Supraglottic laryngeal carcinoma resection by radiofrequency coblation under a multifunctional opener in four cases and literature analysis / 中国基层医药

Objective:To investigate the efficacy and feasibility of radiofrequency resection of supraglottic laryngeal carcinoma under a multifunctional opener.Methods:The clinical data of four cases of supraglottic laryngeal carcinoma (type T1N1M0 in two cases, T2N1M0 in one case, and T1N0M0 in one case) who received treatment in the Affiliated Hospital of Jining Medical University during January-June 2019 were retrospectively analyzed. Radiofrequency resection of supraglottic laryngeal carcinoma under a multi-functional opener combined with bilateral neck II-IV region lymph node dissection was performed. Swallowing, breathing and phonation were observed and analyzed based on references.Results:Among the four cases, two cases had a normal diet at 3 days after surgery, one case had a normal diet at 7 days after surgery, and one case had a normal diet at 16 days after surgery. Tracheotomy was not performed in any case. After surgery, breathing and speech communication were not affected.Conclusion:Radiofrequency surgery under a multifunctional opener can be used for treatment of early supraglottic laryngeal cancer. It is an effective treatment with minimal trauma, mild postoperative pain and promotes the early recovery of normal swallowing function.

Primary epiglottic follicular variant of peripheral T-cell lymphoma

The follicular variant of peripheral T-cell lymphoma, not otherwise specified, is very rare. Primary epiglottic follicular variant of peripheral T-cell lymphoma is extremely rare in clinical practice. Here, we report the first case of a follicular variant of peripheral T-cell lymphoma not otherwise specified in a 44-year-old Chinese man, who presented with a tumor in the middle of the epiglottis tongue surface. Microscopically, the tumor had a vague nodular growth pattern and the morphology of the nodules was different from each other at low power. Atypical lymphoid cells were medium to large in size and had round nuclei, with an irregular nuclear membrane, distinct nucleoli, and rapid mitotic activity. Plasma cells were found surrounding the nodules. The tumor cells were positive for follicular helper T-cell markers (CD10, PD-1, CXCL13, and BCL-6). The EBER was negative by in situ hybridization. Polymerase chain reaction-based analysis showed monoclonal rearrangements of TCR?, TCR?, and polyclonal rearrangements of IgH, IgK, and IgL. The clinical and imaging features and the prognostic factors of FV PTCL-NOS remain poorly understood. Thus, investigation of more cases and longer follow-up is necessary to understand the disease and to identify the best treatment to improve prognosis.

TBC Epiglótica como causa infrecuente de Odinofagia. Reporte de caso / Epiglottic TB as an uncommon cause of Odynophagia. Case report

Introducción: la tuberculosis epiglótica constituye una entidad rara, cuya frecuencia ha experimentado un aumento en los últimos años, secundaria al desarrollo de nuevos métodos diagnósticos y el incremento en la esperanza de vida. Típicamente se presenta en personas inmunocomprometidas, siendo más frecuentes los casos secundarios a una infección primaria pulmonar. Presentación de caso: paciente adulto mayor que consulta por odinofagia y pérdida de peso de varios meses de evolución, se diagnosticó el cuadro inicialmente como una infección respiratoria alta. Al no presentar mejoría es referido al servicio de gastroenterología donde se realizó endoscopia digestiva alta, en la que se evidenció una lesión granulomatosa a nivel de epiglotis. Por histopatología se confirma diagnóstico de tuberculosis. Conclusiones: la tuberculosis epiglótica es una entidad rara, representando menos del 1% de las causas de tuberculosis extra pulmonar.

LwPTL: a novel classification for upper airway collapse in sleep endoscopies / LwPTL: uma nova classificação para o colapso das vias aéreas superiores em endoscopias do sono

