Ent January-March 2013 by IJCP

January-March 2013

Asian Journal of

Online Submission

IJCP Group of Publications Dr Sanjiv Chopra Prof. of Medicine & Faculty Dean Harvard Medical School Group Consultant Editor Dr Deepak Chopra Chief Editorial Advisor

Dr KK Aggarwal CMD, Publisher, Group Editor-in-Chief

Ear, Nose Throat

January-March 2013

from the desk of editor

5 Adenotonsillectomy, â&#x20AC;&#x2DC;Should or Should not beâ&#x20AC;&#x2122;

Jasveer Singh

Dr Veena Aggarwal MD, Group Executive Editor from the desk of group editor-in-chief

Editor

Dr Jasveer Singh Anand Gopal Bhatnagar Editorial Anchor

7 Sore Throats Mostly Viral, Not Strep

KK Aggarwal

IJCP Editorial Board Obstetrics and Gynaecology Dr Alka Kriplani Dr Thankam Verma, Dr Kamala Selvaraj

clinical study

ENT Dr Jasveer Singh

8 Inheritance Pattern of Anterior Deviated Nasal Septum among Children

Cardiology Dr Praveen Chandra Dr SK Parashar

Paediatrics Dr Swati Y Bhave Dr Balraj Singh Yadav Dr Vishesh Kumar, Dr Satish Tiwari Diabetology Dr CR Anand Moses, Dr Sidhartha Das Dr A Ramachandran, Dr Samith A Shetty Dentistry Dr KMK Masthan Dr Rajesh Chandna

Ahmed Eltayeb Mohammed, Rahmat B Omar, N Prepageran, Raman Rajagopalan

Original article

11 Impact of Tonsillectomy on Quality-of-life in Children: Our Experience

Neelima Gupta, Lakshmi Vaid, PP Singh

Gastroenterology Dr Ajay Kumar Dermatology Dr Hasmukh J Shroff Nephrology Dr Georgi Abraham

case report

15 Congenital Choanal Atresia

Neurology Dr V Nagarajan Journal of Applied Medicine & Surgery Dr SM Rajendran Advisory Bodies Heart Care Foundation of India Non-Resident Indians Chamber of Commerce & Industry World Fellowship of Religions

Susank Sebastian, Devjani Choudary, Payal Garg, Vipin Kamboj

18 A Case Report on Primary Nasal and Nasopharyngeal Tuberculosis with Review of Literature

P Kiran Kumar, Kalpana Sharma, Anandita Das, Himajit Kumar Barman

case report

Published, Printed and Edited by Dr KK Aggarwal, on behalf of IJCP Publications Ltd. and Published at E - 219, Greater Kailash, Part - 1 New Delhi - 110 048 E-mail: editorial@ijcp.com

21 Unusual Presentation of Lipoma: A Case Report

Printed at IG Printers Pvt. Ltd., New Delhi igprinter@rediffmail.com

Suryapratap Singh

25 Bilateral Antrochoanal Polyps in an Adult Female: A Rare Case

The copyright for all the editorial material contained in this journal, in the form of layout, content including images and design, is held by IJCP Publications Ltd. No part of this publication may be published in any form whatsoever without the prior written permission of the publisher.

P Verma, N Jain, M Arya, L Vaid, PP Singh

28 Acinic Cell Carcinoma of the Parotid Subramaniam Vinayak Easweran, Lokesh, Raghvendra U, Yuvraj, Manjula

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photo quiz

32 Swollen Masses in the Nose

Practice Guidelines

34 CDC Publishes Statement on Cough and Cold Medications in Children

Note: Asian Journal of Ear, Nose and Throat does not guarantee, directly or indirectly, the quality or efficacy of any product or service described in the advertisements or other material which is commercial in nature in this issue.

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35 News and Views

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from the desk of editor

Dr Jasveer Singh

Visiting Consultant, City Hospital Affiliated with Sir Ganga Ram Hospital Rajinder Nagar, New Delhi

Adenotonsillectomy, ‘Should or Should not be’

s the autum and winter arrives the number of young patients come with nasal discharge and recurrent sore throat. References from pediatrician to ENT specialist is very frequent. As a responsible ENT surgeon, one has to evaluate the proper cause of such recurrent catarrh and proper treatment is necessary to be given. I am inspired to write on this particular subject as, in the recent past, I have seen the cases in average 3-4 years old children, who have been advised adenotonsillectomy in the 1st or 2nd episode of catarrh. The cases had enlargement of tonsils and adenoids, as is common in urinary respiratory tract infection (URTI). The hypertrophied adenoids showed radiological shadows. The question is whether one should advise surgical intervention or not? I have got adequately excellent results with conservative treatment and only after the 10 days of proper medical treatment, the size of tonsils and adenoids are seen to shrink considerably, not requiring surgical intervention. The lymphoid tissue contributes to an important immune system of human body. It helps in maintaining the immunity particularly delayed immunity and memory of immunity. The removal of tonsil and adenoids may affect the fighting capacity of our immune system. Though, there is no common consensus on the indications for tonsillectomy or adenoidectomy, yet there are definite/ absolute indications for tonsillectomy. These are: 1) Hypertrophied tonsils causing sleep apnea; 2) peritonsillar abscess; 3) streptococcal carriers; 4) unilateral enlargement suggesting malignancy. Similarly, there are only two absolute indications for adenoidectomy: 1) Hypertrophy causing the sleep apnea; 2) recurrent secretory otitis media with pain and effusion. However, there are some added indications with some diagnostic and therapeutic importance. As far as the tonsillar size is concerned various grading systems have evolved, most widely referred of which is Brodsky grading system. According to this Grade 0: Tonsils within the tonsillar fossa. Grade 1: Tonsils just outside of the tonsillar fossa, ≤25% of the oropharyngeal width. Grade 2: Tonsils occluding 26 to ≤50% of the oropharyngeal width. Grade 3: Tonsils occluding 51 to <75% of the oropharyngeal width. Grade 4: Tonsil occluding >75% of the oropharyngeal width. Let us see what various associations opine regarding this. 2011 Guidelines from the AAO-HNS USA paradise criteria for tonsillectomy Chronic tonsillitis: Minimum frequency of sore throat episodes: Seven or more episodes in the preceding year, OR five or more episodes in each of the preceding two years or more episodes in each of the preceding 3 years. Clinical features (sore throat plus the presence of one or more qualifies as a counting episode temperature >38.3°C, OR 101°F, cervical lymphadenopathy (tender lymph nodes or >2 cm), OR Positive culture for Group A b-hemolytic streptococcus. Treatment: Antibiotics had been administered in conventional dosage for proved or suspected. Each episode and its qualifying features had been substantiated by contemporaneous notation in a clinical record. Hypertophy: Causing upper airway obstruction leading to sleep apnea, (trouble swallowing), sleep disorders or cardiopulmonary complications. Usually, removal of both the tonsils and adenoids are indicated.

Asian Journal of Ear, Nose and Throat, January-March 2013

from the desk of editor Peritonsillar abscess: Unresponsive to medical management and drainage documented by surgeon, unless surgery performed during acute stage. Streptococcal carrier: Chronic or recurrent tonsillitis associated with the streptococcal carrier state and not responding to b-lactamase-resistant antibiotics. Unilateral Enlargement: Unilateral tonsil enlargement presumed euplastic. Although without other indications (abnormal appearance, physical examination, symptoms or history) most asymmetries can be followed conservatively. “A joint Position paper of the Pediatrics and Child Health Division of The Royal Australasian College of Physicians and The Australian Society of Otolaryngology Head and Neck Surgery.” Conclusions The indications for tonsillectomy/adenotonsillectomy are: ÂÂ

Upper airway obstruction in children with obstructive sleep apnoea (OSA)

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Frequent recurrent acute tonsillitis

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Peritonsillar abscess

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Suspected neoplasm

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Uncommon indications.

Indications for tonsillectomy and adenoidectomy: Consensus document by the Spanish Society of ORL and the Spanish Society of Pediatrics. ÂÂ

Recurrent tonsillitis

ÂÂ

Recurrent peritonsillar abscess/PTA/quinsy tonsillitis

ÂÂ

OSA syndrome

Adenoidectomy ÂÂ

Priorities: Hypertrophy of the adenoids with a clinical history of severe OSA syndrome; suspected malignant disease

ÂÂ

Relatives: Adenoidal hypertrophy, (manifesting as buccal breathing, persistent night-time snoring, persistent bilateral rhinorrhea, nasal respiratory insufficiency, closed rhinolalia), which causes chronic nasal respiratory insufficiency and that coexists with (OSA syndrome, craniofacial deformity and infections).

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Recurrent acute otitis media

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Chronic otitis media

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Secretory otitis media

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Rhinosinusitis.

The priority indications are equivocal by all the groups. And if surgery is necessary for the help of patient, it should be performed, but if can be avoided without compromising with future prognosis, it should be. Hence the message is clear “The enlargement of tonsils and adenoids in respiratory catarrh needs proper management by surgeon, not a hasty decision of surgery and patience follow up of treatment by the patient.”

Dr Jasveer Singh E-mail: asianjasveer@gmail.com

Asian Journal of Ear, Nose and Throat, January-March 2013

from the desk of group editor-in-chief Dr KK Aggarwal

Padma Shri and Dr BC Roy National Awardee Sr. Physician and Cardiologist, Moolchand Medcity, New Delhi President, Heart Care Foundation of India Group Editor-in-Chief, IJCP Group and eMedinewS Chairman Ethical Committee, Delhi Medical Council Director, IMA AKN Sinha Institute (08-09) Hony. Finance Secretary, IMA (07-08) Chairman, IMA AMS (06-07) President, Delhi Medical Association (05-06) emedinews@gmail.com http://twitter.com/DrKKAggarwal Krishan Kumar Aggarwal (Facebook)

Sore Throats Mostly Viral, Not Strep ÂÂ

Most throat infections are viral and should not be treated with antibiotics, according to new guidelines from the Infectious Diseases Society of America, reports Medscape in the journal Clinical Infectious Diseases.

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Seventy percent of Americans with a sore throat receive antibiotics. However, bacteria are responsible for only 20-30% of pediatric cases and 5-15% of adult cases.

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Although bacterial and viral throat infections often have overlapping symptoms, other symptoms, such as cough, rhinorrhea, hoarseness and oral ulcers, strongly suggest a viral infection.

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A sore throat is more likely to be caused by Group A strep if the onset of pain is sudden, swallowing hurts, and a fever is present. Such cases can be evaluated using a stand-alone rapid antigen detection test. Because children younger than three years are unlikely to have strep throat, testing is unnecessary, with the exception of certain circumstances such as an infected older sibling.

ÂÂ

Throat cultures should only be used to confirm negative antigen tests in children and adolescents.

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They should be eschewed in adults because of their low risk for strep throat and even lower risk for complications such as rheumatic fever.

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Once strep throat is confirmed, the treatment of choice remains a 10-day course of penicillin (or its congener amoxicillin), which has a narrow spectrum of activity, is cheaply available and carries a low-risk for adverse events.

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Penicillin or amoxicillin is the choice for treating strep because they are very effective and safe in those without penicillin allergy, and there is increasing resistance of strep to the broader-spectrum - and more expensive macrolides, including azithromycin.

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The guidelines also recommend against tonsillectomy for children with repeated throat infection, except in very specific cases (e.g., children with obstructive breathing), because the risks of surgery are generally not worth the transient benefit.

Asian Journal of Ear, Nose and Throat, January-March 2013

clinical study

Inheritance Pattern of Anterior Deviated Nasal Septum among Children AHMED ELTAYEB MOHAMMED, Rahmat B Omar, N Prepageran, Raman Rajagopalan

Abstract This is an observational, descriptive study to look for any inheritance pattern of anterior deviated nasal septum (DNS) among children compared to their parents. A total of 60 patients with clinically confirmed DNS and their parents participated in this study. All of these patients were examined first to confirm clinical anterior DNS and then their parents were examined for anterior DNS by using a cold metal tongue depressor and anterior rhinoscopy. Data was collected, analyzed and entered into a computer database and statistically analyzed using SPSS for windows (version 12.0). The analysis thus showed that in 49 patients (81.7%) either one of the parents or both of them had anterior septal deviation similar to the patients. Eleven patientâ&#x20AC;&#x2122;s (18.3%) parents either did not have DNS or had it to the opposite side. In comparing the patients DNS to their parents, 90.5% of fathers with DNS had their DNS corresponding to the same side and similar to their children compared to 78% of mothers with DNS who had their DNS corresponding to the same side and similar to their children. This result could indicate a preliminary finding of the possibility of hereditary pattern in anterior deviation of the nasal septum.

