Sunil Kumar Saxena

Pott's puffy tumor in pediatric age group: A retrospective study

OBJECTIVE To study the etiology, clinical features and treatment outcomes of pediatric Potts puffy tumor (PPT). METHODS This retrospective study was carried by reviewing medical case record of pediatrics PPT cases admitted to our hospital from January 2010 to august 2011. Data regarding the patients demographic details, presenting symptoms and signs, etiology, laboratory findings, imaging findings, management, complications and outcomes of treatment were collected and analyzed. RESULTS A total of five cases of PPT were found. Three were male and two were female with a mean age of 11.6 years. All patients presented with headache, fever and tender forehead swelling. Nasal polyps and discharging sinuses over forehead were present in one case and one case had preseptal orbital cellulites in addition to PPT. None of the patient had intracranial complications. Three cases (60%) were secondary to acute frontal sinusitis, one case was as complication of chronic sinusitis and one case was because of trauma. Contrast enhanced Computerized tomography (CECT) demonstrated features of acute sinusitis in 3 cases, sinonasal polyp in one, fracture of anterior table of frontal bone in one case, subperiosteal collection and erosion of anterior table frontal bone in all cases. All patients required surgical intervention; Endoscopic approach 2 cases (40%), combined approach in 2 cases (40%) and external approach in one case (20%) in addition to aggressive antibiotic treatment. There was purulent discharge in frontal sinuses in all cases. In 2 cases (40%), culture of pus drained during surgery was positive; one case methicillin resistant Staphylococcus aureus sensitive to vancomycin, other Pseudomonas aeruginosa sensitive to ceftazidime and amikacin. All cases improved with treatment. There were no postoperative complications or facial cosmetic deformity except facial scar in three cases. The average hospital stay was two weeks and ranged from 10 days to 21 days. All patients received antibiotics for 6-8 weeks to treat osteomyelitis of the frontal bone. The average length of follow up was 9 months (range 6-18 months). All patient are doing well and are under regular follow up. CONCLUSIONS PPT is a complicated infection of frontal sinusitis and trauma that requires broad spectrum antibiotics and surgical treatment. Diagnosis is made by high clinical suspicion of this condition and confirmed by CECT. Early treatment results in favorable outcomes and decreases the risk of further complications.

Myiasis in different types of carcinoma cases in southern India

Myiasis maggots were isolated from the cancerous wounds, when the patients reported to the Department of ENT-OPD, JIPMER, Pondicherry. Maggots were identified to Chrysomyia bezziana based on characteristic patterns of posterior and anterior spiracles. Although the categories of cancer wounds were different, invasions were due to C. bezziana, which is very common in suburban areas of Tamil Nadu and Pondicherry in southern parts of India. This observation showed the importance of hygiene and sanitation in tropical countries with high fly population and emphasised the need for correct diagnosis of this obligatory myiasis, which was destructive. Through proper health care, further destabilization due to myiasis was avoided.

Recurrent neck infection with branchial arch fistula in children

OBJECTIVE Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side. METHODS A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases. RESULTS The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence. CONCLUSION Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.

True thyroglossal fistula.

Thyroglossal duct anomalies are the most common malformations in the neck and constitute 70% of all the congenital cervical masses. They are more common in the pediatric population under 5 years of age, and 60% of lesions are diagnosed before the age of 20. They represent remnants from the embryological migration of thyroid tissue from foramen caecum to the thyroid fossa. The thyroglossal duct cyst may rupture spontaneously and present as a draining sinus, which has been erroneously called a thyroglossal fistula, although communication with foramen caecum is extremely rare. We hereby present a case of true thyroglossal fistula in a 21‐year‐old male with a fistulous communication between the neck skin and foramen caecum. Laryngoscope, 2009

Topical Mitomycin C in functional endoscopic sinus surgery.