Abstract Introduction: There is no consensus on a single classification system for the obstructive findings in drug-induced sleep endoscopy. Previous classification systems have neglected to address the upper retropalatal obstruction, the segmental division of the lateral pharyngeal wall and the primary or secondary nature of laryngeal collapse. Objective: To propose, illustrate and evaluate a more comprehensive and yet simple classification for drug-induced sleep endoscopy findings. Methods: Cross sectional study in a tertiary sleep surgery unit. A total of 30 patients with obstructive sleep apnea underwent drug-induced sleep endoscopy according to a new classification system called LwPTL, and its findings were analyzed according to obstructive sleep apnea severity and body mass index. LwPTL incorporates the description of upper retropalatal collapse, distinguishes the lateral pharyngeal wall collapse into three levels and clarify when laryngeal collapses are primary or secondary. Results: 93.3% of the patients presented lateral pharyngeal wall collapse, usually at the level of the velum (73.3%). 80% presented multilevel collapse. Regarding the upper retropalatal region, LwPTL identified 10% of the cases presenting lateral salpingopharyngeal obstruction and 6.6% with high palatal collapse. 3.3% presented epiglottic collapse. Patients presenting lower levels of collapse, either from the lateral wall and/or tongue and/or larynx, represented 30% of the cases and had significantly more severe obstructive sleep apnea, without significant differences in body mass indexes. Conclusion: LwPTL seems a simple and straightforward staging system for classifying drug-induced sleep endoscopy, distinguishing the important upper retopalatal obstruction and the primary and secondary laryngeal collapses, providing more information for appropriate treatment selection.

Resumo Introdução: Não há consenso sobre um sistema único de classificação para os achados obstrutivos da endoscopia do sono induzido por drogas. Os sistemas de classificação anteriores negligenciaram a abordagem da obstrução retropalatal alta, a divisão segmentar da parede lateral da faringe e a natureza primária ou secundária do colapso laríngeo. Objetivo: Propor, ilustrar e avaliar uma classificação mais abrangente e simples para os achados da endoscopia do sono induzido por drogas. Método: Estudo transversal em uma unidade terciária de cirurgia do sono. Foram submetidos à endoscopia do sono induzido por drogas 30 pacientes com apneia obstrutiva do sono, de acordo com um novo sistema de classificação denominado LwPTL, e seus achados foram analisados de acordo com a gravidade da apneia obstrutiva do sono e índice de massa corpórea. O LwPTL incorpora a descrição do colapso retropalatal alto, distingue o colapso da parede faríngea lateral em três níveis e esclarece quando os colapsos laríngeos são primários ou secundários. Resultados: Apresentaram colapso da parede faríngea lateral 93,3% dos pacientes, geralmente no nível do palato mole (73,3%). Em 80% dos pacientes o colapso foi multinível. Em relação à região retropalatal alta, o LwPTL identificou 10% dos casos com obstrução salpingo-faríngea lateral e 6,6% com colapso alto do palato. Em 3,3% ocorreu colapso epiglótico. Pacientes com colapso em regiões baixas, tanto da parede lateral e/ou língua como e/ou laringe, representaram 30% dos casos e apresentaram apneia obstrutiva do sono significativamente mais grave, sem diferenças significantes no índice de massa corpórea. Conclusão: O LwPTL parece um sistema de estadiamento simples e direto para classificar os achados da endoscopia do sono induzido por drogas, distingue a importante obstrução retropalatal alta e os colapsos laríngeos primários e secundários, fornece mais informações para uma seleção adequada do tratamento.

Clinical effect of excise epiglottis cyst by CO2 laser and high frequency under micro-laryngoscope / 中国内镜杂志

Objective To compare the clinical feasibility of excising epiglottis cyst by CO2 laser and high frequency under laryngomicroscope. Methods 44 cases with epiglottic cysts were divided into two groups, with 22 cases in observation group (OG) and also 22 cases in control group (CG). All patients were operated by a laryngomicroscopic surgery under a general anesthesia, while cases in OG under CO2 laser and patients in CG under high frequency electric knife to remove the cyst. Then, analyse and compare the clinical feasibility. Results The average operating time is significantly shorter , and the VAS of sore throat is obviously lower in OG than that in CG. Thanks to the accurate and precise operation by CO2 laser, the epiglottis cysts are able to be removed intact, the surrounding tissues and epiglottic cartilage are better protected. There is no recurrence in both groups. Conclusion The operation performed with CO2 laser under micro-laryngoscope holds such advantages as accurate and easy to operate, better protect cyst wall, and fewer side hurting.