Keywords: Nasal septum, deviation, inheritance

n many patients with septal deviation there is no obvious history of trauma. Molding theory was proposed.1 But, it was found that the type of delivery, the presentation, the parity, the birth weight and gestation period did not have any significance with regard to frequency of these lesions.2 This is in agreement with Jazbi (1974), who found instances of deviated nasal septum (DNS) after cesarean section.3 Four percent of fetuses had septal deviations and that, this was present at a time before either compression or birth trauma could be implicated as possible causative factors.3,4 The incidence of these neonatal septal deviations is about 4%.2 Although these lesions may be due to both trauma and genetic factors, recent research tends to suggest that the role of trauma is less important than was once believed. There has been no studies conducted so far similar to this study to demonstrate the DNS is hereditary, hence this study.

Faculty of Medicine Dept. of Otolaryngology University Malaya, Kuala Lumpur, 50603 E-mail: prepageran@yahoo.com

Asian Journal of Ear, Nose and Throat, January-March 2013

Material and Methods This prospective descriptive cross-sectional observational study was conducted in the Otorhinolaryngology (ENT) outpatient clinic in a tertiary center in a developing country for a period of six months (May 2005-Oct 2005). Children below the age of 12 were included in this observational study. Children who were found to have DNS on examination who presented to the ENT clinic for non-nasal symptoms and accompanied by both parents were chosen as an inclusion to this study. Patients and/or parents with history of nasal trauma or any previous nasal surgeries were excluded. All patients included in the study were examined for visible external deformity and for caudal dislocation followed by anterior rhinoscopy for septal deviation. Once, it was confirmed that the child had a clinical DNS, the child was included into the study. A cold spatula test was performed to observe degree of obstruction by the misting on the spatula. The parents were then asked regarding any history of nasal obstruction and the parents are then examined in the same manner. The examination was performed by a single investigator to reduce investigator bias. The data collected was entered into a computer database and subsequently analyzed with SSPS for windows (version 12.0).

clinical study Results Sixty patients with clinical DNS were included in this observational study comprising of 37 males (61.7%) and 23 females (38.3%). The age distribution of the patients is between 2-12 years old with a mean age of 7.2 years and standard deviation of 2.98 years. There were 22 patients (36.7%) aged between 2-5 years, 25 patients (41.7%) aged between 6-10 and 13 patients (21.7%) aged between 11-12. As this study was conducted in a multiracial country, the racial distribution included 26 Malays (43%), six Chinese (10%), 24 Indian (40%) and four from other races (7%). On examination of the patients, 33 patients (55%) had anterior deviation of the nasal septum to the left side and 27 patients (45%) had anterior deviation of the nasal septum to the right side (Table 1). Only 19 patients (32%) were symptomatic while 41 patients (68%) were asymptomatic. Thirteen patients (22%) has caudal dislocation. In comparing the patients DNS to their father, 42/60 (70%) of patient’s fathers had DNS as well, out of which only 38 (63.3%) fathers had anterior DNS to the same side and similar to the patient’s (child) while four (6.7%) fathers had anterior DNS to the opposite side. Thus, 90.5% of fathers with DNS had their DNS corresponding to the same side and similar as their children. In comparing the patient’s DNS to their mothers, 41/60 (68.3%) mothers had DNS as well, out of which only 32/60 (53.3%) mothers had anterior DNS to the same side and similar to the patient’s (child) while nine (15%) mothers had anterior DNS to the opposite side. Thus, 78% of mothers with DNS had their DNS corresponding to the same side as their children (Tables 2 and 3).

Table 1. The Deviation of the Nasal Septum to the Right/Left in the Study Group (Children) DNS No/percentage

Right

Left

27/60 (45%)

33/60 (55%)

Table 2. The Breakdown of Parents Side of DNS in Comparison with the Children DNS to the same side

DNS opposite side

DNS (total, either side)

Mother

32/60 (53.3%)

9/60 (15%)

41/60 (68.3%)

Father

38/60 (63.3%)

4/60 (6.7%)

42/60 (70%)

Table 3. No. of DNS among Parents to the Same Side as Children from the Total DNS DNS to the same side of children Mother

32/41 (78%)

Father

38/42 (90.5%)

In comparison of patients DNS with their parents (mothers and fathers), 49/60 (81.7%) of either/both parents had anterior deviation of the nasal septum to the same side of the patient (children) while 5/60 (8.3%) parents did not have any deviated septum at all. Five out of 60 parents had DNS to the opposite side and only one child had both parents with DNS to the opposite side. DISCUSSION DNS is a common nasal finding in both clinical and surgical setting. The etiological factors range from trauma to developmental error (genetic factors).3 This observational study was undertaken to evaluate if there is a hereditary pattern in DNS and if this could be supported by comparing children with DNS to their parents. To eliminate bias in the study population as this was performed in ENT Clinic, only patients without nasal symptoms were included after those with history of trauma or previous surgery were excluded. Only 32% of the patients studied were actually symptomatic upon further questioning although nasal symptom were not their presenting complain to the ENT Clinic. Thus, most patients with anterior DNS are not symptomatic or it is possible that they may have become accustomed to the deviation and are no longer aware of the anatomical anomaly. This study revealed that DNS is more common in males than in females (61.7%). With regards to race, ethnic Malay (26/60) predominate in this study population, which largely reflects the population of the surrounding catchment area, where the hospital is situated. Deviation to left side (55%) is more common than the right side corresponding to previous published studies.1,5 The study reveals that 90% (55/60) of patients had both parents with anterior nasal deviation, out of which 49/60 (81.7%) had DNS similar to their children. In 82% of patients, either or both parents had similar DNS. This appears to correspond to the hypothesis of a possible hereditary pattern via a developmental defect.5

Asian Journal of Ear, Nose and Throat, January-March 2013

clinical study In 38/60 (63%) patients, their fathers had deviation similar to their children while in 32/60 (53%) patients, their mothers had deviation similar to the patients. There does not appear any dominant influence by the gender of the parents. A positive correlation between appearances of type 6 septal deformity in both mothers and fathers of children with this deformity has been shown in previous study.6 This study is not without limitation and they include the lack of proper assessment of the posterior part of the septum as endoscopy in a child could be technically difficult. We did not take into consideration the degree of deviation of the nasal septum although type and shape of the deviation were matched between children and parents. The objective of the study was simply to assess if there is a possibility of a hereditary pattern in anterior DNS. However, it can be inferred from this study that there is a suggestion of a hereditary pattern in the development of anterior DNS. However, a larger sample size and a probable study of the grandparents also may help in confirmation of this inference and work out the pattern of inheritance.

Asian Journal of Ear, Nose and Throat, January-March 2013

Conclusion The results appear to support the probability of a hereditary pattern in the incidence of anterior DNS. REFERENCES 1. Gray LP. Deviated nasal septum. Incidence and etiology. Ann Otol Rhinol Laryngol Suppl 1978;87(3 Pt 3 Suppl 50):3-20. 2. Kent SE, Rock WP, Nahl SS, Brain DJ. The relationship of nasal septal deformity and palatal symmetry in neonates. J Laryngol Otol 1991;105(6):424-7. 3. Jazbi B. Nasal septum deformity in newborn. Diagnosis and treatment. Clin Pediatr 1974;13(11):953-6. 4. Harkavy KL, Scanlon JW. Dislocation of the nasal triangular cartilage after cesarean section for breech presentation without labor. J Paediatr 1978;92(1):162. 5. Jeppesen F, Windfeld I. Dislocation of the nasal septal cartilage in the newborn. Aetiology, spontaneous course and treatment. Acta Obstet Gynecol Scand 1972;51(1): 5-15. 6. Mladina R, Subaric M. Are some septal deformity inherited? Type 6 revisited. Int J Pediatr Otorhinolaryngol 2003;67(12):1291-4.

Original article

Impact of Tonsillectomy on Quality-of-life in Children: Our Experience Neelima Gupta*, Lakshmi Vaid**, PP Singh†

Abstract An important requirement of contemporary medicine is the assessment of patient benefit or change in health status resulting from medical or surgical intervention. Tonsillectomy is a commonly performed surgery in children. Its indications and benefits have been documented in the literature but to the best of our knowledge, there have been no Indian studies to measure the quality-of-life (QoL), post-tonsillectomy in children. Objective: To assess QoL of children after tonsillectomy, with or without adenoidectomy. Study design and setting: Retrospective study in a tertiary referral center. Methodology: The sample consisted of 136 children who had undergone tonsillectomy with or without adenoidectomy over a period of two years. The parents of these children were sent a questionnaire to assess their QoL six months after the surgery. The questionnaire used is a modified version of Glasgow Children’s Benefit Inventory (GCBI), a post intervention, health-related benefit measure. Results: Forty-four questionnaires were returned (32.2% response rate). Four questionnaires were declared invalid. Two parents reported worsening of a few symptoms, resulting in a negative score. In the remainder the total score ranged from 2.08 to 91.6. Conclusions: Sixty-eight percent of the parents were extremely satisfied after the surgery. Overall the parents reported change for the better in various observed aspects of the life of their children as reflected in the positive scores after intervention. Most of them reported decreased number of visits to the doctor and decreased need for antibiotic prescription i.e. there was an improvement in the ‘physical health’ aspect of the life of children. But, there was no change observed in the ‘emotional and psychosocial’ aspect of behavior in children.

Keywords: Quality-of-life, tonsillectomy, children

onsillectomy and adenotonsillectomy are common surgical procedures performed in children. But, their indications are still variable and differ from center-to-center. In the past, the most frequent indication for surgery was recurrent tonsillitis. There has been a rise in obstructive sleep apnea as a significant indication from 0% in 1978 to 19% in 1986.1 Various studies have studied the effect of tonsillectomy in children suffering from upper airway obstruction. This study was designed to study the effect of tonsillectomy on the quality-of-life (QoL) of children, with the idea

*Associate Professor **Professor †Professor and Head Dept. of ENT University College of Medical Sciences and GTB Hospital, New Delhi Address for correspondence Dr Neelima Gupta A-304, Abhyant Apartments 2, Vasundhara Enclave, New Delhi - 100 096 E-mail: write2drneelima@yahoo.com

that the beneficial effects of tonsillectomy could be ascertained and more pertinent recommendations for surgery may be formulated. As far as our knowledge goes, there are very few Indian studies that have studied the effect of tonsillectomy on QoL of children. Methodology Study design: Retrospective study. Study area: Children operated for tonsillectomy or adenotonsillectomy in a hospital setting. Case selection: One hundred thirty-six children consecutively operated over a period of two years were selected from records. Twelve years was taken as the upper age limit. Questionnaires were mailed to all of them with a self-addressed envelope. Only 44 parents returned questionnaires (response rate of 32%). Out of the respondents the age group of children ranged from four years to 12 years with the mean being 8.45 years. The male female ratio was 1.2:1.

