Canal-down mastoidectomy: experience in 81 cases.

OBJECTIVES: To identify the common presentation(s) and the clinical and operative finding(s) in patients with cholesteatomatous and long-term noncholesteatomatous chronic suppurative otitis media and to adapt a surgical management best suited to ensure long-term safety in these Papua New Guinean patients for whom postoperative follow-up is minimal. DESIGN: Retrospective case series. SETTING: Port Moresby General Hospital, the tertiary referral center for otolaryngologic services. PATIENTS: Eighty-one patients in all age groups who received a clinical diagnosis of chronic suppurative otitis media, with or without cholesteatoma, with or without its associated complications. INTERVENTION: Canal-down (modified radical) mastoidectomy with wide meatoplasty. MAIN OUTCOME MEASURE AND RESULTS: Adults were more commonly affected than adolescent or pediatric cases, and there was a male preponderance. The median age was 24 years (range, 13 months to 73 years). Otorrhea remained the most common presentation in all age groups. Postauricular abscesses and fistulae were seen frequently. Cholesteatoma and granulation with polypoidal mucosa were frequent operative findings; a high incidence involved both the attic space and the antrum. Five (6%) patients had preoperative facial paralysis; in addition, postoperative facial paralysis developed in three (4%) patients. The incidence of postoperative "wet ear" was high in all age groups. Meningitis was the most common intracranial complication, followed by lateral sinus thrombosis. There were seven (9%) deaths altogether, and all the deaths occurred as a direct result of otogenic intracranial complication. CONCLUSION: Lack of health consciousness, poor socioeconomic status, and lack of health care delivery system resulted in late presentations and poor postoperative follow-up. Hence, the canal-wall-down technique with wide meatoplasty is recommended to ensure a best possible one-time treatment in Papua New Guinean patients with cholesteatomatous or long-term "dangerous" chronic suppurative otitis media with or without complications.

The syndrome of frontonasal dysplasia, spastic paraplegia, mental retardation and blindness: a case report with CT scan findings and review of literature.

Frontonasal dysplasia is defined as hypertelorism, telecanthus and broad bridge of the nose with absent or bifid tip of the nose. The clinical, the CT scan and the operative findings of a case of frontonasal dysplasia with spastic paraplegia, mental retardation, blindness, and cleft lip and cleft palate are discussed. The contemporary literatures on this rare congenital anomaly are also reviewed.

Adult head and neck lymphomas in Papua New Guinea: a retrospective study of 70 cases.

BACKGROUND: During a 10-year period (1986-95), 70 adult Papua New Guineans with head and neck lymphomas were seen in the 18 years-and-above age group. METHODS: The clinical information was obtained from the medical records section of the Port Moresby General Hospital. Relevant treatment modalities and the follow-up data were acquired from the National Cancer Centre, Angau Memorial Hospital, Lae. RESULTS: Of a total of 227 adult lymphomas recorded in a 10-year period, 70 cases were seen in the head and neck region. Non-Hodgkin's lymphoma constituted 56 cases, which included seven cases of adult Burkitt's-like lymphoma. Fourteen cases of Hodgkin's lymphoma were recorded. CONCLUSIONS: In Papua New Guinea, malignant lymphomas primarily affecting the head and neck region were seen in 30.8% of all lymphomas. This constitues 2.8% of all malignancies in this region. These lymphomas appear to be more aggressive at this site. Proper tissue diagnosis and combination chemoradiotherapy are the key factors in its management.

Paediatric tracheostomy: an analysis of 40 cases.

Tracheostomy in the paediatric patient has been associated with significant morbidity and mortality compared to that in the adult. A retrospective analysis was made of 40 patients up to the age of 12 years having tracheostomies. Upper airway obstruction made up the commonest (32 patients, or 80 per cent) indication for paediatric tracheostomy in our series where males slightly outnumbered females. The majority (31 patients, or 77.5 per cent) underwent the operation under general anaesthesia with endotracheal intubation. Thirty-four (85 per cent) patients underwent 'planned' tracheostomies and six (15 per cent) underwent 'crash' procedures. Thirteen (32.5 per cent) patients were under the age of one year when tracheostomies were performed. The maximum duration of tracheostomies was between one week to within a month and after one month to within three months; each containing 11 (27.5 per cent) patients. Sixty-four different surgical procedures were performed on these patients in which laryngoscopy and bronchoscopy were the commonest procedures. Nine (22.5 per cent) had early post-operative and 14 (35 per cent) had late post-operative complications. Among these 40 children with tracheostomies, one (2.5 per cent) died due to a tracheostomy-related cause and 10 (25 per cent) due to the primary disease process itself. Tracheostomies performed to provide access for general anaesthesia for other surgical procedures were associated with a better prognosis.

