Subglottic Stenosis in Children: Preliminary Experience from a Tertiary Care Hospital.

INTRODUCTION: This retrospective study describes our experience in the evaluation and management of infants with subglottic stenosis. MATERIALS AND METHODS: The study included 10 patients aged between 1 wk and 18 months with 6 cases having congenital subglottic stenosis and 4 cases having acquired subglottic stenosis. RESULTS: 6 patients had grade I, 3 patients had grade II, and 1 patient had grade III subglottic stenosis. Tracheostomy was required in 4 patients at the time of presentation. 7 patients were treated successfully with Bougie dilation followed by topical application of mitomycin, whereas 1 patient who failed to serial dilation needed open reconstructive procedure. Laser excision of the anterior subglottic web was performed in one patient. Another patient with underlying cerebral palsy could not be operated upon and was managed with tracheostomy. CONCLUSION: Subglottic stenosis may be effectively man-aged with endoscopic surgical techniques, although the number of such sittings required varies with the type and severity of stenosis. Open surgical procedures need to be individualised as per the needs of the patient only after all the other endoscopic possibilities have been exhausted.

Prelingual Deafness: An Overview of Treatment Outcome.

Prelingually deaf child is one who is either born deaf or who lost his or her hearing early in childhood, before acquiring language. A child with subnormal hearing acuity suffers from consequences of hearing loss compounded by impaired speech development. The period from birth to 3 years of life is critical for the development of speech and language, therefore, there is need for early identification and assessment of hearing loss and early rehabilitation in children. 40 patients were evaluated clinically, radiologically and audiologically to assess the degree of patient's handicap. The modes of treatment included use of hearing aid in patients with moderate, moderately-severe, severe or profound HL and cochlear implantation in patients with profound HL. Each patient was followed for 18 months and results were calculated in terms of speech perception (CAP) and language (REELS) development of the patient. Out of the 40 patients, 60% (n = 24) were females and 40% (16) were males. 50% (n = 20) patients had PSNHL, 32.5% (n = 13) had SSNHL, 10% (n = 4) had MSSNHL and 7.5% (n = 3) had MSNHL. 30% (n = 12) of patients had significant radiological findings. Among the hearing aid users patients with PSNHL got no benefit at the end of 18 months whereas the patients with cochlear implantation had significant improvement. Also the patients managed at a younger age (<3 years) had a significantly better outcome then those managed later. Early identification of hearing loss, that is followed by immediate and appropriate intervention results in better language, speech, and social-emotional development when compared to children treated at a later age.

Indications of implant removal: A study of 83 cases.

INTRODUCTION: Fracture fixation has become advanced with the advent of new and custom metal implants for each type of bone/fracture. After union though, the implant ceases to be important and may be removed. Routine removal is advocated by some and opposed by others. Nevertheless, some patients require removal of the hardware because of various implant-related problems. Our study was aimed at identifying the most common causes for implant removal. OBJECTIVE: To investigate the common indications of orthopedic implant removal surgeries. METHODS: Adult patients admitted for implant removal in our department were included in the study. They were operated in the next OT list. They were then followed for an average 4 months for resolutions of symptoms or appearance of new problems. RESULTS: A total of 83 patients were studied. 71 of them were males. The mean age was 38 years. The reasons for removal of implants were found to lie in five categories: Pain/discomfort/prominent hardware, infected hardware, implant failure, elective (patient's insistence), and other reasons. Overall, the most frequently removed implants in our series were distal tibial/ankle plates (14.45% of implants removed), femoral intramedullary (IM) nails (13.25%), olecranon wires and plates (12.04%), and tibial IM nails and patellar tension band wirings (9.53% each). DISCUSSION AND CONCLUSION: The clinical indications of implant removal are not well established, and few definitive data exist to guide whether routine implant removal is appropriate. Symptomatic hardware frequently needs removal. We found that pain and implant prominence (mechanical symptoms) are the most common indications. Infection is the next most common, followed by hardware failure. Other indications are implant failure, bone resorption due to excessive stress shielding and patient's will. Removal is, however, not an easy surgery, and several factors such as bone ingrowth and wear of the implant may make its removal difficult.

Nasopharyngeal Angiofibroma: Paradigm Shift in Management.

