Jyoti P. Dabholkar

Secondary laryngeal tuberculosis revisited.

Introduction: Laryngeal tuberculosis is often misdiagnosed and is a highly contagious public health problem. The changing pattern of the clinical involvement of this disease poses a diagnostic challenge. The authors report four cases of laryngeal tuberculosis encountered in a short span of one month. Materials and Methods: All the four patients who presented to us with hoarseness had underlying active lesions in the lung. In spite of that they presented with mainly laryngeal symptoms and a multitude of findings on laryngeal examination. A diagnosis could be established owing to a high index of clinical suspicion, and due consideration given to the chest findings and positive sputum examination. The patients showed an excellent response to antituberculous therapy. Results and Conclusions: This study underlines the varied nature of laryngeal tuberculosis and the importance of addressing the hoarseness of a patient at the earliest, for the prompt diagnosis of this infectious condition.

Primary thyroid schwannoma masquerading as a thyroid nodule.

The thyroid gland is a very rare site for head and neck schwannomas. Till date there have been only 19 reported cases in English literature. Only 25% of schwannomas occur in the head and neck region, most of them arising in relation to the peripheral nerves and cervical sympathetic chain. We report a similar case, with clinical and sonological features of a benign thyroid nodule. The diagnosis of schwannoma was established on the final histopathology report and a review of the slides and the imaging was done to confirm the site of origin. A thorough review of earlier reported cases was done. We summarize the existing knowledge on this entity, emphasizing the challenge of diagnosing it pre-operatively.

Juvenile nasopharyngeal angiofibroma: clinical factors associated with recurrence and proposal of a staging system.

Juvenile nasopharyngeal angiofibroma (JNAF) is a rare histologically benign vascular tumor found exclusively in adolescent males. It can be aggressive and locally invasive with a potential of involving vital intracranial structures and is also associated with high rate of recurrence. It is an age-old fact that JNAF grows with finger like projections into natural bony crevices and it is imperative that a wide exposure is achieved to visualize and remove this extensively vascular tumor. These ‘touch me not’ tumors can be generally completely removed even in Stage III and IV (except Stage IVb tumor) if the surgeon has achieved proper exposure after adequate bone work. This article by Carrillo et al. invites criticism for large number of patients receiving radiotherapy (27/54, either primarily or adjunctive). Though it can be argued that out of the 30 cases (total of Stage III and IV), radiotherapy was justified in stage IV cases (n1⁄4 18), yet majority of Stage III (n1⁄4 12, according to INCAN classification) could have been managed without RT. Use of RT in a large number of patients will send across a wrong message to the world about the management protocol. It goes without saying that for such a benign lesion of childhood, RT should not be given injudiciously since it carries the risk of developing malignancy later in life, and that RT can be done away with better exposure at the cost of wide bone removal. Nevertheless, it can be offered when disease is unresectable or residual disease is left behind or when complete resection carries the serious risks of mortality/morbidity, damage to adjacent structures in cranial cavity/brain. It also raises an important question regarding the treatment philosophy for a benign but a locally destructive tumor/condition like JNAF. We feel that the most important factor affecting the recurrence is the extension of the disease intradurally with infiltration of cavernous sinus, pituitary fossa or optic chiasma. Major controversial issues in management of Stage III and IV JNAF are the selection of appropriate approach (external/degloving/ endoscopic), need for preoperative embolization, treatment of tumor recurrence and the role of RT. In this article it is shown that pre-operative embolization cases had more mean blood loss as compared to other cases, which goes contrary to reports published worldwide. In our series (unpublished data), the average blood loss was about 600 cm without doing preoperative embolization because of cost considerations. However, wherever necessary, we do expose external carotid artery in neck and clamp it temporarily at the time of tumor removal. The flaw in the proposed classification is the absence of sub staging in Stage IV with Stage IV B (Andrews–Fisch classification) carrying bad prognosis. The recurrence in the series is about 18 out of 45 cases. A recurrence of 8 out of 12 cases in Stage IV can perhaps be explained, but the recurrence rate in Stage III (8/18) is not justified and is probably represents poor exposure in spite of their technique of negative margins in the surgical bed. We believe that even recurrences should be addressed with surgery (either external or endoscopic) depending on the location and size of the tumor. In spite of the fact that endoscopic approach to JNAF has generated lot of interest recently, it is advisable to address only Stage I/II and limited Stage III tumors by this approach, especially since tumors with far lateral extension in Infratemporal fossa have more chances of recurrence in inexperienced hands. But endoscopes can be quite useful for exploring and removing smaller components along with the external approaches. I know these tumors always involve the issues of cosmesis and probably more so in western world, but the decision regarding the approach should not be at the expense of adequate exposure. The article is thought provoking and stirs up the major controversy regarding the selection of modality for management of Stage III and IV JNAF. In my opinion, we should deal this tumor with more aggressive surgical approach (especially with availability of osteoplastic maxillotomy procedures), but treading cautiously to avoid significant morbidity and mortality.