Asian Journal of Ear, Nose and Throat, January-March 2013

Original article We adapted the questionnaire from the Glasgow Children’s Benefit Inventory (GCBI), which has 24 questions on the consequences of a specified intervention on various aspects of the child’s day-to-day life, without reference to any specific symptoms.2 The questionnaire was modified and translated in to Hindi (mother tongue) and was pre-tested among a group of parents prior to its administration. It was also tested for its consistency and internal validity. We also added one question (Question number 25), which asked for the parents overall satisfaction with the intervention. The questionnaire was self-administered and was filled-up by either parent of the operated child. The questions were worded to apply to child of any age. The pattern of responses assesses the child’s QoL in terms of emotion, physical health, learning and vitality. For each question, a response was given on a 5-point Likert type rating scale, with the central point being ‘no change’ and the extremes representing ‘much better’ and ‘much worse’. Assigning the individual responses a numerical value from –2 to +2, adding the total score and dividing by 24, calculated a summary score for the questionnaire. The score was multiplied by 50 to produce a result on a scale from –100 (maximum harm) to + 100 (maximum benefit). Observation and Results Forty-four questionnaires were returned out of 136. Four were declared invalid since a few questions were unanswered in these forms. On calculating the scores, two questionnaires had a negative score of –8.33 and –20.83. The rest had positive scores ranging from 2.08 to 91.6. Responses related to questions pertaining to selfconsciousness, embarrassment, easy distraction, selfesteem, confidence and self-care addressing the factor of ‘emotion’ were mostly responded to as ‘no change’. Similarly, the questions assessing change in learning, concentration, liveliness, fun with friends and leisure activities addressing the factors of ‘learning’ and ‘vitality’ were responded to as ‘no change’. Questions relating to overall life, absences from school, colds, visit to the doctor and need for antibiotic prescriptions, addressing the factor of ‘physical health’ were uniformly answered with ‘much better’ as shown in Table 1, which shows the number of parents who gave a particular response. The figures in bold indicate that this is the response ticked by the maximum number of parents. No statistically

Asian Journal of Ear, Nose and Throat, January-March 2013

significant difference was observed in responses regarding change in food habits; sleep pattern, learning and progress of the child; as they were either answered with ‘little better’ or ‘no change’. Limitations of the study: Ideally, a pre- and postcomparison on QoL of the patients should have been done, but due to logistic constraints a comparative study could not be undertaken. Similarly, no matched control group of unoperated children was available. The attrition rate was very high, as only 32% respondents returned the filled up questionnaire may be because of the socioeconomic background, lack of permanent addresses and literacy level constraints of our population. But, considering that there are few Indian studies in this area, our findings add substantively to the existing knowledge regarding impact of tonsillectomy on the QoL of the children. Discussion As decisions concerning resource allocation become increasingly stringent it is important to understand the personal impact of diseases and their treatment beyond the standard medical morbidity or functional limitations so that this can be incorporated into the decision-making process. This has led to studies pertaining to outcome measures and effect of disease and management on QoL. On review of literature we encountered various studies that assessed the QoL before and after an intervention. We used a retrospective measure of assessment of QoL after tonsillectomy. The advantages of the retrospective approach are that it halves the burden of questionnaires for the parents, it is much more sensitive to change, and it can be used in conditions for which a sizeable cohort of patients can take years to build up.2 It has been shown in a few studies that trials commonly use serial measurements by the patients at two points in time while clinicians use the patient’s retrospective assessment of change made at one point in time. Retrospective measures were found to be more sensitive to change than serial measures and correlated more strongly with patient’s satisfaction with change.3 Therefore, we chose to use a retrospective measure. Paradise and Bluestone et al4 studied the efficacy of tonsillectomy for recurrent throat infection in 187 children in randomized as well as nonrandomized trials. They found that tonsillectomy with or without adenoidectomy was unequivocally effective for two years, and probably for one more year in reducing the

Original article frequency and severity of episodes of throat infection. Differences between the treatment groups in regard to secondary outcome measures such as number of visits on which isolated cervical lymphadenopathy was found, number of parent reported sore-throat days and school absent days due to sore-throat, were less clear cut and of uncertain clinical importance. In our study, majority of parents reported decrease in visits to the doctor, improvement in school attendance and decrease in episodes of cold. Our study has a follow- up of only six months; so, we have not studied infection rate following tonsillectomy.

excessive daytime sleepiness and QoL postoperatively. Parental reporting of asthma, bedwetting, concentration, school performance and intellectual or developmental progress were not statistically different between the two groups.5 In our analysis also 67.5% of the parents observed â&#x20AC;&#x2DC;no changeâ&#x20AC;&#x2122; in level of concentration or intellectual progress of the child after intervention. Ali and his group6 concluded from their study on 33 children, that following surgery relief of mildto-moderate sleep-disordered breathing improves behavior and functioning. In our study, 50% of the parents said they had observed no change in behavior of the child after surgery while 30% said that the behavior had changed for the better. Pediatricians and otolaryngologists should advice parents that adenotonsillectomy most likely results in improvement

In a study comprising of 138 children, compared with children who had not undergone adenotonsillectomy, parents of the adenotonsillectomy group more frequently reported improvement in breathing, snoring,

Table 1. Number of Responses to the Questions Assessing Various Aspects of QoL Question

Much better

Little better

No change

Little worse

Much worse

Overall life

Things they do

Behavior

Progress and development

Liveliness

Sleep

Food

Self-consciousness

Family harmony

Fun with friends

Embarrassment

Distractibility

Learning

Absences from school

Concentration

Irritability

Self-esteem

Happiness

Confidence

Self-care

Leisure

Colds

Visits to doctor

Need for medication

Overall satisfaction

The figures in bold indicate the response given by maximum number of parents.

Asian Journal of Ear, Nose and Throat, January-March 2013

Original article in breathing, sleep and QoL but should be guarded in promising improvement in behavior and development. Some studies have shown improvement in all aspects of the life of children. Goldstein7 in a pilot study demonstrated a high prevalence (28%) of abnormal behavior in children undergoing T & A for chronic upper airway obstruction. The Child Behavior Checklist (CBCL) scores significantly improved following T & A. Subclasses that showed improvement were withdrawn behavior, somatic complaints, attention problems and thought problems. Similarly De Serres et al8 in their study of 101 children found large, moderate and small improvements in QoL in 74.5%, 6.1% and 7.1% of children, respectively. Sleep disturbance, caregiver concern and physical suffering were the most improved domains, although significant changes also occurred for speech and swallowing problems, emotional disturbance and activity limitations. However, in our study 57.5% and 67.5% parents observed no change in the child’s activities and his interaction with friends, respectively as shown in Table 1. In their study on 64 children who underwent tonsillectomy, Goldstein et al9 found that behavioral and emotional difficulties are found in children with sleep disordered breathing before treatment and improve after intervention. They used the CBCL total problem T scores as their outcome measure. Flanary10 studied both short-term and long-term effect of adenotonsillectomy on general and disease specific QoL in children suffering from upper airway obstruction secondary to adenotonsillar hypertrophy. This study used both Children’s Health Questionnaire Parent Form-28 and OSA-18 QoL measures and found that CHQPF-28 psychosocial summary scores did not show significant improvement in the short-term or longterm results. Mitchell11 also confirmed that caregiver concerns were reduced after tonsillectomy and the domain with the most significant improvement was sleep disturbance while least improvement was seen in emotional distress. We observed in our study that 42.5% parents reported ‘a little better’ sleep pattern in their children while 27.5% parents observed no change in sleep pattern. Conclusion Tonsillectomy definitely leads to an improvement in the QoL in children and 68% of parents were extremely satisfied with the surgical outcome. Almost all the parents reported decrease in visits to the doctor and in antibiotic prescription but there were no significant changes observed in the emotional aspects and personality of the children. The low response rate led

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to a small sample size so we could not apply any tests of statistical significance. A control group of children who are followed-up with no surgical intervention will help in concluding that improvement is because of the surgical intervention. Also, our results can only give insight into short-term QoL improvements because we thought that if we send the questionnaires any later it will lead to further reduction in response rate. However, these limitations not withstanding we conclude that tonsillectomy has a positive impact on QoL of children. References 1. Rosenfeld RM, Green RP. Tonsillectomy and adenoidectomy: changing trends. Ann Otol Rhinol Laryngol 1990;99(3 Pt 1):187-91. 2. Kubba H, Swan IR, Gatehouse S. The Glasgow Children’s Benefit Inventory: a new instrument for assessing healthrelated benefit after an intervention. Ann Otol Rhinol Laryngol 2004;113(12):980-6. 3. Fischer D, Stewart AL, Bloch DA, Lorig K, Laurent D, Holman H. Capturing the patient’s view of change as a clinical outcome measure. JAMA 1999;282(12):1157-62. 4. Paradise JL, Bluestone CD, Bachman RZ, Colborn DK, Bernard BS, Taylor FH, et al. Efficacy of tonsillectomy for recurrent throat infection in severely affected children. Results of parallel randomized and nonrandomized clinical trials. N Engl J Med 1984;310(11):674-83. 5. Constantin E, Kermack A, Nixon GM, Tidmarsh L, Ducharme FM, Brouillette RT. Adenotonsillectomy improves sleep, breathing, and quality of life but not behavior. J Pediatr 2007;150(5):540-6, 546.e1. 6. Ali NJ, Pitson D, Stradling JR. Sleep disordered breathing: effects of adenotonsillectomy on behaviour and psychological functioning. Eur J Pediatr 1996;155(1): 56-62. 7. Goldstein NA, Post JC, Rosenfeld RM, Campbell TF. Impact of tonsillectomy and adenoidectomy on child behavior. Arch Otolaryngol Head Neck Surg 2000;126(4):494-8. 8. De Serres LM, Derkay C, Sie K, Biavati M, Jones J, Tunkel D, et al. Impact of adenotonsillectomy on quality of life in children with obstructive sleep disorders. Arch Otolaryngol Head Neck Surg 2002;128(5):489-96. 9. Goldstein NA, Fatima M, Campbell TF, Rosenfeld RM. Child behavior and quality of life before and after tonsillectomy and adenoidectomy. Arch Otolaryngol Head Neck Surg 2002;128(7):770-5. 10. Flanary VA. Long-term effect of adenotonsillectomy on quality of life in pediatric patients. Laryngoscope 2003;113(10):1639-44. 11. Mitchell RB, Kelly J, Call E, Yao N. Quality of life after adenotonsillectomy for obstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg 2004;130(2):190-4.

case report

Congenital Choanal Atresia SusanK Sebastian, Devjani Choudary, Payal Garg, Vipin Kamboj

Abstract Bilateral choanal atresia presents with respiratory distress and feeding difficulty in newborns. We are reporting a case of bilateral bony choanal atresia in a neonate. Computed tomography (CT) confirmed the clinical diagnosis. This baby also had a ventricular septal defect with left to right shunt. Endoscopic surgical correction with stenting was done. Nasal airway was well-established and feeding problems were corrected following the procedure.

Keywords: Nasal endoscopy, drilling

ongenital choanal atresia is due to congenital closure between the nasal cavity and pharynx. Bilateral choanal atresia is suspected when a new born infant presents with respiratory distress and cyanosis relieved by crying. Early surgical management is indicated in bilateral cases as soon as the general condition of the infant is stabilized.

