Suja Sreedharan

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.

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.

Perichondritis of the auricle and its management

OBJECTIVE To conduct a study of patients presenting with perichondritis of the auricle and to analyse the possible aetiological factors responsible, the bacteriological agents involved, the treatment modalities and the complications of such infections. SETTING Academic department of otolaryngology. DESIGN A retrospective clinical study of patients treated over a five-year period. PARTICIPANTS Sixty-one patients with clinically proven perichondritis of the auricle, with or without diabetes mellitus (i.e. malignant otitis externa). RESULTS Based on the severity of the disease, otherwise uncomplicated patients were assigned to group A and divided into three cohorts. Patients with perichondritis secondary to malignant otitis externa were analysed separately as group B. Men formed the majority of the patients and most were young (16-35 years). Trauma was the main cause (46 per cent) and Pseudomonas aeruginosa the most common micro-organism isolated. The condition was managed conservatively with antibiotics alone in 19 patients (31 per cent) and these cases had no residual deformity at follow up (group A, stage one). Incision and drainage was performed in a further 19 patients (31 per cent), resulting in minor residual deformity in one half (group A, stage two). Debridement was performed in 17 patients, and these patients had either gross (29 per cent) or minor residual deformity (71 per cent; group A, stage three). Six patients with perichondritis secondary to malignant otitis externa were managed by wound debridement via a post-auricular approach; all had minor residual deformities. CONCLUSIONS Perichondritis can be divided into two groups, depending on cartilage loss and on the presence or absence of malignant otitis externa. The treatment used and the residual deformity that will ensue are entirely dependent on the stage of disease.

Tuberculosis of the temporomandibular joint and parotid secondary to tuberculous otitis media.

The incidence of tuberculous otitis nedia (TOM) is less than 1% in any population of patients with chronic ear problems. Temporomandibular joint (TMJ) tuberculosis (TB) and parotid abscess have never been reported as a complication of TOM. Here we describe 1 such case. A 62-year-old woman presented with pain and swelling over the left side of face for 45 days duration. She had difficulty opening her mouth and a history of left ear discharge for 3 months that was purulent, profuse, nonblood stained, and foul smelling. She gave no history of trauma, recurring episodes of fever, or weight loss. Examination showed a tender, fluctuant swelling on the left side over the parotid with a 2-cm trismus. Otoscopy revealed granulation in the external auditory canal (EAC) and middle ear with profuse foul-smelling purulent ear discharge, a marginal perforation in the pars tensa in the posterior quadrants, and a tympanic membrane (TM) remnant anteriorly. Erythrocyte Sedimentation Rate (ESR) was 65 mm/1st hour. Mantoux was negative. A computed tomography scan showed an abscess of the left parotid gland, erosion of condyle of the mandible, and TMJ on the left side with sequestrum. Chest x-ray was normal. Mastoid x-ray showed sclerotic changes on that side. The biopsy report of mastoid granulations was negative for Acid Fast Bacilli (AFB) and grew Staphylococcus aureus alone. A parotid exploration was done, and the abscess was drained. The facial nerve and the deeper lobe were intact. The condyle of the TMJ was necrosed. A condylectomy was performed. Histopathological examination (HPE) of bone and parotid showed areas of necrosis. Typical tubercles of Mycobacterium tuberculosis were also found, composed of Langerhans giant cells and lymphocytes. The culture also grew Mycobacterium tuberculosis. A biopsy specimen from middle ear granulations was taken once again due to a strong suspicion that the TB originated from the mastoid. This biopsy proved to be negative. Three weeks later, a mastoid exploration was done. There was discharge and pale granulations in the EAC,

Presentation and management of deep neck space abscess

ObjectiveTo study the presentation, etiology, microbiology and morbidity of deep neck space infections.Study DesignRetrospective study Methods: 29 patients admitted in Kasturba Medical College Hospital, Mangulore, India between January 1997 and December 2002 with deep neck space infections.,were included in the study.RemitsThe most common space involved was the parapharyngeul space. No specific etiology was determined in .38%; an odontogenic cause was discovered in 28% of the patients; tonsillar/pharyngeal infections in 24% of patients and foreign body impaction in 7% of cases. The main morbidity was due to mediastinitis (5 patients). I patient succumbed to the disease. Mixed flora with aerobic and anaerobic infections was identified in most of the cases.

