Prognosticators of Excision of Giant Intra-Oral Tumors in a Resource-Challenged Setting: A Case Report.

Minor salivary glands are widely distributed in the mucosal surface of the lips, palate, nasal cavity, pharynx, and larynx, thus can arise from any of these primary sites. Intra-oral minor salivary gland tumors (IMSGTs), while considered rare in the general population are relatively more common when compared to all the other extra-oral sites. Pleomorphic adenoma, as seen in the index patient, is the most commonly diagnosed benign IMSGT. Intra-oral minor salivary gland tumors are not uncommon and depending on their size, nature, and location can be associated with severe limitation of the Patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality. In addition to these deleterious effects, they present a major surgical challenge to the surgeon, who has to determine the safest, most feasible access to ensure complete, or near-complete excision, as well as to the anesthetist, who needs to secure a definitive airway through the nose or mouth, both of which could be significantly restricted by the presence of the tumor. The aim is to present our successful management of one of the largest intra-oral minor salivary gland tumors documented in the literature, highlighting the specific measures we undertook to tackle the peculiar surgical and anesthetic challenges we faced. It had been two years since surgery and the patient is thriving with a markedly improved quality of life and no features of recurrence. The patient is a 50-year-old male with a slowly growing painless, left palatal mass in the roof of the mouth of 10 years duration with recurrent spontaneous bloody discharge effluent and snoring. There was an associated history of dysphagia to solid with associated choking spells, a left-sided facial asymmetry with no cheek swelling, odynophagia, sore throat, or difficulty with breathing. There was ipsilateral loss of upper incisors and dental anarchy about two years before presentation. No other nasal, otologic, or ophthalmic symptoms were present. No neck swelling, stiffness, cough, or chest symptoms. The oropharyngeal physical examination was highly restricted due to the intra-oral size of the mass. Figure 1. There was facial asymmetry with a bulge of the left maxilla, left-sided levels 1b and 2 non-tender lymph node enlargements, freely mobile, not adhered to the skin. A craniofacial CT scan revealed extensive isodense heterogeneously enhancing intra-oral soft tissue mass occupying the entire palate/oral cavity and encroaching laterally on the masticator and the parapharyngeal space with erosion of the left maxillary floor and hyoid bone Figure 2. The patient had an excision biopsy of the palatal mass with a free margin. No frozen section at the time of surgery. Histology revealed Pleomorphic adenoma and was followed up for 2 years with no evidence of recurrence. Prognosticators are delay in presentation leading to an increase in size of the mass and severe limitation of the patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality, the surgeon not being overwhelmed, the skillful Anaesthesist that could maneuver the nasal cavity without us doing tracheostomy and the successful outcome of the surgery.