CASE REPORT A 2.52 kg neonate girl was born to Gravida 1 Para 1 mother following full-term normal delivery at St. Stephen’s Hospital, New Delhi, Apgar score at the time of birth was 9,9,9. Soon after birth the baby developed respiratory distress with cyanosis and her arterial partial pressure oxygen (PaO2) dropped to 88% at room air. A size 5 French suction catheter could not be passed thorough the nares to nasopharynx. Baby was immediately resuscitated and shifted to neonatal intensive care unit. Clinical examination of the baby revealed an active vigorous girl with intermittent cyanosis. Respiratory rate was 46-50/minute and chest was bilaterally clear. But, the baby continued to develop intermittent respiratory distress with labored breathing, cyanosis and fall in oxygen saturation. These episodes would resolve spontaneosly with the baby turning pink on

Dept. of ENT St. Stephen’s Hospital, New Delhi - 110 054 E-mail:drsusanjohn@rediffmail.com

crying. Respiratory distress was precipitated whenever oral feeding was attempted. Hence orogastric feeding was started, which the baby tolerated well. Chest X-ray was normal. Routine blood investigations were done. Echocardiogram confirmed a small ventricular septal defect (VSD) with left to right shunt. No other abnormalities were detected on detailed systemic examination. Eyes and ears were found to be normal. With a provisional diagnosis of choanal atresia, a high-resolution computed tomography (HRCT) scan of nose and pharynx was done, which revealed bilateral choanal atresia with thick bony obstruction more on the left side (Fig. 1). Mouth breathing was encouraged by a nipple secured in mouth. Orogastric tube feeding was continued. In spite of these conservative measures, no significant improvement in spontaneous nasal breathing and oral feeding could be achieved. Hence, surgical repair was planned. Choanae were reconstructed by transnasal endoscopic approach. Intraoperatively the diagnosis was confirmed by examination with a 0° 2.7 mm nasal endoscope. Both choanae were found to be completely blocked by bony atretic plates. A number 6 uretheral sound could not be passed. After packing the nasopharynx, posterior septal flaps were elevated. Posteroinferior part of the bony septum was removed using otologic drill and curettes and continued until the posterior choanae were opened. Drilling was confined to posterior, medial and inferior part of the nasal cavity. Flaps were reposited and a 3 number endotracheal tube fashioned

Asian Journal of Ear, Nose and Throat, January-March 2013

case report nasopharynx. First described in 1,755 by Roederer, it has an incidence of one in 6,000-8,000 births.1 Obstruction may be membranous in 10% or bony in 90% of cases. About 65-75% is unilateral. Seventy-five percent of bilateral cases are associated with other anomalies.2 The most frequent anomalies being CHARGE syndrome, Downâ&#x20AC;&#x2122;s syndrome and Treacher Collinâ&#x20AC;&#x2122;s syndrome. Bilateral bony atresia was present in this baby with a small ventricular septal defect but other abnormalities were absent. Pathophysiology has been attributed to persistence of the buccopharyngeal membrane, failure of bucconasal membrane of Hochstetter to rupture, medial outgrowth of the vertical and horizontal processes of the palatine bone and mesodermal adhesion formation in the choanal region.3

Figure 1. Bilateral choanal atresia with thick bony obstruction.

Figure 2. Right choana.

Figure 3, Left choana.

Newborn baby is an obligate nasal breather until 4-6 weeks. Bilateral choanal atresia produces complete nasal obstruction and can lead to aspiration and asphyxiation in early life. Cycles of respiratory obstruction and cyanosis relieved by crying is suggestive of this condition. Further, these episodes get precipitated while feeding and during sleep. At this point, emergency care is by inserting an oral airway. Inability to pass a 5F catheter through the nostrils to nasopharynx will prove the diagnosis. This can be further confirmed by a flexible nasopharyngoscopy and CT scanning. HRCT is the investigation of choice in the diagnosis and evaluation of congenital choanalatresia.4 CT scan helps the surgeon to assess the type of atresia, thickness of atresia, other causes of nasal obstruction like amid nasal stenosis and abnormalities of the skull base. CT scan of this baby revealed bilateral bony obstruction and was useful in planning further treatment.

DISCUSSION

Several procedures like, transnasal, transpalatal and transseptal approaches have been described for the repair of choanal atresia.5 The objective of repair is to correct the anatomical abnormality and provide a good long-term nasal airway with least interference to the surrounding structures. With the availability of pediatric nasal endoscopes and microsurgical drilling devices transnasal endoscopic approach has gained popularty.6,7 Nasal endoscope allows the surgeon to have excellent visualization of atretic plate while drilling. Hence, operating time is shorter and the blood loss is less.8

Congenital choanal atresia is a developmental failure of posterior nasal cavity to communicate with the

Postoperative stenting using silastic or portex endotracheal tubes is recommended fora minimum

as a stent was kept in both nasal cavities and secured in place. Stent was removed after four weeks. Nasal endoscopy four weeks after surgery revealed bilateral patent choanae with minimal edema of the flap on left side (Figs. 2 and 3). Child is under regular follow-up and is able to breathe through the nose and breastfeed without any distress.

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case report period of four weeks.9 Postoperative medical treatment includes nasal decongestants, saline nasal spray and antibiotics to deal with bacterial rhinitis. Good care of the stent and removal of granulation tissue and follow-up examination with endoscopes also play a major role in postoperative management. Meticulous postoperative care greatly influences the success of the surgical procedure.9 conclusion CT is the definitive investigation in case of congenital choanal atresia. Early surgical repair is indicated in bilateral choanal atresia. Transnasal endoscopic repair provides excellent results.

edition, Part 2, Pediatric Otorhinolaryngology. Clarke R (Ed.), Edward Arnold Publishers 2008:p.1070-2. 3. Tewfik TL, Meyers AD. Choanal atresia. Emedicine. medscape.com/article/872409-overview#ao104. Accessed on 2/6/2012. 4. Hasegawa M, Oku T, Tanaka H, Watanabe I, Suzuki S. Evaluation of CT in the diagnosis of congenital choanal atresia. J Laryngol Otol 1983;97(11):1013-5. 5. Winther LK. Congenital choanal atresia. Arch Dis Child 1978;53(4):338-40. 6. Eladl HM. Transnasal endoscopic repair of bilateral congenital choanal atresia: controversies. J Laryngol Otol 2010;124(4):387-92.

References

7. Winther LK. Congenital choanal atresia. Anatomic, physiological, and therapeutic aspects, especially the endonasal approach under endoscopic vision. Arch Otolaryngol 1978;104(2):72-8.

1. Gordon CB, Mandees EK. Mathes Plastic Surgery. 2nd edition, Vol. 3, Part 2, Saunders, Elsevier 2006:p.763-4.

8. Panda NK, Narang A, Srinivas S. Bilateral congenital choanal atresia. Indian J Pediatr 2002;69(10):917-20.

2. Wyatt M. Nasal obstruction in children. Scott-Brownâ&#x20AC;&#x2122;s Otorhinolaryngology, Head and Neck Surgery. 7th

9. Sadek SA. Congenital bilateral choanal atresia. Int J Pediatr Otorhinolaryngol 1998;42(3):247-56.

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case report

A Case Report on Primary Nasal and Nasopharyngeal Tuberculosis with Review of Literature P Kiran Kumar*, Kalpana Sharma**, Anandita Das†, Himajit Kumar Barman†

Abstract Tuberculosis (TB) is a serious, worldwide disease that affects people in many developing countries. TB involvement of the nose, nasopharynx and paranasal sinuses is extremely rare and constitutes 2-6% of extrapulmonary TB. The following is a case report of primary nasopharyngeal TB with unusual presentation.

Keywords: Tuberculosis

uberculosis (TB) is a serious, worldwide disease that affects people in many developing countries and one of the leading cause of death. There has been a steady increase in the number of reported TB cases. Several factors are to be responsible for the recent resurgence of TB. The aquired-immunodeficiency syndrome (AIDS) epidemic is thought to play a significant role. Extrapulmonary TB has likewise dramatically increased. Extrapulmonary TB occurs in 15% of all patients. This is rarely infectious and typically contains bacterial counts lower than that found in cavitatory pulmonary disease. Tuberculous involvement of the nose, nasopharynx and paranasal sinuses is extremely rare and constitutes 2-6% of extrapulmonary TB and 0.1-1% of all forms of TB.1,2 Nasal TB occurs mainly from the hematogenous or lymphatic extension of pulmonary TB. Primary nasopharyngeal TB probably occurs due to reactivation

*Postgraduate Trainee **Associate Professor †Registrar Dept. of ENT, Guwahati Medical College, Guwahati, Assam Address for correspondence Dr Kalpana Sharma Associate Professor, Dept. of ENT Ashirwad Apartment Basisthapur, Byelane-3, Beltola, Guwahati, Assam - 781 028 E-mail: kalpanasharmak@yahoo.co.uk

Asian Journal of Ear, Nose and Throat, January-March 2013

of dormant acid-fast bacilli (AFB) in the adenoids or due to direct mucosal infection after inhalation of the bacilli.3 Primary nasal TB is much rarer but can happen when the nasal mechanism of mucociliary clearance and lysosomal bactericidal activity fail such as in cases of trauma or atrophic changes.4 We report a rare case of primary nasal TB with extension into the nasopharynx in an immunocompetent adult female. Case report A 35-year-old patient presented to the Dept. of Otolaryngology, Guwahati Medical College, Guwahati with the complaints of nasal blockage since six months and nasal discharge with occasional bleeding per nose since six months. Nasal blockage was progressive and more on the right side. There was associated bleeding per nose infrequently, mild in amount and associated with mucoid discharge. There was history of headache, fever, weight loss and difficulty in swallowing, which was more for solid. There was no history of trauma. On general examination, the patient was cachectic and had pallor and cervical lymphadenopathy. On anterior rhinoscopy, a pale fleshy mass was seen in the right nostril, which was not sensitive to touch and did not bleed on touch. On examination, of the oral cavity, the mass was seen extending to the oropharynx through the nasopharynx and producing a bulge in the palate.

case report Routine investigations showed hemoglobin (Hb) (-5.4 g/dl). Erythrocyte sedimentation rate (ESR) was raised. Chest X-ray was normal. Mantoux test was negative. Sputum for AFB was negative. VDRL and HIV tests were negative. Computed tomography (CT) scan PNS showed a polyploidal mass in the nasal cavity, nasopharynx and oropharynx extending to the right pyriform sinus. There was no invasion of adjacent structures.

Figure 1. Photogragh showing oropharyngeal extension.

Biopsy was taken from the nasal mass and the oral cavity mass. The histopathology showed epitheloid granulomas as well as Langhanâ&#x20AC;&#x2122;s giant cells and epitheloid cells. Fine-needle aspiration cytology (FNAC) from the lymph node was suggestive of reactive hyperplasia. Since, our patient did not have pulmonary involvement and appearance of reactive cervical lymph nodes after the primary symptoms of nasal destruction, epistaxis and nasal discharge; it is likely that this is a case of primary nasal and nasopharyngeal TB. The patient was started on four drug regimen of isoniazid, rifampicin, ethambutol and streptomycin. The patient responded to the treatment. The nasal mass has regressed. The patient is currently in follow-up. Discussion Tuberculosis is a pulmonary disease caused by Mycobacterium tuberculosis. However, the disease can affect the nose as an extension from the pulmonary infection or rarely, primarily. In the head and neck region, 80-90% of the nonpulmonary TB is found. Nasal involvement with TB was first described in 1761 by Giovanni Morgagni.5

Figure 2. CT showing the extent of the mass.

Figure 3. Photograph showing regression of mass.