To report on a series of patients of nasopharyngeal angiofibroma of varied ages with different stages and management algorithm which reduced morbidity associated with this tumour. Retrospective. We report a series of ten patients who presented to a tertiary care institution and were diagnosed to have NA from 2012 to 2014. Patients were categorized by Radkowski staging and data was collected to document differences in terms of presentation, operative technique, and postoperative course. All patients underwent preoperative embolization. Stage I and selected stage II lesions were approached endoscopically while the remainder underwent open resection. In comparison with open procedures, endoscopic procedures had less intraoperative blood loss (350 vs. 630 cc), operative time (90 vs. 150 min) and the average hospital stay was one day less (3 vs. 4 days). Proper preoperative work up including nonsurgical intervention in the form of embolisation and selecting proper surgical approach is rewarding in case of angiofibromas of all stages which help to reduce morbidity associated with these benign tumours.

Thyroglossal Duct Cysts: A Clinicosurgical Experience.

Thyroglossal cyst is the most common congenital neck mass and occurs in 7% of the population. They occur due to failure of thyroglossal duct to involute and atrophy thyroglossal duct cysts often occur in pediatric patients. Majority of them are found infrahyoid region. The purpose of the present study is to report our 5 year clinical experience of thyroglossal cysts in terms of clinical features and surgical findings with special emphasis on naked eye extend of patent thyroglossal duct when present. To the best of our knowledge this is first clinical study which has reported the extend of thyroglossal duct on naked eye. This prospective observational study was done in the Postgraduate Department of ENT, Head and Neck surgery of Government medical college, Srinagar for a period of five years from January 2011 to January 2016. Thirty patients of histopathologically confirmed thyroglossal cysts were enrolled in the study. Patients were initially diagnosed on the basis of clinical history, examination and USG findings suggestive of cyst. Clinical data and surgical data in terms of size and location of cyst, presence or absence of thyroglossal duct etc. was analyzed and formulated in tables for patients who had histopathologically confirmed cyst. Mean age was 10 years. Majority (73.3%) were less than 15 years of age. Males were 22 in number (73.3%) while females compromised 26.7% of population. Ninety percent of patients presented with neck swelling. Erythema/redness over swelling was seen in 13.3% of patients. Majority (83.3%) of cysts were subhyoid in location. Thyroglossal ducts were seen to be patent for different lengths and areas. Majority of patients (80%) had tract arising from cyst and disappearing at superior border of hyoid body while three patients (10%) had patent thyroglossal duct from cyst to vallecular mucosa. A complete patent thyroglossal duct was seen in one patient (3.3%) from cyst to base of tongue. Complete Absent tract was seen in two patients (6.7%). Majority (70%) of cysts were having size between 1.6 and 3 cm. Intraoperative 10% of cyst got ruptured. Thyroglossal cysts are most commonly seen in pediatric males. Most of them present with visible midline neck swelling. In few cases cyst can rupture after repeated infections leading to sinus formation. Most of them are subhyoid in location. These cysts are usually of size 1.5-3 cm. Complete patent thyroglossal duct from cyst to tongue musculature is rarely seen while most of the times, a patent duct just disappears at the superior border of body of hyoid. None of our cysts had malignant features.

Imaging Evaluation of Pediatric Sensorineural Hearing Loss in Potential Candidates for Cochlear Implantation.

