Ibrahim Ketenci

The Pott’s puffy tumor: a dangerous sign for intracranial complications

The Pott’s puffy tumor is a subperiosteal abscess of the frontal bone associated with osteomyelitis. The purpose of this article is to alert the physician to the severe complications of this entity. The records of six patients were reviewed retrospectively. There were four adults and two adolescents. Nasal endoscopy showed edematous, polypoid mucosa in middle meatus in three and nasal polyps in the rest. At initial admission, two had orbital subperiosteal abscess, but normal cranial CT findings. During hospitalization, three experienced frontal lobe abscess and one frontal cerebritis. Endoscopic sinus surgery was performed in all with external drainage of Pott’s puffy tumor in addition to antibiotherapy. Three patients underwent craniotomy/craniectomy for removal of frontal lobe abscesses. One patient with frontal lobe abscess died. Pott’s puffy tumor may result in potentially dangerous intracranial complications. Early diagnosis and treatment are essential to reduce morbidity and mortality.

Extranasopharyngeal angiofibroma originating from the nasal septum.

Angiofibroma arising outside the nasopharynx is unusual. The nasal septum is an extremely rare site for an angiofibroma to originate, and, to date, only 3 cases have been reported in the literature. We reported here the fourth case of nasal septal angiofibroma. A 27-year-old male patient with nasal deformity applied to the Erciyes University ENT Department. He also complained of nasal obstruction on the right for 6 years. Two years ago, he had experienced an epistaxis, which oozed for 2 weeks after being packed. Neither the patient nor his family had a history of any hematologic disorder. On examination, an external nasal deviation to left was remarkable. A dark grayish mass was seen through the right nostril, between the nasal septum and the inferior turbinate on anterior rhinoscopy. There was no mass in the nasopharynx on posterior rhinoscopy via endoscope. http://www.entnet.org/journal/casereports/OTO-24.pdf/

Rhinocerebral mucormycosis: experience in 14 patients.

OBJECTIVE Mucormycosis is an opportunist, often lethal fungal infection which occurs in immunocompromised patients. We present our experience in 14 patients with this condition. PATIENTS AND METHODS A retrospective chart review was conducted for 14 patients treated for rhinocerebral mucormycosis. RESULTS Nine patients had diabetes mellitus and six had a haematological malignancy. Nine patients had cutaneous and/or palatal necrosis. Eleven patients were treated with amphotericin B and five with liposomal amphotericin B. Endoscopic sinus surgery was performed in five patients with disease limited to the sinonasal cavity; nine patients underwent more extensive surgery. Five patients with disease limited to the sinonasal cavity survived, while nine patients with widely disseminated disease died. Five of the nine diabetic patients died, as did five of the six patients with haematological malignancy. CONCLUSION Patients with rhinocerebral mucormycosis spreading outside the sinonasal cavity have a poor prognosis.

Castleman's Disease as an Unusual Neck Mass: Case Report

Castlemans disease is a rare, benign disease of unknown cause that induces reactive lymph node hyperplasia, most commonly in the mediastinum. It has 2 histologic subtypes: hyaline vascular and plasma cellular. A definitive diagnosis necessitates tissue biopsy. A specimen may be even misdiagnosed as lymphoma in frozen section. Surgery is the treatment of choice for the solitary form, whereas chemotherapy, radiotherapy, and steroids are proposed for the multicentric type. A neck mass diagnosed as Castlemans disease in a 48-year-old woman is reported.

Guillotine and dissection tonsillectomy in children

Tonsillectomy as an outpatient or same day-stay procedure is becoming increasingly popular. A retrospective study was performed on 1,049 children who underwent tonsillectomy and adenotonsillectomy either with guillotine or dissection with snare method. The dissection method was performed both under general anaesthesia and with local anaesthesia, but the guillotine method was performed only with local anaesthesia. Generally, bleeding control required no special intervention in the guillotine method but haemostasis was achieved by ligation and electrocauterization in one-third of the patients in the dissection group operated under general anaesthesia. The greatest percentage of haemorrhage in both methods occurred within the first four post-operative hours. There was a 1.8 per cent incidence of severe reactive haemorrhage required surgical intervention in the dissection group operated under general anaesthesia, but there was no such case in the guillotine group. The results of this study show that in carefully selected children guillotine tonsillectomy with local anaesthesia is a safe, time saving and cost-effective procedure.

Indolent mucormycosis of the sphenoid sinus.

A 63-year-old woman complained of severe headache for 3 months. She also had a history of chronic sinusitis. Endoscopic findings revealed polypoid changes in the sphenoethmoidal recess but no pathology in the ostiomeatal complex. Complete blood count and serum chemistries were normal. The fasting blood sugar was 89 mg/dL. VDRL and HIV tests were negative. A chest radiograph did not reveal any abnormality. Skin testing to inhalant allergens was negative. IgG and IgE levels were found to be within normal ranges. The CT-finding showed a heterogenous density in the right sphenoid sinus extending into ethmoid cells (Fig 1, A). Magnetic resonance imaging (MRI) with gadolinium revealed a hypointense mass on T1-weighted scans and a hyperintense heterogen mass showing peripheric enhancement in the right sphenoid sinus on T2weighted scans (Fig 1, B). An endoscopic right sphenoethmoidectomy was performed, and cheesy material filling the right sphenoid sinus as well as an edematous mucosa was found and removed. The natural ostia of the sphenoid sinus was enlarged so the sinus was irrigated. Histopathology revealed necrotic debris that contained broad, nonseptate branching hyphae characteristic of mucormycosis (Fig 2). However, the culture failed to grow. Her headache was relieved after the operation. The patient was followed up by endoscopic examinations monthly. Biopsy and repeat CT scans 2 months after surgical intervention showed no recurrence. She has been free of disease for more than 6 months after the operation.

