Sudesh Kumar

A Comparative Review of Treatment of 80 Mandibular Angle Fracture Fixation with Miniplates Using Three Different Techniques

Standard treatment of mandibular angle fracture with miniplates according to recommendations of Champy et al. (1976) consists of fixation with one miniplate at superior border of mandible ventral to external oblique line. In certain constellations, second miniplate at lower border may provide additional stability. In this retrospective study 80 patients with mandibular angle fracture were divided into 3 sub-groups reported at DIRDS Faridkot were treated by intraoral, extraoral and combined intraoral and transbuccal approach. There was no significant difference in complication rates encountered with these techniques. Decision regarding treatment approaches for open reduction of mandible fracture often relates to surgeon’s experience and training. In some cases, choice is affected by availability of equipment. More difficult cases involving endentulous atrophic mandible or comminution should be considered for extraoral approach. Intraoral open reduction and fixation was used for non-comminuted and non-complicated fractures. The combined transbuccal/Intraoral procedure is now preferred method because of ease of use and facilitation of placement of plate in neutral mid point area of mandible.

Utility of LMA for emergency tracheostomy in an infant with pierre Robin syndrome

SIR—Infants with Pierre Robin syndrome (PRS) are at high risk of hypoxia because of upper airway obstruction and securing the airway in these patients is a challenge for most, if not all anesthesiologists. Having laryngeal mask airway (LMA) and fibre optic bronchoscope (FOB) in our difficult airway armamentarium makes us more comfortable and confident in planning our anesthesia. Here we report a case of sick infant with PRS who was anesthetized with LMA for emergency tracheostomy. A 1-month-old male infant weighing 2.4 kg with PRS, peroxisomal disorders, cerebral venous thrombosis and atrophy, uncontrolled seizure disorder and frequent apneic spells was scheduled for emergency surgical tracheostomy. In preanesthetic evaluation, we found that the baby was being nursed in prone position with nasal airway in place. Peripheral pulseoximeter reading was 100% with O2 supplementation although the vital sign chart revealed frequent episodes of desaturation with lowest readings of 70%. Risk of anesthesia was explained to the parents and patient was shifted to operating room (OR) in prone position. On OR table patient was turned supine and induced with sevoflurane in O2 keeping him on spontaneous respiration. After attaining sufficient depth, it was possible to ventilate him with a nasal airway. Laryngoscopy revealed Cormack and Lehane grade 4 visibility. Size 1 LMA was inserted and patient could be ventilated adequately through it. Fiber optic bronchoscopy through LMA showed good view of larynx. However, it was decided to go ahead with the tracheostomy without endotracheal (ET) intubation. Patient’s ventilation was assisted without using any muscle relaxant. Tracheostomy was completed without any intraoperative complications. Repeat fiber optic bronchoscopy showed the tracheostomy tube in proper position, well below the cricoid ring. The most definitive way of airway management in any patient is ET intubation. But, there are many advantages of doing tracheostomy with LMA. We regularly perform percutaneous tracheostomy in our adult intensive care unit with LMA unless there is a high risk of aspiration or patient requires high PEEP to maintain O2 saturation. There is no need to withdraw the endotracheal tube (ETT) at the time of initial puncture of trachea or thereafter for insertion of tracheostomy tube. The risk of accidental extubation, rupture of cuff, coiling of guidewire on ETT etc. can be avoided and site of initial needle puncture and guidewire insertion can be properly visualized with FOB through LMA during the procedure. In neonates and small infants undergoing surgical tracheostomy, the field of activity of the surgeons encroaches on to that of anaesthesiologists because of small size of head and neck. Manipulation of ETT can be difficult and accidental extubation at that time can have disastrous consequences particularly if the patient is a case of difficult intubation like PRS. Endotracheal intubation can be an uphill task in patients with PRS if equipments and expertise for neonatal fiberoptic bronchoscopy are not available. In emergent situations, as mentioned earlier, transferring a sick and desaturating infant to an advance facility without a definitive airway is all the more risky. LMA can be very useful in these situations. Many reports quote awake intubation as the preferred technique to secure the airway in this subset of patients to avoid any catastrophe during induction of anesthesia (1). The process of awake intubation in an otherwise normal neonate is discredited because of various life threatening complications including bradycardia, laryngospasm, laryngo-tracheal injury, intraventricular hemorrhage etc (2,3). Insertion of LMA in an awake neonate will be less stressful compared with ET intubation. Once the LMA is inserted and positioned properly, inhalational anesthetic agents such as sevoflurane can be administered to anesthetize the patient maintaining spontaneous respiration and then proceed to fiber optic intubation. Anesthetizing infants with PRS after LMA insertion and then successful ET intubation using FOB has been described by Martin et al. (4) Reinserting a dislodged LMA during the process of FOB aided intubation, after inducing anesthesia through LMA, should be easier than before when it was performed in an awake struggling neonate. We routinely perform many diagnostic fiber optic bronchoscopies in neonates and infants through nasal route under inhalational anesthesia (oxygen & sevoflurane) with the patient breathing spontaneously. Spontaneous ventilation is maintained through a nasal airway introduced in one of the nostrils and attached to the anesthetic breathing circuit which will also have a CPAP effect. If proper size nasal airway is not available, we use ETT (with internal diameter 3 ⁄ 3.5) cut at a length 1 cm more than distance between nares and tragus as nasal airway and fix it securely. Lignocain 1% is sprayed on the mucosa through the FOB as it is advanced through the pharynx into the trachea. In our experience, even very sick neonates from ICU do not tolerate fiber optic bronchoscopy without local anesthetic instillation and most of them desaturate if CPAP is not applied. Fiber optic bronchoscopy followed by intubation in a fully awake neonate can never be easy and atraumatic. Anand et al. (2) have opined that ET intubation without the use of analgesia or sedation should be performed only for urgent resuscitations in the delivery room or other life-threatening situations when intravenous access is unavailable. LMA can facilitate fiber optic CORRESPONDENCE 409

