Cimetidine for recurrent respiratory papillomatosis in pregnancy as an alternative adjuvant treatment.

BACKGROUND: We report the first case of cimetidine as an alternative adjuvant therapy in a pregnant woman with recurrent respiratory papillomatosis (RRP). A 40 year old woman at 19 week gestation presented with progressive hoarseness and shortness of breath for 1 month. Flexible nasopharyngolaryngoscopy revealed multiple papillomatous lesions over both vocal cords and subglottic area obstructing 60% of her airway. She had previously been diagnosed with juvenile onset RRP at the age of 5 and underwent endoscopic clearance regularly every 6 months. METHOD: The patient was started on a trial of oral cimetidine at a dose of 30 mg/kg and responded well, eventually requiring endoscopic excision only after 2 years. Subsequently, she underwent in vitro fertilisation treatment and stopped taking her cimetidine. After undergoing endoscopic clearance of her papillomata under general anaesthesia, she restarted on cimetidine during her 2nd and 3rd trimester. RESULTS: Ensuing follow-up demonstrated stable minimal papillomata lesions on her right inferior surface of her vocal cord with no recurrence on her left vocal cord and subglottic area. CONCLUSION: Cimetidine is generally safe and not known to be associated with any major teratogenic risks during pregnancy. RRP is postulated to worsen in pregnant women due to the increase in oestrogen levels during pregnancy. Hence, adjuvant therapy was imperative for our patient to reduce recurrent papillomata formation during her pregnancy. Larger scale studies are warranted to assess the use of long-term high-dose cimetidine in terms of efficacy and safety in pregnancy.

How I do it: novel use of a modified nasopharyngeal airway in laryngotracheal stenosis as a temporary stent.

BACKGROUND: This paper reports the innovative use of a modified nasopharyngeal airway device as a temporary stent in patients with laryngotracheal stenosis. It also discusses the technique of endoscopic stent placement, and our experience in terms of the indications and suitability. METHOD: The nasopharyngeal airway device was modified to use as an airway stent by trimming it to the desired length. Next, the stent was inserted endoscopically and anchored using a novel approach. RESULTS: The surgery was performed successfully without complications. The patients had full use of their voice while the stent was in situ. No significant granulation tissue was observed. CONCLUSION: This paper demonstrates the feasibility of using a nasopharyngeal airway device as a temporary stent to prevent restenosis in cases where the patients have a strong demand for phonation. The modified nasopharyngeal airway device is potentially very promising, but cases must be selected carefully to avoid compromising efficacy and safety.

Experience with 2D Exoscope System for Bilateral Simultaneous Cochlear Implant Surgery in the Era of the COVID-19 Pandemic.

We report the first case series utilizing the exoscope exclusively for bilateral simultaneous cochlear implant surgery and discuss the advantages, disadvantages, as well as surgical outcomes in the Covid-19 era. The VITOM® 2D is compatible with enhanced PPE and draping techniques which can improve safety while providing comparable surgical outcomes.

Atypical Isolated Infections of the Infratemporal Fossa: A Diagnostic Challenge.

INTRODUCTION: Atypical infratemporal fossa infections are rare and potentially fatal. CASE REPORT: A case of an aspergillosis localized in the infratemporal fossa and another case of tuberculosis of the infratemporal fossa originating from the maxillary sinus, is described. The first patient was immunocompromised and showed symptoms of facial numbness; whereas the other was an immunocompetent man who complained of trigeminal neuralgia type pain. It was difficult to differentiate between infection and tumour despite the utilization of computed tomography scans and magnetic resonance imaging. CONCLUSION: These cases illustrate the need for a high index of suspicion; in addition to endoscopic confirmation and histopathology to establish precise diagnosis and early intervention.

Endoscopic transnasal approach to anterior and middle cranial base lesions.

We present our experience in managing pathologies involving the anterior and middle cranial base using an endoscopic transnasal approach, highlighting the surgical technique, indications, and complications. The different types of endoscopic approaches used include the transtuberculum/transplanum, transcribiform, transsellar, and cavernous sinus approaches. The common indications include repair of cerebrospinal fluid leaks (both spontaneous and post traumatic) and excision of pituitary adenomas, meningiomas, craniopharyngiomas, esthesioneuroblastomas, and other malignancies of the anterior cranial base. Careful reconstruction is performed with the multilayer technique utilizing fat, fascia lata, and fibrin sealant. The endoscopic transnasal approach, coupled with the present-day sophisticated neuronavigation systems, allows access to lesions in the midline extending from the cribriform plate to the craniovertebral junction. However, preoperative planning and careful selection of cases with evaluation of each case on an individual basis with regard to the lateral extension of the lesion are imperative.

Combined endoscopic transnasal and transoral approach for extensive upper cervical osteoradionecrosis.