Les glandes salivaires mineures sont largement réparties à la surface muqueuse des lèvres, du palais, de la cavité nasale, du pharynx et du larynx, et peuvent donc survenir à partir de l'un de ces sites primaires. Les tumeurs des glandes salivaires mineures intra-orales (TGSMIO), bien que considérées comme rares dans la population générale, sont relativement plus courantes par rapport à tous les autres sites extra-oraux. L'adénome pléomorphe, tel que celui observé chez le patient index, est la TGSMIO bénigne la plus fréquemment diagnostiquée. Les tumeurs des glandes salivaires mineures intra-orales ne sont pas rares et, en fonction de leur taille, de leur nature et de leur emplacement, peuvent être associées à une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère et même une mortalité. Outre ces effets délétères, elles présentent un défi chirurgical majeur pour le chirurgien, qui doit déterminer l'accès le plus sûr et le plus faisable pour assurer une excision complète ou presque complète, ainsi que pour l'anesthésiste, qui doit assurer une voie aérienne définitive par le nez ou la bouche, tous deux pouvant être significativement restreints par la présence de la tumeur. L'objectif est de présenter notre prise en charge réussie de l'une des plus grandes TGSMIO documentées dans la littérature, mettant en évidence les mesures spécifiques que nous avons prises pour relever les défis chirurgicaux et anesthésiques particuliers auxquels nous avons été confrontés. Deux ans après l'intervention, le patient se porte bien avec une nette amélioration de sa qualité de vie et aucune manifestation de récurrence. Le patient est un homme de 50 ans présentant une masse palatine gauche en croissance lente et indolore dans le palais depuis 10 ans, avec des écoulements sanguins spontanés récurrents et des ronflements. Il y avait une histoire associée de dysphagie aux solides avec des épisodes d'étouffement, une asymétrie faciale du côté gauche sans tuméfaction de la joue, une odynophagie, un mal de gorge ou des difficultés respiratoires. Il y avait une perte ipsilatérale des incisives supérieures et une anarchie entaire environ deux ans avant la présentation. Aucun autre symptôme nasal, otologique, ophtalmique n'était présent. Aucun gonflement du cou, raideur, toux ou symptômes thoraciques. L'examen physique de l'oropharynx était fortement limité en raison de la taille intra-orale de la masse. Figure 1. Il y avait une asymétrie faciale avec une bosse du maxillaire gauche, des ganglions lymphatiques non douloureux des niveaux 1b et 2 du côté gauche, mobiles librement, non adhérents à la peau. La tomodensitométrie craniofaciale a révélé une masse tissulaire molle intraorale extensive, hétérogène, rehaussée de manière isodense occupant l'ensemble du palais/cavité buccale et empiétant latéralement sur les muscles masticateurs et l'espace parapharyngé, avec érosion du plancher du maxillaire gauche et de l'os hyoïde. Figure 2. Le patient a subi une biopsie d'excision de la masse palatine avec une marge libre. Aucune section congelée n'a été réalisée lors de la chirurgie. L'histologie a révélé un adénome pléomorphe et un suivi de 2 ans n'a montré aucun signe de récurrence. Les facteurs pronostiques comprennent le retard de la présentation entraînant une augmentation de la taille de la masse et une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère voire une mortalité, le chirurgien ne se laissant pas dépasser, l'anesthésiste compétent pouvant manœuvrer dans la cavité nasale sans avoir recours à une trachéotomie, et le succès de l'intervention chirurgicale. MOTS-CLÉS: Intraoral; Glande salivaire mineure; Excision; Tumeur; Pronostiqueurs.

Accidental Decannulation OF TRACHEOSTOMY TUBES - Case Series.

Tracheostomy tube (TT) is usually removed in a planned manner once the patient ceases to have the condition that necessitated the procedure. Accidental decannulation or extubation refers to inadvertent removal of tracheostomy tube out of the stoma. It could prove fatal in an otherwise stable patient. We review a variety of unexpected and often-overlooked causes of accidental decannulation with suggestions on preventive measures. We therefore present three cases of accidental decannulation of tracheostomy tubes in order to report our experiences in the management of the condition. CONCLUSION: Accidental decannulation occurs both in hospitalized and patient on home care of their tracheostomy tubes. Reduction in neck circumference due to weight loss predisposes to accidental decannulation, which could be prevented by suturing the flange to the skin.

Bacteriological agents of chronic discharging ears and their antibiotic sensitivity pattern in Ido - Ekiti, Nigeria.

AIMS AND OBJECTIVES: To identify bacterial agents of chronic discharging ear and determine their antibiotic sensitivities pattern in Ido - Ekiti, Nigeria. PATIENTS AND METHODS: Swab specimens of each chronically (>8 weeks) discharging ears of patients with chronic suppurative otitis media (CSOM) presenting to the Ear, Nose and Throat (ENT) clinic of the Federal Medical Centre, Ido Ekiti were bacteriologically cultured aerobically and the antibiotic sensitivity pattern of the recovered organisms determined by the modified Kirby-Bauer disc-diffusion method over a three year period starting from January 2005. RESULTS: Seventy eight patients with CSOM whose age ranged between 3 months and 85 years were seen during the study period with 73.1% of them having unilateral disease and majority were children < 15 years (71.8%). Out of 99 ear swabs that were examined, 87.9% were culture positive with 90.8% yielding a single isolate. Coliforms (34.7%) were the most frequent isolated group of organisms. Other isolates included Staphylococcus aureus (26.3%), Proteus spp (24.2%), Pseudomonas spp (9.5%) and Klebsiella spp (5.3%). Sparfloxacin and ciprofloxacin showed highest activity on all the isolates unlike cefuroxime and ceftiaxone to which all isolates were resistant. CONCLUSION: Chronic discharging ear is caused by bacteria agents most sensitive to quinolones but resistant to cefuroxime and ceftiaxone. Treatment of patients with CSOM in Ido-Ekiti with the quinolones is recommended except where contraindicated.

