer, Head and Neck cancer, T4b oral cancer, ITF, and Compartment surgery. Then, some of these terms were used in combination for the search. Finally, a result was manually checked for relevant articles. A narrative review is presented from the surgeon's perspective in the management of T4b oral cancer.
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Diagnostic efficacy of computed tomography and magnetic resonance imaging in detection of cervical lymph node metastasis among patients with oral cancer in India – Systematic review and meta-analysis p. 132
Saraswathi K Gopal, S Priyadharshini, V Poongodi, BG Harsha Vardhan
Background: Oral cancer in India accounts for two-third of global incidence. Ninety percent are squamous cell type that are prone to neck lymph node metastasis. Computed tomography (CT) and magnetic resonance imaging (MRI) are common imaging methods used in our clinical practice for treatment planning, determine the prognosis and after treatment follow-up. Aim: The aim of this study was to assess the diagnostic efficacy of CT and MRI in detecting cervical lymph node metastasis among oral cancer patients in India using systematic review and meta-analysis. Methods: Literature search was conducted by manual search as well as in academic databases such as Scopus, PubMed, Medline, ScienceDirect, and Google Scholar from 2000 to 2021. Based on inclusion and exclusion criteria's, studies were analysed and tabulated. Qualitative assessment of included studies was done with QUADAS-2 which assessed the risk of bias. Further meta-analysis was done to know the efficacy of CT and MRI in identifying lymph node metastases. Results: A total of 14 studies including 516 participants were involved. With overall pooled sensitivity and specificity in the meta-analysis, CT showed a sensitivity of 92% and specificity of 70% and MRI had a sensitivity of 75% and specificity of 91%, which was identified in ROC curve in detecting the cervical lymph node metastasis. The diagnostic criteria for MRI and CT in identifying cervical lymph node metastasis includes key features like increases in size, round shape, structural changes, and extra nodal extension. Conclusion: CT has a good sensitivity and MRI has a good specificity, which are essential for selective neck dissection.
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The comparative effect of lidocaine-remifentanil intravenous infusion and gargle on hemodynamic responses and sore throat and cough after endotracheal extubation: A randomized clinical trial p. 142
Mohammad Shabani, Hesameddin Modir, Farzad Zamani Barsari
Purpose: The present evidence-based clinical study addressed the therapeutic effectiveness of lidocaine-remifentanil intravenous infusion versus gargle on attenuation of hemodynamic responses and prevention of sore throat and cough after endotracheal extubation. Materials and Methods: In a double-blind clinical trial whereby 76 cases receiving endotracheal intubation under general anesthesia were classified into two intervention groups being treated with lidocaine-remifentanil mixture administered by either intravenous infusion or gargle using balanced block randomization. Hemodynamic parameters including heart rate and blood pressure during surgery and in recovery every 15 min and respiratory symptoms such as cough, hoarseness, and sore throat during recovery and at certain postoperative time points of 2, 4, 8, 12, and 24 h were gathered. Pain score was measured by a Visual Analog Scale. Statistical analysis was conducted using the software SPSS v22 by Chi-square and independent t-test. Results: No statistically significant observed intergroup in terms of oxygen saturation, heart rate, mean blood pressure, need for analgesic medication, duration of surgery, and the incidence of cough and hoarseness (P > 0.05), but not in pain score in recovery and eight postoperative hours. While the intergroup difference was found at other times, the intravenous infusion group was associated with less pain score, compared to the gargling group (P > 0.05). Conclusion: A reduction in sore throat observed in subjects receiving an intravenous infusion compared to those receiving the gargling intervention during recovery and 8 h after surgery. We have convincing evidence to support the superiority of intravenous therapy comprising of lidocaine and remifentanil; however, larger sample size is needed to establish whether or not the interventions are effective.
