Nasopharyngeal Cyst Causing Hearing Loss: Case Report and Review of Literature.

Symptomatic nasopharyngeal cysts are relatively uncommon. Here is a case report of 50 years of age female with hearing loss secondary to the nasopharyngeal cyst. She underwent endoscopic marsupialization and achieved normal hearing postoperatively.The study aims to determine the incidence of hearing loss, radiological patterns and histopathological findings associated with the nasopharyngeal cyst.

Parathyroid carcinoma: lessons from a rare malignancy of head and neck-a case series.

Parathyroid carcinoma (PC) is a very rare head-neck malignancy. Because the symptoms of parathyroid carcinoma are similar to those of benign causes of hyperparathyroidism, it may be not easy to detect it before surgery. The management of PC after initial surgery will be perplexing because of the adequacy of surgery. We wish to describe the difficulties encountered throughout treatment using a literature review. We conducted a retrospective analysis of individuals with parathyroid carcinoma who had treatment at our department between 2017 and 2022. We gathered data on the clinical profile, investigations, management of hypercalcemia, surgical techniques, histopathological features, adjuvant therapy, and outcomes. We treated three patients with parathyroid carcinoma: Two patients with inferior parathyroid carcinoma and one with superior parathyroid carcinoma. Generalized weakness and bony pain are the predominant symptoms. In all cases, the tumor was located using 99Tc MIBI / SPECT scintigraphy and Ultrasonography. Hemithyroidectomy and tumor excision were done as the surgery of choice. All are disease-free at the 12th-month follow-up. We suggested that parathyroid hormone testing be performed in all bony fibrous lesions to rule out hyperparathyroidism. PC is a likely diagnosis when there is noticeable throat swelling, elevated PTH levels greater than 400 IU/L, and serum calcium levels greater than 15 mg/dL.

Contemporary risk factors for a longer hospital stay following bidirectional cavopulmonary anastomosis.

BACKGROUND: Despite high survival after bidirectional cavopulmonary anastomosis, a considerable number of patients suffer significant post-operative morbidities related to prolonged length of stay. METHODS: A single-center retrospective cohort study of all consecutive patients undergoing a first-time bidirectional cavopulmonary anastomosis from 2006 to 2019. RESULTS: Prolonged length of stay was defined as hospital stay greater than the 75th percentile for our cohort. Of 195 patients who met inclusion criteria, the median post-operative length of stay was 8 days (interquartile range, 4-15 days). Prolonged length of stay was defined as greater than 15 days. In multivariate analysis, greater than mild systemic atrioventricular valve regurgitation (odds ratio 3.7, 95% CI 1.05-13.068, p = 0.04), longer length of stay after the initial palliative procedure (odds ratio 1.028, 95% CI 1.004-1.05, p = 0.02), and pre-operative higher superior vena cava oxygen saturation (odds ratio 0.922, 95% CI 0.85-0.99, p = 0.04) maintained statistical significance as independent risk and protective factors for prolonged length of stay. A one-level increase in the severity of pre-operative systemic atrioventricular valve regurgitation was associated with a multiplicative change in the odds ratio of prolonged length of stay of 5.45 (p = 0.005) independent of the severity of systemic ventricular dysfunction. CONCLUSION: Pre-operative characteristics with greater than mild systemic atrioventricular valve regurgitation, longer length of stay after the initial palliative procedure, and lower superior vena cava oxygen saturation were associated with prolonged length of stay after a first-time bidirectional cavopulmonary anastomosis.

Sinonasal mucormycosis and liposomal amphotericin B: A quest for dose optimization.

OBJECTIVES: Sinonasal mucormycosis is a serious fungal infection. Early diagnosis and prompt antifungal therapy along with surgical intervention is the key to its management. Liposomal amphotericin B (LAmB) given intravenously is the antifungal agent of choice. However, the current literature is not clear on its optimum dosage. We did a retrospective study to find the optimum dose of LAmB in cases with sinonasal mucormycosis. MATERIALS AND METHODS: Thirty patients diagnosed with mucormycosis involving sinonasal, rhino-orbital, or rhino-orbito-cerebral regions and receiving only LAmB as pharmacotherapy were included in our retrospective study from 2017 to 2020. A multiple logistic regression model was developed to correlate the total dose of LAmB and other parameters with the final outcome which was defined clinico-radiologically as improved, worsened, or death. The dose of LAmB which led to the first significant change in urea, creatinine, and potassium levels was also determined. RESULTS: The model showed a good fit in goodness-to-fit analysis (Pearson = 0.999, deviance = 0.995), while the likelihood ratio was statistically significant (0.001). The overall model prediction was 83.3%. However, the correlation of outcome with any of the variables, including mean LAmB dose per kilogram (82.2 ± 13.02 mg/kg), was statistically not significant. CONCLUSION: Many patient-related factors (such as age, comorbidities, extent of the disease, and side effects from LAmB therapy), which vary on a case-to-case basis, contribute to the outcome in a mucormycosis patient. The optimum dose of LAmB for improved outcome still requires individualization guided by experience, till well-designed studies address the question.