Audit of Pediatric ENT Injuries.

BACKGROUND: Ear, Nose and throat (ENT) injuries are relatively common in children. Sometimes they may result in disfigurement or dysfunction of the affected parts. This study was aimed at the pattern and mechanisms of ENT injuries encountered by children in Ilorin located in north central Nigeria. It is therefore our hope that the information will go a long way to assist other African countries as well in health care plans for children. OBJECTIVES: The study was aimed at determining the pattern and causes of ENT injuries in children in Ilorin. METHODOLOGY: This was a descriptive cross sectional, prospective study of all pediatrics patients aged 15 years and below who were managed between January 2005 and December 2009 (a period of 5 years) for ENT trauma in the accident & emergency unit, wards and clinics of University of Ilorin Teaching Hospital. Most of them were treated as out-patients; a few of them needed admission for some procedures. Patients with injuries to other areas than ENT were not included in this study. The data that were analyzed included the age, sex, presenting complaints, duration of symptoms prior to presentation, diagnoses, treatments and complications. RESULTS: Two hundred and seventy-one children were studied, of which 168 (62.0%) were males and 103 (38.0%) were females. Most of the children, 97 (35.8%), were between age group of 6-10 years, 81 (29.9%) aged 5 years and below, while the rest were 11-15 years of age. Injuries due to foreign bodies in Ear, Nose and Throat accounted for 80 (29.5%) of the causes. Falls accounted for 60 (24.4%) of cases while Road Traffic Injuries (RTI), 42 (15.5%) of cases. Bleeding was the commonest presenting symptom. Most of the children, 97 (35.8%) presented within 1 hour of injury while the least, 45 (16.6%), presented more than 8 hours after the injury. 132 (48.7%) had injuries in the Ear, 117 (43.2%) in the Nose and 22 (8.1%) in the Throat. CONCLUSION: ENT injuries in pediatrics are relatively common in our environment with injuries from FB insertion/ingestion being the commonest. This is closely followed by falls. Several disabilities and morbidity may result from the trauma like anosmia, facial palsy and permanently depressed nose. These have impact on psychology of the child. For these reason close monitoring of children by parents and care-givers cannot be overemphasized. Also these injuries are avoidable causes of death and disability in children.

Nasal osteogenic chondrosarcoma: a case report.

BACKGROUND: Osteosarcomas and chondrosarcomas are the most common malignancies of the jaw bones. Nasal osteogenic chondrosarcoma is rarely reported. OBJECTIVE: To draw attention to a rare tumour, osteogenic chondrosarcoma. METHODS: A middle aged woman presented with a three month history of nasal blockade and mucopurulent discharge. She was fully clinically evaluated including anterior rhinoscopy and plain radiograph. RESULTS: Detailed history, physical examination and plain radiography showed features suggestive of antrochoanal polyp with differential diagnoses of sino nasal and nasopharyngeal tumour. At emergency tracheostomy, examination under anaesthesia, meticulous nasal and nasopharyngeal tumour clearance was done. Histopathological examination of the mass revealed osteogenic chondrosarcoma. CONCLUSION: Though rare, osteogenic chondrosarcoma affects nasal bones. Clinically the tumour mimicks an antro-choanal polyp and is associated with the challenge of recurrence.

Clinico-pathological pattern of nasopharyngeal carcinoma in Ilorin, Nigeria.

