Awake fiberoptic intubation in a patient with known difficult airway due to huge thyroid goiter

Thyroid enlargement or goiter has been considered a risk factor for difficulty in airway management during anaesthesia and surgery. Moderate to huge size along with retro-sternal extension makes it an anticipated difficult airway scenario. In this report, we present a case of huge goiter with compression symptoms and patient cannot be intubated by conventional direct laryngoscopy at a district hospital a week ago. CT scan revealed extension of mass into superior mediastinum compressing right brachiocephalic vein and superior vena cava. We successfully performed awake fiberoptic intubation with local/topical anaesthesia of airway. We have discussed the significance of careful approach, planning and preparation in the management of such a case

LASER treatment of laryngeal papillomatosis in a young child: anaesthetic and surgical management

The authors report the case of a 4-year boy who required anaesthetic and surgical care during LASER excision of laryngeal papillomatosis. He presented with hoarseness and stridor and underwent emergency tracheostomy after confirmation of laryngeal papillomas on CT scan. He required LASER treatment under general anaesthesia with a requirement of paediatric LASER-safe endotracheal tube but unfortunately, this was not available in the country. Balanced anaesthesia technique using inhalational anaesthetic, muscle relaxant and narcotic is used with modifications. After three successful surgical sessions, the airway became patent and tracheostomy was de-cannulated. The perioperative issues surrounding this process are discussed including anaesthetic induction in the patient with a compromised airway, maintenance anaesthetic techniques, methods used for ventilation during LASER surgery of the upper airway, surgical implications and hazards of LASER to the operating room personnel

Extracranial meningioma: an unusual presentation of a mass over inner canthus of left eye

Meningiomas are commonly encountered as intracranial brain tumours, but extracranial meningiomas do occur although seen rarely. Here we present a case of extracranial meningioma presenting as a mass over the medial canthus of left eye and the glabella with extension into the left ethmoid sinuses, without any neurological symptoms or signs. The patients underwent surgical excision, plastic surgical reconstruction and adjuvant radiotherapy after 3-dimensional conformal treatment planning

Comparison of different treatment modalities in advanced laryngeal hypopharyngeal squamous cell carcinoma

To compare outcome of patients with advanced laryngeal hypopharyngeal squamous cell carcinoma treated surgically or with chemotherapy and/or radiotherapy. Observational study. The Aga Khan University Hospital, Karachi, from January 2000 to December 2005. Medical records of already treated stage-Ill and IV squamous cell carcinoma of larynx/hypopharynx patients were reviewed. Group-A comprised of patients treated with surgery +/- adjuvant therapy whereas non-surgically managed patients were labeled as group-B. One hundred and nineteen out of 275 met the inclusion criteria. Kaplan Meier technique was used to estimate mean recurrence time with standard errors. Cox proportional hazard regression was used to estimate the hazard ratio with 95 percent confidence interval for gender, age and tumour location. Sixty two percent of group-A and 49% patients of group-B were stage-Ill. In group-A, 40% patients received postoperative adjuvant therapy while in group-B, 45% received concomitant chemoradiation. Mean follow-up duration was 18.3 months. Mean recurrence time was 1369 +/- 193 days. In group-A, mean recurrence time was 2097 +/- 277 days. It was 399 +/- 68 days for group-B patients [p <0.001]. The hazard ratio of recurrence in hypopharyngeal tumours was 1.5 times [95% CI 0.68, 3.30] as compared to tumours of larynx. The hazard ratio of recurrence was 1.98 times [95% CI 0.99, 3.95] when both larynx and hypopharynx were involved as compared to when tumour was localized to larynx only. No residual disease was noted at the completion of treatment in surgical group-A while 62% patients of the group-B had residual disease at the completion of treatment. Larynx was retained in only 25% patients in group-B. Statistically significant difference was noted in disease free outcome when stage-Ill and IV larynx hypopharynx cancer was managed surgically as compared to non-surgical management. Chances of retaining larynx are only 25% when managed non-surgically

Correlation of radiologic evidence of rhinosinusitis with the criteria set by task force for rhinosinusitis [TFR]