Batwing incision for a case of bilateral fungal zygomatic osteomyelitis.

Zygomatic osteomyelitis is a rare occurrence due to rich collateral blood supply of bone. A man in his 30s presented with complaints of pain over bilateral cheek and pus discharge below the eye on lateral aspect. He was a known case of COVID-19 associated mucormycosis postendoscopic debridement of sinuses 3 months back. Radiology revealed bilateral destruction of zygoma with discharging sinus. Microbiological analysis confirmed aseptate hyphae in pus, and a diagnosis of bilateral fungal zygomatic osteomyelitis made. Under general anaesthesia, sequestrectomy done using bilateral lateral rhinotomy with extended Dieffenbach's approach (batwing incision). Postsurgery 3000 mg of liposomal amphotericin was administered. There was no enophthalmos or restricted eye movements postoperatively. Follow-up MRI suggested minimal inflammatory enhancement in maxillary sinus. Patient was discharged on oral antifungals.

Outcomes of Catheter-Related Arterial and Venous Thrombosis After Enoxaparin Therapy in Neonates and Infants With Congenital Heart Disease.

OBJECTIVES: Outcomes of catheter-related arterial and venous thrombosis after enoxaparin therapy in neonates and infants with congenital heart disease. DESIGN: A single-center retrospective cohort study. SETTING: Cardiac ICU. PATIENTS: Patients under 1 year old cared for in the cardiac ICU at Nicklaus Children's Hospital from January 2015 to January 2019 and treated with enoxaparin for central vascular catheter-related arterial and venous thrombosis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One-hundred fifty-six events of central catheter-related arterial and venous thrombosis were included in the study. Arterial thrombi accounted for 109 (69.9%) and venous thrombi for 47 (30.1%) of the events. Femoral vessels were the most commonly affected site (88.5%). Therapeutic outcomes were analyzed in 106 events, excluding those without follow-up imaging. The analysis was stratified by age into neonates and infants and catheter types into arterial and venous catheter groups. Therapeutic dose of enoxaparin was higher in neonates (median 1.8 mg/kg/dose) compared with infants (1.6 mg/kg/dose; p = 0.001). Complete resolution was seen in 68%, partial resolution in 19%, nonresolution in 13% of the events. The complete resolution was higher for arterial than venous (85% vs 65.6%; p = 0.032) thrombi with a shorter duration of enoxaparin treatment (23 vs 43 d; p = 0.014). Complete resolution was lowest in neonates with venous thrombosis (42.9%). The median time to complete resolution by Kaplan-Meier analysis was 24.9 days in the overall cohort, 34.3 days in neonates, 24.9 days in infants, 20 days in arterial, and 44.9 days in venous catheter group. CONCLUSIONS: A high proportion of vascular catheter-related thrombi identified in infants with congenital heart disease resolve with enoxaparin treatment. In all patients with thrombosis, arterial versus venous thrombosis is associated with greater odds of resolution.

Utilisation of RAM cannula for non-invasive respiratory support for infants in the cardiac ICU.

BACKGROUND: Children with CHD carry an additional burden of pulmonary insufficiency, often necessitating prolonged ventilatory support, especially in the peri-operative phase. There has been an increase in the utilisation of non-invasive ventilatory support for these children. The objective of this study was to evaluate the utilisation, safety, and outcomes of RAM cannula as a tool for escalation and de-escalation of respiratory support in paediatric cardiac patients less than one year of age. METHODS: A single-centre retrospective cohort study of patients supported with RAM cannula. RESULTS: A total of 275 instances of RAM use were included in the study, 81.1% being post-operative. Patients were stratified into escalation and de-escalation cohorts based on the indication of non-invasive ventilation. The success rate of using RAM cannula was 69.5% overall, 66.1% in the escalation group, and 72.8% in the de-escalation group. At baseline, age at cardiac ICU admission >30 days, FiO2 ≤ 40%, PaCO2 ≤ 50 mmHg; and after 12 hours of non-invasive ventilation support respiratory rate ≤ 60/min, PaO2 ≥ 50 mmHg, PaCO2 ≤ 50 mmHg; and absence of worsening on follow-up chest X-ray predicted the success with a sensitivity of 95% in the logistic regression model. Successful support was associated with a significantly shorter unit stay. CONCLUSIONS: RAM cannula can be safely used to provide non-invasive support to infants in the cardiac ICU for escalation and de-escalation of respiratory support. Factors associated with success can be used to make decisions about candidacy and appropriate timing of non-invasive ventilation use to maximise effectiveness.

Nonopioid analgesics for perioperative and cardiac surgery pain in children: Current evidence and knowledge gaps.

