Rajan Syal

Cerebrospinal fluid otorhinorrhoea due to inner-ear malformations: clinical presentation and new perspectives in management.

OBJECTIVE In children cerebrospinal fluid (CSF) otorhinorrhoea can be due to congenital inner-ear malformations. Cochlear dysplasia associated with a defect in the stapes footplate is usually the cause of the CSF leak. Repair of the CSF leak in these cases is usually done by packing the vestibule with muscle or fascia. This traditional method of repair has a 30 to 60 per cent failure rate. MATERIAL AND METHODS CSF otorhinorrhoea due to congenital inner-ear anomalies in four patients was repaired using multiple-layer packing of the vestibule with glue, muscle and fascia, reinforced by a pedicle temporalis muscle graft. Intra-operatively, continous lumbar drainage was performed. RESULTS Repair of the CSF leak was successful in four cases and no recurrence was noticed. Inner-ear magnetic resonance imaging (MRI) using three-dimensional fast-spin echo (3D FSE) T2-weighted imaging (T2WI) and 3D steady-state free precession (FIESTA) sequences was found to be a very helpful, noninvasive investigation to localize the site and route of the CSF leak. CONCLUSIONS Children presenting with recurrent meningitis and CSF rhinorrhoea should be investigated for congenital inner-ear anomalies. In these cases CSF fistulae should be repaired using fibrin or cyanoacrylate glue and intra-operative continuous lumbar drainage; 3D FSE T2WI and 3D FIESTA MRI sequences of the inner ear are helpful.

Multiple intraosseous hemangiomas—investigation and role of N‐butylcyanoacrylate in management

Primary intraosseous hemangiomas are rare (0.7% of all osseous neoplasms), benign, slow‐growing neoplasms. These lesions are usually solitary. We are reporting a case of multicentric intraosseous hemangiomas. Investigation, treatment options, and role of N‐butylcyanoacrylate (NBCA) in management will be discussed.

Recurrent and residual juvenile angiofibromas.

INTRODUCTION In the surgical management of juvenile nasopharyngeal angiofibromas the possibility of recurrences and residual tumours is always there. This study was undertaken to predict the prognostic factors determining recurrence of juvenile nasopharyngeal angiofibroma and to find out the usual sites of these tumours. MATERIAL AND METHODS The medical records of 95 patients with histologically proven juvenile nasopharyngeal angiofibroma were reviewed retrospectively. The commonest surgical approach used was a combined transpalatal and transmaxillary approach with a lazy S incision. A conservative lateral infratemporal approach was used in three cases. RESULTS Complete removal of the juvenile nasopharyngeal angiofibroma was achieved in 78 (82 per cent) of the cases in a single operation. A residual tumour was found in 17 (18 per cent) cases and recurrences occurred in 13 (13.7 per cent) cases. CONCLUSIONS Extensions into the pterygoid fossa and basisphenoid, erosion of the clivus, intracranial extensions medial to the cavernous sinus, invasion of the sphenoid diploe through a widened pterygoid canal, feeders from the internal carotid artery, a young age and a residual tumour were risk factors found associated with recurrence of juvenile nasopharyngeal angiofibroma.

Bilateral Ramsay Hunt syndrome in a diabetic patient

BackgroundHerpes zoster oticus accounts for about 10% cases of facial palsy, which is usually unilateral and complete and full recovery occurs in only about 20% of untreated patients. Bilateral herpes zoster oticus can sometime occur in immunocompromised patients, though incidence is very rare.Case presentationDiabetic male, 57 year old presented to us with bilateral facial palsy due to herpes zoster oticus. Patient was having bilateral mild to moderate sensorineural hearing loss. Patient was treated with appropriate metabolic control, anti-inflammatory drugs and intravenous acyclovir. Due to uncontrolled diabetes, glucocorticoids were not used in this patient. Significant improvement in hearing status and facial nerve functions were seen in this patient.ConclusionsHerpes zoster causes severe infections in diabetic patients and can be a cause of bilateral facial palsy and bilateral Ramsay Hunt syndrome. Herpes zoster in diabetic patients should be treated with appropriate metabolic control, NSAIDS and intravenous acyclovir, which we feel should be started at the earliest. Glucocorticoids should be avoided in diabetic patients.

Unusual Clinical and MRI Features of a Cerebellopontine Angle Medulloepithelioma

We describe for the first time an unusual location and clinical presentation of medulloepithelioma, a rare embryonal tumor. A 5-year-old child presented with sudden onset of bilateral hearing loss. On imaging, the lesion appeared to be extra axial and was located in the right cerebello-pontine (CP) angle, extending into middle fossa along the trigeminal ganglion and in front of the brain stem into the opposite CP angle. It did not show any enhancement following contrast administration and had restricted diffusion on diffusion-weighted imaging, simulating an epidermoid. However, in vivo localized proton MR spectroscopy revealed a creatine peak dominated by a large choline resonance, peak of glycine with lactate/lipid and invisible N-acetylaspartate suggestive of a neoplastic lesion and not an epidermoid. Only subtotal resection could be performed and the patient had a stormy post-operative course due to extensive dissemination of the disease.