Clinical effect of excise epiglottis cyst by CO2 laser and high frequency under micro-laryngoscope / 中国内镜杂志

Objective To compare the clinical feasibility of excising epiglottis cyst by CO2 laser and high frequency under laryngomicroscope. Methods 44 cases with epiglottic cysts were divided into two groups, with 22 cases in observation group (OG) and also 22 cases in control group (CG). All patients were operated by a laryngomicroscopic surgery under a general anesthesia, while cases in OG under CO2 laser and patients in CG under high frequency electric knife to remove the cyst. Then, analyse and compare the clinical feasibility. Results The average operating time is significantly shorter , and the VAS of sore throat is obviously lower in OG than that in CG. Thanks to the accurate and precise operation by CO2 laser, the epiglottis cysts are able to be removed intact, the surrounding tissues and epiglottic cartilage are better protected. There is no recurrence in both groups. Conclusion The operation performed with CO2 laser under micro-laryngoscope holds such advantages as accurate and easy to operate, better protect cyst wall, and fewer side hurting.

Treatment of epiglottis cyst by Nd:YAG laser combined with clamp under electronic laryngoscope / 中国内镜杂志

Objective To study the effect of the treatment of epiglottis cyst by Nd:YAG laser combined with clamp under electronic laryngoscope. Methods Under superficial anesthesia, ninety cases of epiglottis cyst complicated with a series of pharyngeal clinical symptoms which were treated by Nd:YAG laser combined with clamp guided under electronic laryngoscope. Results Eight patients were not reexamined, and the rest 82 patients were followed up after one month, the body sensation and laryngeal obstruction disappeared or relieved signiifcantly. After further conifrmation by laryngoscope, the cysts of 79 cases were disappeared, and 3 cases were considered residual, the cysts was clamped out and treated by biopsy forceps Laser, further checked after 2 months by laryngoscope, the cysts disappeared! 100%recovered. Conclusion Treatment of epiglottis cyst by Nd:YAG laser combined with clamp under electronic laryngoscope has many advantages such as clear vision, accurate positioning, less hemorrhage, less postoperative complications, less recurrence rate and less pain. Treatment is effective and worthy of clinical promotion.

Effect of Vallecular Ballooning in Stroke Patients With Dysphagia

OBJECTIVE: To investigate the improvement of dysphagia after balloon dilatation and balloon swallowing at the vallecular space with a Foley catheter in stroke patients. METHODS: This study was conducted between May 1, 2012 and December 31, 2015, and involved 30 stroke patients with complaints of difficulty in swallowing. All patients underwent videofluoroscopic swallowing study (VFSS) before and after vallecular ballooning. VFSS was performed with a 4 mL semisolid bolus. For vallecular ballooning, two trainings were performed for at least 10 minutes, including backward stretching of the epiglottis and swallowing of a balloon located in the vallecular space, by checking the movement of the Foley catheter tip in real time using VFSS. RESULTS: After examination of the dysphagia improvement pattern before and after vallecular ballooning, laryngeal elevation (x-axis: pre 2.62±1.51 mm and post 3.54±1.93 mm, p=0.038; y-axis: pre 17.11±4.24 mm and post 22.11±3.46 mm, p=0.036), pharyngeal transit time (pre 5.76±6.61 s and post 4.08±5.49 s, p=0.043), rotation of the epiglottis (pre 53.24°±26.77° and post 32.45°±24.60°, p<0.001), and post-swallow pharyngeal remnant (pre 41.31%±23.77% and post 32.45%±24.60%, p=0.002) showed statistically significant differences. No significant difference was observed in the penetration-aspiration scale score (pre 4.73±1.50 and post 4.46±1.78, p=0.391). CONCLUSION: For stroke patients with dysmotility of the epiglottis and post-swallowing residue, vallecular ballooning can be considered as an alternative method that can be applied without risk of aspiration in dysphagia treatment.

Adult acute epiglottitis: An eight - year experience in a Philippine tertiary government hospital

