Kishore Chandra Prasad

Osteomyelitis in the head and neck

Conclusion. All bones of the facial skeleton and spine are susceptible to osteomyelitis due to various predisposing conditions. Current radiological tools are sufficient to provide adequate diagnosis. Treatment can be conservative resection of the diseased bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more radical. Objective. In todays antibiotic era, osteomyelitis in the head and neck is a rare occurrence. Dealing with osteomyelitis in head and neck bones is not the same as in other bones of the body due to the nature of the bones, complex anatomy of the region, and esthetics. Our purpose was to analyze the behavior of osteomyelitis in the head and neck bones and its management. Materials and methods. A total of 84 cases of osteomyelitis in head and neck were reviewed in a 10-year period. Pus for culture, antibiotic sensitivity, and radiology were the main investigations. A medical line of treatment was effective in acute cases. Surgery was opted for in chronic cases. Results. Mandible, frontal bone, cervical spine, maxilla, temporal bones, and nasal bones were involved, in descending order of frequency, i.e. the mandible was the most common bone affected. Nine patients were diagnosed as having acute osteomyelitis (11%); 75 were diagnosed as having chronic osteomyelitis (89%). Radiation-induced ORN leading to osteomyelitis was the most common cause of osteomyelitis of the mandible (13 of the 32 cases; 41%). Odontogenic infections and chronic sinusitis each gave rise to osteomyelitis in 3 of 10 cases (30%) of the patients with osteomyelitis of the maxilla. Chronic sinusitis was the main cause of frontal bone osteomyelitis in all 20 cases (100%). Tuberculosis (10 of 15 cases; 67%) and malignancy (5 of 15 cases; 33%) were the main predisposing factors in cervical spine osteomyelitis. Malignant external otitis (MEO) with diabetes mellitus was an underlying factor in all four cases of osteomyelitis of the temporal bone. Of the 18 patients with a diagnosis of ORN, the mandible was found to be the most susceptible bone (13 cases; 72%), followed by the maxilla (four cases; 22%) and cervical spine (1 case). Acute osteomyelitis responded to antibiotics. Sequestrectomy was carried out in all chronic cases but in cases of ORN more radical surgery was performed.

Tuberculosis in the head and neck: experience in India

OBJECTIVE With improvement in economic and social conditions and the use of effective anti-tubercular therapy, the developed nations, and most developing nations, have enjoyed a decline in tuberculosis for several decades. It is now seen that extra-pulmonary presentations form a major proportion of new cases, especially since the advent of the acquired immunodeficiency syndrome epidemic. Therefore, it is important that otolaryngologists are aware of tuberculosis in the head and neck region and its varied manifestations. We report the increased incidence of isolated head and neck tuberculosis, its various presentations and clinical manifestations over a 10-year period. MATERIALS AND METHODS A 10-year (1995-2004), retrospective study was undertaken by the department of otolaryngology and head and neck surgery, Kasturba Medical College, and its allied hospitals, Mangalore, South India, involving a group of 165 patients with head and neck tuberculosis. Each patient underwent a detailed clinical examination and a battery of investigations. Most patients were treated with anti-tubercular therapy alone; others required surgical intervention followed by Anti-tubercular therapy (ATT). In addition, those with human immunodeficiency virus infection or malignancy were treated with anti-retroviral therapy and radiotherapy, respectively. RESULTS Of the 165 cases, 121 (73.3 per cent) had isolated tubercular lymphadenitis, 24 (14.5 per cent) had laryngeal tuberculosis, four (2.4 per cent) had tubercular otitis media, three (1.8 per cent) had tuberculosis of the cervical spine, three (1.8 per cent) had tuberculosis of the parotid, eight (5 per cent) had tuberculosis of the oral cavity, one had tuberculosis of the temporo-mandibular joint and one had tuberculosis of the nose. Fine needle aspiration cytology was highly effective in the diagnosis of tubercular lymphadenitis (92 per cent) but not so for other sites. The purified protein derivative (PPD) test was positive in only 20 per cent of cases. Pus for culture and sensitivity was positive only in caries of the spine and mandibular tuberculosis. Excision biopsy and histopathological examination were required to make a diagnosis in tuberculosis of the oral and nasal cavities, salivary glands, ear, temporo-mandibular joint, and mandible. There were 40 cases (24.2 per cent) with coexisting pulmonary tuberculosis and five cases (3 per cent) with coexisting malignancy. Of the 65 patients who were tested, 30 per cent were found to have coexisting human immunodeficiency virus infection. CONCLUSION In addition to cervical lymphadenitis, tuberculosis in the head and neck region can produce isolated disease in the oral cavity, ear, salivary glands, temporo-mandibular joint, nose and larynx. Seventy-five per cent of our head and neck tuberculosis patients did not have pulmonary involvement. Fine needle aspiration cytology was highly effective in the diagnosis of nodal tuberculosis, but histopathological examination was required to make the diagnosis in other head and neck sites. The PPD test was not effective as a diagnostic tool. If the otolaryngologist maintains a high index of suspicion, an early diagnosis can be made with the help of simple investigations. Successful outcome depends upon appropriate chemotherapy and timely surgical intervention when necessary.