The development of consensus guidelines for diagnosis and treatment for rhinosinusitis has been significant challenge for otolaryngology and primary care providers. A major break through emerged in 1997 when task force for Rhinosinusitis [TFR] set forth consensus diagnostic guidelines for acute, sub-acute and chronic sinusitis, later revised in 2003. But still there is no gold standard identified to diagnose chronic rhinosinusitis. In our study we have seen the degree of agreement between TFR criteria for CRS and CT scan paranasal sinuses findings. To examine the degree of agreement between the task force criteria for chronic rhinosinusitis and CT scan findings for rhinosinusitis. All the patients had two major or one major with two minor symptoms defined by TFR criteria were enrolled. All the patients underwent assessment as per TFR criteria and diagnosed positive or negative. CT scan paranasal sinuses of all the patients were also done and were assessed as per Lund Mackay CT scoring system. Degree of agreement between these two diagnostic modalities was seen. Forty patients were enrolled for this study. Degree of agreement between TFR criteria for CRS Lund Mackay CT scati scoring system was found to be 0.615 [+1-95% Cl + 0.54 1- +/- 0.689].When we saw the sensitivity and specificity of TRF criteria against CT scan it was calculated to be 88% and 100% respectively. Positive and negative predictive value for this criteria was came out to be 100% and 25%. Degree of agreement between TFR criteria and CT scan for CRS is satisfactory. TFR criteria is highly specific to diagnose CRS

Neck recurrence in early carcinoma tongue

To study the efficacy of different locoregional treatment options for tongue cancer in determining the prognosis, with reference to recurrence of disease in neck. This is a retrospective analysis of 80 patients with early [T1/T2] carcinoma tongue who had hemiglossectomy with or without neck surgery and radiotherapy for 14 years. Eighty patients were included in this study, 49 [61.3%] men and 31 [38.8%] women; 36 [45%] patients with T1 lesion and 44 [55%] with T2 lesion. Sixty two patients [77.5%] were staged cN0 and 18 patients had a clinically palpable neck nodes [cN+]. Thirty seven patients were pathologically negative [pN0], whereas 22 were pathologically positive [pN+] and 21 were not operated so they were staged pathologically [pNx] [undissected necks]. Thirty patients received postoperative adjuvant radiotherapy. The median follow-up was 16.5 months with a range of 10-120 months. The over-all rate of recurrence in neck was 32.5% [27 patients]. The rate of recurrence was 23% in T1 and 45.8% in T2 lesion [P-value 0.09] without radiotherapy. The recurrence rates with T1 lesion patients who were given adjuvant radiotherapy did not change significantly whereas with T2 lesions the recurrence rate decreased from 45% to 25% in the group without radiotherapy. Recurrence rate was higher in undissected neck as compared to patients who underwent elective neck dissection having radiotherapy and staged pN0 [P-value 0.009] or pN+ [P-value 0.005]. Patients having therapeutic neck dissection, on comparison of final pathological node staging [i.e. pN0 or pN+] the rate of recurrence in patients pN+ was 56% and in group with pN0 it was 11%, with [P-value 0.046]. We did not find any effect of age, gender and surgically resected margins of primary early tongue tumor on recurrence of disease in neck. There was no significant difference between primary tumor stage T1 and T2 lesions on neck recurrence when treated with surgery alone, but adjuvant radiotherapy further reduced the neck recurrence in T2 groups. Adjuvant radiotherapy also showed a significant reduction in recurrence rates in both pN0 and pN+. Undissected necks have higher incidence of neck recurrence than dissected neck irrespective of pathological status of neck metastasis

midfacial degloving approach for excision of juvenile angiofibroma

Midfacial degloving is a well known technique for entering the nasal and paranasal cavities, the nasopharynx and the base of skull. We report our experience with midfacial degloving approach, applied to two patients with Juvenile Angiofibroma of nasal cavity and nasopharynx. We have found this approach ideal for access to the nasopharynx and infratemporal fossa while avoiding an external skin incision. The long term cosmetic results are excellent along with complete excision of the tumour

Laryngeal pathology

This study was conducted to assess the incidence and clinical presentation in patients with laryngeal symptoms of more than six weeks duration. It includes 81 patients. Every patient was admitted and had direct laryngoscopy and biopsy under G.A. Out of 81 patients, 16% had inflammatory lesions, 9% had pseudotumours, 15% had benign tumours and 60% had malignant tumours. Smoking, Pan and Alcohol were found to be main etiological factors for malignant disease and male to female ratio was higher for males in malignant tumour. Patients who had surgery, showed better long term survival. Early presentation to the surgeon is of paramount importance in long term survival of patients

Fish bone in the neck

An unusual cause of swelling in the neck is presented, due to fish bone, after it was swallowed and got stuck six weeks earlier. It travelled from pharynx to lower part of neck accompanied by inflammatory reaction around it