Mohammad Adeel

Post-traumatic pseudoaneurysm of internal carotid artery: a cause of intractable epistaxis

In this case report, the authors are presenting a case of a 35-year-old lady who presented to our clinic with recurrent episodes of massive epistaxis and loss of right eye vision for last 6 months following road traffic accident. There was no other significant medical and surgical history. Bleeding episodes were sometimes very severe with loss up to 400–500 cc and would stop spontaneously. She was given multiple blood transfusions after these episodes. A complete otorhinolaryngological examination including rigid endoscopy and coagulation investigation did not reveal any abnormality. CT with contrast of paranasal region showed blood within the right sphenoid sinus with linear fracture of the lateral wall with post-traumatic cavernous pseudoaneurysm of internal carotid artery localised to right sphenoid sinus. That was managed successfully by embolisation using a detachable balloon and a coil. She was followed up in the clinic at 6 weeks and 6 months interval with no symptoms.

A case of otogenic tetanus.

The authors are presenting our experience of managing an interesting case of a 12-year-old girl who presented to our clinic with otorrhea for 3 months and trismus for 1 week. Examination showed bilateral ear discharge with central perforations in tympanic membranes, palatal paralysis and trismus. Systemic examination revealed only mild stiffness of hand muscles. CT-scan head and neck was done to look for intracranial complications of otitis media. However; it revealed only decreased pneumatisation of mastoid cells. She was admitted in the hospital and started on intravenous and local antibiotics after sending ear swab and blood cultures. But she showed no improvement in 48 h. So on the clinical suspicion (trismus and stiffness of hands) remote possibility of otogenic tetanus was considered and she was given tetanus toxoid and immunoglobulins. She gradually showed improvement in her symptoms. Thereafter, culture from ear discharge was also reported positive for Clostridium tetani.

Deep neck space infections; retrospective review of 46 patients

Aims: To study clinical presentation, management, and outcome of deep neck space infections (DNSI). Settings and Design: A retrospective case series was conducted in the Section of Otolaryngology of a tertiary care University Hospital from 2001 to 2011. Materials and Methods: A retrospective review of charts of the patients who were treated for deep neck space (DNSI) at our department from 2001 to 2011 was carried out. Forty-six patients fulfilled our inclusion criterion and were included in the study. A structured Performa was used for data collection and the following variables were recorded including demographics (age and gender), co-morbidities (diabetes mellitus, HIV), symptoms, etiology, infection site, bacteriology, culture growth imaging modality used, surgical intervention, and hospital stay. Results: The mean age of our patients was 30.8 years; 32 were male and 14 were female. Neck pain was the most common symptom found in 38 patients (82.60%) and most common space involved was parapharyngeal space which was seen in 20 patients (43.47%). Etiology of DNSI in majority of our patients, i.e., 18 (39%) was unknown followed by dental and tonsil problems in 12 (26%) and 10 (22%) patients, respectively. Of 46 patients, 36 underwent intervention and of these 26 cases had positive culture results. The most common organism cultured was Streptococcus seen in 8 patients (22.2%). Ten patients (21.73%) were treated medically alone. Mean hospital stay was 3.33 days with a minimum of 2 days and a maximum of 17 days stay. There was no mortality in our series of patients. Conclusions: The deep neck space infection is still a challenging disease in otolaryngology. Its presentation may be masked and bacterial culture might not be conclusive but it still needs early diagnosis and prompt management whether conservative or surgical. CT scan is a standard modality for differentiating between cellulitis and abscess. Most of the patients need surgical intervention and tracheostomy should be considered if air way protection is needed.

Malignant otitis externa: Cranial nerve palsies, skull-base erosions and prognosis

Introduction: Malignant otitis externa (MOE) is an infection of the temporal bone usually affecting elderly diabetic patients, which can potentially be life threatening. The causative organism is most commonly Pseudomonas aeruginosa. Objective: Objective of the study was to review our experience of managing patients with MOE. The second objective was to compare the outcome of patients with and without cranial nerve paralysis and bony erosions evident on computed tomography (CT ) scan. Materials and Methods: Our departmental database was searched for all patients hospitalized with the diagnosis of MOE between January 2000 and December 2009. A total of 21 patients were included in the study based on our inclusion criteria. Variables studied were: Clinical features including edema and granulations in external auditory canal (EAC), presence of otalgia, exudate, bony erosions of EAC, mastoid or petrous apex on CT scan and diabetes mellitus or other immunocompromised state. Outcome was assessed in terms of mortality and cure. Fisher′s exact test was applied to find out effect of nerve palsies and bony erosions on outcome. Result and Conclusion: MOE is an aggressive and life-threatening infection. The mortality rate was found to be 14.3%. Analysis of findings revealed no statistically significant effect of temporal bone erosions and neuropathies on outcome.