Schwanomma arising from mental nerve: a rare entity

Schwannomas or neurilemmomas are benign tumors of the nerve sheath that are single, well encaspsulated, bening and arise from the perineural schwann cells. They may arise either in central or peripheral nerves. Approximately 25–45% of all schwannomas are present in the head and neck region. The overall incidence of intra-oral schwanommas is 1% with most common site being tongue followed by buccal mucosa and lastly lip and gingival. Here we present a case report of lower lip schwanomma arising from mental nerve. On physical examination, a smooth globular swelling was present in the lower lip on right side, 2 cm × 3 cm in size and of firm, non-tender in character with regular margins. The patient underwent surgery and the lesion was excised intraorally with sublabial incision. Final pathological diagnosis was made as “schwannoma.” The patient has been following up for 6 months and there is no evidence of any recurrence. High index of suspicion is required and Schwannoma should be considered as a differential diagnosis in oral cavity bening lesions. The final diagnosis is based on histopathology report and immunohistochemical analysis. The treatment of these tumors is complete resection. The prognosis of such cases is extremely good, without any recurrence.

Introduction to the first issue of International Journal of Otorhinolaryngology and Head and Neck Surgery

In the recent times, great developments have taken place in the field of otorhinolaryngology and head and neck surgery. Modern ossicular prosthesis, middle ear implants, cochlear implants and BAHA have given a solution to hearing loss especially sensori-neural hearing loss. The sinus endoscope has gone beyond the confines of paranasal sinuses and has made visualisation of anterior skull base surgery possible. Thus enabling ENT surgeon to operate pituitary tumour and aggressive benign tumours like angiofibroma with intracranial extent. Head and neck surgery is a happening field and I have seen many youngsters wanting to take this field. Transoral laser surgery via microlaryngoscopy and transoral robotic surgery have evolved and day is not so far when robotic surgery will be available at many centers. With advent of recent advanced radiation techniques like IMRT, IGRT and bio-radiation, laryngeal preservation is possible today. In arena of research, molecular markers and personalized medicine, whereby treatment can be tailored according to patient’s genetic makeup, is farfetched dream but I am sure that will be available soon. Research and dissipation of attained knowledge is the keystone for progress and better future. With these goals in mind, I feel elated to release the first issue of our journal “International Journal of Otorhinolaryngology and Head and Neck Surgery”. Our aim is to provide a platform for researchers and clinicians to present their work and help them to share their knowledge across the globe. We also want to encourage the young minds to publish their projects and dissertations. Our journal is an international, indexed and peer reviewed journal. We have resorted to open access policy for the benefits of users and readers. The success of any journal is by contribution of colleagues and experts, so kindly give constant support and feedback to improve it’s quality.

Spontaneous CSF otorrhea in cases of Mondini’s dysplasia: a rare cause of recurrent bacterial meningitis

Inner ear anomaly is rare developmental anomaly with Mondini’s dysplasia being the most common. The perilymphatic fistula cause due to high pressure condition in anomalous inner ear result into CSF otorrhea which become a tract for bacteria to reach central nervous system and cause recurrent meningitis. We are presenting 3 cases of Mondini’s dyaplasia which had CSF leaking into middle ear cleft which was diagnosed with HRCT of temporal bone with cisternography and MRI cisternography and were managed successfully with surgical repair by trans-mastoid approach.