Primary involvement of the nose is uncommon. It is most often associated with either pulmonary TB or lupus vulgaris of the facial skin. Fewer than 50 cases have been reported in the literature to date. It is believed to be caused by either inhalation of infectious particles or direct inoculation from a contaminated finger. The relatively low incidence of primary nasal TB is thought to be related to protective functions of the nose including ciliary movement, the bactericidal action of nasal secretions and the filtering effect of the nasal vibrissae. The probable importance of an intact mucosal epithelium in providing protection against the infection has support from the observation of Abbott et al who were able to isolate the tubercle bacilli from the mouth washings of 44.9% of the patients with active pulmonary TB.6

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case report Nasal TB have been reported in patients between the ages of 11 and 84 years, with presenting symptoms like nasal obstruction, anterior and posterior nasal discharge, nasal discomfort, epistaxis, crusting, epiphora, recurrent nasal polyps and ulceration. Cervical lymphadenopathy is a common accompaniment.7 Endoscopic examination may reveal a polyploidal mass, ulceration, plaque or diffuse mucosal thickening.8-10 A recent review report of 36 cases shows a predominance of middle-aged women, which is similar to our case.11-14 Diagnosis is made by identifying TB bacteria from tissue. Histology demonstrates both caseating and noncaseating granulomas, with a greater number of epitheloid cells and Langhans giant cells than in other granulomas. Microscopy demonstrates ASF with Z-Z-N or auramine-rhodamine fluorescent staining. Newer diagnostic tools such as polymerase chain reaction (PCR), DNA probes, HPLC, hold promise; however, they are not widely available and are too expensive for routine use.6 Nasal TB is extremely rare and other forms of granulomatous diseases must also be considered. In our patient, clinical findings (epistaxis and progressive nasal obstruction) and CT findings (proliferative nasal mass with nasopharyngeal and extensive oropharyngeal extension pushing the palate forwards) and the age group of the patient suggested a malignancy. But, a comprehensive diagnosis was made possible on the basis of: ÂÂ

Compatible histopathology appearance of biopsied tissue

ÂÂ

Demonstration of AFB on biopsy specimen.

diagnosis of TB, our final diagnosis was not established until the histopathology examination and the diagnosis was confirmed by the patient’s rapid response to antitubercular treatment. References 1. Lau SK, Kwan S, Lee J, Wei WI. Source of tubercle bacilli in cervical lymph nodes: a prospective study. J Laryngol Otol 1999;105(7):558-61. 2. Rohwedder JJ. Upper respiratory tract tuberculosis. Sixteen cases in a general hospital. Ann Intern Med 1974;80(6):708-13. 3. Sithinamsuwan P, Sakulsaengprapha A, Chinvarun Y. Nasopharyngeal tuberculosis: a case report presenting with diplopia. J Med Assoc Thai 2005;88(10):1442-6. 4. Singh AP, Malhotra V, Brar T, Agarwal AK, Khurana N. Primary tuberculosis of nose with intracranial extension: a rare presentation. Indian J Tuberc 2010;57(4):220-2. 5. Waldman SR, Levine HL, Sebek BA, Parker W, Tucker HM. Nasal tuberculosis: a forgotten entity. Laryngoscope 1989;91(1):11-6. 6. Abbott JN, Briney AT, Denaro SA. Recovery of tubercle bacilli from mouth washings of tuberculous dental patients. J Am Dent Assoc 1955;50(1):49-52. 7. Waldron J, Van Hasselt CA, Skinner DW, Arnold M. Tuberculosis of the nasopharynx: clinicopathological features. Clin Otolaryngol Allied Sci 1992;17(1):57-9. 8. King AD, Ahuja AT, Tse GM, van Hasselt AC, Chan AB. MR imaging features of nasopharyngeal tuberculosis: report of three cases and literature review. AJNR Am J Neuroradiol 2003;24(2):279-82. 9. Tas E, Sahin E, Vural S, Turkoz HK, Gursel AO. Upper respiratory tract tuberculosis: our experience of three cases and review of article: Int J Otorhinolaryngol 2007;6:1.

The least invasive investigation for diagnosis is Mantoux test, which is usually positive in TB but a negative test does not rule out the disease as in our case. The ESR may be elevated, as was in our case and thus it is a good therapeutic indicator, though not specific.

10. Johnson JT, Yu VL (Eds.). Infectious Diseases and Antimicrobial Therapy of Ear, Nose and Throat. 1st edition, WB Saunders Company: Philadelphia 1997:p.206.

The treatment of nasal TB follows the same guidelines established for extrapulmonary TB. Therapeutic courses are approximately six months, with an initial two month course of four different antitubercular drugs, followed by four additional months of a two drug antibiotic course. As our patient did not exhibit any other symptoms that would have suggested a

12. Sharan R. Primary tuberculosis of the nose. Practitioner 1981;225(1360):1506-7.

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11. Butt AA. Nasal tuberculosis in the 20th century. Am J Med Sci 1997;313(6):332-5.

13. Dixit R, Dave L. Primary nasal tuberculosis. Lung India 2008;25(2):102-3. 14. Nayar RC, Al Kaabi J, Ghorpade K. Primary nasal tuberculosis: a case report. Ear Nose Throat J 2004;83(3): 188-91.

case report

Unusual Presentation of Lipoma: A Case Report Suryapratap Singh

Abstract Lipoma is a benign tumor of adipose tissue and one of the most common benign neoplasms of the body. However, its occurrence in oral cavity is very rare. It accounts for 90-91% on the trunk and proximal portions of the extremities and only 1-4% of benign neoplasms of mouth affecting predominantly the buccal mucosa, floor of mouth and tongue. Here, we present a case of an intraoral lipoma in a 30-year-old male patient. After three years follow-up, the patients showed no signs of recurrence.

Keywords: Adipocytes, lipoma, oral, surgery

ipomas are the most common soft tissue mesenchymal neoplasms, with 15-20% of cases involving the head and neck region and only 1-4% affecting the oral cavity.1 A lipoma in the mouth is an asymptomatic slowly growing rare benign tumor of mesenchymal origin consisting of fat.1 It may present in various forms, as a sessile or pedunculated and single or lobulated tumor of variable sizes although mostly below 3 cm diameter, and generally surrounded by a fibrous capsule. The first description of an oral lesion was provided in 1848 by Roux in a review of alveolar masses, where he referred to it as a ‘yellow epulis’.2

Case Report A 30-year-old male patient presented in Dept. of Surgery with a round nodule in the right region of the mouth (Fig. 1). The patient informed that the tumor had grown within the last six months, which affected chewing and speech but was painless. An intraoral smooth well-defined sessile nodule of similar color to the surrounding mucosa was observed in the mucosa, a little above the alveolar ridge; it measured about 2.5 × 1.5 cm in size. Radiography

The etiology of lipoma is uncertain; some authors have suggested endocrine, traumatic and hereditary causes.1 The diagnosis is made by pathology of an incisional or excisional specimen. An important feature is that the tumor tends to float when placed in a 10% formaldehyde solution.1 Treatment consists of conservative surgical removal of the lipoma; recurrences are rare. The purpose of this study was to report a case of a patient with an oral lipoma; treatment consisted of surgical excision. The study includes a case report and a review of the literature.

Dept. of Traumatology, Surgery and Neurosurgery NMCH, Nellore

Figure 1. Preoperative presentation of intraoral lipoma at buccal mucosa.

Asian Journal of Ear, Nose and Throat, January-March 2013

case report The pathogenesis of lipoma is uncertain, but they appear to be more common in obese people. However, the metabolism of lipoma is completely independent of the normal body fat. If the caloric intake is reduced, lipoma does not decrease in size, although normal body fat may be lost. Lipomas are adipose mesenchymal neoplasms that rarely occur within oral cavity (1-4%). Lipids unavailable for metabolism7 coupled with the autonomous growth of a lipoma have rendered it to be a true benign neoplasm.8 Lipomas are slowly enlarging, with a soft, smoothsurface mass of the submucosal tissues. When it is superficial, there is a yellow surface discoloration. The lesion may be pedunculated or sessile and occasional cases show surface bosselation.4

Figure 2. Histopathology of specimen showing fat cells.

revealed no bone involvement. An excision biopsy was carried out (Fig. 2). Microscopically, these tissues revealed sheets of mature fat cells containing clear cytoplasm and eccentric nucleus, with no evidence of cellular atypia or metaplasia, which confirmed that it was a lipoma. The tumor was placed in 10% formaldehyde, where it floated, suggesting fat content. The patient is currently being monitored and so far no recurrence has occurred. Discussion Lipomas of the mouth are benign tumors; they grow slowly, do not infiltrate other tissues, do not ulcerate, and are painless. The cheek is the commonest site of occurrence in the intraoral cavity followed by tongue, floor of the mouth, buccal sulcus and vestibule, palate, lip and gingiva.3 This pattern corresponds closely to the quantity of fat deposit in the oral cavity. They are relatively rare in the mouth and the maxillofacial region.1,4 According to the literature, mouth lipomas are distributed evenly between sexes; most of these patients are aged over 40 years.5 The case is similar to other published reports, as the patient was aged 57 years. Generally, their prevalence does not differ with gender, although a predilection for men has been reported5 and they occur most often in patients older than 40 years.6

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Multiple lipomas of head and neck have been observed in neurofibromatosis, Gardner syndrome, encephalocraniocutaneous lipomatosis, multiple familial lipomatosis and proteus syndrome. Generalized lipomatosis have been reported to contribute to unilateral facial enlargement in hemifacial hypertrophy.9 Although its etiology is unknown, possible causes may include trauma, infection, chronic irritation and hormone alterations.5 In few cases of lipoma, rearrangement of 12q, 13q, 6p chromosomes have been observed.2 Clinically, oral lipomas generally present as mobile, painless submucosal nodules, with yellowish tinge, as observed in our cases. In some cases, oral soft tissue lipomas can present as a fluctuant nodule. Because of these clinical features, other lesions, such as oral dermoid and epidermoid cysts and oral lymphoepithelial cysts must be considered in the differential diagnosis of oral lipomas.10 Also, most oral lymphoepithelial cysts are found on the floor of the mouth, soft palate and mucosa of the pharyngeal tonsil,11 which are uncommon sites for oral lipomas. Oral dermoid and epidermoid cysts also present as submucosal nodules and, typically, occur on the midline of the floor of the mouth.12 However, oral dermoid and epidermoid cysts can occur in other locations of oral mucosa. Because an oral lipoma can occasionally present as a deep nodule with normal surface color, salivary gland tumors and benign mesenchymal neoplasms should also be included in the differential diagnosis.13 Definitive diagnosis depends on correlation between the histological and clinical features.14

case report The histopathology remains the gold standard in the diagnosis of lipoma. Lipomas are not very different in microscopic appearance from the surrounding fat. Like fat, they are composed of mature fat cells, but the cells vary slightly in size and shape and are somewhat larger, measuring upto 200 mm in diameter. Subcutaneous lipomas are usually thinly encapsulated and have distinct lobular patterns. Deep-seated lipomas have a more irregular configuration, largely depending on the site of origin. All are well-vascularized, but under normal conditions, the vascular network is compressed by the distended lipocytes and is not clearly discernible. Lipomas are occasionally altered by the admixture of other mesenchymal elements that comprise an intrinsic part of the tumor. The most common element is fibrous connective tissue, which is often hyalinized and may or may not be associated with the capsule or the fibrous septa. Lipomas with these features are often classified as fibrolipomas.15 Quite often, however, lesional fat cells are seen to ‘infiltrate’ into surrounding tissues, perhaps producing long thin extensions of fatty tissue radiating from the central tumor mass. When located within striated muscle, this infiltrating variant is called intramuscular lipoma (infiltrating lipoma), but extensive involvement of a wide area of fibrovascular or stromal tissues is best termed as lipomatosis. Occasional lesions exhibit excess numbers of small vascular channels (angiolipoma), a myxoid background stroma (myxoid- lipoma, myxolipoma), or areas with uniform spindle- shaped cells interspersed among normal adipocytes (spindle cell lipoma). When spindle cells appear somewhat dysplastic or mixed with pleomorphic giant cells with or without hyperchromatic enlarged nuclei, the term ‘pleomorphic lipoma’ is applied. When the spindle cells are of smooth muscle origin, the term myolipoma may be used. It is angiomyolipoma when the smooth muscle appears to be derived from the walls of arterioles. Rarely, chondroid or osseous metaplasia may be seen in a lipoma, which is described as chondroid lipoma, osteolipoma or ossifying lipoma. On occasions, lipomas of the buccal mucosa cannot be distinguished from a herniated buccal fat pad, except by the lack of a history of sudden-onset after trauma. Otherwise, lipomas of the oral and pharyngeal region are not difficult to differentiate from other lesions, although spindle cell and pleomorphic types of lipoma must be distinguished from liposarcoma.14 Most of these microscopic variations do not affect the prognosis, which is usually good.16

The treatment of oral lipomas, including all the histological variants is simple surgical excision. Although the growth of oral lipomas is usually limited, they can reach great dimensions, interfering with speech and mastication and reinforcing the need for excision.17 Surgical excision is the ideal treatment with rare recurrence as we did in our case. Conclusion Presented in this report is a case of intraoral lipoma in 30-year-old male. In referencing the literature to date, this type of case has been rarely documented. Solitary lipomas have enthused little interest in the past and have largely been ignored in the literature. The reason is that the most lipomas grow insidiously and cause few problems other than those of a localized mass. Approximately 15-20% of lipoma occurs in the head and neck region. Among the reported intraoral lipomas, 50% occur in the buccal mucosal region. Surgical excision is the ideal treatment with excellent outcome, however, complete resection should be emphasized as this is the key factor to avoid recurrence. It is therefore important to diagnose the lesion correctly in the physical examination and histopathology to establish the prognosis. Healthcare professionals need to understand this disease to treat it adequately. References 1. Fregnani ER, Pires FR, Falzoni R, Lopes MA, Vargas PA. Lipomas of the oral cavity: clinical findings, histological classification and proliferative activity of 46 cases. Int J Oral Maxillofac Surg 2003;32(1):49-53. 2. Rajendran R. Shafer’s Oral Pathology. 5th edition, Elsevier: Amsterdam 2006:p.194-5. 3. de Visscher JG. Lipomas and fibrolipomas of the oral cavity. J Maxillofac Surg 1982;10(3):177-81. 4. Cawson RA, Binnie WH, Speight PM, Barrett AW. Lucas’s Pathology of Tumors of the Oral Tissues. 4th edition, Churchill Livingstone: New York 1984:p.176-9. 5. Furlong MA, Fanburg-Smith JC, Childers EL. Lipoma of the oral and maxillofacial region: Site and subclassification of 125 cases. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004;98(4):441-50. 6. Epivatianos A, Markopoulos AK, Papanayotou P. Benign tumors of adipose tissue of the oral cavity: a clinicopathologic study of 13 cases. J Oral Maxillofac Surg 2000;58(10):1113-7; discussion 1118. 7. Vindenes H. Lipomas of the oral cavity. Int J Oral Surg 1978;7(3):162-6.