Computerized tomography (CT) and magnetic resonance (MR) are complementary in the imaging of the labyrinth, the internal auditory canal and the brain in children with sensorineural hearing loss who are being evaluated for cochlear implantation. An accurate anatomical description of the inner ear is essential in the preoperative work up. Computerized tomography visualizes the bony structures, whereas MR can discern soft-tissue components including intra labyrinthine fluid, cerebrospinal fluid (CSF), nerves, and vessels within the IAC. This prospective study was conducted in the Department of Otorhinolaryngology, Head & Neck Surgery, Government Medical College, Srinagar. 40 children in the age group of 1-16 years with unidentified causes of bilateral SNHL were analysed radiologically over the period of 2 years from Dec 2011 to Jan 2014. Each patient underwent MRI and high resolution CT scanning of temporal bone in axial and coronal planes. Out of the 40 patients 22 were males (55 %) and 18 were females (45 %). 30 patients (72.5 %)in our study had normal radiological scans. Five patients (12.5 %) had B/L large vestibular aqueduct and two patients (5 %) had internal auditory canal stenosis with cochlear nerve hypoplasia on CT and MR imaging. Cochlear dysplasia was present in two patients (5 %) and semicircular canal dysplasia was present in one patient (2.5 %) as an isolated finding on HRCT. In addition isolated cochlear nerve hypoplasia was present in one patient (2.5 %). Hyperintense basal ganglia lesion suggestive of kernicterus was present in one patient (2.5 %) and hyperintense posterior parietal and occipital white matter lesions suggestive of congenital CMV infection was present in one patient (2.5 %) on MR imaging. Arachnoid cysts of middle cranial fossa was an incidental finding present in one patient. Radiological abnormalities of the inner ear are not uncommon. Computerized tomography and MRI are important modalities to analyze the inner ear in children with unexplained SNHL. MRI with an extremely small field of view should be used to study possible abnormalities of the vestibulocochlear nerves.

Clinical predictors for successful uvulopalatopharyngoplasty in the management of obstructive sleep apnea.

Objective. To assess the clinical parameters for successful uvulopalatopharyngoplasty in the management of obstructive sleep apnoea syndrome documented with pre- and postoperative polysomnography. Materials and Methods. A study group of 50 patients diagnosed as having OSA by full night polysomnography were assessed clinically and staged on basis of Friedman staging system. BMI and neck circumference were considered, and videoendoscopy with Muller's maneuver was done in all to document the site of obstruction. The study group divided into surgical and nonsurgical ones. Twenty-two patients out of fifty were then selected for uvulopalatopharyngoplasty. The selection of surgical group was done primarily on basis of clinical parameters like neck circumference, Friedman stage of the patient and site, and/or level of obstruction of patient. Postoperative polysomnography was done six months after surgery to document the change in AHI score. Result. The study group consists of fifty patients with mean age of 44.4 ± 9.3 years. UPPP was done in twenty-two, and the result of the surgery as defined by 50% reduction in preoperative AHI with postoperative AHI < 20/h was seen to be 95.2%. Postoperative change in AHI done after 6-month interval was seen to be statistically significant with P value < 0.001. Conclusion. UPPP is ideal option for management of obstructive sleep apnoea syndrome in properly selected patients on the basis of Friedman stage and site of obstruction detected by videoendoscopy with Muller's maneuver.

Rare case of renal cell carcinoma with mandibular swelling as primary presentation.

Introduction. Renal cell carcinoma accounts for approximately 3% of adult malignancies and 90-95% of neoplasms arising from the kidney. This disease is characterized by a lack of early warning signs, diverse clinical manifestations, and resistance to radiation and chemotherapy. Approximately one-third of patients with renal cell carcinoma have metastatic disease at initial presentation. Fifteen percent of patients with renal cell carcinoma are said to present with metastases in the head and neck region. Most of the metastases from RCC to the head and neck involve the thyroid gland. The head and neck are unusual sites for metastases, but skin, skeletal muscle, thyroid gland, nasal cavity and paranasal sinus metastases have been reported. Case Report. The following report describes a rare case where the patient presented with mandibular swelling of short duration as the primary complaint without any symptom or sign pertaining to urinary tract and was found to have renal cell carcinoma on further workup. Conclusion. Metastatic renal cell carcinoma is a diagnostic dilemma especially when there is no pointer historically towards renal cell carcinoma as was in our case. An unusual vascular osteolytic lesion in head and neck in a middle-aged person should be dealt with high index of suspicion with renal cell carcinoma at the back of the mind.

Intravenous radiocontrast induced anaphylactoid reaction: a rare cause of death.

Anaphylactoid reaction after the injection of iodinated contrast media can be life threatening. A 23-year-old woman presented to the emergency room with abdominal pain and fever, for couple of days duration. After completion of a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast, the patient complained of feeling hot and shortness of breath. She became unresponsive, cyanotic, and developed asystole. The patient was successfully intubated without any laryngeal oedema or bronchial spasm. Despite all resuscitation efforts the patient died. The patient had undergone CT scans with contrast three times in the past. An autopsy could not reveal any obvious cause and the serum tryptase concentration was 211 ng/ml (normal <9 ng/ml).