Rakesh Datta

Primary cavernous hemangioma of thyroid gland

We report a case of cavernous hemangioma presenting as a case of solitary nodule of thyroid.A 25-year-old male presented with a slowly growing solitary swelling in front of neck of 16 years duration. There was no history of pain over the swelling, change in voice or dyspnea. On clinical examination, a 6 × 4 cm irregular, hard, freely mobile swelling could be felt in the thyroid region. Ultrasonography (USG) showed a single hypoechogenic mass in the left lobe of the thyroid with coarse calcifications. X-ray of neck also showed coarse calcifications [Figure 1]. Computed tomography (CT) scan showed a heterogeneously enhancing mass of 4.9 × 4.4 cm diameter in the left lobe of the thyroid deviating the trachea to the right. Multiple dense calcific densities were noted in the nodule [Figure 2]. Fine needle aspiration cytology (FNAC) of the mass was attempted twice but was inconclusive and only blood could be aspirated. The patient was euthyroid and showed no signs of local spread or lymphadenopathy. Surgery in the form of left hemithyroidectomy was done. Peroperatively, tumor mass was found to be hard in consistency and well encapsulated. Gross pathology showed a well-circumscribed nodule with hemorrhagic and calcified areas. On histopathology, nodule was divided into multiple lobules with areas of hemorrhage, fibrosis, hyalinization and calcifications. Some of these calcifications were located in dilated vessels and classical cavernous vascular spaces could be seen [Figure 3]. A diagnosis of primary intrathyroid cavernous hemangioma was made.Lesions similar to hemangiomas secondary to FNAC have been reported. These have been ascribed to vascular proliferation in organized hematoma following the FNAC leading to a histological resemblance to cavernous hemangioma.

24-hour dual-probe ambulatory pH-metry findings in cases of laryngopharyngeal reflux disease

Background: Laryngopharyngeal reflux disease (LPRD) cases are common in clinical practice and usually neglected for want of a definitive diagnosis. Diagnosis requires a documented evidence of fall in pH levels in the laryngopharynx with dual-probe 24-hour ambulatory pH-metry. Aim: To study pH-metry findings in laryngopharyngeal reflux cases. Settings and Design: Study was done in a tertiary teaching hospital. Material and Methods: A total of 30 normal volunteers (Group A) and 65 patients (Group B) with complaints of hoarseness of voice for more than six weeks in the age group of 20 to 40 years were studied. A thorough ENT examination including fiberoptic laryngoscopy (FOL) was done on all cases. Group B was further divided into two subgroups. Subgroup B1 (n = 32) consisted of FOL positive and subgroup B2 (n = 33) comprised of FOL negative patients by reflux finding score. 24-hour ambulatory pH-metry was done for both groups. Results: Group A had no abnormal reflux patterns. In Subgroup B1, all 32 patients showed at least single laryngopharyngeal reflux episode over the 24-hour period. The most common pattern was 2 to 5 episodes occurring in 16/32 cases. Of the 32, five (15.6%) also had abnormal De Meesters score (gastroesophageal reflux disease [GERD] positive). In subgroup B2, 2 of 33 patients showed a typical LPR on 24-hour ambulatory pH-metry, despite showing LPRD negativity on FOL. None had an abnormal De Meesters score. Conclusion: LPRD may not coexist with GERD. Two to five reflux episodes pattern were found to be more common in LPR patients. Dual-sensor pH-metry is confirmatory for establishing diagnosis of LPRD.

Herpes simplex laryngitis following primary genital herpes

Primary genital herpes is associated with involvement of extragenital sites like thighs, buttocks, fingers and pharynx. This involvement occurs due to autoinoculation, orogenital exposure from the source and also seeding due to viremia in the initial period. Involvement of larynx in a case of primary genital herpes is extremely rare prompting us to report this case.