@#<p style="text-align: justify;"><strong>OBJECTIVE:</strong> To review cases of adult acute epiglottis in a tertiary government hospital and describe the clinical presentations, diagnostics performed, management and outcomes. <br /><strong>METHODS:</strong><br /><strong>Design:</strong> Retrospective Chart Review<br /><strong>Setting:</strong> Tertiary Government Hospital<br /><strong>Participants:</strong> Records of patients admitted by or referred to the Department of Otolaryngology Head and Neck Surgery with a diagnosis of acute epiglottis from January 2008 to August 2014 were identified from the department census and charts were retrieved from the Hospital Record Section and evaluated according to inclusion and exclusion criteria. Information regarding demographic data, clinical features, laboratory and other diagnostic examinations, medical management, and length of hospital stay were collected.<br /><strong>RESULTS:</strong> There were 20 cases in 7 years and 8 months. Most were male, 18 to 37-years-old, presenting with dysphagia, odynophagia and a swollen epiglottis on laryngoscopy. Abnormal soft-tissue lateral radiographs of the neck and leukocytosis were seen in 73% and 83%, respectively. Intravenous antibiotics and corticosteroids were administered in all cases, and mean hospital stay was 11.2 days.<br /><strong>CONCLUSION:</strong> Adult acute epiglottis should be highly suspected in patients presenting with dysphagia, odynophagia, and muffling of the voice even with a normal oropharyngeal examination. History of respiratory infection, co-morbidities, smoking and alcohol intake, concomitant laryngeal pathology and supraglottic structure insults contribute to development of the disease. Laryngoscopy is still the gold standard in diagnosis. Airway protection is mandatory but prophylactic intubation or tracheostomy are not advised. Intravenous antibiotics are necessary and corticosteroids may be of benefit. </p>

A Case of Laryngeal Cavernous Lymphangioma / 대한이비인후과학회지

Lymphangiomas are rare congenital lesions of the lymphatic system, and about 90% of them are diagnosed within 2 years of age. The most common site is the head and neck region, where approximately 75% of all lymphangiomas occur. However, the laryngeal involvement of lymphangioma is uncommon and most of these cases are direct invasion from the neck. Isolated lymphangioma of the larynx is extremely rare and only a few cases have been reported in the English literature. In our case, correct preoperative diagnosis was difficult due to the rarity of the isolated laryngeal lymphangioma and its resemblance to epiglottic cyst. Careful laryngeal endoscopic examination is needed and imaging study such as CT or MRI may be helpful.

A Case of Erdheim-Chester Disease with Laryngeal Involvement / 대한이비인후과학회지

Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis with multi-organ involvement. Bones, cardiovascular system, central nervous system, kidney, skin and many different organs can be involved but laryngeal involvement has not been reported in literatures. The diagnosis of ECD was based on clinical manifestations and immunohistochemical findings including CD68(+), CD1a(-) and S100(-). Currently, Interferon-a is the most extensively studied agent in the treatment of ECD and serves as the 1st line of treatment. Surgical resection of involved lesions can be tried but it leads to temporary improvement. A 60-year-old man visited with respiratory symptoms because of ECD with laryngeal involvement. We resected the obstructive lesion to relieve the symptoms. Tissue biopsy gave a diagnosis of ECD. As it is rare to encounter ECD involving the larynx, we report this case with a review of literatures.

El uso del ultrasonido en el manejo de la vía aérea / Airway management using ultrasound

Ultrasonography as a diagnostic and therapeutic tool has greatly impacted the anesthesiologist's routine in multiple practical applications. However, only recently there have been some reports published in the literature on the use of ultrasonography for the management of the airway in the surgical and ICU patients. Being a portable, easy to use, non-invasive tool that does not require any ionizing energy, ultrasonography becomes highly attractive when the anesthesiologist faces practical issues in a difficult airway. The purpose of this review was precisely to show the potential uses of ultrasonography for difficult airway management, from the literature perspective. There is enough trials-based evidence so far to recommend the use of ultrasonography for the following situations: identification of anatomical airway structures, static detection of a failed or esophageal intubation, dynamic airway measurements, and size determination of endotracheal tubes; identification of predictors of a difficult airway in patients with challenging necks, and trans-tracheal techniques to secure the airway Nevertheless, further studies with strong methodological quality are required to show the potential of ultrasonography to impact the difficult airway management and the morbidity and mortality associated with this condition.

