Ajith Nilakantan

Primary cavernous hemangioma of thyroid gland

We report a case of cavernous hemangioma presenting as a case of solitary nodule of thyroid.A 25-year-old male presented with a slowly growing solitary swelling in front of neck of 16 years duration. There was no history of pain over the swelling, change in voice or dyspnea. On clinical examination, a 6 × 4 cm irregular, hard, freely mobile swelling could be felt in the thyroid region. Ultrasonography (USG) showed a single hypoechogenic mass in the left lobe of the thyroid with coarse calcifications. X-ray of neck also showed coarse calcifications [Figure 1]. Computed tomography (CT) scan showed a heterogeneously enhancing mass of 4.9 × 4.4 cm diameter in the left lobe of the thyroid deviating the trachea to the right. Multiple dense calcific densities were noted in the nodule [Figure 2]. Fine needle aspiration cytology (FNAC) of the mass was attempted twice but was inconclusive and only blood could be aspirated. The patient was euthyroid and showed no signs of local spread or lymphadenopathy. Surgery in the form of left hemithyroidectomy was done. Peroperatively, tumor mass was found to be hard in consistency and well encapsulated. Gross pathology showed a well-circumscribed nodule with hemorrhagic and calcified areas. On histopathology, nodule was divided into multiple lobules with areas of hemorrhage, fibrosis, hyalinization and calcifications. Some of these calcifications were located in dilated vessels and classical cavernous vascular spaces could be seen [Figure 3]. A diagnosis of primary intrathyroid cavernous hemangioma was made.Lesions similar to hemangiomas secondary to FNAC have been reported. These have been ascribed to vascular proliferation in organized hematoma following the FNAC leading to a histological resemblance to cavernous hemangioma.

Impact of 18 F-Fluorodeoxyglucose Positron Emission Tomography/Computed Tomography Scan on Initial Evaluation of Head and Neck Squamous Cell Carcinoma: Our Experience at a Tertiary Care Center in India

The efficacy of the whole body (WB) 18 F-fluorodeoxyglucose ( 18 F-FDG) positron emission tomography-computed tomography (PET-CT) as a part of conventional initial staging in all cases of head and neck squamous cell carcinoma (HNSCC) is still controversial with various studies in literature giving contradictory reports. We conducted this study at a government tertiary care oncology center in India to identify the impact of WB 18 F-FDG PET-CT scan on HNSCC staging and treatment. A prospective clinical study of patients of HNSCC who were evaluated and treated at our center was performed. The patients included in the study were HNSCC of the oral cavity, oropharynx, hypopharynx, larynx, nasopharynx, and carcinoma of unknown primary site (CUPS) with cervical metastasis. The study design was to evaluate the cases of HNSCC initially by staging with conventional investigations followed by staging with the information derived from WB 18 F-FDG PET-CT scan. At the end of the conventional investigations, a tumor, node, metastasis (TNM) staging as per AJCC 7 th edition, and a detailed treatment plan as per NCCN 2012 guidelines was decided in consultation with the multidisciplinary oncology team of the hospital. WB 18 F-FDG PET-CT scan was carried out in all these patients. The findings of WB 18 F-FDG PET-CT were then interpreted with the staging with conventional investigations to identify the cases with change in staging and also those in whom the treatment protocol would be affected. Descriptive analysis of demographic data and analytical analysis of the sensitivity and specificity of WB 18 F-FDG PET-CT scan and also the change in staging and treatment plan after WB 18 F-FDG PET-CT scan was analyzed using SPSS version 18. A total of 131 patients met the inclusion criteria, which included 123 males and 8 females. The various sites involved among the study group are oral cavity 11 (8.3%), oropharyn × 39 (29.7%), hypopharyn × 31 (23.6%), laryn × 34 (25.9%), nasopharyn × 4 (3%), and CUPS 12 (9.1%). The majority of cases studied were of T2 and T3 stage, and changes in T staging after WB 18 F-FDG PET-CT scan were minimal and not statistically significant (P > 0.5). In the nodal staging after WB 18 F-FDG PET-CT scan, there was a statistically significant change in identification of nodal metastasis in N0 group and also identification of additional multiple/bilateral nodes (N2b and N2c). 3 (2.2%) patients had a change in M status with identification of distant metastasis in lungs (2 patients) and in the liver and lung (1 patient). Of the 131 patients, 75 (57.25%) underwent surgical management with or without adjuvant treatment (Group I) and 56 (42.74%) patients underwent nonsurgical management (Group II). There was no significant statistical difference in sensitivity and specificity of 18 F-FDG PET-CT scan in detecting cancer among the two groups. Considering all the patients in this study, WB 18 F-FDG PET-CT scan showed an overall sensitivity of 95.2% and specificity of 80%. In this study, change in TNM staging after WB 18 F-FDG PET-CT was seen in 22 (16.8%) patients and an alteration in the treatment in 21 (16.1%) patients, which were both found to be statistically significant (P < 0.5). In our study, WB 18 F-FDG PET-CT scan has shown to have an impact on initial staging of disease affecting the change in treatment protocol in a significant number of patients. The effect of this change in staging and treatment on the eventual morbidity and mortality rates is not known. In practice, the use of 18 F-FDG PET-CT scan is limited, owing to the high cost and low availability. A realistic evaluation of cost versus benefit needs to be undertaken to identify the impact of using 18 F-FDG PET-CT scan as a mode for initial evaluation of HNSCC.