In recent literature, there has been an interest in the use of Mitomycin C to reduce post-operative complications following endoscopic sinus surgery. We report our results on a prospective, randomized controlled trial involving 50 patients with chronic bilateral rhino sinusitis. We eliminated various confounding factors by studying a single group of patients, with symmetrical disease, without pre-existing gross anatomical abnormalities. Patients requiring revision sinus surgery were excluded. On completion of the surgery, a cotton pledget soaked in Mitomycin C was placed in one nostril (test) and saline-soaked pledget (control) was placed in the other side of the nose, both in the middle meatus. The side of the nasal cavity receiving the topical Mitomycin C was randomized. The patients were assessed periodically (first week, first month, third month and sixth month) for synechiae formation and presence or absence of their symptoms. At the first week follow up, there was a statistically significant difference in the incidence of synechiae between the saline and Mitomycin C side. Furthermore, there was a statistically significant improvement with regards to patient symptoms (nasal block and discharge) in the Mitomycin C side when compared to the saline side. At the third and sixth month, there was no difference between the two groups. The incidence of adverse tissue reaction (granulation, discharge, polypoidal mucosa and crusting) was less in the Mitomycin C side when compared to the saline side at the first month follow up. Topically applied Mitomycin C reduces the incidence of synechiae in the immediate post-operative period in patients undergoing endoscopic sinus surgery. There is also an improvement in nasal obstruction and discharge with a reduction in the incidence of adverse tissue reaction in the early post-operative period.

The efficacy of radiofrequency volumetric tissue reduction of hypertrophied inferior turbinate in allergic rhinitis.

OBJECTIVES To evaluate the efficacy of radiofrequency volumetric tissue reduction (RFVTR) technique in treatment of allergic inferior turbinate hypertrophy (ITH) and to study its effect on nasal mucociliary clearance. MATERIALS AND METHODS This prospective study was conducted over 50 perenial allergic rhinitis patients with persistent nasal obstruction due to bilateral ITH refractory to medical management received one time RFVTR of both inferior turbinates. Symptoms were subjectively assessed by Visual Analog Scale (VAS) and mucociliary clearance was measured by saccharin transit time (STT) pre-operatively, at 1 week, 1, 3, and 6 months post-operatively. RESULTS Forty-seven subjects completed study. All patients had significant symptomatic improvement which started from 1 week post-operatively and persisted up to 3 months. Post-operative VAS scores of nasal obstruction, rhinorrhea, sneezing, headache, and snoring at 1 week 1, 3 and 6 month follow up visits significantly decreased (P < 0.05) whereas significant decreased in post-operative VAS scores of hyposmia was observed at 1 month follow up (P < 0.05). Though increase in VAS scores was observed during 6 month follow up, the difference between pre-operative and 6 month post-operative mean VAS score was statistically significant (P < 0.05). Symptomatic improvement in nasal obstruction, rhinorrhea, sneezing, headache, hyposmia, and snoring persisted in 89.4%, 95.6%, 97.8%, 88.5%, 46.7%, and 100% of patients, respectively, during 6 month follow up. There was no significant change in STT following RFVTR except at 1 week follow up (P < 0.0001). CONCLUSION RFVTR is safe and effective in treatment of ITH in allergic rhinitis patients.

Complete congenital third branchial fistula with left-sided, recurrent, suppurative thyroiditis.

OBJECTIVE We report an extremely rare case of a complete congenital third branchial arch fistula in a nine-year-old boy. METHOD A case report and a review of the English literature concerning third branchial arch fistula of congenital origin are presented. RESULTS A nine-year-old boy presented with a history of a small opening in the middle third of the anterior neck since birth, with recurrent surrounding swelling. There was no history of surgical drainage or spontaneous rupture. Computed tomography with contrast injection into the external cervical opening revealed a patent tract from the neck skin to the base of the pyriform sinus. Complete excision of the tract up to the pyriform sinus with left hemithyroidectomy was performed. Follow up at 22 months showed no recurrence. CONCLUSION To our knowledge, this case represents a very rare occurrence of the congenital variety of complete third branchial arch fistula at an unusual site. This case indicates that third branchial arch fistula can be complete, and may present in the anterior neck, an unusual site. In such cases, computed tomography fistulography and injection of dye into the pyriform sinus enables intra-operative delineation of the tract.