La ecografía como herramienta diagnóstica y terapéutica ha tenido un gran impacto en el quehacer rutinario del anestesiólogo en múltiples áreas de aplicación práctica. Sin embargo, es hasta hace poco en donde han aparecido en la literatura reportes de su uso en situaciones que involucra el manejo de la vía área del paciente en cirugía y unidades de cuidados intensivos. Al ser esta una herramienta portable, fácil de usar, no invasiva y sin necesidad de energía ionizante, la hace altamente atractiva al momento de resolver preguntas prácticas del anestesiólogo que se ve enfrentado a una vía área difícil. Justamente el objetivo de esta revisión fue mostrar desde la literatura cuales son los potenciales usos de los ecografía en el manejo de la vía área. Hasta el momento los estudios muestran suficientes elementos para recomendar su uso en los siguientes situaciones: identificación de estructuras anatómicas en la vía área; detección estática de intubación fallida o esofágica; mediciones dinámicas de la vía área y determinación del tamanño de tubos endotraqueales; predictores de vía área difícil en pacientes con cuello desfavorable; y técnicas transtraqueales para aseguramiento de la vía área. A pesar de ello, aún se requieren mayores estudios con suficiente calidad metodológica en donde se demuestre que el uso de la ecografía si puede llegar a impactar en el manejo de la vía área difícil y en la morbimortalidad generada por esta entidad.

Asymptomatic Absent Epiglottis.

Absence or hypoplasia of the epiglottis is a rare anomaly. Most patients, with absent or hypoplastic epiglottis, have presented, life-threatening symptoms of respiratory distress and severe aspiration in infancy or early childhood. We report a case of completely asymptomatic 30 year old female with absent epiglottis posted for modified radical mastoidectomy for chronic suppurative otitis media (CSOM).

Observation of Clinical Efficacy of Dong’s Pushing Epiglottis Cartilage Method for the Treatment of Children Food Retention / 中国中医药信息杂志

Objective To observe the clinical efficacy of Dong’s Pushing Epiglottis Cartilage Method for the treatment of children food retention through randomized, parallel and controlled clinical trial.Methods Totally 72 children diagnosed with children food retention were randomly divided into treatment group and control group, 36 cases for each group. Children of the treatment group were treated with Dong’s Pushing Epiglottis Cartilage Method, while children of the control group were treated with acupuncture Four Seam. The clinical symptoms, gastric half-emptying time and antral contraction frequency of the two groups before and after the treatment were compared. Results After treatment, integral of clinical symptom in both groups were obviously improved compared with before treatment (P0.05). After treatment, gastric half-emptying time and antral contraction frequency of the both groups were obviously improved, with significant difference (P0.05). The total effectiveness of the treatment group was 97.2% (35/36) and the control group was 94.4% (34/36), with no significantly difference (P>0.05).Conclusion Dong’s Pushing Epiglottis Cartilage Method has relatively good clinical efficacy for the treatment of children food retention.

An Adult With Thumb Sign In The Lateral Neck Radiograph

Acute epiglottitis though relatively common in pediatric patients as compared to adults, present with almost similar clinical presentations. They include voice change, difficulty or painful swallowing and sometimes with upper airway obstruction. Physical finding of swollen epiglottis is difficult to be obtained owing to the danger of introducing laryngeal mirror into the oropharynx as to avoid contact spasm. The diagnostic thumb sign appearance on lateral neck radiograph is considered pathognomonic of epiglottitis. We report a case of an adult with clinical features and radiological finding of an acute epiglottitis, which did not resolve with antibiotic treatment. Subsequent imaging confirmed the presence of an abscess in the epiglottic mucosa.

Cisto assintomático em região da valécula: relato de caso / Asymptomatic vallecular cyst: case report / Quiste valecular asintomático: relato de caso

Paciente do sexo masculino, 56 anos, apresentou-se para excisão de glioblastoma intracraniano multiforme. Após ser rotineiramente monitorado, o paciente foi pré-oxigenado. Anestesia e paralisia foram induzidas com propofol (200 mg), fentanil (50 µg) e vecurônio (9 mg). Laringoscopia direta com lâmina Macintosh número 3 revelou um cisto pedunculado de 2x2 cm, que surgia do lado direito da valécula e impedia a intubação endotraqueal. Enquanto o paciente permanecia anestesiado, consultamos rapidamente um otorrinolaringologista e o cisto foi aspirado por uma seringa com agulha de calibre 22G sob laringoscopia direta. Aspiramos 10 cc de líquido. Intubação traqueal foi feita em seguida sem intercorrências com sonda de 9,0 aramada e com balão. Uma opção para a intubação com fibra óptica pode ser a aspiração cuidadosa do cisto para facilitar a intubação.