BACKGROUND: Nasopharyngeal carcinoma is an uncommon tumour in Nigeria but the burden of the disease in terms of morbidity and mortality is very high. AIM: The aim of the study was to document the clinic-pathological characteristics of nasopharyngeal carcinoma in Ilorin, North central Nigeria. MATERIALS AND METHODS: This was a retrospective review of all patients seen in ENT department, University of Ilorin Teaching Hospital with the diagnosis of nasopharyngeal carcinoma between January 1 st 1999 and December 31st,2008. The patient's biodata, clinical presentation and histopathological findings are presented. The histopathological diagnosis was in accordance with the 1991 WHO classification. RESULTS: A total of 30 patients with histologically confirmed nasopharyngeal carcinoma seen during the study period accounted for 2% of the total cancers recorded in Ilorin cancer registry. There were 20 males and 10 females with a mean age of 48.7 ± 15.9 years. The commonest presenting complaint was cervical lymphadenopathy in 96.7% of patients followed by epistaxis (66.7%) and hearing loss (66.7%). Identifiable risk factors included regular intake of ungutted salted smoked fish (76.7%) and tobacco use (23.3%) with some having both risk factors. Histologically, undifferentiated carcinoma was the commonest (70%) followed by well-differentiated keratinizing squamous cell carcinoma (20%) and differentiated nonkeratinizing squamous cell carcinoma (10%). CONCLUSION: Undifferentiated carcinoma was the commonest type of nasopharyngeal carcinoma reported from this study especially among males in the 4th and 5th decades of life. Identifiable risk factors included consumption of ungutted salted smoked fish with tobaccon usage. diagnosis with effective referral system and easy access to radiotherapy would improve the survival outcome in patients with the disease.

Clinico-Pathological Pattern of Nasopharyngeal Carcinoma in Ilorin, Nigeria

Nasopharyngeal carcinoma is an uncommon tumour in Nigeria but the burden of the disease in terms of morbidity and mortality is very high. The aim of the study was to document the clinic-pathological characteristics of nasopharyngeal carcinoma in Ilorin, North central Nigeria. This was a retrospective review of all patients seen in ENT department, University of Ilorin Teaching Hospital with the diagnosis of nasopharyngeal carcinoma between January 1st 1999 and December 31st,2008. The patient's biodata, clinical presentation and histopathological findings are presented. The histopathological diagnosis was in accordance with the 1991 WHO classification. A total of 30 patients with histologically confirmed nasopharyngeal carcinoma seen during the study period accounted for 2% of the total cancers recorded in Ilorin cancer registry. There were 20 males and 10 females with a mean age of 48.7 ± 15.9 years. The commonest presenting complaint was cervical lymphadenopathy in 96.7% of patients followed by epistaxis (66.7%) and hearing loss (66.7%). Identifiable risk factors included regular intake of ungutted salted smoked fish (76.7%) and tobacco use (23.3%) with some having both risk factors. Histologically, undifferentiated carcinoma was the commonest (70%) followed by welldifferentiated keratinizing squamous cell carcinoma (20%) and differentiated nonkeratinizing squamous cell carcinoma (10%).Undifferentiated carcinoma was the commonest type of nasopharyngeal carcinoma reported from this study especially among males in the 4th and 5th decades of life. Identifiable risk factors included consumption of ungutted salted smoked fish with tobaccon usage. Early diagnosis with effective referral system and easy access to radiotherapy would improve the survival outcome in patients with the disease

Traumatic tympanic membrane perforation: an aetiological profile.

BACKGROUND: Traumatic perforation of the tympanic membrane may be due to direct or indirect source. The aim of the study is to profile the various aetiologies of traumatic tympanic membrane perforation in Ilorin, north central Nigeria.A retrospective review of 64 patients seen at the University of Ilorin Teaching hospital, Ilorin, Nigeria over a ten year period (January 1998 to Dec 2007) with history of traumatic tympanic membrane perforation from various causes, these also included multiply injured patients with bleeding from middle ear as part of their presentations. The data retrieved included the biodata, the clinical presentations, source of injury, the clinical findings and the treatment outcome. The data were entered into an SPSS version 11 computer soft ware and analyzed descriptively. FINDINGS: Sixty four (64) ears were analysed, Age range 6 months to 50 yrs, mean age of 29.2 yrs 7.9% of them were

Parental satisfaction with post-adenotonsillectomy in the developing world.