Comparação do uso de implante de Silastic(r) com titânio pré-fabricado na tireoplastia tipo I

Introduction: Type I thyroplasty is the treatment of choice for unilateral vocal cord palsy with no spontaneous recovery. Objectives: To compare the use of silastic implant with titanium vocal fold medializing implant (TVFMI®) in type I thyroplasty for unilateral vocal cord palsy with respect to subjective and objective improvement in voice, endoscopic changes in vocal cords, surgical time, and cost effectiveness. Methodology: This was a prospective study conducted on 40 patients with unilateral vocal cord paralysis who underwent type I thyroplasty with either silastic implant or TVFMI®. Pre-operative and four-week post-operative assessment and statistical comparison were performed by videolaryngoscopy, stroboscopy, perceptual assessment (GRBAS), subjective (voice handicap index) analysis of voice, and computer-assisted acoustic and electroglottographic assessment. The duration of surgery and cost of implant were also recorded. Results: Although both implants showed improvement in quality of voice following thyroplasty, TVFMI® presents slightly better results in objective voice analysis. The surgery time for TVFMI®insertion was shorter, but the costs were higher. Conclusion: TVFMI® may be preferred for medialization thyroplasty as it presents better voice results and demands less surgical time; however, it is costlier than silastic implant.INTRODUCTION Type I thyroplasty is the treatment of choice for unilateral vocal cord palsy with no spontaneous recovery. OBJECTIVES To compare the use of silastic implant with titanium vocal fold medializing implant (TVFMI®) in type I thyroplasty for unilateral vocal cord palsy with respect to subjective and objective improvement in voice, endoscopic changes in vocal cords, surgical time, and cost effectiveness. METHODOLOGY This was a prospective study conducted on 40 patients with unilateral vocal cord paralysis who underwent type I thyroplasty with either silastic implant or TVFMI®. Pre-operative and four-week post-operative assessment and statistical comparison were performed by videolaryngoscopy, stroboscopy, perceptual assessment (GRBAS), subjective (voice handicap index) analysis of voice, and computer-assisted acoustic and electroglottographic assessment. The duration of surgery and cost of implant were also recorded. RESULTS Although both implants showed improvement in quality of voice following thyroplasty, TVFMI® presents slightly better results in objective voice analysis. The surgery time for TVFMI®insertion was shorter, but the costs were higher. CONCLUSION TVFMI® may be preferred for medialization thyroplasty as it presents better voice results and demands less surgical time; however, it is costlier than silastic implant.

Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty

Introduction: Type I thyroplasty is the treatment of choice for unilateral vocal cord palsy with no spontaneous recovery. Objectives: To compare the use of silastic implant with titanium vocal fold medializing implant (TVFMI®) in type I thyroplasty for unilateral vocal cord palsy with respect to subjective and objective improvement in voice, endoscopic changes in vocal cords, surgical time, and cost effectiveness. Methodology: This was a prospective study conducted on 40 patients with unilateral vocal cord paralysis who underwent type I thyroplasty with either silastic implant or TVFMI®. Pre-operative and four-week post-operative assessment and statistical comparison were performed by videolaryngoscopy, stroboscopy, perceptual assessment (GRBAS), subjective (voice handicap index) analysis of voice, and computer-assisted acoustic and electroglottographic assessment. The duration of surgery and cost of implant were also recorded. Results: Although both implants showed improvement in quality of voice following thyroplasty, TVFMI® presents slightly better results in objective voice analysis. The surgery time for TVFMI®insertion was shorter, but the costs were higher. Conclusion: TVFMI® may be preferred for medialization thyroplasty as it presents better voice results and demands less surgical time; however, it is costlier than silastic implant.INTRODUCTION Type I thyroplasty is the treatment of choice for unilateral vocal cord palsy with no spontaneous recovery. OBJECTIVES To compare the use of silastic implant with titanium vocal fold medializing implant (TVFMI®) in type I thyroplasty for unilateral vocal cord palsy with respect to subjective and objective improvement in voice, endoscopic changes in vocal cords, surgical time, and cost effectiveness. METHODOLOGY This was a prospective study conducted on 40 patients with unilateral vocal cord paralysis who underwent type I thyroplasty with either silastic implant or TVFMI®. Pre-operative and four-week post-operative assessment and statistical comparison were performed by videolaryngoscopy, stroboscopy, perceptual assessment (GRBAS), subjective (voice handicap index) analysis of voice, and computer-assisted acoustic and electroglottographic assessment. The duration of surgery and cost of implant were also recorded. RESULTS Although both implants showed improvement in quality of voice following thyroplasty, TVFMI® presents slightly better results in objective voice analysis. The surgery time for TVFMI®insertion was shorter, but the costs were higher. CONCLUSION TVFMI® may be preferred for medialization thyroplasty as it presents better voice results and demands less surgical time; however, it is costlier than silastic implant.

Inverted papilloma of frontal sinus with intracranial extension.

Inverted papilloma (IP) is a benign epithelial neoplasia that accounts for 0.5–4% of all primary nasal tumours.1 It is characterised by an endophytic or inverted growth pattern of epithelium with ramifications into the underlying stroma rather than outward proliferation from the surface with an intact epithelial basement membrane.2 It affects all ages, most commonly males (M:F 3:1–5:1) in the fifth to the seventh decades of life (average age 53 years).1,3 The most frequent sites are the lateral nasal wall near the middle turbinate or ethmoid recesses and the maxillary sinuses. Although a benign lesion, IP is characterised by its relatively high recurrence rate, local aggressiveness and potential for malignant transformation. We present a rare case of IP arising from frontal sinus with extension into anterior cranial fossa treated with craniofacial resection.

Contact Endoscopy - A promising tool for evaluation of laryngeal mucosal lesions

Early diagnosis of laryngeal cancer is important for favourable treatment outcome. Due to morbidity and difficulties associated with surgical biopsy, a need has always been felt for an easy, non invasive yet accurate tool for knowing histopathological nature of mucosal lesions. Contact Endoscopy (CE) is one such technique which is capable of providing real time and magnified images of cellular structure of superficial layers of various mucosal surfaces with obvious advantages and potential for wide clinical application. In this review, a summary of role and efficacy of CE in diagnosis, treatment and follow up of various laryngeal mucosal lesions is presented. We searched Pubmed, Medline, Cochrane and Google scholar for articles on CE for mucosal lesions of larynx. For better understanding of the technique, articles on CE of other non-laryngeal sites of head and neck were also reviewed. Article selection was limited to human studies without restriction to language and year of publication. Reference lists from identified articles were also searched. Six prospective original articles, three descriptive studies and one review article on CE of laryngeal lesions are included in this review and their findings summarized. Common findings on examination of cellular architecture and vascular patterns described by various authors are also tabulated. The literature revealed high sensitivity (90-94.7%), specificity (81-100%) and accuracy (88-94%) of CE in diagnosis of laryngeal lesions across the published studies. CE is a promising non invasive tool for evaluation of laryngeal mucosal lesions. However, further prospective, randomized, double blinded studies as well as research to improve the technique to overcome the existing limitations are required before defining its precise role in clinical practice.