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Contralateral neck dissection in oral cavity cancers crossing midline: A look in the mirror p. 148
Sachin Wani, Nishith Modi, M Srinitya, Rajiv Bhatt, Shishir Shah, Ankit Shah, Nikita Choksi
Introduction: Oral cavity cancer is the most common cancer in our country. In patients with oral cavity squamous cell carcinoma (OCSCC) elective neck dissection results in higher rates of overall survival and disease-free survival. Nodal metastasis in OCSCC is related to poor prognosis. Elective ipsilateral node dissection is recommended in all patients. Contralateral nodal metastasis is associated with poorer prognosis. The purpose of our study is to identify the predictors and factors associated with bilateral or contralateral nodal metastasis in oral cavity cancers reaching or crossing the midline. Materials and Methods: All patients of oral cavity cancer where the primary cancer was reaching or crossing the midline, operated during 3 years in a single institute were taken up for the study. All patients underwent surgery of primary cancer and bilateral neck dissection. Patients with truly lateral disease not approaching midline, history of any previous oncologic treatment, and recurrent cancers, and patients with two or more primaries were excluded from the study. Results: Out of 93 patients, 43% of the buccal mucosa – gingivobuccal sulcus region and 57% of the tongue – floor of mouth region. Out of 46 patients having nodal metastasis (50%), 26.8% of patients had bilateral nodal metastasis, but none had isolated contralateral nodal metastasis. On univariate and bivariate analysis, we found tumor grade, stage, site of ENE, and presence of multiple ipsilateral positive nodes were significant factors predicting contralateral nodal metastasis. Conclusion: Surgical management of the contralateral neck in oral cavity cancer is a complex issue. The simplistic approach of doing contralateral neck dissection in all oral cavity cancers when disease crosses midline is not sufficient. The presence of contralateral neck node metastasis in the absence of positive ipsilateral neck is very rare (0% in our study). There are other important clinic radiological factors such as DOI >10 mm, involvement of skin and bone, and presence of extranodal extension and location of primary tumor which also need to be considered in decision-making algorithm.
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Diagnostic role of galectin-3 immunohistochemistry in thyroid lesions p. 152
Karishma Sarin, Ranjeev Bhagat, RP S. Punia, Arjun Das, Uma Handa
Background: Galectin-3 (Gal-3) is a good diagnostic marker for thyroid cancer. Evaluation of diagnostic accuracy of this marker complements the morphological assessment of a particular thyroid lesion. The aim of this study was to evaluate the immunohistochemical expression and diagnostic role of Gal-3 in various surgically resected thyroid lesions. Materials and Methods: Surgically resected thyroid specimens from 50 patients with hematoxylin and eosin (H and E)- and Gal-3-stained sections were studied. Results: The age of the patients ranged from 14 to 64 years. Of the 50 patients, 12 (24%) were male and 38 (76%) were females. Various histopathological diagnoses included were inflammatory lesions 8 (16%), hyperplastic lesions 15 (30%), and benign 2 (4%) and malignant 25 (50%) lesions. On quantitative analysis of Gal-3 immunostaining, 16/16 (100%) of the papillary thyroid carcinoma (PTC) cases showed a positive expression. In the rest of the malignant cases, 5 (20%) of follicular thyroid carcinoma, 3 (12%) of medullary thyroid carcinoma, and 1 (4%) of anaplastic thyroid carcinoma showed a negative expression. The PTC cases showed a statistically significant difference from the rest of the benign lesions (P = 0.000). In PTC cases, the sensitivity of Gal-3 came out to be 100%, specificity was 64%, positive predictive value was 75.3%, negative predictive value was 100%, and accuracy was 82%. Conclusion: The data thus obtained indicate that Gal-3 is a valuable marker for differentiating classical PTC and its common variants (follicular variant and microcarcinoma in our study) from the other benign and malignant lesions. Gal-3 as a diagnostic marker for thyroid cancer can lead to improved outcomes for individuals diagnosed with equivocal or suspicious lesions.
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Comparative evaluation of sclerostin levels in gingival crevicular fluid of periodontal health and disease before and after nonsurgical periodontal therapy p. 157
Ankita Mathur, D Gopalakrishnan, Sharath Shetty, Vini Mehta, Shreya Bagwe
Aim: The purpose of this study was to measure the concentration of sclerostin in the gingival crevicular fluid (GCF) before and after 1, 3, and 6 weeks of nonsurgical periodontal therapy (NSPT) in subjects with and without chronic periodontitis. Materials and Methods: An interventional study was conducted among 35 subjects of age groups 30–50 years. Subjects were divided into three groups: Group I (10 healthy individuals), Group II (10 gingivitis), and Group III (15 chronic periodontitis only). Clinical parameters assessed were gingival index (GI), plaque index (PI), probing pocket depth (PPD), and clinical attachment level (CAL). The GCF samples were collected from all the groups at baseline and in Group III at baseline and 1, 3, and 6 weeks after NSPT using micropipettes. Results: Table 1 shows age and gender details. Although the mean sclerostin concentration in GCF (ng/ml) was highest in Group III at baseline (5.41 ± 0.68) and lowest in Group 1 (4.98 ± 0.46), there was no statistically significant difference (P < 0.05) when intergroup comparison was done [Tables 2 and 3]. PPD and CAL measured for Group III were 6.93 + 1.2 and 7.67 + 1.2, respectively. PI (2.52 + 0.25) and GI (2.52 + 0.17) were measured highest in Group III [Table 4]. Conclusion: There was a substantial decrease in the concentration of sclerostin in the GCF of chronic periodontitis patients after 1, 3, and 6 weeks after NSPT. This proves sclerostin to be a responsive measure of inflammation in periodontal destruction.
