Ganesh S Kamath

Tracheo-innominate artery fistula: a rare complication in a laryngectomized patient

A tracheo-innominate artery fistula is an uncommon but frequently fatal complication of tracheostomy. Rarely, it can also occur in laryngectomized patients. We report a post-laryngectomy, post-radiotherapy patient using a metal tracheostomy tube, who developed a tracheo-innominate artery fistula about two months after radiotherapy. To our knowledge this is only the second reported case in a laryngectomized patient. The computed tomography (CT) angiography findings helped confirm the diagnosis and the patient was successfully managed by surgical exploration and ligation of the innominate artery. Coagulase negative Staphylococcus aureus was cultured from a tracheal swab. The clinical features, CT angiography findings, management protocols and possible aetiological factors are discussed.

A Rare Case of Congenital Diaphragmatic Hernia With Ectopic Liver and Absent Pericardium

We present a 37-year-old woman with a rare combination of absent pericardium with congenital diaphragmatic hernia. Only 3 patients with congenital diaphragmatic hernia with complete absence of pericardium and ectopic liver have been described, and all of them were neonates. This interesting case gives us an opportunity to study the natural history of this rare combination of anatomic defect and consolidate the existing scarce data on this condition.

Suicide by combined insulin and glipizide overdose in a non-insulin dependent diabetes mellitus physician: a case report.

A case of self-injected insulin intoxication with an oral hypoglycaemic agent glipizide overdose in a type-II/non-insulin dependent diabetes mellitus (NIDDM) individual, a physician by profession, is presented with a review of the literature. The case demonstrates the need for thorough scene investigation, perusal of clinical details and complete autopsy to certify the death caused by combined insulin and glipizide overdose, and the manner of death. A meticulous search in the English literature reveals that hardly any fatal cases of combined insulin and glipizide overdose have been reported, with almost no cases from India, thus making this case report relevant and unique.

Non-functioning Aortocaval Paraganglioma Masquerading as Celiac Lymphnodal Metastasis

An extra-adrenal paraganglioma is a rare tumour derived from chromaffin cells of sympathetic ganglia. This report documents a rare case of a non-functional aortocaval paraganglioma in a 24-year-old woman with persistent abdominal pain. Computed tomography revealed a solid mass, measuring 2.5x3cms, localized between the celiac trunk and superior mesenteric artery in aortocaval location along with right ovarian cystic mass. A clinical diagnosis of malignant ovarian tumour with celiac nodal metastasis was made. Excision and pathological analysis of both revealed an aortocaval extra-adrenal paraganglioma and benign ovarian cyst. On serial follow-up the patient was in a good health, asymptomatic and without evidence of tumour recurrence. This case emphasizes the necessity of including extra-adrenal paraganglioma in the differential diagnosis and management of retroperitoneal tumours, despite its rarity.

Isolated Cervical Rib Fracture

Isolated fracture of a cervical rib is a very rare entity. Cervical rib fracture due to heavy backpack usage is a new occupational hazard for students. Cervical rib fracture usually presents as a painless swelling or as thoracic outlet syndrome. We report two patients with cervical rib fractures, one of them secondary to backpack usage, and review the available literature.

Delayed repair for aortic root abscess - is it justified?

Results A 55 yr old gentleman presented with high grade fever since 2mths and dyspnoea on exertion since 1mth. Echocardiography revealed severe AR with vegetations and a diagnosis of infective endocarditis was made after blood cultures grew coagulase negative staphylococcus. He was in pulmonary oedema on presentation with renal failure needing non-invasive ventilator support and low dose inotropes. He responded to appropriate intravenous antibiotics. He was investigated for malaena and CT scan showed splenomegaly with cirrhosis suggestive of portal hypertension and there was suspicion of an aortic root abscess. Upper GI scopy showed oesophageal varices. He was referred for aortic valve replacement. Repeat transoesophageal echocardiograms did not show the root abscess and his renal dysfunction contraindicated repeat CT scans. He was taken up for banding for varices and surgery was delayed for a month. The inflammatory markers returned to normal; renal function recovered to normal and heart failure resolved as well. Appropriate antibiotic cover was continued for the 4 weeks after banding. An elective aortic valve replacement was planned with a tissue valve considering the varices. At surgery a cavity of 0.5 cm × 0.5 cm × 1 cm was found between the LCCRCC junction medial to the pulmonary artery. The annulus was reconstructed with obliteration of the cavity. He made a good recovery thereafter.

Tuberculosis can cause anything in the world except pregnancy

Results A 37 year old male patient presented with class III dyspnoea on exertion. He was hypertensive with dialysis dependent end stage renal disease and dialysed using an AV Fistula on the left upper limb. Echocardiography showed severe AR and LV dysfunction. CT Coronary angiography showed aortic root to be 5 cm and saccular aneurysms in the circumflex and the right coronary artery with complete occlusion of RCA. A Bentall procedure was planned. Intraoperatively, there was a mass arising from anterior chest wall measuring 6 cm × 5 cm attached to the Left Internal Mammary artery with multiple enlarged paratracheal and mediastinal lymph nodes. Frozen section from the mass and lymph nodes did not reveal any malignancy. The oncosurgeon felt that the mass was malignant looking at its extent and CT characteristics. Pragmatically a mechanical aortic valve replacement and saphenous vein grafts to the OM and PDA were performed after a discussion between the clinicians instead of a root replacement. The final histopathology showed tuberculosis of the lymph nodes with no malignancy in the mass. The patient underwent dialysis postoperatively and needed inotropes till day 4. He was started on anti-tuberculosis medications and was discharged on postoperative day 10. In retrospect the coronary aneurysms and the root dilatation with aortic regurgitation could have been caused by tuberculosis.

When images lie: a variant of suprascapular artery found incidentally

Left internal thoracic artery (LITA) injection during coronary angiography of a 57-year-old man taken for coronary artery bypass graft showed a large branch arising very high from the LITA, about 1 cm past its origin. Even after harvesting the LITA to a very high extent to get this branch, it could not be found (figure 1). Hence, it was decided to dissect up to the origin of the LITA. The internal mammary vein accompanying the LITA was divided between ligaclips. This allowed clear visibility of the subclavian vein, which was then traced to its drainage into the internal jugular vein. The subclavian vein was obscuring vision of the left …

Left maxillary artery pseudoaneurysm: a rare and late postoperative complication after head and neck cancer treatment

We report a case of a 50-year-old man presented with pulsatile swelling in the left side of the face since 2 months and a continuous sinus discharge since 3 days. Three years earlier, he was operated for squamous cell carcinoma (SCC) of the left lower alveolus and underwent surgical excision with myocutaneous flap reconstruction, followed by chemoradiotherapy. CT angiogram of the expansile swelling revealed pseudoaneurysm of third part of the left maxillary artery and treated by surgical intervention.