Emergency cardiopulmonary bypass for impassable airway.

INTRODUCTION Some medical emergencies need compromised airway management as the first measure. Most of these cases are first seen by an ENT surgeon, whose proper evaluation and timely intervention can prove decisive. Knowledge of alternatives for airway management can prove life-saving, although these may require the active involvement of other specialities. CASE REPORTS Two patients, a 27-year-old man and a 31-year-old woman, presented in respiratory distress with cyanosis. Each had a pedunculated mass in the lower trachea above the carina, with about 90 per cent tracheal lumen obstruction. They were managed successfully with femorofemoral cardiopulmonary bypass and restoration of airway. CONCLUSION Femorofemoral cardiopulmonary bypass can be a relatively safe option which gains time for airway management in such conditions. Knowledge of this procedure among ENT surgeons can lead to timely intervention, in properly selected cases, which can save valuable time.

Otogenic brain abscess : management by otologist

INTRODUCTION Fifty per cent of brain abscesses in adults and 25 per cent of those in children are otogenic in origin. The current neurosurgical options are to drain the abscess repeatedly through burr holes or to excise it completely with the capsule. We successfully managed 10 cases of brain abscess by draining through the transmastoid route. The technique and its advantages are discussed. MATERIAL AND METHODS The patients underwent surgery at two different institutions. Computed tomography scanning and magnetic resonance imaging were performed, along with diffusion-weighted imaging and in vivo proton magnetic resonance spectroscopy. The abscesses were drained via a transmastoid route. RESULTS In eight cases, ear disease and brain abscess were treated in a single-stage procedure. In the remaining two cases, residual brain abscess was excised subsequently by our neurosurgical colleagues. CONCLUSIONS Transmastoid drainage of pus can successfully treat mastoid disease and brain abscess in a single surgical intervention. Residual abscess can be subsequently excised, with relatively reduced morbidity. Repeated needling is also avoided with this approach. Diffusion-weighted imaging and proton magnetic resonance spectroscopy are helpful.

Primary aneurysmal bone cyst of coronoid process

BackgroundAneurysmal bone cysts are relatively uncommon in the facial skeleton. These usually affect the mandible but origin from the coronoid process is even rarer. To the best of our knowledge, this is the first reported case of a coronoid process aneurysmal bone cyst presenting as temporal fossa swelling.Case presentationA 17 year old boy presented with a progressively increasing swelling in the left temporal region developed over the previous 8 months. An expansile lytic cystic lesion originating from the coronoid process of the left mandible and extending into the infratemporal and temporal fossa regions was found on CT scan. It was removed by a superior approach to the infratemporal fossa.ConclusionAneurysmal bone cyst of the coronoid process can attain enormous dimensions until the temporal region is also involved. A superior approach to the infratemporal fossa is a reasonable approach for such cases, providing wide exposure and access to all parts of the lesion and ensuring better control and complete excision.

Management of difficult airway in intratracheal tumor surgery

BackgroundTracheal malignancies are usual victim of delay in diagnosis by virtue of their symptoms resembling asthma. Sometimes delayed diagnosis may lead to almost total airway obstruction. For difficult airways, not leaving any possibility of manipulation into neck region or endoscopic intervention, femorofemoral cardiopulmonary bypass can be a promising approach.Case PresentationWe are presenting a case of tracheal adenoid cystic carcinoma (cylindroma) occupying about 90% of the tracheal lumen. It was successfully managed by surgical excision of mass by sternotomy and tracheotomy under femorofemoral cardiopulmonary bypass (CPB).ConclusionAny patient with recurrent respiratory symptoms should be evaluated by radiological and endoscopic means earlier to avoid delay in diagnosis of such conditions. Femorofemoral cardiopulmonary bypass is a relatively safe way of managing certain airway obstructions.

Apophysomyces elegans causing acute otogenic cervicofacial zygomycosis involving salivary glands

Zygomycosis is an invasive, life threatening fungal infection that usually affects immunocompromised hosts. In the head and neck region, rhino-orbito-cerebral zygomycosis is more common than the cervicofacial variety. We report the first case of otogenic cervicofacial zygomycosis caused by Apophysomyces elegans involving the salivary glands, an uncommon site of infection. The case began after a trivial trauma in a diabetic patient and despite surgical debridement and liposomal amphotericin B therapy, the patient died due to extensive involvement and metabolic/hemodynamic complications.