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Expression of human epidermal growth factor receptor 2/Neu in oral leukoplakia p. 162
Ashesh Kumar Jha, Vansh Verma, Karsing Patiri, Nikhil Arora
Background: Molecular alterations in premalignant lesions of the oral cavity are not well known. Many reports have found increased human epidermal growth factor receptor 2 (HER-2) expression in oral cancer. Overexpression of HER-2 in premalignant lesions may denote its positive contribution in the malignant transformation of these lesions. Materials and Methods: Twenty-three samples of leukoplakia were stained by routine H and E to assess any dysplasia; five samples of normal mucosa were used as control. Immunohistochemical staining for HER-2 was done. ASCO/CAP 2018 guidelines were used for reporting the results. The percentage of lesions expressing cytoplasmic or membranous expression was calculated. Results: One sample of leukoplakia with severe dysplasia expressed focal membranous staining. Cytoplasmic staining was observed in 3/9 (33.33%) dysplastic leukoplakia. Only one nondysplastic leukoplakia expressed cytoplasmic HER-2 staining. Conclusions: Membranous expression in severe dysplasia and higher expression in oral cancer are in concordance with the multistep theory of carcinogenesis.
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The staggering hypothyroidism in head-and-neck cancer patients after combined multimodality treatment: Dealing with the anesthetic dilemma p. 167
Bindu Kizhakkevelikkakathu Vasu, Sunil Rajan, Niranjan Kumar Sasikumar, Sruthi Cherakulam Babu, Manu Sudevan, Jerry Paul
Background and Aims: Hypothyroidism is common following treatment of head-and-neck malignancy. We aimed to assess the incidence of hypothyroidism in patients posted for operations with a history of radical neck surgeries with or without adjuvant chemoradiotherapy, their requirement of induction agents, hemodynamic changes, and recovery time following general anesthesia. Methods: This was a prospective, nonrandomized single-arm study conducted in 100 patients aged 18–85 years, who were posted for surgery under general anesthesia after 3 months of radical neck surgery with or without adjuvant therapy. All patients received a standardized general anesthesia protocol. Patients were grouped into those having either hypothyroidism or those in the euthyroid state. Results: Seventy-two percent of patients had varying degrees of hypothyroidism. There was significant reduction in heart rate (HR) and mean arterial pressure (MAP) from preinduction values at 1, 3, 5, and 10 min after intubation in patients with hypothyroidism. The reduction in both HR and MAP was significantly pronounced throughout postintubation period in the hypothyroid patients as compared to the patients with normal thyroid function. The mean induction dose of propofol was significantly lesser for hypothyroid patients compared with euthyroid (0.85 ± 0.17 mg/kg vs. 1.62 ± 2.52 mg/kg), with prolonged recovery time. The incidence of hypotension was significantly high among the hypothyroid patients. Conclusion: The incidence of hypothyroidism in patients after radical neck surgery with or without adjuvant chemo-radiotherapy is as high as 72%. These patients required less anesthetic agents for the induction of general anesthesia and developed profound hypotension after induction which persisted after intubation and had a prolonged recovery time.