Assessment of eustachian tube function in tympanoplasty

Objective: A clinically useful test for eustachian tube function (ETF) is still lacking. Here we plan to evaluate the mucociliary function of the ET by saccharin and methylene blue test, and compare the outcome of surgery with normal and abnormal ET functions. Study Design: Case series with planned data collection. Setting: Department of Otolaryngology–Head and Neck Surgery, Kasturba Medical College, Mangalore (Manipal University), a tertiary care center in South India. Subjects and Methods: This study comprised 86 patients diagnosed with mucosal chronic otitis media in quiescent/inactive stage. All were subjected to a detailed clinical examination and investigations. Preoperative evaluation of ETF was compared with postoperative outcome of surgery, and the results were analyzed. Results: The saccharin test and methylene blue dye test had a good correlation in evaluating ETF. The mean value for saccharin perception time and the clearance time for methylene blue were 17.5 and 8.1 minutes, respectively. ETF was best in anterior, worst among posterior, and intermediate in subtotal perforations. Type 1 tympanoplasty was successful in 94 percent with normal ETF and in 68 percent with partial dysfunction. Conclusion: The saccharin test is a simple, cost-effective, and valuable diagnostic tool to assess the mucociliary function of the ET. The outcome of middle ear surgery would be a success in normal ETF, whereas in partial dysfunction the outcome need not necessarily be a failure.

Teratocarcinosarcoma of the nose, paranasal sinuses and nasopharynx

Teratomas affecting the head and neck are rare tumours of ambiguous origin. The benign form is seen in children and mostly affects the nasopharynx. Malignant tumours in the upper jaw have been reported rarely. They are almost exclusively seen in the adult male. They are highly aggressive tumours that are difficult to diagnose pre-operatively due to the varied histological patterns. Treatment options available are surgery, radiotherapy or a combination of both. Despite intensive treatment, the prognosis is still poor. A rare case of teratocarcinosarcoma of the nose, paranasal sinuses and nasopharynx in a 25-year-old male is presented. The tumour had a non-germ cell tumour origin. The clinical features, pathologic characteristics and treatment are detailed. It was managed by surgery, radiotherapy and chemotherapy.

Early Oral Feeds in Laryngectomized Patients

Objectives: It is a common practice to start oral feeding after 7 to 10 days in patients who have undergone laryngeal surgeries. It was our observation that when oral feeds were initiated earlier than this period, there was no increase in the incidence of pharyngocutaneous fistulas. This prospective study is about our experience in initiating early oral feeds in the postoperative period (on the 2nd day) in laryngectomized patients. Methods: Seventy-eight patients underwent laryngectomy with or without partial pharyngectomy over a period of 38 months between October 2001 and December 2004. The oral feeds were initiated on the 2nd postoperative day in 40 patients. Thirty-eight patients served as controls in whom feeds were initiated after the 10th postoperative day. Results: Only 1 patient in the study group and 2 patients in the control group developed pharyngocutaneous fistulas. Most patients in the control group wished to avoid nasogastric intubation in the recovery period because of discomfort, gastric symptoms, and the need to taste food. Conclusions: With this study we can assume that in a select group of patients, it is possible to initiate oral feeding much earlier in the postoperative period than was formerly thought.

Branchial anomalies: diagnosis and management.

Objective. To find out the incidence of involvement of individual arches, anatomical types of lesions, the age and sex incidence, the site and side of predilection, the common clinical features, the common investigations, treatment, and complications of the different anomalies. Setting. Academic Department of Otolaryngology, Head and Neck Surgery. Design. A 10 year retrospective study. Participants. 30 patients with clinically proven branchial anomalies including patients with bilateral disease totaling 34 lesions. Main Outcome Measures. The demographical data, clinical features, type of branchial anomalies, and the management details were recorded and analyzed. Results and Observations. The mean age of presentation was 18.67 years. Male to female sex ratio was 1.27 : 1 with a male preponderance. Of the 34 lesions, maximum incidence was of second arch anomalies (50%) followed by first arch. We had two cases each of third and fourth arch anomalies. Only 1 (3.3%) patients of the 30 presented with lesion at birth. The most common pathological type of lesions was fistula (58.82%) followed by cyst. 41.18% of the lesions occurred on the right side. All the patients underwent surgical excision. None of our patients had involvement of facial nerve in first branchial anomaly. All patients had tracts going superficial to the facial nerve. Conclusion. Confirming the extent of the tract is mandatory before any surgery as these lesions pass in relation to some of the most vital structures of the neck. Surgery should always be the treatment option. injection of dye, microscopic removal and inclusion of surrounding tissue while excising the tract leads to a decreased incidence of recurrence.

Osteomyelitis of the temporal bone: terminology, diagnosis, and management.