Primary osteogenic sarcoma of the tongue.

A 56-year-old man presented with the difficulty of swallowing and respiratory distress due to a large tumour arising from the tongue and occupying the entire oral cavity. Histological examination revealed it to be an extraskeletal osteogenic sarcoma. The tumour was excised. After six weeks, he came back with massive local recurrence and bleeding from the tumour, but died despite chemotherapy. Review of the literature revealed only four other such cases of this rare tumour. A brief review of these four cases is also made.

The syndrome of elongated styloid process.

Symptom-complex associated with the elongated styloid process is more common than generally thought. The exact etiology of this syndrome has not yet been fully understood. The present article is a review of the symptoms, physical signs, theories of causation, diagnosis and treatment of this condition. During the 20 years period from 1975 to 1995, 35 symptomatic patients with the established diagnosis of elongated styloid process were managed. Their diagnosis were confirmed by clinical and radiological examinations. Surgical shortening of the elongated processes were done by intraoral transtonsillar approach under general anaesthesia. Twenty were bilateral and 15 were unilateral elongations. Eighteen were males and seventeen were females. Largest distribution of patients in age was seen in the fifth decade of life. Pain in the throat was most frequently encountered as the presenting complaint. A total of 31 patients obtained complete symptomatic relief within 6 months following operation. In four patients there were either incomplete relief or recurrence of symptoms after operations. Elongated styloid process may be one of the causes annoying maxillofacial or craniocervical pain. It requires thorough clinical examination of the head and neck, and should be confirmed radiologically. Occasionally multidisciplinary cooperation may be needed to come to a diagnosis. Surgical shortening of the elongated process is the only way to give symptomatic relief to the patient. Further research is needed to understand the aetiogenesis of this condition.

Malignant tumours of the nasal cavity and the paranasal sinuses in a Melanesian population.

Malignant tumours of the nasal cavity and paranasal sinuses are usually associated with poor prognosis. From 1986 to 1995, 50 such tumours were managed in Papua New Guinea. Twenty-nine of these arose in the maxillary sinus, 15 in the nasal cavity, four in the ethmoid sinus and two in the frontal sinus. Males were more frequently affected than females. No specific carcinogenic factor was apparent in these patients who were uniformly distributed all over the country. Advanced local disease with multiple symptoms and signs was common during presentation. Systemic and neck node metastases were infrequent. Histopathologically, squamous cell carcinoma was the commonest type of tumour. Satisfactory results were obtained by combination therapy consisting of surgery, irradiation, and systemic chemotherapeutics agents. Better health consciousness and health care delivery system are essential for early diagnosis, regular posttreatment follow-up and improved survival of these patients.

Ortner's syndrome revisited.

Hoarseness of voice due to paralysis of the left recurrent laryngeal nerve caused by a dilated left atrium in mitral stenosis as discussed by Ortner, is a subject of controversy. Different authors have cited different mechanisms as explanation. A variety of cardiac problems such as primary pulmonary hypertension, ischaemic heart disease, various congenital heart disorders can all lead to paralysis of the left recurrent laryngeal nerve. Most authors believe that pressure in the pulmonary artery causes the nerve compression. In Papua New Guinea cor pulmonale and rheumatic heart disease are the commonest cardiac disorders seen. Ortner's syndrome is a rarity and has never been reported from here before. Here three different case reports are presented with mitral stenosis, primary pulmonary hypertension and combined mitral stenosis and regurgitation and the pathogenesis of hoarseness is discussed.

Benign pleomorphic adenoma of the larynx: report of a case and review and analysis of 20 additional cases in the literature.

Among the benign pleomorphic adenomas of the minor salivary glands, those that develop in the larynx are very rare. One such case of benign pleomorphic adenoma of the larynx in an adult female is described. The patient was treated with epiglottectomy with a lateral pharyngotomy approach. Review of the literature showed an additional 20 well-described cases of benign pleomorphic adenoma of the larynx. These patients usually present with hoarseness, dyspnea or dysphagia, or any combination of these depending on the site of origin and the size of the tumor. Occasionally the tumor may be discovered incidentally. The tumor can occur in any part of the larynx with the epiglottis being the most common site. Clinically they are indistinguishable from other benign laryngeal neoplasms, as surface mucosal lining remains intact. Histopathological examination is used to make the definitive diagnosis, but rarely, misinterpretation may occur. Conservative surgery provides a lasting cure.