Management of the node negative early carcinoma tongue

ObjectiveTo determine the role of thickness of the primary lesion in early Squamous Cell Carcinoma (SCC) of the oral tongue for decision-making regarding the management of possible occult cervical node metastases.SettingTertiary referral centrePatientsPatients who were treated by the authors for early (T1, T2) primary lesions in the oral tongue in two malignancy treatment centres of the Armed Forces Medical Services were included in this prospective study. Where the primary lesion was less than 04 mm in depth, the neck was not addressed electively. Those who developed nodal disease in the neck on follow up were subjected to comprehensive neck dissection. In those patients where the tumour thickness was more than 04 mm, the neck was addressed with at least a supra-omohyoid neck dissection. Postoperative radiotherapy was given as per standard indications. The patients were followed up as per standard protocol.ResultsDisease free survival rate achieved was 86% and this compares well with survival rates achieved by other workers.ConclusionTreatment of neck nodes in early (T1,T2) SCC of the oral tongue can be expectant in cases where tumour thickness is less than 04 mm, but where it is more than 04 mm elective treatment of the neck is recommended.

Therapeutic interventions by speech language pathologist in managing adult dysphagia: An evidence based review

The speech and language pathologist provides nonsurgical, nonpharmacological treatment to patients with oropharyngeal dysphagia. There is a notable lack of knowledge or awareness among the professionals in managing dysphagia using this therapeutic intervention. The present article, therefore, reviews the therapeutic interventions offered by speech and language pathologist in managing adult dysphagia and its efficacy data. Literature was searched and all the therapeutic interventions offered were included and studies were quoted mentioning their efficacy. In general, positive therapy effects were found.

Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty✩✩Please cite this article as: Malik A, Ramalingam WVBS, Nilakantan A, Nair S, Ramesh AV, Raj P. Comparison of the use of silastic with titanium prefabricated implant in type I thyroplasty. Braz J Otorhinolaryngol. 2014;80:156-60.

Introduction: Type I thyroplasty is the treatment of choice for unilateral vocal cord palsy with no spontaneous recovery. Objectives: To compare the use of silastic implant with titanium vocal fold medializing implant (TVFMI®) in type I thyroplasty for unilateral vocal cord palsy with respect to subjective and objective improvement in voice, endoscopic changes in vocal cords, surgical time, and cost effectiveness. Methodology: This was a prospective study conducted on 40 patients with unilateral vocal cord paralysis who underwent type I thyroplasty with either silastic implant or TVFMI®. Pre-operative and four-week post-operative assessment and statistical comparison were performed by videolaryngoscopy, stroboscopy, perceptual assessment (GRBAS), subjective (voice handicap index) analysis of voice, and computer-assisted acoustic and electroglottographic assessment. The duration of surgery and cost of implant were also recorded. Results: Although both implants showed improvement in quality of voice following thyroplasty, TVFMI® presents slightly better results in objective voice analysis. The surgery time for TVFMI®insertion was shorter, but the costs were higher. Conclusion: TVFMI® may be preferred for medialization thyroplasty as it presents better voice results and demands less surgical time; however, it is costlier than silastic implant.INTRODUCTION Type I thyroplasty is the treatment of choice for unilateral vocal cord palsy with no spontaneous recovery. OBJECTIVES To compare the use of silastic implant with titanium vocal fold medializing implant (TVFMI®) in type I thyroplasty for unilateral vocal cord palsy with respect to subjective and objective improvement in voice, endoscopic changes in vocal cords, surgical time, and cost effectiveness. METHODOLOGY This was a prospective study conducted on 40 patients with unilateral vocal cord paralysis who underwent type I thyroplasty with either silastic implant or TVFMI®. Pre-operative and four-week post-operative assessment and statistical comparison were performed by videolaryngoscopy, stroboscopy, perceptual assessment (GRBAS), subjective (voice handicap index) analysis of voice, and computer-assisted acoustic and electroglottographic assessment. The duration of surgery and cost of implant were also recorded. RESULTS Although both implants showed improvement in quality of voice following thyroplasty, TVFMI® presents slightly better results in objective voice analysis. The surgery time for TVFMI®insertion was shorter, but the costs were higher. CONCLUSION TVFMI® may be preferred for medialization thyroplasty as it presents better voice results and demands less surgical time; however, it is costlier than silastic implant.

Laryngeal framework surgery for adductor spasmodic dysphonia

Adductor spasmodic dysphonia is difficult to diagnose and treat. Botulinum toxin is considered to be treatment of choice for adductor spasmodic dysphonia. We present a case here, who had become refractory to the effects of botulinium toxin. He subsequently underwent type II thyroplasty and had satisfactory improvement in voice with it.