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Risk for obstructive sleep apnea in patients with bipolar disorder, prevalence from Kashmir p. 173
Rayees Ahmad Wani, Shabir Ahmad Dar, Naveed Nazir Shah, Inaamul Haq, Suraya Gani
Background: An association exists between obstructive sleep apnea (OSA) and bipolar disorder (BD). The prevalence of OSA in BD has significantly increased during the past two decades. We aimed to assess the prevalence of risk for OSA in BD. Materials and Methods: This was a hospital-based, cross-sectional, case–control study. Out of 218 participants enrolled in the study, 109 had BD and 109 were recruited for comparison in the control group. All the participants were asked to complete the Berlin Questionnaire, a self-assessment tool to establish the risk for OSA. Results: About two-thirds of the patients with BD were found to be at risk for OSA as compared to the 19.27% of prevalence in the control group. Patients of BD at high risk for OSA were males, had significantly higher body mass index (BMI), with comorbid physical illnesses, and in those who were on a combination of valproate and lithium in comparison to valproate alone. Conclusion: Patients with BD had significantly higher BMI in comparison to controls. In comparison to controls, significant higher percentage of patients with BD had higher risk for OSA in comparison to healthy controls. Our finding of over half of patients being in the high-risk range should be sufficient to sensitize clinicians and raise awareness concerning OSA in BD.
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Percutaneous dilatational tracheostomy: an observational study at tertiary level teaching hospital p. 179
Rajeev Kumar Shah, Bipin Koirala, Lalit Kumar Rajbansi, Batsalya Arjyal
Introduction: Tracheostomy is the most commonly performed procedure worldwide. It is mainly done in critically ill patients requiring long-term ventilation, facial trauma, laryngeal fractures, laryngeal malignancy, etc., Converting from endotracheal intubation to tracheostomy has many benefits in terms of maintaining laryngeal function, feeding, and safety, it is more comfortable than endotracheal intubation. Tracheostomized patients require less analgesics and sedatives. It also helps in easier and early weaning from the mechanical ventilator, possibility of speech, and initiation of oral intake of medication. Percutaneous dilatational tracheostomy (PDT) is a safe and feasible procedure performed at bedside with minimal invasive technique in the intensive care unit (ICU). This all contributes to shorter ICU stay and hospital stay which becomes more cost-effective. Methods: This is a prospective observational study that was conducted in the 22-bedded neurointensive care and medical ICU of Birat Medical College and Teaching Hospital. The data were collected from August 01, 2021, to February 28, 2022. All patients needing tracheostomy for prolonged intubation, protection of airway, and to maintain tracheobronchial toileting was taking under study. Results: Our study was a prospective observational regarding PDT. A total of 71 patients were included in the study. Out of which, 39 (54.9%) were male and 32 (45.1%) were female with the ratio of (1.2:1). The age of the patients ranged from 18 to 82 years with the mean age of 53.25 years. The most common indication of PDT was prolonged intubation and that accounted for 29 (40.8%) of the patients which was followed by airway protection in 27 (38%) patients and to maintain pulmonary hygiene was seen in 15 (21.1%) patients. Conclusion: Tracheostomy is among the most frequently performed procedures in critically ill patients. PDT is a safe and feasible procedure performed at bedside with minimal invasive techniques in ICU.
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Diagnostic tool in treatment planning of dentinal hypersensitivity: T-scan the unheeded newer dimension p. 183
Shivani Sachdeva, Sanket Shinde, Harish Saluja, Vipin Dehane
Background: Occlusion is dynamic and plays an important role in the functioning of the stomatognathic system. Disturbance in one of the components of the stomatognathic system may result in hypersensitivity of teeth, orofacial pain, migraine, and temporomandibular joint (TMJ) disorders. Coronoplasty performed using articulating paper is the conventional method for occlusal corrections. T-scan is a computerized occlusal analysis system that overcomes the limitations of articulating paper. Methods: Patients with Myofascial Pain Dysfunction Syndrome (MPDS) having dentinal hypersensitivity were taken into consideration. The joint vibratory analysis is performed using JVA device to rule out any TMJ disorders. T-scan-assisted coronoplasty is performed. The patient is asked to score for dentinal hypersensitivity on a visual analog scale pre- and postoperative. Results: Occlusion and disocclusion time are reduced along with hyperactivity of the muscles after T-scan-assisted coronoplasty. There is a reduction in dentinal hypersensitivity postoperative. Conclusion: T-scan quantifies the forces and hence proved a boon in the field of dentistry. The present case report highlights coronoplasty assisted with T-scan for diagnosis and treatment planning of hypersensitivity of teeth and hence it is the future of dentistry.
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Nasal spur causing permanent damage to intubating video bronchoscope p. 188
Jerry Paul, Sunil Rajan, Niranjan Kumar Sasikumar, Lakshmi Kumar
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