Approaches to subperiosteal orbital abscesses

The purpose of this paper is to evaluate the epidemiology, clinical features, management and complications of subperiosteal orbital abscesses (SPOA)—a serious complication of rhinosinusitis. Retrospective data of 36 patients with SPOA secondary to acute rhinosinusitis from January 1998 to December 2011 were evaluated. Patients were analyzed in terms of age, gender, clinical features, CT findings, surgical procedures, microbiology, and complications. Twenty-three males and 13 females aged from 3 to 76 were evaluated. Nine patients—seven of which were under the age of 10—with small medial SPOA were treated only with medical management. Of the 13 with medial SPOA, transnasal endoscopic approach was performed for 10 and external approach for 3 to drain the abscess. As for the 12 patients with superior SPOA, 8 were treated via combined approach and 4 via external approach. The most common microorganisms were streptococci in children and anaerobes in adults. Total loss of vision developed in two adults with diabetes mellitus (DM). One patient with superior SPOA died due to frontal lobe abscess. Young children with small medial SPOA without significant ocular signs may successfully be managed medically. Surgical drainage is indicated for nonmedial abscesses, large medial abscesses with severe visual loss and with insufficient response to medical management. The risk of blindness from SPOA is higher in patients with DM.

Premedication Methods in Nasal Endoscopy: A Prospective, Randomized, Double-Blind Study

Objectives To identify the optimal pharmacological method of preparing patients for nasal endoscopy. Methods Twenty healthy volunteers were enrolled in this prospective, randomized, double-blind study. Four types of medications were applied in their nostrils with binary combinations of spray bottles on four different days in a random order: placebo (normal saline [NS]+NS), decongestant (NS+oxymetazoline), anesthetic (NS+lidocaine), and decongestant plus anesthetic (oxymetazoline+lidocaine). Rigid nasal endoscopy was performed 10 minutes after spray application. The volunteers evaluated the discomfort caused by each spray application, and nasal pain scores due to the passage of the endoscope. The physicians quantified nasal decongestion using a visual analogue scale. Endoscopy duration as well as pulse and mean blood pressure (MBP) before spray application, 10 minutes after the application, and immediately after endoscopic examination were also recorded. Results The discomfort caused by lidocaine was significantly higher than that caused by the other sprays (P<0.001). The lowest pain score related to endoscopy was obtained for oxymetazoline+lidocaine (P<0.001). Nasal decongestion was best achieved with NS+oxymetazoline (P<0.001). Endoscopy duration was the shortest for oxymetazoline+ lidocaine (P<0.05). Statistically significant MBP changes were only seen with the application of NS+oxymetazoline (P<0.05). However, neither MBP nor pulse rate change was significant clinically. Conclusion Application of decongestant and anesthetic sprays together seems to be the best method of pharmacological preparation of patients for nasal endoscopy.

A Rare Cause of Positional Dyspnea: Hypopharyngeal Hamartoma

Hypopharyngeal hamartomas are quite rare tumors that may cause nutritional or respiratory problems in neonates and infants. They may be confused with other benign laryngeal lesions. In this study a 7-month-old infant with congenital stridor and positional dyspnea caused by a hypopharyngeal hamartoma was reported with review of the literature. Hypopharyngeal hamartomas should be considered in the differential diagnosis of pathologies that cause respiratory or feeding problems in neonates or infants.

Comparação entre dexmedetomidina e sulfato de magnésio em hipotensão controlada durante cirurgia funcional endoscópica dos seios paranasais

BACKGROUND AND OBJECTIVES It is crucial to decrease bleeding during functional endoscopic sinus surgery. Our primary goal was to investigate the effects of magnesium sulfate and dexmedetomidine used for controlled hypotension on the visibility of the surgical site. METHODS 60 patients aged between 18 and 65 years were enrolled. In the magnesium sulfate group (Group M), patients were administered 40mg/kg magnesium sulfate in 100mL saline solution over 10min as the intravenous loading dose 10min before induction, with a subsequent 10-15mg/kg/h infusion during surgery. In the dexmedetomidine group (Group D), patients were administered 1μg/kg dexmedetomidine in 100mL saline solution as the loading dose 10min before surgery and 0.5-1μg/kg/h dexmedetomidine during surgery. Deliberate hypotension was defined as a mean arterial pressure of 60-70mmHg. RESULTS Bleeding score was significantly decreased in Group D (p=0.002). Mean arterial pressure values were significantly decreased in Group D compared to that in Group M, except for the initial stage, after induction and 5min after intubation (p<0.05). The number of patients who required nitroglycerine was significantly lower in Group D (p=0.01) and surgeon satisfaction was significantly increased in the same group (p=0.001). Aldrete recovery score ≥9 duration was significantly shorter in Group D (p=0.001). There was no difference between the two groups in terms of recovery room verbal numerical rating scale. CONCLUSIONS Dexmedetomidine can provide more effective controlled hypotension and thus contribute to improved visibility of the surgical site.