An unusual foreign body: a whole fish in the throat.

A wide variety of foreign bodies lodging in the upper aerodigestive tract are encountered in otolaryngological practice. These are mostly associated with acute symptoms calling for prompt removal. We report a case where a whole fish was accidentally lodged in the throat of a 17-year-old boy. The patient presented with severe respiratory and swallowing difficulty. The fish was removed as an emergency procedure.

Cystic lesions of the nasal cavity and the paranasal sinuses: report of two unusual cases.

The clinicopathological features of two unusual cystic lesions, one arising in the nose, a calcified mucocele or a calcified retention cyst and the other in the maxillary sinus, a dentigerous cyst originating in a supernumerary tooth, are described. The literature on these two rare lesions is briefly reviewed.

Nasopharyngeal osteosarcoma as second malignant neoplasm in a post-treated unilateral retinoblastoma: report of a case and review of literature.

A rare case of osteosarcoma primarily originating in the nasopharynx of an 11-year-old Papua New Guinean female who received irradiation and multi-agent chemotherapy for unilateral non-hereditary retinoblasma is described. The relevant literature is briefly reviewed. The complex role of radiation, cytotoxic drugs and genes in the development of a second malignant neoplasm in association with retinoblasma is also discussed.

Neck abscess secondary to perforation and complete extraluminal migration of a pharyngeal foreign body (wire): a case report.

Only a small number of ingested foreign bodies perforate the food passage and even a smaller fraction migrate extraluminally. This report describes a 15-year-old male patient who developed neck abscess due to perforation and complete extraluminal migration of a pharyngeal foreign body (wire). The wire was removed by surgical exploration of the neck, while the lumen of the upper food and air passages were normal.

Klippel-Feil syndrome with congenital conductive deafness: report of a case and review of literature.

Klippel-Feil syndrome is a clinical triad consisting of short neck, decreased head mobility, and low occipital hairline. Additional deformities of the musculoskeletal and the neural system may also be present. Otological defects occur in about one third of these patients. They are seen either unilaterally or bilaterally and accompanied by deafness which may be perceptive, or mixed, or rarely conductive in type. They are caused either by dysplasia of the labyrinth and/or internal auditory canal, or by the middle and the outer ear. We present a report of a case of Klippel-Feil syndrome with congenital conductive deafness. Detailed radiological investigations failed to show any malformations of the middle ear. At operations, thick glue was removed from the middle ear cavities, and dehiscent fallopian canals and bulging of the facial nerve in the tympanic segment were seen. One year postoperatively, audiometry showed a hearing gain of only 20 dB on both sides. Review of the literature shows that there is a trend among the contemporary otologic surgeons to undertake curative surgery whenever possible, so as to improve the hearing, despite isolated reports of various difficulties and complications of curative surgery.

Paediatric myringoplasty in India.

In comparison to chronic non-suppurative otitis media, the incidence of chronic suppurative otitis media is no less in developing countries. This is due to lack of consciousness, low socioeconomic condition, and increased susceptibility to upper respiratory tract infection. Thirty-two ears of 20 patients between the ages of 5 and 12 years are included in this study who underwent myringoplasty, and were followed up for 3 months to 1 year postoperatively. Successful take of the graft was 60% in patients of 5 to 8 year age group, and 72.7% in 9 to 12 year age group. Postoperative air conduction was elevated up to 10 dB level in all the successful ears. In paediatric patients, the tympanic membrane perforation should be repaired to reduce the enormous degree of morbidity, and economic and social disability which afflict so many hundred thousands of people.

Computed tomography for determining pathways of extension and a staging and treatment system for juvenile angiofibromas.

Computed tomography (CT) has changed the preoperative assessment protocol of juvenile angiofibromas as it shows the extent of the tumor and its pathways of extension. Hence, operation can be done sooner and with minimal blood loss. Using CT scanning in 22 patients with nasopharyngeal angiofibromas, we found different pathways of extension of the tumor. We report a new staging system and surgical approaches, based on the stage of the tumor.