PURPOSE: Osteoradionecrosis (ORN) is a rare yet well-recognized complication following radiotherapy to the head and neck. We illustrate the only case of a spontaneous extrusion of the sequestered C1 arch through the oral cavity and discuss our experience with a combined endoscopic transnasal and transoral approach for cervical ORN. METHODS: A 56-year-old female presented with a 3-month history of blood-stained nasal discharge. She had been treated with radiotherapy for nasopharyngeal carcinoma 25 years earlier. Flexible nasal endoscopy demonstrated an exposed bone with an edematous posterior nasopharyngeal mass. Computed tomography showed a pre-vertebral mass with destruction of C1 and C2. She underwent occipito-cervical fusion followed by a combined transnasal and transoral endoscopic debridement of non-viable bone in the same perioperative setting. Healing of the raw mucosa was by secondary intention and reconstruction was not performed. RESULTS: Histopathological examination reported ulcerated inflamed granulation tissue with no evidence of malignancy. During follow-up, she remained neurologically intact with no recurrence. CONCLUSION: Using both nasal and oral spaces allows placement of the endoscope in the nasal cavity and surgical instruments in the oral cavity without splitting the palate. Hence, the endoscopic transnasal and transoral approach has vast potential to be effective in carefully selected cases of cervical ORN.

Basaloid Squamous Cell Carcinoma: An Unusual Ball-Valve Laryngeal Obstruction.

INTRODUCTION: A rare case of basaloid squamous cell carcinoma (BSCC) of the larynx, which has not been previously reported, is described. CASE REPORT: A 60-year-old man was presented to the Otolaryngology Department with progressive dyspnoea and dysphagia to solids for over a period of 1 week. Direct laryngoscopy revealed a tumour at the laryngeal aspect of the epiglottis, which prolapsed into the laryngeal inlet each time the patient inspired. This resulted in an inspiratory stridor despite adequate glottic opening and normal mobility of the vocal cords. CONCLUSION: Therefore, in cases where a ball-valve lesion causes intermittent life-threatening airway obstruction, BSCC of the larynx, though rare, must be considered as a differential diagnosis.

Combined transnasal and transoral endoscopic approach to a transsphenoidal encephalocele in an infant.

PURPOSE: This paper reports an unusual case of a transsphenoidal encephalocele and discusses our experience with a minimally invasive management. To the best of our knowledge, we present the first case of a combined endoscopic transnasal and transoral approach to a transsphenoidal encephalocele in an infant. METHODS: A 17-day-old boy, who was referred for further assessment of upper airway obstruction, presented with respiratory distress and feeding difficulties. Bronchoscopy and imaging revealed a transsphenoidal encephalocele. At the age of 48 days, he underwent a combined endoscopic transnasal and transoral excision of the nasal component of the encephalocele. This approach, with the aid of neuronavigation, allows good demarcation of the extra-cranial neck of the transsphenoidal encephalocele. We were able to cauterize and carefully dissect the sac prior to excision. The defect of the neck was clearly visualized, and Valsalva manoeuvre was performed to exclude any CSF leak. As the defect was small, it was allowed to heal by secondary intention. RESULTS: The patient's recovery was uneventful, and he tolerated full feeds orally on day 2. Postoperative imaging demonstrated no evidence of recurrence of the nasal encephalocele. Endoscopic follow-up showed good healing of the mucosa and no cerebrospinal fluid leak. CONCLUSIONS: The surgical management of transsphenoidal encephalocele in neonates and infants is challenging. We describe a safe technique with low morbidity in managing such a condition. The combined endoscopic transnasal and transoral approach with neuronavigation is a minimally invasive, safe and feasible alternative, even for children below 1 year of age.

Basaloid squamous cell carcinoma of the oropharynx: comparison of two cases and review of the literature.

We describe a rare case of BSCC in the retromolar trigone with only 3 other cases in the literature and also compare the differences between 2 cases of BSCC in terms of presentation and progression. The first patient had a markedly slower progression with painful retromolar trigone swelling over 4 months without nodal metastases. In contrast, the second patient gave a 2-week history of neck swelling with nodal involvement, indicating extremely rapid progression. Our management was tailored accordingly with the first patient undergoing intraoral excision of tumour and adjuvant radiotherapy while the other had bilateral neck dissection with postoperative chemoradiotherapy. Both patients achieved good outcome and are free from disease.

Anaesthesia for a child with adrenoleukodystrophy: A case report and review of the literature.

We present a 9-year-old boy with X-linked cerebral adrenoleukodystrophy (X-linked ALD) and previous umbilical cord transplant who required general anaesthesia. An anaesthetic plan for each individual should be tailored to ensure the best possible anaesthetic care for these patients. The anaesthetic considerations include mental retardation, seizure disorder, hypotonia, liver function abnormalities, gastro-oesophageal reflux, impaired adrenocortical function and immunosuppression. Pre-operative sedation should be avoided because of hypotonia of the pharyngeal muscles. Anti-convulsants are continued, and potentially epileptogenic anaesthetic agents are avoided. The patient was intubated using a modified rapid sequence induction with a head up position of 30 degrees. Four other cases have been reported in literature. Nevertheless, there is still no established anaesthetic management for these patients, and total intravenous anaesthesia can be considered as a safe and alternative method of anaesthesia. To the best of our knowledge, this is the first reported use of total intravenous anaesthesia with propofol and remifentanil in a case of cerebral adrenoleukodystrophy, and with a favourable outcome.