A 56-year-old man presented himself for an intracranial glioblastoma multiforme excision. After being routinely monitored, he was preoxygenated. We induced anesthesia and paralysis with 200 mg propofol, 50 µg fentanyl and 9 mg vecuronium. Direct laryngoscopy with a Macintosh 3 blade revealed a 2x2 cm cyst, pedunculated, arising from the right side of the vallecula preventing the endotracheal intubation. While the patient remained anesthetized, we urgently consulted an otolaryngologist and aspirated the cyst with a 22-gauge needle and syringe under direct laryngoscopy. We aspirated 10 cc of liquid content. This was followed by an uneventful tracheal intubation with a 9.0 enforced spiral cuffed tube. An alternative to fiberoptic intubation may be careful cyst aspiration to facilitate the intubation.

Un paciente del sexo masculino, de 56 años, llegó para una resección de glioblastoma intracraneal multiforme. Posteriormente a la rutina de monitorización, el paciente fue pre-oxigenado. La anestesia y la parálisis se indujeron con propofol (200 mg), fentanilo (50 µg) y vecuronio (9 mg). La laringoscopia directa con lámina 3 Macintosh arrojó un quiste pedunculado de 2x2 cm que surgía al lado derecho de la valécula e impedía la intubación endotraqueal. Mientras el paciente permanecía anestesiado, consultamos rápidamente un otorrinolaringólogo y el quiste fue aspirado por una jeringa con una aguja calibre 22G bajo laringoscopia directa. Aspiramos 10 cc de líquido. La intubación traqueal se hizo enseguida sin intercurrencias con una sonda de 9,0 y un alambre en espiral y con balón. Una opción para la intubación con fibra óptica puede ser la aspiración cuidadosa del quiste para facilitar la intubación.

The Effect of Balloon Dilation at the Vallecular Using Videofluoroscopic Swallowing Study on Patient Who Has a Dysphagia

Authors have previously experienced the effect of balloon dilation at the vallecular by utilizing the video-fluoroscopic swallowing study (VFSS) and the urethral catheter to physically stretch and spread in the direction of the posterior inferior towards the patients who have claimed for dysphagia symptoms due to epiglottic dysfunction. A 72-year-old male patient has been diagnosed with rectal cancer and have been treated with an ileocolostomy after the intubation. After the removal of tracheal intubation, the patient complained of dysphagia. Foods and drinks could not be transmigrated into the esophagus due to the inability of the epiglottis to bend backward in the direction of posterior inferior on VFSS. The epiglottis was physically stretched and spread in the direction of posterior inferior by utilizing the balloon attached to a urethral catheter. After stretching and spreading the epiglottis in the direction of posterior inferior, the bolus remaining in the epiglottic vallecula was decreased. For a patient who is experiencing dysphagia due to an epiglottis disorder, it seems that an epiglottis balloon dilation supported by VFSS and a urethral catheter may be appropriate for the treatment of dysphagia symptoms.

Penetrating Neck Laceation with Epiglottis Amputation Which Was Successfully Repaired / 대한이비인후과학회지

Penetrating traumatic laryngeal injuries are relatively rare and traumatic injuries to the epiglottis are extremely rare. The present case is 58-year old man with suicidal history, chronic alcoholism, and schizophrenia who complained of neck laceration and unconsciousness after stab injury. Examination revealed a large transverse laceration of 7 cm in size, penetrating deep to the level of thyroid cartilage from the lateral border of the sternocleidomastoid muscle, exposing the thyroid cartilage. There was about a 3 cm-sized deep wound under the thyroid gland level but no major vessel injury. The stump of transected epiglottis accompanied by rupture of thyroid membrane was shown but the esophagus was intact. We sewed the amputated epiglottis with the rest of the epiglottis by using two Lambert sutures with vicryl 4-zero on each side under general anesthesia. There was no necrosis of the severed epiglottis, swallowing difficulty, and aspiration on eating food. We report here on the penetrating laceration with subtotal transection of epiglottis that was successfully repaired.

Fish Bone Piercing Epiglottis: A Case Report.

Pharyngoesophageal fish bone is a commonly encountered ORL emergency. Usually the patient is able to point the most painful site to suggest location of the foreign body, immediately after ingestion. We report a patient with chronic, severe odynophagia which later on was found to have a fish bone piercing through epiglottis. The symptoms were present for more than 10 months before definite diagnosis was made and removal was done.