Radiotherapeutic effect on oropharyngeal flora in head and neck cancer.

The effect of radiotherapy on oropharyngeal bacterial and mycotic flora was studied. Thirty five patients were included from whom swabs were taken before and at the end of irradiation. Fifteen controls were included.It was found that Streptococcus pneumoniae was significantly decreased at end of irradiation, while there wan an increase in Staphylococcus aureus. Pseudomonas, Bacteroides and Candida species. There was no change in culture and sensitivity pattern prior to and after radiotherapy.

Role of estimation of arterial blood gases in the management of stridor

AimWe studied the epidemiology and etiology of stridor in our patients along with the role of arterial blood gas (ABG) analysis in their management. We also reviewed their prognostic indices and the clinical outcomes.Materials and methodsIt was a prospective study in a tertiary referral hospital in which 72 patients presenting with stridor, were independently evaluated by 3 different clinicians and clinically classified into mild, moderate and severe. Based on ABG values (pH, PO2, PCO2), we defined 3 groups of patients viz, those in respiratory failure, impending respiratory failure and those with no evidence of failure. Treatment was directed at the cause of stridor. Clinical outcomes were assessed and results classified as resolved, improved, stable and death.ResultsOut of 72 patients, kappa coefficient of agreement between the 3 observers were found to be 0.014, indicating poor interobserver reliability for the working clinical classification. However, ABG analysis indicated otherwise, with 6 patients in respiratory failure, 19 progressing to impending failure. Hence we complied by the more objective ABG analysis in planning management. Laryngomalacia in children and hypopharyngeal malignancies in adults were found to be the most common causes of stridor in our study. As compared to other conditions, laryngomalacia in children had a poorer outcome (p = 0.001).ConclusionEarly detection of impending respiratory failure was instrumental in achieving better clinical outcomes in our patients presenting with stridor. Thus we inferred that ABG analysis is a valuable tool in the effective management of stridor.

Antrochoanal polyps and allergy-A comparative study.

Antrochoanal polyps, are solitary polyps arising from the maxillary autrum. Their aetiology largely remains unknown; allergy has been implicated. The study attempts to define the relation between antrochoanal polyps and allergy and the need for such an investigation by studying 24 cases with antrochoanal polyps and comparing them with 20 cases of sinonasal polyps. Nasal smear cytology, serum total IgE and polyp fluid IgE was evaluated. 52.38% of cases turned out to be allergic. In their presentation, antrochoanal polyps do not significantly differ from other polyps.

Primary clear cell carcinoma of the nasopharynx

A 22-year-old female with epistaxis and nose block had a pink, smooth, mucosa covered lesion occupying the nasopharynx. The histopathology and immunohistochemistry of the lesion confirmed the diagnosis of clear cell carcinoma (CCC). Detailed evaluation ruled out a primary tumor elsewhere in the body. After complete excision of the tumor patient received radiotherapy (60 Gray in 30 fractions over 6 weeks). Patient is recurrence free on her 3-year follow-up. Primary CCC of the head and neck is rare. In the past 30 years, less than 100 cases have been reported in English literature. Out of these, only nine cases had nasopharyngeal origin. The literature review of those cases along with our case report suggest that complete excision of nasopharyngeal CCC along with radiotherapy leads to prolonged recurrence free interval. However, extensive tumors of nasopharynx exhibit poor prognosis with repeated local recurrences.

Leaving a mark: Multiple geometric areas of alopecia

Post-operative alopecia is a rarely reported group of scarring and non-scarring alopecia.1 It usually presents as a solitary oval patch, most commonly on the occiput.2 We report a case, where a patient developed multiple geometric areas of alopeci