Sampath 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.

The role of wait-and-scan and the efficacy of radiotherapy in the treatment of temporal bone paragangliomas.

Objective To define the role of wait-and-scan and radiotherapy (RT) in the treatment of temporal bone paragangliomas and to review the literature on the outcomes of RT as a treatment modality. Materials and Methods This was a retrospective and literature review. The records of 381 patients with 382 tumors between 1988 and 2012 were analyzed. Patients who were subjected to initial wait-and-scan or primary RT were analyzed for tumor response, facial, and lower cranial nerve status on follow-up (FU). Results and Observations None of the 145 patients (38%) with Class A and B tumors were subjected to wait-and-scan or RT and all were operated on. Of the 237 patients (62%) with Class C and D tumors, 47 (19.8%) were subjected to an initial wait-and-scan policy and 1 (0.4%) underwent primary RT. In 24 patients subjected to wait-and-scan with a FU of less than 3 years, tumor remained stable in 22 patients (92%). In 12 patients with a FU between 3 and 5 years, the tumor remained stable or regressed in 10 patients (83%). In 11 patients with a FU of more than 5 years, the tumor remained stable or regressed in 5 patients (45%). A literature review of the results of RT did not conclusively prove that it was effective as a primary modality of treatment for temporal bone paragangliomas. Conclusion In elderly patients with advanced tumors, a wait-and-scan approach is recommended, and RT is initiated only when fast-growing tumors are detected. There is insufficient evidence in literature to suggest that RT could be an effective alternative to surgery in Class C and D tumors.

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.

Current trends in the management of the complications of chronic otitis media with cholesteatoma.

Purpose of reviewComplications of cholesteatoma can be of a different nature from those of other otitis media. This review aims to undertake an analysis of current literature regarding management of the complications of cholesteatoma. Recent findingsDespite a significant decline in the incidence of complications secondary to cholesteatoma in developed countries it is still a considerable problem in the developing countries. Among intratemporal complications, facial nerve paralysis and labrynthine fistula and among intracranial complications, meningitis, brain abscess and lateral sinus thrombosis are most common. In cases of facial nerve paralysis, decompression with complete disease eradication is considered to be the mainstay of treatment and usefulness of an epineural incision and the range of the decompression are still debatable. Labyrinthine fistula is commonly managed by a single staged matrix removal, followed by closure of the fistula. Partial labrynthectomy in difficult cases is gaining favor among surgeons today. Meningitis and brain abscesses are treated with antibiotics and steroid therapy followed by surgery when the patient is neurologically stable. In lateral sinus thrombosis, mastoidectomy and removal of infected tissue is the primary treatment. Sinus incision and thrombectomy does not seem to improve recanalization and anticoagulation is usually not necessary. Treatment of meningoencephalic herniations is based mainly on the diameter of the herniation. SummaryThere is considerable debate in the management of almost every complication of cholesteatoma. Multicentric studies to compare the efficacies of various treatment modalities are the need of the hour to come to definitive conclusions regarding the best treatment options.

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.

State of the art in temporal bone malignancies.

Purpose of reviewTo discuss the histological variants, tumor staging, work up and the latest trends in the treatment of malignancies of the temporal bone. Recent findingsBecause of the rarity of this subset of tumors, there has been no serious attempt to study tumor histologies of the temporal bone other than the squamous cell carcinomas (SCCs). The modified Pittsburgh tumor staging, though popularly used, was primarily developed only for SCC of the external auditory canal. Recent studies have shown that this staging is not without faults. There is also divergence of opinions regarding the surgical procedures to be adopted in treating temporal bone carcinomas. Moreover, the role of radiotherapy and chemotherapy has not been clearly defined. SummaryIn this review, we analyzed all the histological varieties of tumors that can arise from the temporal bone and classified them. The merits and demerits of the modified Pittsburgh tumor staging has been discussed outlining the need for further refining this system. The surgical approaches and their applications with respect to the extent of the tumor have been defined. The role of parotidectomy, neck dissection and adjuvant radiotherapy has been discussed.

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.

The long-term outcomes of wait-and-scan and the role of radiotherapy in the management of vestibular schwannomas.

Objective To analyze the growth characteristics in patients assigned to wait and scan in vestibular schwannomas (VSs) during long-term follow-up. Background The wait-and-scan policy and radiotherapy (RT) are conservative management strategies for VSs. A better insight into the natural history of the tumor and growth patterns is quintessential in planning optimal management. Methods The charts of 576 patients with unilateral sporadic VSs who were assigned to wait and scan at our center from 1986 to 2013 were reviewed. A systematic review of radiosurgical literature was done and compared with results of wait and scan. Results The overall mean follow-up was 36.9 ± 30.2 months. One hundred fifty-four patients with a 5-year follow-up were analyzed separately for patterns of tumor growth. Varied combinations of growth patterns were observed. Eighty-four (54.5%) tumors showed no growth throughout 5 years, 12 (7.8%) showed slow growth throughout 5 years, 2 (1.3%) tumors showed fast growth throughout 5 years. A total of 134 tumors (87%) showed favorable growth patterns for wait and scan. When the results of wait and scan were compared with those of RT, it pointed to the possibility that at least a portion of control of tumor by RT could be attributed to the natural course of the tumor. Conclusion The wait-and-scan modality is ideal for management of VSs in the elderly population and also in younger patients with intrameatal tumors. Considering the fact that a large percentage of tumors do not require any form of treatment, the role of RT in VSs needs to be reinvestigated.