Contact Endoscopy - A promising tool for evaluation of laryngeal mucosal lesions

Early diagnosis of laryngeal cancer is important for favourable treatment outcome. Due to morbidity and difficulties associated with surgical biopsy, a need has always been felt for an easy, non invasive yet accurate tool for knowing histopathological nature of mucosal lesions. Contact Endoscopy (CE) is one such technique which is capable of providing real time and magnified images of cellular structure of superficial layers of various mucosal surfaces with obvious advantages and potential for wide clinical application. In this review, a summary of role and efficacy of CE in diagnosis, treatment and follow up of various laryngeal mucosal lesions is presented. We searched Pubmed, Medline, Cochrane and Google scholar for articles on CE for mucosal lesions of larynx. For better understanding of the technique, articles on CE of other non-laryngeal sites of head and neck were also reviewed. Article selection was limited to human studies without restriction to language and year of publication. Reference lists from identified articles were also searched. Six prospective original articles, three descriptive studies and one review article on CE of laryngeal lesions are included in this review and their findings summarized. Common findings on examination of cellular architecture and vascular patterns described by various authors are also tabulated. The literature revealed high sensitivity (90-94.7%), specificity (81-100%) and accuracy (88-94%) of CE in diagnosis of laryngeal lesions across the published studies. CE is a promising non invasive tool for evaluation of laryngeal mucosal lesions. However, further prospective, randomized, double blinded studies as well as research to improve the technique to overcome the existing limitations are required before defining its precise role in clinical practice.

Laryngopharyngeal Reflux : Larynx on Fire.

Laryngopharyngeal Reflux (LPR) is a commonly occurring and recently described clinical entity due to the retrograde flow of gastric contents into the pharynx. It accounts for many symptoms of upper airway including hoarseness, chronic throat irritation and globus sensation. The sensitive laryngeal mucosa is prone to damage by the combination of acid and pepsin. The inflammatory changes that follow are presumed to cause the symptoms and predispose the individual to laryngeal disorders. Diagnosis can usually be made clinically based on symptoms and laryngeal signs but a 24 hour pH metry is essential to establish diagnosis. Treatment centres on lifestyle modifications, vocal hygiene measures and long term use of proton pump inhibitors. Recent research in this field may lead to a better understanding of the pathophysiology of the disease and change the way LPR is managed.

Management of the node negative early carcinoma tongue

ObjectiveTo determine the role of thickness of the primary lesion in early Squamous Cell Carcinoma (SCC) of the oral tongue for decision-making regarding the management of possible occult cervical node metastases.SettingTertiary referral centrePatientsPatients who were treated by the authors for early (T1, T2) primary lesions in the oral tongue in two malignancy treatment centres of the Armed Forces Medical Services were included in this prospective study. Where the primary lesion was less than 04 mm in depth, the neck was not addressed electively. Those who developed nodal disease in the neck on follow up were subjected to comprehensive neck dissection. In those patients where the tumour thickness was more than 04 mm, the neck was addressed with at least a supra-omohyoid neck dissection. Postoperative radiotherapy was given as per standard indications. The patients were followed up as per standard protocol.ResultsDisease free survival rate achieved was 86% and this compares well with survival rates achieved by other workers.ConclusionTreatment of neck nodes in early (T1,T2) SCC of the oral tongue can be expectant in cases where tumour thickness is less than 04 mm, but where it is more than 04 mm elective treatment of the neck is recommended.

Leadership challenges in multinational medical peacekeeping operations: Lessons from UNIFIL Hospital

Commanding a military multinational and multilingual healthcare facility can be a formidable task with very little margin for error. The authors were in leadership positions of UNIFIL Hospital, unique in its diversity of both staff and clientele. Experience about the challenges faced and methods adopted to overcome them will be shared. Troops from diverse backgrounds differ in their competency, and also in their attitudinal approach to situations. It is imperative for the medical commanders to identify these differences, and work towards harnessing individual strengths to form a cohesive unit. Frequent rotation of team members and thereby difficulty in adapting to new environment makes the tasks more challenging. Challenges can be broadly categorized in those dealing with functional roles (providing medical support) and command and control issues. Linguistic challenges especially in situations where professionals have to work as a coordinated unit remains a major challenge. The threat of medical errors arising out of misunderstandings is very real. Gender sensitization is essential to avoid potential unpleasant situations. Interpersonal conflict can easily go out of hand. The leadership has to be more direct and deliberate relying less on hierarchy and more on direct communication. A strict enforcement of UN standards for equipment and competence, frequent joint medical drills help to overcome interoperability issues and develop mutual confidence. Leadership in multinational UN hospitals is a demanding task with its peculiar set of challenges. A systematic and deliberate approach focused on mutual respect, flexibility and direct leadership can help medical commanders in such situations.

