Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial

Abstract Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo (p < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Intraoperative Use of Analgesics in Tonsillar Fossa and Postoperative Evaluation with Visual analogue Scale Scores-A Prospective, Randomized, Placebo-Controlled, Double-Blind Clinical Trial.

Introduction Posttonsillectomy pain results in significant morbidity to the patients. There is a disagreement in the literature regarding the use of local anesthetics during tonsillectomy. The aim of this placebo-controlled, double-blind study is to evaluate the effect of peritonsillar administration of local anesthetics. Objective To evaluate the role of intraoperative use of analgesics in tonsillar fossa and postoperative evaluation with visual analogue scale (VAS) scores in achieving pain relief after tonsillectomy procedure Methods In this study, 180 patients were randomized to 1 of the 6 groups: bupivacaine infiltration, lidocaine infiltration, normal saline infiltration, bupivacaine packing, lidocaine packing, and normal saline packing. Pain caused by speaking, swallowing, and on rest was assessed using VAS at 4, 8, 12, 16 hours, and at discharge. Results Significant analgesia was obtained in patients who received bupivacaine infiltration and packing compared with placebo ( p < 0.05). The majority of the study subjects had no postoperative complications, and patients receiving bupivacaine infiltration required less additional analgesics in the first 24 hours after surgery. Conclusion We advocate the use of bupivacaine infiltration or packing immediately following the procedure to achieve adequate postoperative analgesia.

Venous thromboembolism-incidence of deep venous thrombosis and pulmonary embolism in patients with head and neck cancer: a tertiary care experience in Pakistan

Introduction Although venous thromboembolism (VTE) is seen with morbidity and mortality in various surgical specialties, scarce data are available in the head and neck surgery domain. Objective We aim to determine the incidence of VTE in patients receiving surgery for head and neck cancer. Methods Four hundred thirteen patients who underwent head and neck surgery procedures between 2005 and 2013 were reviewed retrospectively. All patients with head and neck surgery had received thromboprophylaxis (i.e., compression stockings and subcutaneous heparin). Patient demographics, operating time, and length of hospital stay were analyzed. The incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) during the initial postoperative hospitalization was assessed. Results Twelve patients were identified who developed VTE. Three patients developed DVT, and nine developed PE. The incidence of DVT and PE was 0.72 and 2.17%, respectively. Interestingly, all of these patients had undergone excision of extensive head and neck cancers accompanied by a reconstructive procedure. Patients who developed PE had a longer hospital stay compared with those who only had DVT. There were overall three mortalities in the nine patients who developed PE. Conclusion Although VTE has a low incidence, it is a known complication of extensive head and neck surgeries with life-threatening outcomes. We recommend early mobilization and physiotherapy with the possible aid from appropriate mechanical and pharmacologic thromboprophylaxis.

Venous Thromboembolism-Incidence of Deep Venous Thrombosis and Pulmonary Embolism in Patients with Head and Neck Cancer: A Tertiary Care Experience in Pakistan.

Introduction Although venous thromboembolism (VTE) is seen with morbidity and mortality in various surgical specialties, scarce data are available in the head and neck surgery domain. Objective We aim to determine the incidence of VTE in patients receiving surgery for head and neck cancer. Methods Four hundred thirteen patients who underwent head and neck surgery procedures between 2005 and 2013 were reviewed retrospectively. All patients with head and neck surgery had received thromboprophylaxis (i.e., compression stockings and subcutaneous heparin). Patient demographics, operating time, and length of hospital stay were analyzed. The incidence of symptomatic deep venous thrombosis (DVT) and pulmonary embolism (PE) during the initial postoperative hospitalization was assessed. Results Twelve patients were identified who developed VTE. Three patients developed DVT, and nine developed PE. The incidence of DVT and PE was 0.72 and 2.17%, respectively. Interestingly, all of these patients had undergone excision of extensive head and neck cancers accompanied by a reconstructive procedure. Patients who developed PE had a longer hospital stay compared with those who only had DVT. There were overall three mortalities in the nine patients who developed PE. Conclusion Although VTE has a low incidence, it is a known complication of extensive head and neck surgeries with life-threatening outcomes. We recommend early mobilization and physiotherapy with the possible aid from appropriate mechanical and pharmacologic thromboprophylaxis.

