Dharambir S. Sethi

Deep neck abscesses – changing trends

A retrospective review was conducted of 64 patients with deep neck abscesses. Based on clinical and operative findings, these abscesses were categorized as retropharyngeal abscess (29 patients), parapharyngeal abscess (10 patients), Ludwigs angina (19 patients), or necrotizing cervical fasciitis (six patients). Regional trauma from an ingested foreign body was the cause for 59 per cent of the patients with a retropharyngeal abscess. In 90 per cent of subjects with Ludwigs angina, an odontogenic cause was established; however, in the majority of cases of parapharyngeal abscess (80 per cent) and necrotizing fasciitis of the neck (85 per cent), aetiology was unknown. Fifty-five patients (86 per cent) required open neck drainage. In the remaining nine (14 per cent) endoscopic drainage of the abscess was possible. Eight patients (12 per cent) needed a tracheotomy for airway control. The overall mortality was eight per cent despite aggressive anti-microbial therapy and early surgical intervention. Thirty-four cultures grew aerobic organisms. Seventy-six per cent of these were gram-negative microorganisms. The bacteriological pattern of deep neck abscesses is changing and may be responsible for the considerable mortality rate with which the abscesses are still associated despite anti-microbial therapy.

Endoscopic management of lesions of the sella turcica

The excellent visualization and minimally invasive surgical technique of endoscopic sinus surgery was applied to the management of 40 patients with sellar lesions. Endoscopic management of sellar lesions offers, not only the advantage of improved visualization, but also magnification, and a panoramic perspective of the important relationships of the sella turcica. In the past year, we have managed 40 subjects with sellar lesions, endoscopically: 38 patients had pituitary adenomas and two a craniopharyngioma. At our hospital, the endoscope has replaced the operating microscope for surgery for pituitary adenomas and other sellar lesions. The endoscopic approach to the sphenoid sinus and the sella is performed by an ENT surgeon and the ablative surgery performed by a neurosurgeon. Our experiences, using the endoscope to perform surgery on sellar and parasellar lesions, are reported and the advantages, over the operating microscope, which is traditionally used are discussed. The technique for endoscopic management of sellar lesions is described.

Isolated sphenoid lesions: diagnosis and management.

Isolated sphenoid lesions are rare. It is likely that isolated sphenoid sinus disease is underreported for a number of reasons. First, the presenting symptoms are often nonspecific; second, the inaccessibility of the sinus precludes optimal physical examination; and third, before the advent of CT and MRI scanning, radiologic examination of the sinus was inadequate. Endoscopic evaluation and current imaging techniques with CT or MRI have contributed to an increase in diagnosis of these lesions. Twenty-one patients with isolated sphenoid lesions that I treated in a 4-year period are presented. The pathology was unilateral sphenoid sinusitis (8), sphenoid mucoceles (4), inflammatory spheno-choanal polyp (3), inverting papilloma (2), invasive pituitary adenoma (1), carcinoma (1), aspergilloma (1), and fibrous dysplasia (1). Endoscopic biopsy was carried out in 7 patients (33.3%). A precise diagnosis after endoscopy, biopsy, and imaging studies was established in all patients. Definitive treatment included an endoscopic sphenoidotomy in 15 (71.4%). Five patients (23.8%) were treated with other therapeutic modalities. One patient did not require any definitive treatment. The combined use of imaging techniques and diagnostic nasal endoscopy allows for an accurate diagnosis and enables minimally invasive techniques to be tailored to the patients disease. Isolated sphenoid pathology may be very insidious and present with nonspecific symptoms. It is therefore not surprising that these lesions have been regarded as an uncommon entity because of the lack of adequate diagnostic facilities in the past. Plain radiographs and examination with a headlight offer little diagnostic information on sphenoid pathology. The increased use of endoscopy in routine nasal examination and advances in imaging techniques of this area will probably result in more frequent diagnosis of these lesions. Twenty-one patients with isolated sphenoid lesions that I treated in a 4-year period are presented. The patient characteristics, presentation, diagnosis, and management of these lesions are described. An important feature emerging on studying these lesions was that a preoperative diagnosis, made possible by nasal endoscopy and CT/MRI scan, was invaluable in planning the treatment of these patients. Definitive endoscopic management of these lesions was possible in 15 patients.

Diagnostic and Therapeutic Approach to Migrating Foreign Bodies

Ingested foreign bodies are the commonest otolaryngological emergency in Singapore and other parts of Southeast Asia. One of the uncommon complications of ingested foreign bodies is migration, which has the potential to cause morbidity and mortality. A retrospective study of 24 patients presenting from 1990 to 1996 at Singapore General Hospital was done to evaluate the presentation, investigation, and diagnosis of migrated foreign bodies. Of interest, most patients had ingested foreign bodies within 24 hours. All the migrated foreign bodies were linear, sharp fish bones. Migration is said to have occurred in the presence of positive neck radiography and negative rigid esophagoscopy. Computed tomography is the investigation of choice to confirm migration. All patients had neck exploration, and factors for successful outcome are discussed. This is the largest series in the literature to date.

