J. Madana

Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children.

INTRODUCTION Chronic suppurative otitis media (CSOM) is the most common cause of childhood hearing impairment in the developing countries and atticoantral type is associated with increased incidence of intracranial and extracranial complications. This study was undertaken to define the microbiology of atticoantral type of chronic otitis media and the antibiotic sensitivity pattern, thereby reducing the potential risks of complications. MATERIALS AND METHODS A retrospective study was done in the Department of Otolaryngology, JIPMER, Puducherry from the year August 2003 to October 2009 using the medical record department database to retrieve the patient details. During this study period, 223 children with atticoantral type CSOM consisting of 126 males and 97 females with an age range of 1-14 years were assessed. Patients with persistent otorrhea for more than 3 months with atticoantral type of chronic otitis media were selected. The exudates were collected under sterile conditions and inoculated onto culture media; bacterial growth and antibiotic sensitivity pattern were studied. RESULTS Nine species of micro organisms were isolated from the middle ear aspirate, Pseudomonas aeruginosa being the most predominant isolate constituting about 32% (72 discharging ears) of the total isolates followed by Proteus mirabilis (20% of isolates) and Staphylococcus aureus (19% of isolates). Gram negative organisms accounted 58% of total isolates and gram positive organisms constituted 22% isolates. Candida albicans and methicillin resistant S. aureus were identified in 4% and 2% of isolates, respectively. 100% of Pseudomonas isolates showed susceptibility to ceftazidime and a high sensitivity (92% of isolates) to ciprofloxacin and 88% isolates were sensitive to amikacin. 100% of P. mirabilis isolated from inoculates showed sensitivity to ceftazidime and ciprofloxacin. It also showed 87-97% sensitivity to ceftriaxone, amikacin and ampicillin. All (100%) of the Staphylococcus isolates were sensitive to vancomycin and 84-86% were sensitive to ciprofloxacin and erythromycin. In general, gram negative organisms showed increased sensitivity to ceftazidime, ciprofloxacin and amikacin, while gram positive organisms to vancomycin, erythromycin and ciprofoxacin. CONCLUSION Continuous and periodic evaluation of microbiological pattern and antibiotic sensitivity of cholesteatomatous CSOM is necessary to decrease the potential risks of complications by early institution of appropriate systemic and topical antibiotic alongside mastoid exploration. We believe that our data may contribute to an effective medical management of chronic suppurative otitis media with cholesteatoma. Since the most common organisms in our clinical set up being P. aeruginosa, P. mirabilis and S. aureus, which showed a percentage susceptibility of 100% to ceftazidime and vancomycin, thus making it an empirical antibiotic combination therapy of choice in the recent times.

Recurrent neck infection with branchial arch fistula in children

OBJECTIVE Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side. METHODS A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases. RESULTS The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence. CONCLUSION Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.

True thyroglossal fistula.

Thyroglossal duct anomalies are the most common malformations in the neck and constitute 70% of all the congenital cervical masses. They are more common in the pediatric population under 5 years of age, and 60% of lesions are diagnosed before the age of 20. They represent remnants from the embryological migration of thyroid tissue from foramen caecum to the thyroid fossa. The thyroglossal duct cyst may rupture spontaneously and present as a draining sinus, which has been erroneously called a thyroglossal fistula, although communication with foramen caecum is extremely rare. We hereby present a case of true thyroglossal fistula in a 21‐year‐old male with a fistulous communication between the neck skin and foramen caecum. Laryngoscope, 2009

Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis.