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case report 8. Miles DA, Langlais RP, Aufdemorte TB, Glass BJ. Lipoma of the soft palate. Oral Surg Oral Med Oral Pathol 1984;57(1):77-80.

13. Tan MS, Singh B. Difficulties in diagnosing lesions in the floor of the mouth - report of two rare cases. Ann Acad Med Singapore 2004;33(4 Suppl):72-6.

9. Lawoyin JO, Akande OO, Kolude B, Agbaje JO. Lipoma of the oral cavity: clinicopathological review of seven cases from Ibadan. Niger J Med 2001;10(4):189-91.

14. Gnepp DR. Diagnostic Surgical Pathology of the Head and Neck. 1st edition, Saunders: Philadelphia 2010:p.192.

10. Anavi Y, Gross M, Calderon S. Disturbed lower denture stability due to lipoma in the floor of the mouth. J Oral Rehabil 1995;22(1):83-5.

15. Weiss SW, Goldblum JR. Enzinger and Weissâ&#x20AC;&#x2122;s Soft Tissue Tumors. 5th edition, Mosby: Philadelphia 2007:p.571-639.

11. Flaitz CM. Oral lymphoepithelial cyst in a young child. Pediatr Dent 2000;22(5):422-3.

16. Neville B, Damm DD, Allen CM, Bouquot J. Oral and Maxillofacial Pathology. Saunders: Philadelphia 2008:p. 523-4.

12. Longo F, Maremonti P, Mangone GM, De Maria G, Califano L. Midline (dermoid) cysts of the floor of the mouth: report of 16 cases and review of surgical techniques. Plast Reconstr Surg 2003;112(6):1560-5.

Asian Journal of Ear, Nose and Throat, January-March 2013

17. Chidzonga MM, Mahomva L, Marimo C. Gigantic tongue lipoma: a case report. Med Oral Patol Oral Cir Bucal 2006;11(5):E437-9.

case report

Bilateral Antrochoanal Polyps in an Adult Female: A Rare Case P Verma*, N Jain*, M Arya**, L Vaid†, PP Singh†

Abstract Antrochoanal polyps are usually single, unilateral and more frequent in children and adolescents. We report a bilateral antrochoanal polyp in an adult female, which is a rare presentation.

Keywords: Bilateral antrochoanal polyp, functional endoscopic sinus surgery

ntrochoanal polyps are more frequent in children and young adults. They are usually unilateral and of infective in origin. It is a benign, solitary, polypoidal lesion, which arises from maxillary sinus and grows by extension, more commonly through the antral accessory ostium into middle meatus and then to the choana and nasopharynx. It is dumbbell-shaped and having three parts nasal, antral and choanal. It represents 3-6% among nasal polyposis in the general population. In this paper, we report a rare case of bilateral antrochoanal polyp in an adult female and discuss the etiology and management.

Case report A 25-year-old female patient presented to ENT OPD complaining of gradually increasing nasal obstruction in both nostrils for one year. Snoring, anosmia and feeling of lump in throat for last two months. Patient was treated by her general practitioner but showed no improvement. On clinical examination, there was complete bilateral nasal obstruction by soft tissue with mucopurulent

*Senior Resident **Junior Resident †Professor Dept. of Otorhinolaryngology University College of Medical Sciences and Guru Teg Bahadur Hospital, New Delhi Address for Correspondence Dr Lakshmi Vaid F-22, Kirti Nagar, New Delhi - 110 015 E-mail: prof.vaid@gmail.com

Figure 1. CT scan paranasal sinus (coronal and axial section), soft tissue density in both nasal cavity and maxillary sinus. Polyp of left nasal cavity extending into nasopharynx. Both side osteomeatal complex were widened and blocked.

Asian Journal of Ear, Nose and Throat, January-March 2013

case report discharge. The polyps were seen on both side nasal cavity arising from middle meatus area. On posterior rhinoscopy a polypoidal mass present in nasophrynx coming through left choana. General physical examination of patient was within normal limit. There was no personal or family history of allergy, asthma, diabetes and tuberculosis. Routine blood and urine examination was within normal limit. X-ray paranasal sinus, waters view showing opacity in the both maxillary antrum and nasal cavities. Computed tomography (CT) of the nose and paranasal sinus both axial and coronal cuts showed soft tissue opacification of bilateral maxillary sinus extending into bilateral nasal cavities and nasopharynx. Osteomeatal complex of both nasal cavities was widened and blocked. The polyps were removed under general anesthesia by functional endoscopic sinus surgery (FESS). The polyps were pale white in color and had smooth glossy surface. They were soft in consistency. The gross appearance showed that both polyps had three parts antral, nasal and choanal. All the three parts were removed transnasally. The patient had an uneventful postoperative course and was discharged from hospital after removal of bilateral anterior nasal pack on second postoperative day with no specific medication. Histological examination of the polyp showed them to be of inflammatory nature. Review of the patient at six months revealed no recurrence. Discussion Antrochoanal polyp is a large, fleshy, polyp, stalked, arises from maxillary sinus, pass through the ostium into the nasal cavity, choana and from there into the nasopharynx. Histologicaly, it is an inflammatory polyp with a ciliated columnar epithelial lining. The stroma is usually edematous and highly vascular, composed of loose connective tissue infiltrated with plasma cells. The antrochoanal polyp commonly occurring under 40 years age group with male-to-female ratio is about 2.3:1. They are usually unilateral. Prevalence of bilateral antrochoanal polyposis is very rare. On search of literature we found only four reported cases (Myatt et al, 1996; Basu et al, 2001; Sami et al, 2006; Yilmaz et al, 2007). Here, we represent a case of bilateral antrochoanal polyp in 25-year-old female with negative history of allergy and asthma.

Asian Journal of Ear, Nose and Throat, January-March 2013

The etiology of antrochoanal polyp remains obscure. It can be infectious or allergic. It is believed that an antrochoanal polyp develops as a complication of chronic antral disease, such as chronic sinusitis. The infectious polyp is characterized by nasal neutrophilia and purulent secretion. Other studies have suggested that a derangement in the metabolism of arachidonic acid, prostaglandins and leukotriens is implicated in the pathogenesis of nasal polyps. It is also recognized that inflammation associated with an allergic diathesis may lead to polypoid changes of the mucosa. Although nasal polyps are associated with analgesics-induced asthma, such a relationship between nasal polyp and nasal allergy has been reported by some authors. Cook et al1 found that 24% of patient with antrochoanal polyps had the aspirin sensitive asthma triad (aspirin sensitivity, nasal polyposis and bronchial asthma). He observed allergy by mean of in vitro test in patient of antrochoanal ployp. Earlier reports have even indicated that the histology of the antrochoanal ployp does not differ significantly from that of nasal polyp. Heck et al (1950) reported that 23.4% of antrochoanal polyp patients had allergy and he concluded that the formation of an antrochoanal polyp is rarely related to allergy. He noted that the antrochoanal polyp is less likely to contain eosinophils and mucous glands. Such histologic distinction could provide clues to the pathogenesis of the antrochoanal polyp. The antrochoanal polyp is generally accepted as a polyp that arises from the edematous antral mucosa. Numerous authors have reported on the clinical feature and origin of the antrochoanal polyp. As early as in 1906, Killian2 suggested that the antrochoanal polyp arises from the growth of a single antral polyp through the wide accessory ostium. He stated that physical factors such as nose blowing, sinus irrigation, and sinus inhalation could contribute to the propulsion of an antral polyp towards the nasal cavity. Later reports suggested developmental error, rupture of enlarged submucous gland with subsequent cyst formation, and expansion of an intrasinus intramural cyst as the mechanism of antrochoanal polyp formation. Berg et al3 demonstrate that antrochoanal polyps develop from an expanding intramural cyst within the maxillary sinus that herniated through the maxillary ostium into the middle meatus from which it extends along the floor of the nose into the nasopharynx. Mills4 on the other hand stated that polyp arises from blocked and ruptured acinous mucous glands. Taylor5 suggested that nasal polyps result from edematous hypertrophy of the respiratory epithelium,

case report rather from distention of glandular structures. Histology shows a respiratory epithelium over a normal basement membrane. The ultrastructure is grossly edematous and the cellular infiltrate is similar to ordinary polyps except that there is no eosinophilia. There is lots of controversy regarding origin of antrochoanal polyp, the close relationship between antrochoanal polyp and the maxillary sinus was first reported by Killian2 in 1906 when he traced the polyp from the nasopharynx to the region of the maxillary sinus ostium but not into the sinus cavity. Kubo mention that the choanal polyps originated from the maxillary sinus mucosa, just inside the ostium. Van Alyea6 found the antrochoanal polyps, in some patients to be attached to the lateral aspects of maxillary sinus with a fibrous or polypoidal pedicle. How and why this pedicle reached the ostium for further expansion into a choanal polyp, was not explained. Mills4 on the other hand, stated that the choanal polyps arises from blocked and ruptured acinous mucous glands during the healing process of a bacterial sinusitis, thus being the extension of a mucocele. In the study done by el-Guindy et al7 the findings regarding the site of origin of the antrochoanal polyp inside the maxillary antrum were that it arose from the medial wall of the maxillary antrum in five cases, from the lateral wall of the maxillary antrum in 14 cases and the site of origin was uncertain in five cases. Berg et al3 from his study of 15 cases of antrochoanal ployp is from the inferolateral wall of the maxillary sinus. In our previous study done in 2004 (IJLO) the site of origin was -7 from inferolateral wall, 2 from inferomedial wall, 2 from superomedial wall and one was having annular origin, out of 20 cases, in eight it was uncertain. Antrochoanal polyp removal by FESS is a safe and effective procedure in recent years. As stated by Kamel.8 Endoscopic surgery in antrochoanal polyp through the middle meatal antrostomy is advantageous as it insure complete removal of the antral part

and diseased mucosa without the need to perform Caldwell-luc antrostomy or inferior meatal antrostomy. It offers preservation of the healthy sinus mucosa for later epithelization. Conclusion Here we conclude, there were two polyps in both nasal cavities of separate infective origin in an adult female diagnosed as bilateral antrochoanal polyp and was completely removed by functional endoscopic sinus surgery. References 1. Cook PR, Davis WE, McDonald R, McKinsey JP. Antrochoanal polyposis: a review of 33 cases. Ear Nose Throat J 1993;72(6):401-2, 404-10. 2. Killian G. Origin of the choanal polyp. Lancet 1906;2: 81-2. 3. Berg O, Carenfelt B, Silfversward C, Sobin A. Origin of choanal polyp. Arch Otolaryngol Head Neck Surg 1988;114:1270-1. 4. Mills CP. Secretory cysts of the maxillary antrum and their relation to the development of antrochoanal polypi. J Laryngol Otol 1959;73(5):324-34. 5. Taylor M. Histochemical studies on nasal polypi. J Laryngol Otol 1963;77:326-41. 6. Van Alyea OE. Management of non-malignant growths in the maxillary sinus. Ann Otol Rhinol Laryngol 1956;65(3):714-22. 7. el-Guindy A, Mansour MH. The role of transcanine surgery in antrochoanal polyps. J Laryngol Otol 1994;108(12): 1055-7. 8. Kamel R. Endoscopic transnasal surgery in antrochoanal polyp. Arch Otolaryngol Head Neck Surg 1990;116(7): 841-3.