Waardenburg syndrome: A rare genetic disorder, a report of two cases

Waardenburg syndrome (WS) is a rare genetic disorder. Patients have heterochromia or eyes with iris of different color, increased inter-canthal distance, distopia canthorum, pigmentation anomalies, and varying degree of deafness. It usually follows autosomal dominant pattern. In this report, two cases have been discussed but no familial history of WS has been found. Counseling of the patient is necessary and cases of irreversible deafness have been treated.

Sudden near-fatal tracheal aspiration of an undiagnosed nasal foreign body in a small child

Foreign body aspiration is a commonly encountered emergency in children. Foreign body can lodge in any site from supra‐glottis to the terminal bronchioles. Symptoms might range from none to respiratory compromise, cardiac arrest and even death depending on location and size. We report successful management of a child who aspirated a nasal foreign body during physical examination in an outpatient department causing complete airway obstruction with special mention about different management options available for managing near total respiratory arrest from an aspirated foreign body in the ED.

A palatal mass.

A 19 year old female patient presented to the ENT department with complaints of slow growing, painless palatal mass for three months duration. On examination, there was a smooth surface 3x3 cm mass arising from the left side of hard palate (Fig. 1) which was firm in consistency on palpation. The rest of ENT examinations were normal. Figure 1 Pre-operative clinical photograph showing the palatal mass The Computed tomography (CT) showed a well defined contrast enhancing mass with no obvious bony erosion, (Fig. 2). The fine needle aspiration cytology from the lesion showed the histological features of epithelial and myoepithelial elements arranged in a variety of patterns and embedded in a mucopolysaccharide stroma. Figure 2 Showing a soft tissue mass arising from the hard palate at the level of ethmoid sinus Questions What is the likely diagnosis in this patient? What is the role of Fine needle aspiration cytology (FNAC) in such lesion? How would you manage this case and what is the role of CT scan in such lesions? Answer Pleomorphic adenoma of minor salivary gland arising from hard palate. The other rare differential diagnosis includes malignant minor salivary gland tumor, neurogenic tumors. Preoperatively, the FNAC has a diagnostic role in such lesions. The mass lesion arising from the hard palate can be a malignant lesion requiring a radical approach. Complete surgical excision under general anesthesia is the treatment of choice for such a lesion (Fig. 3). The preoperative CT scan not only helps in delineating the extent of lesion but also is useful in assessing any bony erosion of hard palate. Figure 3 Post operative scan of the patient showing a clear hard palate at the level of ethmoid sinus Discussion The palate has the highest concentration of minor salivary glands in the upper aero-digestive tract.1 The pleomorphic adenoma is the most common benign minor salivary gland tumor arising from the palate.2 The clinical presentation of such a lesion is typically a firm or rubbery submucosal mass without ulceration or surrounding inflammation. The exact etiology of this tumor is unknown but it is hypothesized that it originates from the intercalated and myoepithelial cell.2 Preoperatively, the fine needle aspiration cytology has a definite diagnostic role and shows epithelial, myoepithelial, and stromal components. The CT scan and magnetic resonance imaging (MRI) showed, always performed to asses for the presence of any bony erosion, soft tissue or nerve involvement. Since the majority of minor salivary gland neoplasms arising from palate are malignant, a detailed history, examination and investigations are essential before the excision of such lesions.3 The complete surgical excision is the treatment of choice in cases such as pleomorphic adenoma. The lesion in the current case was excised completely under general anesthesia and patient was symptoms free in the six months follow up.