OBJECTIVE We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy. METHOD A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented. RESULTS A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence. CONCLUSION To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Simultaneous occurrence of a thyroglossal duct cyst and a lingual thyroid in the absence of an orthotopic thyroid gland

OBJECTIVE We report an extremely rare case of the simultaneous occurrence of a thyroglossal duct cyst and a lingual thyroid in the absence of an orthotopic thyroid gland, in a seven-year-old girl from South India. METHOD Case report and a review of the English language literature on the subject. RESULTS The patient presented with a mass on the tongue that had been present for three years, and an anterior neck swelling that had been present for two years. Examination revealed a midline, pinkish, firm mass present on the posterior one-third of the tongue. The neck showed a midline cystic swelling in the infrahyoid position. Radiological imaging confirmed the clinical findings, revealing the absence of her thyroid gland in the normal location. Sistrunks procedure was performed leaving behind a lingual thyroid. At 13-month follow up, the patient was euthyroid with no recurrence. CONCLUSION To our knowledge the association of a lingual thyroid and a thyroglossal cyst has only been reported once in the literature. The presence of a lingual thyroid in the absence of a normally located thyroid gland or functioning thyroid tissue along the thyroglossal tract, confirmed by radionuclide and computed tomography imaging, may indicate the failure of the normal descent of the thyroid gland during embryonic development. This probable absence of the descent of the thyroid raises questions regarding the origin of thyroglossal duct cysts.

Cervical infection secondary to pyriform sinus fistula of branchial origin

Complete third branchial arch anomalies are rare and have been described only in case reports, affecting mainly children and typically presenting as a cervical inflammatory process. Anomalies of the third and fourth branchial apparatus, though rare, usually present as sinuses/incomplete fistulas of pyriform sinus or recurrent suppurative thyroiditis. A 6‐year‐old girl presented with a small opening on the left side of her anterior neck, which had been present since birth and was associated with recurrent infection. She had no history of incision and drainage of swelling. Computed tomography with contrast injection into the cervical opening revealed a fistulous tract extending from the cervical neck skin to the pyriform fossa. Complete excision of the fistulous tract and left hemithyroidectomy were performed. There was no recurrence at 22 months of follow‐up.

Hypohidrotic ectodermal dysplasia with atrophic rhinitis and nasal myiasis

Hypohidrotic/anhidrotic ectodermal dysplasia is a rare inherited disorder characterized by hypohidrosis/anhidrosis, hypotrichosis, dysodontia and heat intolerance. Most common mode of transmission is X-linked recessive, showing complete expression in males, and only partial manifestations in the female carrier heterozygotes. Features like atrophic rhinitis, nasal and aural myiasis, syndactyly, cleft lip and/or palate, mental retardation and immunodeficiency are uncommonly seen in this syndrome. We hereby report a case of hypohidrotic ectodermal dysplasia with unusual features of atrophic rhinitis and nasal myiasis.

Longstanding malformation of right sided pinna in an elderly man.

The pinna is the second most common site for external ear vascular malformation in the head and neck. These malformations are relatively uncommon in adults and can pose difficult therapeutic challenges. We hereby present a case of a 69‐year‐old man with a congenital lesion in the right pinna consistent with an arteriovenous malformation. The lesion was complicated by ulceration and bleeding for 6 months prior to presentation. Resection of pinna was carried out, and satisfactory functional and esthetic results were obtained. There was no recurrence at 22 months of regular follow up.

Giant congenital auricular arteriovenous malformation

Arteriovenous malformation (AVM) is an uncommon vascular anomaly usually present in intracranial location, however may be present in other sites of the body, mostly in the head and neck region. The lesion may be present since birth or caused by trauma, but may become obvious during puberty or pregnancy. The diagnosis can be confirmed by selective angiography. Treatment usually includes super selective embolization followed by surgical excision within 48 h. We hereby present a rare case of a grotesquely disfiguring congenital auricular arteriovenous malformation in a 77-year-old elderly man, which has recently been complicated by ulceration, infection and hemorrhage in the past 6 months. The pinna showed a 15 cm x 8 cm pulsatile, erythematous, ulcerative hemorrhagic swelling which on angiography revealed tortuous superficial temporal and occipital arteries supplying the lesion. Complete auricular excision with split skin grafting was carried out. The option of preoperative embolization was not considered due to his renal dysfunction and the high dye load required for embolizing the fast flow arteriovenous malformation.