AIM/BACKGROUND: Tonsillectomy with or without adenoidectomy is one of the most commonly performed surgical procedures by the otolaryngologists in the pediatric population. The aim of this study is to evaluate parental expectation and satisfaction following tonsillectomy with or without adenoidectomy. MATERIALS AND METHODS: Hospital-based prospective study of all consented parents whose children had tonsillectomy with or without adenoidectomy over a period of 13 months (February 2008 to February 2009) using a cross-sectional method. Pre- and post-surgical questionnaire-based Interview was conducted for them and information retrieved included biodata, pre- and post-surgical symptoms on follow-up in the clinic of obstructive sleep apnoea, snoring, mouth breathing and rhinorrhea, parental expectation and satisfaction after surgery. All data were entered into statistical data using SPSS version 11 and analyzed and the results are presented in tables and figures. RESULTS: A total of 29 patients had adenotonsillar surgery, who were within the age range of 1.50-14 years with a mean age of 5.50 (SD=4.06+/-0.75). M:F ratio was found to be 3:1 (22 males and 7 females). Parents were satisfied with the expected outcome in terms of symptoms post-operatively in 96.6% while only one 3.4% were not satisfied. CONCLUSION: Majority of the parents (96.6%) were satisfied with the expectation of immediate resolution of symptoms; however, obstructive adenotonsillar hypertrophy remains an important problem to be solved to achieve total parental satisfaction in adenotonsillar operations.

Relationship between epistaxis and hypertension: a study of patients seen in the emergency units of two tertiary health institutions in Nigeria.

BACKGROUND: Both epistaxis and hypertension are common in the general population. OBJECTIVE: This study aimed at determining the prevalence of hypertension among epistaxics, and the relationship between epistaxis and hypertension. METHODS: Retrospective analysis of 62 adults comprising 31 each of males and females with a mean age of 41.4 +/- 16.6 years (range: 18-90 years) that presented in the emergency units of two tertiary health institutions seen over 11 years was done. Main outcome measure was the prevalence of hypertension amongst epistaxics. Seventy-six age and sex-matched patients with bleeding from sites other than the nostrils with no record of epistaxis were selected by simple random sampling as controls. RESULTS: Peak prevalence of epistaxis occurred during the months of January and March. Compared to the controls, the epistaxics had significantly higher blood pressures: (146.1 +/- 40.7 mmHg versus 123.2 +/- 16.3 mmHg systolic, P=0.001), and (91.3 +/- 24.8 mmHg versus 78.2 +/- 12.8 mmHg diastolic, P=0.001), and higher proportions of patients with previous history of hypertension (32.3% versus 7.9%; p<0.001) and family history of hypertension (12.9% versus 2.6%; p<0.02). The proportion of subjects with blood pressure elevation at presentation that remained sustained was significantly higher among the epistaxics than the nonepistaxics (87.5% versus 47.6%, chi2=8.1, P=0.005). The epistaxics had significantly higher prevalence of hypertension than the non-epistaxics (45.2% versus 13.2%, chi2=17.5, p=0.001). Univariate analysis demonstrated association between epistaxis and hypertension (OR=5.4, 95% CI=2.4-12.5, P=0.001), and between epistaxis and age (OR=0.9, 95% CI=1.3-12.5, P=0.02). On multivariate analysis using logistic regression the association between epistaxis and hypertension persisted, after adjusting for age, sex, season and causes of epistaxis (OR=5.6, 95% CI=1.7-15.6, P=0.01). CONCLUSIONS: Our findings support an association between epistaxis and hypertension in the study population.

Profound bilateral sensorineural hearing loss in nigerian children: any shift in etiology?

Deafness, profound hearing loss, is a global problem. However, the causes of, attitudes toward, and management options for deafness differ considerably from region to region. This study seeks to identify the present causes of profound sensorineural hearing loss in Nigeria, which in our environment is almost synonymous to a life sentence of silence and isolation. This is a retrospective survey of children 15 years and below (M = 6.7 years, SD = 3.2). Of the 115 children included in this study, 64 (55.7%) were males, giving a male:female ratio of 5:4. Age group 1-3 years had the highest proportion of hearing loss, 33 (28.7%), and there was a progressive decline in frequency with advancing age. In about a third (34.8%) of patients, causes were unknown, probably congenital. The main acquired causes were febrile illness (18.3%), measles (13.9%), meningitis (8.7%), mumps (6.9%), or severe birth asphyxia (4.3%). Compared to the findings of two decades ago, we conclude that there is no significant shift yet in the etiology of profound sensorineural hearing loss in our environment.