Pilonidal sinus involving the nasal bridge: a rare manifestation.

Pilonidal sinus is very commonly associated with the sacrococcygeal area, but its presence within the head and neck is still unknown to many. Once diagnosed, it is easy to treat and should, therefore, be kept in mind as a possibility when coming across a discharging sinus swelling. We share our experience of two cases of pilonidal sinus presenting over the nasal bridge and their management.

Toluidine blue: yet another low cost method for screening oral cavity tumour margins in third world countries.

OBJECTIVE: To use toluidine blue intra-operatively to identify tumour involved margins after the removal of oral cavity squamous cell carcinoma, and to compare the findings with those of final histopathology. METHODS: The study was conducted at the Aga Khan University Hospital from December 1, 2009, to March 14, 2010, and comprised 56 consecutive patients with biopsy-proven squamous cell carcinoma of oral cavity regardless of grade and stage of tumour. Intra-operatively toluidine blue was used on the resected tumour margins and the staining patterns were assessed. Results were then compared with the final histopathology report. RESULTS: A total of 11(19.64%) margins were positive with toluidine blue staining out of which 8 (14.28%) were false positive. Sensitivity and specificity was found to be 100% and 84.9% respectively with a positive predictive value of 27.2%; a negative predictive value of 100%; and diagnostic accuracy of 85.71%. CONCLUSION: Toluidine blue costs only Rs25 (USD 0.30) and takes only 5 minutes for application and interpretation. It can be used with significant confidence in smaller lesions (T-l and T-II) as an alternative to frozen sections in developing countries where facilities are unavailable. Its use in larger lesions (T-lll and TIV) remains the topic of controversy and awaits a multi centre trial with a larger cohort.

Utility of clinical examination and CT scan in assessment of penetrating neck trauma.

Managing penetrating injuries adequately and effectively depends a great deal on proper assessment of the injury. This study carried out was done at The Aga Khan University Hospital to assess the role of clinical examination and CT scan imaging in evaluation of penetrating neck injuries. A total of 68 students were included, with ages ranging from 3 to 74 years. The involved zones and the injured structures were noted. Results showed a high sensitivity of clinical examination in assessing vascular (81%) and airway trauma (77%), with a low sensitivity for esophageal trauma (34%). For CT scan the sensitivity was 90% for vascular trauma, 83% for airway trauma and 53% for esophageal injuries. Clinical findings and CT scan imaging are important assessment tools for evaluation of penetrating neck traumas, with a high sensitivity for vascular and airway injuries.

Dermatofibrosarcoma protuberans: an unusual case of neck swelling.

Dermatofibrosarcoma protuberans (DFSP) is a relatively intermediate to low grade malignant tumour with high proclivity for local recurrence if excised inadequately. It is a locally aggressive tumour and despite sharing some histological features with fibrohistiocytic tumours, it tends to grow in a more infiltrative manner. We are reporting this rare tumour in a 30-year-old woman where the diagnosis of DFSP was confirmed histologically and by positive immunomarkers at immunohistochemistry.

Diagnostic accuracy of fine needle aspiration cytology in parotid lesions.

