Rhinocerebral zygomycosis in Pakistan: clinical spectrum, management, and outcome.

OBJECTIVE: To study the disease spectrum and salient management features of 36 patients with histopathologically-confirmed rhinocerebral zygomycosis seen at our academic center over a 16-year period. METHODS: Retrospective review of patients admitted to the Aga Khan University Hospital in Karachi, Pakistan from January 1991 to December 2006 with histopathologically-confirmed zygomycosis of the head and neck. RESULTS: Mean patient age was 40 +/- 5.0 years (range, 34-63 years), and 23 (64%) patients were male. Thirty-two (89%) patients were referred from clinical services other than otolaryngology. Underlying predisposing conditions included diabetes mellitus (21 patients), haematologic diseases (9), and renal failure (6). Twenty (55%) patients had limited sinonasal disease, ten (28%) had orbital involvement, and six (17%) had intracranial extension. All patients underwent rigid nasal endoscopy and biopsy, and black necrotic tissue was seen in 22 (61%) instances warranting endoscopic or open surgical debridement. Four of 6 patients undergoing open surgery required orbital exenteration. Overall patient survival was 56% (20/36 patients). Diabetic patients had improved survival (17/21, or 81%) compared to patients with haematologic disorders (3/9, or 33%) (p = 0.001). All six patients with intracerebral disease died. Eighteen of the 22 (82%) patients treated with surgery plus amphotericin B survived vs. two of 14 (14%) receiving amphotericin B alone (p < 0.001). CONCLUSIONS: In rhinocerebral zygomycosis, an aggressive, multidisciplinary, diagnostic and therapeutic approach that utilizes CT or MRI staging, and combines endoscopic or open surgical debridement with amphotericin B-based antifungal therapy offers the best chance of recovery.

Management of allergic fungal sinusitis with postoperative oral and nasal steroids: a controlled study.

In patients with allergic fungal sinusitis, the mainstay of treatment remains surgical removal of allergic mucin and fungal debris. But as a single modality, surgery is associated with high rates of recurrence, so a number of adjunctive medical modalities have been tried, including postoperative corticosteroid therapy. We conducted a study of 63 patients with allergic fungal sinusitis who underwent endoscopic sinus surgery with or without postoperative steroid therapy. A group of 30 patients who had been treated prior to January 2000 had undergone surgery only; their cases were reviewed retrospectively, and they served as historical controls. Another 33 patients who were treated after June 2000 underwent surgery plus oral and nasal steroid therapy. All patients were followed for a minimum of 2 years. Recurrences were seen in 50.0% (15/30) of the no-steroid group and 15.2% (5/33) of the steroid group-a statistically significant difference (p = 0.008). The results of our study strongly support the use of steroids to control allergic fungal sinusitis and prevent its recurrence, and we recommend further study to identify the optimal dosage and duration of therapy.

Cervical esophagotomy for an impacted denture: a case report.

We present the case of a 46-year-old woman with an impacted denture and an impending esophageal perforation. Her family physician initially missed the diagnosis but during a subsequent visit reviewed her x-ray and was able to see the shadow of the denture's wire attachment in her esophagus. The patient was then referred to a tertiary care hospital, where esophagoscopy confirmed the location of the denture, but the surgeon there was unable to remove it. Eighteen days after she had swallowed her denture, she was referred to our hospital. Attempts at removal via rigid esophagoscopy were unsuccessful, but the denture was successfully removed via a cervical esophagotomy. A Gastrograffin swallow performed 1 week postsurgically showed no extravasation of the contrast medium, and subsequent follow-ups were unremarkable. We conclude that cervical esophagotomy is a safe method for removing foreign bodies impacted in the cervical esophagus when they cannot be removed endoscopically.

Nasal packing after septoplasty: a randomized comparison of packing versus no packing in 88 patients.

The once-common practice of packing the nose after septoplasty was based on a desire to prevent postoperative complications such as bleeding, septal hematoma, and adhesion formation. However, it was since found that not only is nasal packing ineffective in this regard, it can actually cause these complications. Although the consensus in the world literature is that packing should be avoided, to the best of our knowledge, no truly randomized study has been undertaken in Southwest Asia upon which to justify this recommendation here. Therefore, we conducted a prospective randomized comparison of the incidence of a variety of postoperative signs and symptoms in 88 patients, 15 years of age and older, who did (n = 44) and did not (n = 44) undergo nasal packing following septoplasty. We found that the patients who underwent packing experienced significantly more postoperative pain, headache, epiphora, dysphagia, and sleep disturbance on the night of surgery. Oral and nasal examinations 7 days postoperatively revealed no significant difference between the two groups in the incidence of bleeding, septal hematoma, adhesion formation, and local infection. Finally, the packing group reported a moderate to high level of pain during removal of the packing. Our findings confirm that nasal packing after septoplasty is not only unnecessary, it is actually a source of patient discomfort and other signs and symptoms.

Iatrogenic insertion of impression mould into middle ear and mastoid and its retrieval after 9 years: a case report.

The magnitude of hearing loss in Pakistan is enormous. One in twelve children of Pakistan suffers from some form of hearing impairment. Many of them are unable to afford surgical procedures and resort to the use of cheap hearing aids fitted by untrained individuals or people lacking the required expertise. This predisposes the patients to significant complications during a process that is otherwise considered safe.We report the case of a child, where the process of making the mould for a hearing aid led to the perforation of the tympanic membrane and pouring of mould material into the middle ear, necessitating surgical intervention. During initial surgery it was thought that all mould had been removed from the middle ear but 9 years later this child underwent cochlear implantation at the same center and remaining part of ear mould was discovered from mastoid cavity.

Migrating foreign body in the thyroid gland, an unusual case.

We report an unusual case of an ingested foreign body in 26 year old female that perforated the esophagus and penetrated the thyroid gland. A neck exploration was done to remove the foreign body.

Surgical emphysema in the neck as a result of a dental procedure.

We report the development of subcutaneous emphysema in a middle-aged woman that occurred several hours after she had undergone a dental restoration procedure. The patient presented to the emergency department, and she was admitted for observation and prophylactic antibiotic coverage. She recovered in 3 days without further intervention and was discharged.