A survey of ear, nose and throat disorders in rural India.

Aims and objectivesThe main aim of this survey was to assess the prevalence of common ear, nose and throat (ENT) disorders in the rural India.SettingAfter initial screening of the patients at the primary health center, a week long camp was organized in a district where entire population resides in the rural area and a complete ENT examination and investigation was done by the ENT specialists.Materials and methodsA total of 950 patients were found to be suffering from the ENT ailments in the total population of thirty thousands of the district (4.31%). Out of the total of 950 patients 36.6% of patients (n = 348) had ear problems, 23.57% (n = 225) had nasal problems, while 16.58% (n = 161) of patients were suffering from the throat disorders. Among the ear patients most common diagnosis was chronic suppurative otitis media (CSOM) 114 and presbyacusis 83. Deviated nasal septum and sinusitis was most common diagnosis in nasal symptoms while gastroesophageal reflux (GERD) was the commonest throat problems seen in this study. Eleven patients had various benign tumors of head and neck and only one patient was found to be having oropharyngeal malignancy. The congenital head and neck lesion was seen in only four patients.ConclusionsIn this survey 4.31% of the rural population of the district were having ENT ailments. The highest numbers rural population (35.65%) were having ear diseases. This was primarily due to low socioeconomic status and lack of awareness of the population. The nasal problem was seen in 23.57%, while throat problem was seen in 16.58%. The percentage of head neck malignancy in this survey was 0.0028.

Cervical nodal metastasis in head and neck cancer: a clinical conundrum

Within a month of being treated with a partial maxillectomy for a stage T2NM (staged as per preoperative MRI and CT) left maxillary antral carcinoma, a patient suffered symptoms of ‘sore throat’ and also tested positive for a streptococcal infection on a swab test. Though appropriate antibiotics relieved symptoms, a minimal dysphagia persisted which was conveniently attributed by the patient as ‘being related to the streptococcal infection’. However, after two months, the 18F-fluorodeoxyglucose positron emission tomography/CT (18F-FDG-PET/CT) which was performed as part of a post-treatment follow-up, demonstrated multiple contralateral avid neck-nodes (levels II–IV). This was histopathologically confirmed to be harbouring metastatic deposits of squamous cell carcinoma (figure 1 …

Requesting clarifications concerning the case report on 'extraskeletal Ewing sarcoma of the sinonasal tract

The authors have assigned the diagnosis as ‘extraskeletal’ Ewing sarcoma, which in our opinion is questionable. The preoperative computed tomography (CT) image reveals a large soft tissue mass involving the nasal cavity and the paranasal sinuses, with bony erosion of the walls of the maxillary sinus. Thus, there is a likelihood that the tumor could indeed have originated from the bony structures of the region. Skeletal origin is more likely, given the additional fact that only 4–7% of all Ewing sarcomas happen to be ‘extraosseous’.