Asian Journal of Ear, Nose and Throat, January-March 2013

case report

Acinic Cell Carcinoma of the Parotid Subramaniam Vinayak Easweran*, Lokesh**, Raghvendra U†, Yuvraj‡, ManjuLA¶

Abstract Acinic cell carcinoma also known as: Acinar/acinous cell carcinoma is a rare salivary gland cancer (6-10%). Involves 3-13% malignancies involve the parotid; it arises also from other glands namely submandibular, minor salivary gland, rarely parapharyngeal spaces,1,2 pancreas and lung (which usually metastasizes). Acinic cell carcinoma usually occur bilaterally, it presents in younger median age. It is a slow growing, painless tumor. It affects females more than males. Facial nerve is spared. If it metastatizes it does so to the lung, bone, CNS, mediastinum, liver and brain.

Keywords: Acinic cell, parotid

cinic cell carcinoma is a rare salivary gland cancer.3 In the past, the malignant nature of this cancer was disputed and hence it was classified as an ‘acinic cell tumor’/benign ‘adenoma’, later due to high potential to recur and metastatize it came to be known as a malignant carcinoma (WHO). Acinic cell carcinoma are typically slow growing, low-grade (highly differentiated) neoplasms. Recurrences (8-60%), metastasis (7-29%) after 3-10 years are uncommon. Patients with lung metastasis have poor prognosis.

Case Report A 25-year-old male presented to the ENT OPD with history of swelling of the left side of the cheek since 2-3 years, which gradually kept increasing to attain the present size. Patient had no evidence of the facial nerve abnormality.

On Examination Swelling present on the left side of the cheek. Soft to firm on palpation, mobile, no rise of local temperature, facial never was normal.

Investigation *ENT Specialist **General Surgeon †Anesthesiologist Pandit General Hospital, Sirsi, North Karnataka ‡Radiologist ¶Pathologist Sirsi Scan Center, North Karnataka

Asian Journal of Ear, Nose and Throat, January-March 2013

Blood Examination Hemoglobin (Hb): 9.2 g/dl, WBC: TC: 5,100 cells/ mm3, DC:N-50%, L-40%, E-8%, M-2%, erythrocyte sedimentation rate (ESR)-31 mm/1st hour, BT-1 minute

case report 30 second, CT-3 minute 15 second, RBS-122 mg/dl, HIV-negative, HBS-negative. Ultrasound A well-defined rounded more predominantly cystic lesion of size 4.3 x 2.7 cm seen involving left parotid gland with internal solid component and internal septae. Soft tissue cystic neoplasm involving parotid gland-possibly benign.

FNAC ÂÂ

Gross: Three milliliter of slight reddish fluid aspirated.

ÂÂ

Micro: Blood stained smears shows many scattered lymphocytes, few neutrophils and ductal epithelial cells, few acini and cystic macrophages on background of proteinaceous material.

Steps of Surgery Patient intubated. Part cleaned and draped. A lazy S insicision taken on the affected side after giving local as

infiltration. Layers dissected, a cystic swelling indentified in the matter of superficial part of the parotid. Swelling and the superficial parotid gland excised and sent for histopathology. Facial nerve identified and preserved. Branch of the greater auricular nerve inadvertently cut. Suturing done in layers. Drain kept at the operated site for the three days. Patient tolerated ID gland tumors procedure well. Postoperatively period patient put on

Asian Journal of Ear, Nose and Throat, January-March 2013

case report injectable antibiotics, painkillers and antacids. Patient discharged on 4th postoperative day.

Histopathological Report ÂÂ

Gross: Partly opened cystic mass, measuring 4 x 3 x 0.4 cm with bosselated surface. The cut surface reveals, focally an irregular thickened and small cystic spaces contain blood clot. No evidence of solid areas.

ÂÂ

Microscopy: Multiple sections show parotid tissue with focally microcystic and papillary cystic glands lined by acinic cells displaying granular cytoplasm and focally clear, vacuolated cells, surrounding stroma contains lymphoid aggregates, hemorrhage and hamosiderin pigments. Few areas show laminated concretions like psammoma bodies within the lumina. There is 0-1 mitotic activity/ hpf.

Impression Features are suggestive acinic cell cacinoma with marked cystic degeneration.

10X

20X

Asian Journal of Ear, Nose and Throat, January-March 2013

20X

Follow-up Patient has been following-up since two months postdischarge. Patient was advised follow-up for first three months and then 3-6 month-yearly.

case report Discussion Acinic cell carcinoma is a rare salivary gland cancer3 accounting for 6-10% of all salivary gland carcinomas and 2-13% of all malignant parotid gland tumors. It arises more frequently in the parotid gland, other sites being submandibular gland, minor salivary gland. It is usually seen bilaterally. On rarer occasions it also presents itself in the pancreas and the lung and if it does it usually metastases. It is seen in the younger age group. It is a slow-growing tumor; itâ&#x20AC;&#x2122;s painless and spares the facial nerve. The sites of its metastasis are lungs, bone, central nervous system (CNS) and liver. In the past, it was considered a benign lesion now itâ&#x20AC;&#x2122;s considered by WHO as malignant due to its recurrence potential and mestasis, recurrences and metastasis after 3-10 years are common. Local recurrences 8-60%, metastasis 7-29%, death-1-26%. Lung metastasis has poorer prognosis. Acinic cell carcinoma is least aggressive of salivary gland cancers. High grade variants of acinic4 cell carcinoma are papillocytic carcinoma or carcinomas with undifferentiated cells in medullary pattern. It belongs to the family of adenocarcinomas. Pancreatic form of acinic cell carcinoma is a rare subtype of exocrine pancreatic cancer those arising from exocrine pancreas include ductal and acinar cell tumors, seen commonly in males. Treatment compromises of surgery and or postoperative radiation.5 Complete and total removal is a must to avoid recurrence, incomplete excision is associated with lower chance of survival, if complete and total tumor removal is not achieved then radiation using fast neutron beam6 is given, conventional radiation7

is used to treat high grade and residual disease after surgery. Chemotherapy has been considered in effective and is used only for pain relief. Acinic cell carcinoma is considered chemo-resistant in literature. Its pancreatic version is treated using intra-arterial infusion chemotherapy. REFERENCES 1. Yokoyama M, Nomura Y, Semba T. Acinic cell carcinoma of the parapharyngeal space: case report. Head Neck 1993;15(1):67-9. 2. Askin FC, Westra WH. Pathologic Diagnosis: Acinic cell carcinoma of the deep lobe of the parotid gland involving the right parapharyngeal space. Arch Otolaryngol Head Neck Surg 1999;125(6): And Archives of Otolaryngology online: Head and Neck Surgery Diagnosis Pathologic Quiz Case / http://archotol. ama-assn.org/issues/v125n6/ffull/orp0699-1b.html. 3. Rare and Exotic Cancers website, 2002 http://home. pacbell.net/markmcc/RARE_CANCERS/rare.html 4. Lewis JE, Olsen KD, Weiland LH. Acinic cell carcinoma. Clinicopathologic review. Cancer 1991;67(1):172-9. 5. North CA, Lee DJ, Piantadosi S, Zahurak M, Johns ME. Carcinoma of the major salivary glands treated by surgery or surgery plus postoperative radiotherapy. Int J Radiat Oncol Biol Phys 1990;18(6):1319-26. 6. Buchholz TA, Laramore GE, Griffin BR, Koh WJ, Griffin TW. The role of fast neutron radiation therapy in the management of advanced salivary gland malignant neoplasms. Cancer 1992;69(11):2779-88. 7. Leborgne F, Zubizarreta E, Fowler J, Ortega B, Mezzera J, Deus JL, et al. Improved results with accelerated hyperfractionated radiotherapy of advanced head and neck cancer. Int J Cancer 2000;90(2):80-91.

Asian Journal of Ear, Nose and Throat, January-March 2013

photo quiz

Swollen Masses in the Nose

25-year-old man presented with complaints of midfacial pain, fever, and general malaise of about 48 hours’ duration. He denied having a cough, rhinorrhea, or nasal congestion. The patient reported being hit in the nose about 10 days earlier and had received no interval treatment. The patient’s temperature was 100.6° F (38.1° C) orally and he had no frontal or maxillary sinus tenderness. Nasal examination revealed bilateral midline nasal swelling (see accompanying figure). The rest of the physical examination was unremarkable.

Question Based on the patient’s history and examination, which one of the following the most likely diagnosis?

C. Nasal polyps.

A. Sinusitis.

D. Foreign body.

B. Septal hematoma.

E. Viral syndrome. SEE THE FOLLOWING PAGE FOR DISCUSSION.

Source: Adapted from Am Fam Physician. 2006;73(9):1617-1618.

Asian Journal of Ear, Nose and Throat, January-March 2013

photo quiz Discussion

Summary Table

The answer is B: septal hematoma.

Condition

Characteristics

The midline swelling of the septum is typical of septal hematoma and is consistent with the patientâ&#x20AC;&#x2122;s history of facial trauma. Typically soft and fluctuant when compressed, a septal hematoma is a collection of blood between the nasal mucosa and the cartilaginous septum. It may occur unilaterally or, more commonly, bilaterally following nasal trauma with or without associated nasal fracture. This urgent condition warrants immediate referral to an otolaryngologist.

Sinusitis

Inflamed nasal turbinates with moderate to marked swelling, mucopurulent discharge

Septal hematoma

Pink, soft, midline swelling of the septum

Nasal polyps

Smooth, glistening nodules, bluish to fleshy in color

Foreign body

Object typically along floor of nose in anterior vestibule

Viral syndrome

Inflamed turbinates, clear to mucopurulent discharge

Management of septal hematoma includes local anesthesia with needle aspiration or incision and drainage. Several days of nasal packing prevents reaccumulation of blood. Ideally, treatment occurs within a few hours of injury.1 If the hematoma is not cleared, the septal cartilage may become necrotic and result in a saddle nose deformity or septal perforation. Accumulated blood may become infected, and antibiotics should follow drainage if abscess is noted. In this patient, fever suggested infection, and this was confirmed after incision and drainage. Patients with sinusitis typically report fever and malaise, as well as frontal or mid facial pain and/or maxillary pain. Physical examination often reveals sinus tenderness, mucopurulent discharge, and inflamed nasal turbinates. However, the nasal turbinates arise from the lateral nasal wall and do not appear as midline swelling. Nasal polyps result from a profound inflammatory response, with resultant swelling of the respiratory epithelium of the nasal and sinus mucosa. Although their exact etiology is not understood completely, nasal polyps often coexist with chronic sinusitis or chronic nasal allergies.2

Foreign bodies, such as pebbles or beads, may be found in the nares of children or developmentally disabled adults. They may present with foul-smelling nasal discharge or signs of nasal obstruction. Viral syndrome may present with malaise, fevers, and clear to mucopurulent nasal dis charge. Swelling of the nasal septum is not usual finding, although inflamed turbinates may be noted. REFERENCES 1. Terrell TR, Leski MJ. Sports medicine. In: Rakel RE, ed. Textbook of family practice. 6th ed. Philadelphia: Saunders, 2002:845-90. 2. Oâ&#x20AC;&#x2122;Handley JG, Tobin E, Tagge B. Otolaryngology. In: Rakel RE, ed. Textbook of family practice. 6th ed. Philadelphia: Saunders, 2002:424-72.