Objective. Histopathology of parotid gland tumors is extremely varied and complex due to heterogeneous cellular composition. Preoperative diagnostic tools include fine needle aspiration cytology, the role of which remains controversial. The aim of this paper is to evaluate the usefulness and accuracy of fine needle aspiration cytology (FNAC) in the diagnosis of parotid gland tumors. Methods. We retrospectively reviewed charts of 129 patients who underwent parotidectomy for parotid lesions at Aga Khan University Hospital from 2002 to 2010. We compared the results of preoperative FNAC with final histopathological diagnosis. Results. Concordance with histological results was observed in 86%, specificity was 98%, sensitivity was 84%, and diagnostic accuracy was 94%. Conclusion. Our results demonstrate that preoperative cytology in parotid lesions is fairly accurate and useful in diagnosing benign from malignant and in planning appropriate approach for treatment.

Malignant peripheral nerve sheath tumour of maxilla.

Malignant peripheral nerve sheath tumour (MPNST) is a very rare entity in head and neck with high rate of recurrences and local invasiveness. This tumour is usually found in lower extremities and only 10-12% occur in head and neck region. The diagnosis is considered as the most elusive and difficult among soft tissue sarcomas because of its non specific presentation, both clinically as well as pathologically. This difficulty has now been overcome by immunohistochemistry. We report here a case of MPNST in a 50 years old male with a localized right maxillary growth.

Harmonic scalpel versus electrocautery tonsillectomy: a comparative study in adult patients.

OBJECTIVE: To compare harmonic scalpel (HS) tonsillectomy with electrocautery (EC) tonsillectomy in terms of operating time, intra-operative blood loss, post-operative pain and secondary haemorrhage. METHODS: Sixty adult patients subjected to tonsillectomy only, were evaluated in this prospective study. The patients were stratified into 2 groups (30 each) based on the dissecting instrument used (HS vs. EC) at Aga Khan University Hospital Karachi Pakistan from June, 2006 to August, 2008. RESULTS: The mean operative time was less in electrocautery group (EC 3.57 +/- 0.85 minutes Vs HS 4.20 +/- 1.37 minutes; p<0.05). The mean intra operative blood loss was less in HS group (EC 3.43 +/- 3.42 ml Vs HS 2.40 +/- 2.74 ml; p =0.10). Post operative pain was significantly lower in harmonic scalpel group as compared to electrocautery group on 1st, 2nd and 3rd postoperative day (p < 0.05). From 3rd postoperative day onwards, although harmonic scalpel group was slightly better in terms of pain on visual analog scale but it was not statistically significant. Secondary haemorrhage after tonsillectomy was less in HS (EC 10% Vs HS 3%; p=0.61). CONCLUSION: Except lesser pain score in early postoperative period, the harmonic scalpel does not provide a major benefit over the more traditional method of electrocautery tonsillectomy.

Parotidectomy: a review of 112 patients treated at a teaching hospital in Pakistan.

OBJECTIVE: The purpose of this study was to analyze the clinical presentation, histopathology and complications following parotid surgery. METHODS: We retrospectively reviewed the charts of 112 patients who underwent parotidectomy from January 2000 to February 2010. Data including age, sex, clinical signs and symptoms, histology and complication were collected from medical records. RESULTS: Of the total, 82 (74%) had benign lesions, 30 (36%) had malignant tumors. The most common benign tumor was pleomorphic adenoma (57%), and the most common malignant tumor was mucoepidermoid carcinoma (16%). Analysis of the correlation between fine-needle aspiration cytology and final histology revealed that fine-needle aspiration sensitivity, specificity and accuracy to 86.6%, 97.6% and 94.6% respectively. The most common complication following parotidectomy was transient facial nerve palsy (18.7%). CONCLUSION: Superficial parotidectomy is associated with a decrease incidence of transient facial nerve dysfunction compared with that of total parotidectomy. High grade or advanced tumour is a predictor of poor outcome which may require adjuvant therapy.

A case of pulmonary sarcoidosis, not tuberculosis.

The case of sarcoidosis of the lungs is described in a 50 years old female who presented with symptoms similar to pulmonary tuberculosis. As she showed no improvement on anti-tubercular therapy, sarcoidosis was suspected and confirmed by endobronchial biopsy and she responded well to treatment.