Clinical application of the validated Hindi VHI in assessing subjective improvement following microlaryngeal surgeries for benign vocal fold lesions: A preliminary report

Objective: To assess the clinical utility of a validated Hindi VHI in the assessment of patients treated microsurgically for benign vocal fold lesions. Design: Prospective study. Setting: Tertiary health care centre. Materials and Methods: The study population comprised 46 patients of either sex with benign vocal fold lesions, who underwent microlaryngeal surgery in our hospital between January, 2011 and May, 2012. An acoustic analysis of all the patients was done using Dr. Speech voice analysis software (Tiger electronics, USA) preoperatively and 6 weeks postoperatively. The parameters analyzed were in terms of perturbation (Jitter and shimmer), normalized noise energy (NNE), and fundamental frequency (F0). A validated Hindi version of VHI was filled by all the patients preoperatively and 6 weeks postoperatively. The results obtained were statistically correlated using SPSS 17 software. Results: There was a significant correlation between the parameters analyzed on Dr. Speech voice analysis software and VHI parameters obtained preoperatively and postoperatively as assessed using Pearsons correlation coefficient. There was a statistically significant improvement in objective voice parameters and VHI scores postoperatively as assessed using Pearsons correlation coefficient. Conclusion: The validated Hindi version of VHI correlates well with the widely used acoustic analysis software (Dr. Speech, Tiger electronics, USA). It also correlates well with voice improvement after surgeries for benign vocal fold lesions. It merits inclusion in the standard evaluation protocol both in the preoperative assessment and postoperative evaluation following surgical treatment for benign vocal fold lesions in Hindi speaking population.

Lateral temporal bone resection for malignancy of external auditory meatus: our approach

ObjectiveSurgical management of tumors of the external ear remains controversial with regard to the extent of resection and the efficacy of piecemeal resection compared to standard en bloc resection. The objective was to study the results of lateral temporal bone resection with soft tissue resection used at our centre in managing a series of such cases.SettingTertiary referral centrePatientsA retrospective study was carried out on seven cases of temporal bone malignancies treated at our center, with lateral temporal bone resection by the otologic microsurgical technique and superficial parotidectomy, with adjuvant radiotherapy where indicated. The mode of presentation, clinical and pathological staging, extent of surgical resection, reconstructive methods used and adjuvant therapy given were evaluated. The disease free survival on follow-up was noted.ResultsDisease free survival achieved was comparable with other published series, with acceptable morbidity patterns.ConclusionLateral temporal bone resection using otologic microsurgical technique with soft tissue resection is an effective way of achieving control of temporal bone malignancies.

Ultrasonography: Its role in nodular thyroid disease

ObjectiveThe objective was to correlate the number, size and extent of the nodules as determined during the preoperative clinical examination of the thyroid gland, USG, intra-operative examination and histopathology. Also, FNAC (with or without USG guidance) and USG findings suggestive of malignancy were correlated with the final histopathology.SettingTertiary referral centrePatientsA retrospective chart review was done for 106 patients who underwent surgery for benign or malignant nodular thyroid disease in our center, between Jan 2004–Dec 2006.ResultsUSG has 7 times higher predictive value than clinical examination in detecting number of nodules and determining size of nodules. USG guided FNAC has a sensitivity of 85.71% and specificity of 90.0% in detecting malignancy in nodular thyroid disease. However for predicting malignancy in thryoid nodules, this study shows that USG has a sensitivity of 20.0% and specificity of 97.67%.ConclusionIn patients with nodular thyroid disease, USG can accurately determine the number and the size of the nodules. It is extremely useful in guiding FNAC; However its role in predicting malignancy is doubtful. We therefore recommend that USG guided FNAC be carried out as a routine in the evaluation of thyroid nodules.