Pediatric recurrent acute suppurative thyroiditis of third branchial arch origin—Our experience in 17 cases

OBJECTIVE To describe clinical presentations, management and treatment outcomes of 17 cases of congenital pyriform sinus fistula (PSF) of third branchial arch origin presenting as left recurrent acute suppurative thyroiditis with cervical abscess. METHOD Medical record of these 17 cases (5-males, 12-females) presented during 2009-2013 were reviewed. RESULTS Average age was 9.6 years (range 3-15 years). Fistulous opening in neck was present in 10 cases (58.8%). Average number of episode of infection from first presentation to definitive diagnosis was 3 (range 2-5). All patient had history of incision and drainage (ID) of abscess (average 2, range 1-3). All cases had barium swallow and CT scan. Sixteen cases had telescopic hypopharyngoscopy. Barium swallow and telescopic hypopharyngoscopy detected PSF in 88.23% (15/17) and 100% (16/16) cases respectively. Fourteen cases were treated by transcervical excision (TE) (fistulectomy with left hemithyroidectomy), two cases were treated by endoscopic chemical cauterization (ECC) of internal opening at pyriform sinus using silver nitrate and only ID of abscess was done in one case. Success rate of TE and ECC was 93% and 100% respectively. Recurrence in one case initially treated by TE was managed successfully by ECC. CONCLUSION Presence of congenital PFS should be suspected when left-sided intra-thyroidal abscess formation occurs as gland is resistant to infection. Strong clinical suspicion, barium swallow study, telescopic pharyngoscopy and CT scan are the key to diagnosis. Both TE and ECC has comparable success rate. ECC may prove a useful and equally effective method of treatment for congenital PFS in future.

Congenital anomalies presenting as recurrent post-auricular abscesses: An institution based retrospective study

OBJECTIVES This report is intended to bring out the association of recurrent postauricular abscess in children with various underlying congenital anomalies. MATERIALS AND METHODS A retrospective study was done in tertiary care setting from the year August 2005 to February 2012 using the medical record department database to retrieve the patient details. During this study period, a total of 215 children with an age range of 1-14 years were treated at the hospital with postauricular abscess. We analysed the data using appropriate statistical tests for parametric and nonparametric data and setting the p value at 0.05 for significance. For testing the association between the recurrence of abscess and the presence of underlying congenital anomalies, Fischers t test was used. RESULTS A total of 215 patients were studied, of which 41 patients presented with recurrence. 26 of the 41 patients (63.4%) had recurrent postauricular abscess with associated congenital anomalies. Among the 26 patients, in 16 patients (62%), the recurrent abscesses were due to postauricular sinuses. Other less common causes were infected post auricular dermoid cyst, first branchial cysts, collaural fistula and congenital aural atresia. There was a statistically significant association of the recurrence of abscess with presence of underlying congenital anomalies. CONCLUSION Paediatric recurrent postauricular abscesses are rare in the post antibiotic era. Their presence should alert a treating physician of an underlying congenital anomaly.

Preoperative Cytodiagnosis of Pleomorphic Adenoma with Extensive Lipometaplasia

BACKGROUND Pleomorphic adenoma with extensive lipometaplasia is a rare, benign tumor of salivary gland origin. To the best of our knowledge, the fine needle aspiration cytologic features of this distinct morphologic entity have not been docnmented before. CASE A 48-year-old male presented with right-sided parotid swelling that was clinically diagnosed as a pleomorphic adenoma. Fine needle aspiration yielded sticky, fatty material; the smears showed features of pleomorphic adenoma with intimately associated, abundant adipose tissue elements. A cytodiagnosis of pleomorphic adenoma with extensive lipometaplasia was rendered and confirmed by histopathologic examination. CONCLUSION Pleomorphic adenoma with extensive lipometaplasia is an unusual benign salivary gland tumor with distinct histomorphology. Cytologically, it is characterized by the presence of an excessive amount of intimately associated adipose tissue in an otherwise-classic pleomorphic adenoma.