Asian Journal of Ear, Nose and Throat, January-March 2013

Practice Guidelines

CDC Publishes Statement on Cough and Cold Medications in Children

ough and cold medications that contain expectorants, antihistamines, nasal decongestants, and cough suppressants are commonly used to treat symptoms of upper respiratory infection in children younger than two years. However, in 2004 and 2005 an estimated 1,519 children younger than two years were treated in U.S. emergency departments for adverse events associated with use of cough and cold medications. Although the U.S. Food and Drug Administration (FDA) has approved the use of cough and cold medications for children two years and older, no FDA-approved dosing recommendations exist for children younger than two years. Therefore, the Centers for Disease Control and Prevention (CDC) has released a statement on the risks of cough and cold medications in children younger than two years. The statement appears in the January 12, 2007, issue of Morbidity and Mortality Weekly Report. Evidence of the effectiveness of cough and cold medications in children younger than two years is limited. Systematic reviews of controlled trials involving these medications conclude that they are no more effective than placebo in reducing symptoms of upper respiratory tract infection. Additionally, cough suppressants containing codeine and dextromethorphan

Source: Adapted from Am Fam Physician. 2007;76(02):298.

Asian Journal of Ear, Nose and Throat, January-March 2013

have not been proven effective, and their use could lead to potential adverse events in children younger than two years. Health care professionals should advise parents against administering cough and cold medications to children younger than two years because of the risk of toxicity and the lack of dosing recommendations. As an alternative to pseudoephedrine and other nasal decongestants, physicians should recommend clearing the childâ&#x20AC;&#x2122;s nasal congestion with a rubber suction bulb or using saline nose drops or a cool-mist humidifier to soften secretions. Health care professionals also should be aware of the risks of serious illness or fatal overdose in children younger than two years who have been given cough and cold medications. To avoid overdose, physicians should prescribe these medications with extreme caution and should inquire about additional overthe-counter medications the child is being given. Additionally, physicians should be certain that parents understand the importance of administering these medications only as directed and are aware of the risk of an overdose if the child is given additional medications with the same ingredients.

around the globe

News and Views

Pertussis diagnosed with voicerecognition technology

Toxic shock from Strep: a ‘lightning strike’

The paroxysmal phase of a pertussis cough is so distinctive that, using voice-recognition technology, researchers have developed a system that can accurately classify a case, or at least assign a probability of it being pertussis, after just a few seconds of coughing. The technology can accurately distinguish pertussis coughs from croup and nonpertussis coughs, Philip Polgreen, MD, MPH, associate professor of internal medicine at the University of Iowa in Iowa City, and director of the Infectious Diseases Society of America’s Emerging Infections Network, explained here at ID Week 2012. (Source: Medscape)

In rare cases, the bacteria responsible for causing strep throat - Group A Streptococcus - can penetrate beyond the superficial surfaces of the body and lead to necrotizing fasciitis, toxic shock syndrome and even death. (Source: Medpage Today)

Group updates Strep throat guidelines Using rapid antigen detection tests will help ensure that only confirmed cases of Group A streptococcal pharyngitis - strep throat - will be treated with antibiotics, according to updated guidelines from the Infectious Diseases Society of America. Positive rapid test results do not need further confirmation with a throat culture, as the tests are highly specific and false-positives are rare, Stanford Shulman, MD, of Northwestern University Feinberg School of Medicine in Chicago, and colleagues stated in recommendations published online in Clinical Infectious Diseases. Negative tests, on the other hand, should be confirmed with throat cultures in children and adolescents, but not in adults, who have a low rate of Group A streptococcal pharyngitis and a low-risk for complications like acute rheumatic fever. The guideline, which updates previous recommendations released in 2002, noted that accurate diagnosis is necessary to target antibiotics to sore throats caused by strep and not those caused by other pathogens, usually viruses. Inappropriate use of antibiotics can lead to the development of drug resistance. (Source: Medpage Today)

FDA expands label for hereditary angioedema drug The FDA has expanded the label of the C1 esterase inhibitor Berinert to allow for self-treatment of hereditary angioedema (HAE) during acute attacks and for use in laryngeal attacks. The intravenous selfadministration requires training from a healthcare professional, according to a statement from maker CSL Behring. HAE, a genetic disorder caused by low levels or improper function of C1-INH protein, is rare. It causes rapid swelling of the skin and tissues, such as face, mouth, throat and abdomen. (Source: Medpage Today) FDA approves icatibant for rare swelling condition The FDA has approved the injectable drug icatibant (Firazyr) to treat acute hereditary angioedema (HAE) attacks, making it the first such medication available in the US that patients with the rare genetic condition can administer themselves. Patients with HAE suffer periodic, painful attacks of severe swelling in various parts of the body including hands, feet, face, abdomen, and sometimes the throat, which can cause airway restriction. It is caused by a deficiency in the C1 esterase enzyme, which regulates inflammatory and coagulation responses. Defective C1-inhibitor can cause a biochemical imbalance that can produce unwanted peptides, which, in turn, induce the capillaries to release fluids into surrounding tissues, causing the swelling. (Source: Medpage Today)

Asian Journal of Ear, Nose and Throat, January-March 2013

Asian Journal of

Ear, Nose Throat

Information for Authors Manuscripts should be prepared in accordance with the ‘Uniform requirements for manuscripts submitted to biomedical journals’ compiled by the International Committee of Medical Journal Editors (Ann. Intern. Med. 1992;96: 766-767). Asian Journal of Ear, Nose and Throat strongly disapproves of the submission of the same articles simultaneously to different journals for consideration as well as duplicate publication and will decline to accept fresh manuscripts submitted by authors who have done so. The boxed checklist will help authors in preparing their manuscript according to our requirements. Improperly prepared manuscripts may be returned to the author without review. The checklist should accompany each manuscript. Authors may provide on the checklist, the names and addresses of experts from Asia and from other parts of the World who, in the authors’ opinion, are best qualified to review the paper. Covering letter – The covering letter should explain if there is any deviation from the standard IMRAD format (Introduction, Methods, Results and Discussion) and should outline the importance of the paper. – Principal/Senior author must sign the covering letter indicating full responsibility for the paper submitted, preferably with signatures of all the authors. – Articles must be accompanied by a declaration by all authors stating that the article has not been published in any other Journal/Book. Authors should mentioned complete designation and departments, etc. on the manuscript. Manuscript – Three complete sets of the manuscript should be submitted and preferably with a CD; typed double spaced throughout (including references, tables and legends to figures). –

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The manuscript should be arranged as follow: Covering letter, Checklist, Title page, Abstract, Keywords (for indexing, if required), Introduction, Methods, Results, Discussion, References, Tables, Legends to Figures and Figures.

All pages should be numbered consecutively beginning with the title page. Note: Please keep a copy of your manuscript as we are not responsible for its loss in the mail. Manuscripts will not be returned to authors.

Title page Should contain the title, short title, names of all the authors (without degrees or diplomas), names and full location of the departments and institutions where the work was performed, name of the corresponding authors, acknowledgment of financial support and abbreviations used. – The title should be of no more than 80 characters and should represent the major theme of the manuscript. A subtitle can be added if necessary. – A short title of not more than 50 characters (including inter-word spaces) for use as a running head should be included. – The name, telephone and fax numbers, e-mail and postal addresses of the author to whom communications are to be sent should be typed in the lower right corner of the title page. – A list of abbreviations used in the paper should be included. In general, the use of abbreviations is discouraged unless they are essential for improving the readability of the text. Summary – The summary of not more than 200 words. It must convey the essential features of the paper. – It should not contain abbreviations, footnotes or references. Introduction – The introduction should state why the study was carried out and what were its specific aims/objectives. Methods – These should be described in sufficient detail to permit evaluation and duplication of the work by others. – Ethical guidelines followed by the investigations should be described. Statistics The following information should be given: – The statistical universe i.e., the population from which the sample for the study is selected. – Method of selecting the sample (cases, subjects, etc. from the statistical universe). – Method of allocating the subjects into different groups. – Statistical methods used for presentation and analysis of data i.e., in terms of mean and standard deviation values or percentages and statistical tests such as Student’s ‘t’ test, Chi-square test and analysis of variance or non-parametric tests and multivariate techniques. – Confidence intervals for the measurements should be provided wherever appropriate.

Asian Journal of Ear, Nose and Throat, January-March 2013

Results – These should be concise and include only the tables and figures necessary to enhance the understanding of the text. Discussion – This should consist of a review of the literature and relate the major findings of the article to other publications on the subject. The particular relevance of the results to healthcare in India should be stressed, e.g., practicality and cost. References These should conform to the Vancouver style. References should be numbered in the order in which they appear in the texts and these numbers should be inserted above the lines on each occasion the author is cited (Sinha12 confirmed other reports13,14...). References cited only in tables or in legends to figures should be numbered in the text of the particular table or illustration. Include among the references papers accepted but not yet published; designate the journal and add ‘in press’ (in parentheses). Information from manuscripts submitted but not yet accepted should be cited in the text as ‘unpublished observations’ (in parentheses). At the end of the article the full list of references should include the names of all authors if there are fewer than seven or if there are more, the first six followed by et al., the full title of the journal article or book chapters; the title of journals abbreviated according to the style of the Index Medicus and the first and final page numbers of the article or chapter. The authors should check that the references are accurate. If they are not this may result in the rejection of an otherwise adequate contribution. Examples of common forms of references are: Articles Paintal AS. Impulses in vagal afferent fibres from specific pulmonary deflation receptors. The response of those receptors to phenylguanide, potato S-hydroxytryptamine and their role in respiratory and cardiovascular reflexes. Q. J. Expt. Physiol. 1955;40:89-111. Books Stansfield AG. Lymph Node Biopsy Interpretation Churchill Livingstone, New York 1985. Articles in Books Strong MS. Recurrent respiratory papillomatosis. In: Scott Brown’s Otolaryngology. Paediatric Otolaryngology Evans JNG (Ed.), Butterworths, London 1987;6:466-470. Tables – These should be typed double spaced on separate sheets with the table number (in Roman Arabic numerals) and title above the table and explanatory notes below the table. Legends – These should be typed double spaces on a separate sheet and figure numbers (in Arabic numerals) corresponding with the order in which the figures are presented in the text.

Asian Journal of Ear, Nose and Throat, January-March 2013

– The legend must include enough information to permit interpretation of the figure without reference to the text. Figures – Two complete sets of glossy prints of high quality should be submitted. The labelling must be clear and neat. – All photomicrographs should indicate the magnification of the print. – Special features should be indicated by arrows or letters which contrast with the background. – The back of each illustration should bear the first author’s last name, figure number and an arrow indicating the top. This should be written lightly in pencil only. Please do not use a hard pencil, ball point or felt pen. – Color illustrations will be accepted if they make a contribution to the understanding of the article. – Do not use clips/staples on photographs and artwork. – Illustrations must be drawn neatly by an artist and photographs must be sent on glossy paper. No captions should be written directly on the photographs or illustration. Legends to all photographs and illustrations should be typed on a separate sheet of paper. All illustrations and figures must be referred to in the text and abbreviated as “Fig.”. Please complete the following checklist and attach to the manuscript: 1. Classification (e.g. original article, review, selected summary, etc.)____________________________ 2. Total number of pages ______________________ 3. Number of tables __________________________ 4. Number of figures _________________________ 5. Special requests __________________________ 6. Suggestions for reviewers (name and postal address) Indian 1._____________Foreign 1.______________ 2._____________ 2.______________ 3._____________ 3.______________ 4._____________ 4.______________ 7. All authors’ signatures______________________ 8. Corresponding author’s name, current postal and e-mail address and telephone and fax numbers _______________________________________ Issue Editor Dr Jasveer Singh Asian Journal of Ear, Nose and Throat

Online Submission Also e- Issue @ www.ijcpgroup.com For Editorial Correspondence

Dr KK Aggarwal

Group Editor-in-Chief Asian Journal of Ear, Nose and Throat E-219, Greater Kailash, Part-1 New Delhi - 110 048. Tel: 40587513 E-mail: editorial@ijcp.com Website: www.ijcpgroup.com