Clinicopathological Behavior and Oncological Outcomes of Malignant Parotid Tumors in a Pakistani Population

Introduction The incidence of salivary gland tumors is influenced by geographical and racial factors resulting in diverse histology. While salivary gland tumors account for a low proportion of head and neck cancers, most malignant tumors of the salivary gland are located in the parotid gland. The goals of this study are to describe the clinicopathological behavior of malignant parotid tumors and explore oncological outcomes related to survival in our Pakistani tertiary care cancer hospital. Methods We conducted a retrospective analysis of 209 patients diagnosed with malignant parotid tumors from 2004 to 2016. Data such as demographics, age, gender, histology, grade, clinical and pathological stage, surgical treatment types and adjuvant modalities used were analyzed using SPSS software version 20. We used Kaplan Meier curves to analyze survival data. Results The median patient age at diagnosis was 40 years, and the ratio of men to women was 1.2:1. Mucoepidermoid carcinoma was the most common histological variant (with a 50% incidence rate) followed by adenoid cystic carcinoma (13%), and adenocarcinoma (10%). Histology has further categorized these malignant tumors into low (34%), intermediate (28%), and high (21% ) grades. The American Joint Committee on Cancer, seventh edition, clinical staging was Stage I (21%), II (28%), III (15%), and IV (34%). The 5-year survival was 68%, and the 10-year survival was 45%. Conclusion Mucoepidermoid carcinoma is the most common malignant parotid histology in our patient population. Advanced age, increased T stage (size > 4 cm), high-grade histology, and cervical nodal involvement decrease overall survival. Open biopsies, piecemeal excisions, and delayed presentation for radiotherapy post-surgery may also have role in adverse outcomes in these malignancies.

An Overview of Laryngeal Cancer Treatment at a Tertiary Care Oncological Center in a Developing Country

Introduction Development of laryngeal cancer is multifactorial, and management is surrounded with controversies. Recent reports suggest a decline in the survival of these patients. We conducted a study to analyze the clinicopathological parameters and compute the outcomes in terms of survival in patients with laryngeal cancer treated at our institution. Methods Electronic charts of 515 patients with Laryngeal cancer treated at our Hospital and Research Center from 2004 to 2014 were retrospectively reviewed. Results Median age was 62 years. Male: female ratio 91%: 9%. Sixty-two percent were smokers. Histologically, all were squamous cell carcinoma. Most common subsite was glottis (88%). Treatment was non-surgical in 92% and surgical in 8%. The five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional control (LRC) were 67%, 74%, 59% and 70%, respectively. OS, DSS, DFS and LRC for early stage (I-II) and advance stage (III-IV) were 81 and 54%, 86 and 63%, 75 and 45%, and 83 and 57%, respectively. Twenty-two percent recurred locally. Of these failures, 19% were inoperable, 36% were surgically salvaged and 34% refused laryngectomy. Conclusions Our survival rates are comparable with published data. The high refusal rate for salvage total laryngectomy is concerning and needs further study to evaluate the reasons.

Ameloblastoma: Management and Outcome

Introduction Ameloblastoma is a locally destructive tumor with a propensity for recurrence if not entirely excised. Management of ameloblastoma poses a challenge for all involved in the field of head and neck surgery because successful treatment requires not only adequate resection but also a functional and aesthetically acceptable reconstruction of the residual defect. Methods Patients who had histologically proven ameloblastoma between 1991 and 2009 were identified from the database of Aga Khan University Hospital. A review of all medical records, radiological images, operative reports and pathology reports was undertaken. Results A total of 15 patients with histologically confirmed ameloblastoma were identified. Out of 15 patients nine were males and six were females with age range from 20 to 60 years (mean age 43 years). The most common symptom found in our patient group was painless facial swelling. In 13 patients the origin of tumor was mandible and in the remaining two the tumor originated from maxilla. Eleven out of 15 patients underwent segmental mandibulectomy, two had maxillectomy and two had enucleation. All patients who underwent segmental mandibulectomy required reconstruction. Reconstruction was done with microsurgical free tissue transfer in eight patients, non-vascularized iliac crest bone graft was used in one patient and two had plating only. All free flaps survived with no evidence of flap loss. The mean follow-up was eight years. There was no evidence of graft failure which was used in one patient. Complication was seen in only one of our patients in the form of plate exposure. Recurrence was seen in two of our cases who primarily underwent enucleation. All patients had satisfactory speech, cosmesis and mastication. Conclusion The management of ameloblastoma still poses a big challenge in spite of being the most common odontogenic tumor. In our study we have found that segmental mandibulectomy with disease-free margin of around 1 cm and immediate reconstruction with free tissue transfer have shown good results.

Clinicopathological Behavior and Treatment-related Outcome of Rare Salivary Duct Carcinoma: The Shaukat Khanum Memorial Cancer Hospital Experience

Background Salivary gland tumors are rare salivary gland malignancies with resemblance to ductal breast carcinoma. We have described clinicopathological behavior and treatment outcomes of this rare malignancy. Methods Salivary duct carcinoma patients treated from 2010 to 2015 were retrospectively analyzed for clinicopathological characteristics and treatment-related outcomes of the disease. Results A total of 12 patients with salivary duct carcinoma were included in the study. All were males with mean age of 52.58 ± 13.43. Parotid gland was the most commonly involved major salivary gland while buccal mucosa and anterior tongue were most common oral cavity sub-sites involving minor salivary glands. The disease-free survival was 75% at 10 months and 25% at 20 months. The mean follow-up time was 12 months. There were three local recurrences and one distant metastasis. Conclusion Salivary duct carcinoma is a locally aggressive tumor with tendency for local recurrence and distant metastasis. Adverse features such as perineural invasion, extra-capsular spread and advanced nodal disease may worsen prognosis.