Acute laryngeal obstruction in a Nigerian Hospital: Clinical presentation and management.

OBJECTIVES: To determine the clinical presentations and management of patients with acute laryngeal obstruction. PATIENTS AND METHODS: A retrospective study of 36 patients with acute laryngeal obstruction to the accident and emergency unit (A&E), emergency paediatric unit (EPU) and the Ear, Nose and Throat diseases clinic (ENT) of the University of Ilorin Teaching Hospital between January 1998 and the December 2002 are presented. RESULTS: The age ranges of the patient were between 1.5 years to 46 years (mean age 29.6 years with male/female ratio of 2:1 Breathlessness (83.3%), hoarseness (66.7%), and noisy breathing (50%) were the main symptoms at presentation. CONCLUSIONS: These 36 patients represented 4.9 % of the in-patients seen by the Otolaryngologists during the period under review and 75% of cases of acute upper airway obstruction managed during this period. The commonest cause of obstruction in this study was laryngeal tumours (47.2%)-laryngeal carcinoma (27.8%) in the adults and juvenile laryngeal papillomas (19.4%) in the paediatric age group; other causes were laryngeal infections (acute and chronic) represented 20% of aetiologic factors. Impacted laryngeal foreign bodies occurred in 5(13.9%) all in the paediatric age group. Eleven (30.6%) were managed conservatively with antibiotics and antikoch's therapy; 12(33.3%) had emergency tracheostomy prior to definitive treatment of direct laryngoscopy in 10 patients (27.8%) for biopsy, removal of foreign bodies and extirpations of juvenile laryngeal papillomas and 3(8.3%) were managed by endotracheal intubations. Health education of the public is recommended to ensure early presentation in hospital as soon as symptoms of laryngeal tumours are noticed and health care providers should refer such cases early.

Recurrent bilateral fronto-ethmoidal mucocoele with intracranial extension: a case report.

Mucocoeles of the paranasal sinuses are relatively uncommon and rarely bilateral, the frontal and ethmoidal sinuses being most commonly affected. Rarely, fronto-ethmoidal mucocoeles expand and extend into the anterior cranial fossa producing mass effect. We report a 66-year-old woman, who presented with a 20-year history of recurrent bilateral progressive proptosis and supra orbital swellings with blindness in the left eye. Ultrasound scan of the left eye showed a large cystic mass in the orbit due to extension of ipsilateral frontal mucocoele. Computed tomographic brain scan showed large bilateral fronto-ethmoidal mucocoeles, erosion of the right orbital roof, right posterior and left anterior sinus walls, and extension of the right frontal sinus into the anterior cranial fossa with mass effect. The patient had a bicoronal craniotomy and bilateral fronto-ethmoidectomy with direct drainage of independent right mucocoele and left mucopyocoele. This case illustrates complications that may result from chronicity and treatment failure in patients with sinus mucocoeles.

Clinicopathological study of head and neck cancers in Ilorin, Nigeria.

Eighty-nine cases of head and neck cancers were studied over a 5-year period (1997--2001) at the University of Ilorin Teaching Hospital, Nigeria. The most common cancer affecting the head and neck region was carcinoma which constituted 70.8% of all the cases studied. It was followed by the lymphomas and blastomas which accounted for 20.2% and 9%, respectively. The nose/paranasal sinuses were the most common site of primary cancer (18%) followed by thyroid (12.4%), nasopharynx (11.3%) and larynx (4.5%). Other sites include a hypopharynx (3.4%), eye (2.2%), palate (2.2%), tongue (2.2%), skin (1.1%), lip (1.1%), salivary gland (1.1%), oropharynx (1.1%). Cervical lymph node metastasis with unknown primary lesion was seen in 10.1%. The peak age incidence was in the fifth decade of life. The improvement in locoregional control of head and neck cancers over the last decades does not appear to modify the final survival of these patients. It is crucial to understand as accurately as possible the risk factors for these malignancies in order to improve primary prevention.