Endoscopic anatomy of the sphenoid sinus and sella turcica

An endoscopic study of the sphenoid sinus was carried out, on 30 cadavers, to understand the important anatomical relationships of the sphenoid sinus, and the sella turcica. The aim was to study the endoscopic anatomy and the variants, and to determine if endoscopic instrumentation and techniques, could play a beneficial role in endoscopic management of sellar lesions. The results of this study are discussed, with particular reference to the important surgical anatomical features of the sphenoid sinus. A surgical technique for the endoscopic transsphenoid approach to the sella turcica was developed. Anatomical variants can be identified endoscopically, and endoscopic techniques have the advantages of improved visualization, magnification, angled vision, and a panoramic perspective of the intrasphenoid anatomy, compared to currently employed methods of pituitary/sellar surgery, using the operating microscope.

Submandibular gland excision: a five-year review

Excision of the submandibular gland is a surgical procedure often undertaken. The procedure is the treatment of choice for patients with neoplasm of the submandibular gland and those with non-neoplastic submandibular disorders which are not controlled with conservative medical measures. Extirpation of the submandibular gland may also be undertaken for diagnostic purposes. This retrospective study of 93 consecutive patients who underwent excision of the submandibular gland in the Department of Otolaryngology, Singapore General Hospital over a five-year period was undertaken to study the indications of surgery, the pathology of the excised submandibular gland and the demographic profile of patients. Fifty-six (60.2 per cent) patients underwent submandibular gland excision for non-neoplastic salivary gland disease while 37 (39.8 per cent) had neoplastic submandibular gland disorders. The commonest pathology encountered was sialadenitis/sialolithiasis (53.76 per cent) followed by pleomorphic adenoma (33.33 per cent). Fine needle aspiration cytology (FNAC) was a valuable pre-operative investigation with a sensitivity and specificity of 94.7 per cent and 100 per cent respectively for neoplastic disease. The morbidity rate for this surgery was 4.3 per cent.

Immunologic Defects in Patients with Chronic Recurrent Sinusitis: Diagnosis and Management

Twenty patients with chronic refractory sinusitis or rhinitis were identified to have immune defects on the basis of total immunoglobulin level, immunoglobulin G subclass, and vaccine response. Eight patients were immunoglobulin A deficient, five had low immunoglobulin levels with vaccine hyporesponse, and four had low immunoglobulin levels with normal vaccine responses. Three subjects showed isolated immunoglobulin G1 deficiency. Demographic variables such as age, sex, infection pattern, and any other related disorders were studied retrospectively, which may have contributed to the diagnosis. An immunologic screen was essential for the diagnosis of immunodeficiency in these patients. Treatment options included prophylactic antibiotics, management of associated allergies, functional endoscopic sinus surgery, and replacement therapy with immunoglobulin in selected patients.

Endoscopic Management of Orbital Apex lesions

Lesions of the orbital apex often present a diagnostic dilemma. Clinical assessment and imaging studies are helpful but a tissue biopsy is often required. The morbidity associated with transcranial approaches to the orbital apex may outweigh the benefits of obtaining a biopsy by these routes. Fine needle aspiration cytology of orbital apex lesions can be performed but there are disadvantages with this method. We describe a transnasal endoscopic technique to biopsy the orbital apex. The technique was used successfully to obtain a tissue diagnosis in six patients with orbital apex lesions. This enabled commencement of definitive treatment. There were no significant complications. The transnasal approach to the orbital apex using the endoscopes is reliable. Endoscopes provide excellent illumination, magnification, and a panoramic view of the operative field.

Sphenoid sinus mucocele: 10 cases and literature review

INTRODUCTION Sphenoid sinus mucoceles represent only 1-2 per cent of all paranasal sinus mucoceles. Patients may present with a myriad of symptoms. Pre-operative investigations include nasoendoscopy, computed tomography and/or magnetic resonance imaging. Treatment is by endoscopic sinus surgery. METHODOLOGY A retrospective review of the archives of the Singapore General Hospital otolaryngology department (1999-2006) identified 10 cases of sphenoid sinus mucocele. Patient demographics, presenting symptoms, investigations and treatment were evaluated. RESULTS The 10 patients identified (three women and seven men) had a mean age of 54.5 years (range 24-70 years). Thirty per cent of patients had a history of nasopharyngeal carcinoma treated with radiotherapy. Presenting symptoms, in order of decreasing frequency, were: ocular symptoms (50 per cent), headaches (30 per cent), nasal discharge (30 per cent) and facial pain (10 per cent). All patients underwent pre-operative computed tomography or magnetic resonance imaging. Twenty per cent of patients had evidence of intracranial involvement on imaging. All patients underwent uncomplicated transnasal sphenoidotomy and drainage of the mucocele. There was no clinical or radiological evidence of recurrence at a mean follow up of 29 months (range 4-90 months). CONCLUSION Sphenoid sinus mucocele is a rare condition. In this study, radiation to the head and neck appeared to be a predisposing factor, and eye symptoms were the commonest presentation. Endoscopic sinus surgery is a safe and effective treatment modality.

Sphenoid sinus mucocoele presenting with isolated oculomotor nerve palsy

We describe two cases of sphenoid sinus mucocoele. Both presented with isolated oculomotor nerve palsy. Mucocoeles involving only the sphenoid sinus are uncommon. They are probably under-diagnosed as they may be asymptomatic or cause non-specific symptoms. Nasal symptoms occur infrequently but the close relationship of the sphenoid sinus to the orbital apex means that ocular symptoms including cranial nerve palsies are a common presenting feature. Involvement of the third cranial nerve in isolation is rare but has important neurosurgical implications which must be excluded before this symptom is attributed to the sphenoid sinus.