Objectives To review the terminology, clinical features, and management of temporal bone osteomyelitis. Design and Setting Prospective study in a tertiary care center from 2001 to 2008. Participants Twenty patients visiting the outpatient department diagnosed with osteomyelitis of the temporal bone. Main Outcome Measures The age, sex, clinical features, cultured organisms, surgical interventions, and classification were analyzed. Results Of the 20 cases, 2 (10%) were diagnosed as acute otitis media. Eighteen (90%) had chronic otitis media. Nineteen (95%) were classified as medial temporal bone osteomyelitis and one (5%) as lateral temporal osteomyelitis. The most common clinical features were ear discharge (100%), pain (83%), and granulations (100%). Facial nerve palsy was seen in seven cases (35%) and parotid involvement in one case. Ten patients (56%) had diabetes mellitus. The organisms isolated were Pseudomonas aeruginosa (80%) and Staphylococcus aureus (13.33%). Histopathology revealed chronic inflammation in 20 patients (100%) and osteomyelitic bony changes in 14 (70%). Surgical debridement was the most preferred modality of treatment (87%). Conclusion A new classification of temporal bone osteomyelitis has been proposed. Bacterial cultures must be performed in all patients. Antibiotic therapy is the treatment of choice. Surgical intervention is necessary in the presence of severe pain, complications, refractory cases, or the presence of bony sequestra on radiology.

Paragangliomas of the Head & Neck: the KMC experience

To determine the clinical features, investigations, intra-operative findings, surgical approaches used and the results of the treatment for paragangliomas of the head and neck. Retrospective study of 14 cases of paragangliomas in head and neck seen over a period of 10 years including five carotid body tumors, seven glomus jugulares and two glomus tympanicums. HRCT scans and bilateral carotid angiography were done in all cases of glomus jugulare. Pre-operative embolization was done in most cases. The trans-cervical approach was used for all cases of carotid body. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare tumors. Postaural tympanotomy approach was used for both patients with glomus tympanicum. In one case of extratympanic glomus jugulare tumor with hypoglossal palsy, a neck exploration was done to isolate and excise the tumor. Five patients with carotid body tumors presented as unilateral, painless, pulsatile swelling in the upper neck. Intra-operatively, three of the tumors were classified into Shamlin’s Grade II and one each into Grade III and Grade I. A carotid blow-out occurred in one of the patients with Grade II disease, which was managed. ECA resection had to be done in one case. Seven patients were diagnosed to have glomus jugulare and two with glomus tympanicum. Six glomus jugulare tumors presented with hearing loss, ear discharge and obvious swelling. Glomus tympanicums presented with hearing loss but no bleeding from the ear. On examination, tumors presented with an aural polyp with no VII nerve deficits. Both tympanicums were classified as Fisch Type A, three of the jugulares classified as Type B, two as Type D2 and one as Type D1. Tumors were found to be supplied predominantly by the ascending pharyngeal artery. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare. The transcanal approach was used for both patients with glomus tympanicum. Paragangliomas are uncommon tumors that need accurate diagnosis and skilled operative techniques. Though the surgical approaches may appear complicated, the removal provides good cure rates with minimal morbidity and recurrence. Lateral skull base approaches should be the armamentarium of every head and neck surgeon.

Primary Otomycosis in the Indian Subcontinent: Predisposing Factors, Microbiology, and Classification

Objective. To define otomycosis and determine the predisposing factors and microbiology in primary otomycosis. Study Design. Prospective study of two years and review of the literature. Setting. Academic Department of Otolaryngology in a coastal city in India. Patients. 150 immunocompetent individuals of whom 100 consecutive patients with a clinical diagnosis of otomycosis are considered as the study group and 50 consecutive patients with no otomycosis are considered as the control group. Results and Observations. Instillation of coconut oil (42%), use of topical antibiotic eardrops (20%), and compulsive cleaning of external ear with hard objects (32%) appeared to be the main predisposing factors in otomycosis. Aspergilli were the most common isolates (80%) followed by Penicillium (8%), Candida albicans (4%), Rhizopus (1%), and Chrysosporium (1%), the last being reported for the first time in otomycosis. Among aspergilli, A. niger complex (38%) was the most common followed by A. fumigatus complex (27%) and A. flavus complex (15%). Bacterial isolates associated with fungi in otomycosis were S. aureus, P. aeruginosa, and Proteus spp. In 42% of healthy external ears fungi were isolated. Conclusion. Aspergillus spp. were the most common fungi isolated, followed by Penicillium. Otomycotic ears are often associated with bacterial isolates when compared to normal ears. Fungi are also present in a significant number of healthy external auditory canals and their profiles match those in cases of otomycosis. The use of terms “primary” and “secondary” otomycosis is important to standardize reporting.

Laryngoceles - presentations and management

IntroductionLaryngoceles usually present as cervical masses with or without hoarseness of voice. They are mostly unilateral and may be symptomatic or asymptomatic. They are classified as internal, external or combined. They have been described to be an occupational hazard among wind instrument players or glass blowers. They also occur in association with neoplasms of the larynx.Materials and methodsHere we report five patients with laryngoceles of whom two had bilateral laryngoceles, which are very rare. One patient had associated laryngeal malignancy for which total laryngectomy was performed. Two cases underwent excision via cervical approach. The rest were managed conservatively.ConclusionSymptomatic cases have to be managed surgically while asymptomatic ones may be managed conservatively.