OBJECTIVE: The purpose of this review is to present the available literature on the use of nonopioid analgesics such as nonsteroidal anti-inflammatory drugs in postcardiac surgery pediatric patients, mainly to focus on patients <1 year of age, and to provide the foundation for future research. MATERIALS AND METHODS: Published studies that address the use on nonopioid medications for postoperative sedation and analgesia in infants and children undergoing cardiac surgery were identified from online sources. Studies were reviewed by two authors independently to assess the quality of the data as well as the evidence. Due to limited availability of such studies, the review was then expanded to include use in noncardiac procedures as well as to expanded age groups. All studies that met the primary objective were included. RESULTS/DATA SYNTHESIS: Majority of the studies in the population of interest were related to use of ketorolac. Five studies specifically addressed ketorolac use in cardiac patients. In addition, studies were reviewed for nonopioid analgesia in noncardiac patients and included as a part of the available evidence as in the case of acetaminophen use. Newer agents as well as agents with very limited information were also acknowledged. CONCLUSION: Nonopioid medications appear to show promise for analgesia in infants undergoing cardiac surgery, with ketorolac being the most potent agent as a potential substitute for opioids. These agents demonstrate a reasonable safety profile even in the very young. There continue to be significant gaps in knowledge before their adoption becomes routine. However, gives the awareness regarding short-term and long-term impact of opioid use in this vulnerable population, and studies of such agents are an urgent need.

Endovascular Management of a Rare Case of Pediatric Vertebral Artery Mycotic Aneurysm: A Case Report.

Pediatric posterior-circulation aneurysms are uncommon, difficult-to-treat lesions associated with significant morbidity and mortality. Infections and trauma are important risk factors in children. Here, we present a 10-year-old boy with a lower respiratory tract infection, rapidly progressive right-neck swelling, and weakness of the right upper limb. Imaging revealed a partially thrombosed right vertebral-artery pseudoaneurysm with multiple cavitory lung lesions. Subsequent laboratory work-up showed underlying primary immunodeficiency disorder (chronic granulomatous disease). The aneurysm was successfully managed by parent-artery occlusion. The child made a complete recovery without neurological sequelae.

Wandering Double-J Stent in the Retroperitoneum: A Case Report.

Background: Double-J (DJ) stent is an integral part of urologic practice. DJ stents can have numerous complications such as persistent irritative symptoms, encrustations, and up and down migrations within the pelvicaliceal system (PCS), but displacement outside the urinary tract is rare. We are presenting a unique case of DJ stent lying outside the PCS for more than a decade. Case Presentation: A 46-year-old female presented with left flank pain and dysuria. She had undergone percutaneous nephrolithotomy in the left side 11 years ago. Imaging studies revealed a forgotten DJ stent with proximal part lying in the PCS with dense encrustations and the distal coil in the retroperitoneum at the level of the contralateral sacroiliac joint with the shaft crossing the midline at fourth lumbar vertebral level. The malpositioned forgotten stent was removed intact using the multimodal endourologic technique. During follow-up, the patient had prompt relief of symptoms and a preserved renal unit. Conclusion: To the best of our knowledge, this is the first report of malpositioned and forgotten DJ stent for more than a decade with lower end lying near the opposite lower ureter managed effectively by an endourologic method.

Have we overcome the complications of laparoscopic nephrectomy? A prospective, cohort study using the modified Clavien-Dindo scale.

INTRODUCTION: Apart from the complexity of procedure and surgeon's experience, surgical complication rates depend on case definition and method of recording data. We prospectively evaluated the complications of laparoscopic nephrectomy (LN) in a current cohort of patients, graded on the modified Clavien-Dindo (CD) scale and compared them with historical cohorts. METHODS: In the Institutional Review Board approved protocol, all patients undergoing LN over a 30-month were enrolled in the study. Clinical parameters, operative data, inhospital course, and 30-day follow-up were recorded prospectively in an electronic database by a resident who did not perform any of the surgeries. The complications were analyzed using the CD scale. RESULTS: A total of 103 patients (age 14-80 years) underwent LN (30 radical, 73 simple) during the study period. Forty-three of these procedures were for inflammatory conditions (stone disease or tuberculosis). Six procedures were converted to open surgery due to vascular injury (2), bowel injury (1), and adhesions (3). There were 45 (46%) complications in the 97 procedures completed laparoscopically including 34 low-grade (CD grade 1, 2) and 11 high-grade (CD grade 3, 4) complications. There was no mortality. Complications were similar in patients undergoing surgery for inflammatory or noninflammatory conditions. CONCLUSIONS: LN continues to be associated with postoperative complications in 46% of cases. However, the complication rates appear to be higher than historical series, possibly due to the more rigorous case-definition and prospective recording.

Prostate Cancer: How Young is too Young?

Prostate cancer is the most common non-cutaneous malignancy in men. It is generally considered a cancer of the elderly, and the median age of presentation is 68 years. However 10% of new diagnoses in the USA occur in men aged ≤ 55 years. This may be due to more prevalent screening nowadays, and may also reflect the diagnosis of an increasingly recognized but underappreciated entity, i.e. early-onset prostate cancer. Patients with early onset prostate cancer pose unique challenges. Current data suggest that early-onset prostate cancer is a distinct phenotype-from both an etiological and clinical perspective- that deserves further attention. We present a case of a 28-year-old man who presented with lower urinary tract symptoms and was diagnosed with advanced stage prostate cancer.

Serum microRNA Expression Profiling: Potential Diagnostic Implications of a Panel of Serum microRNAs for Clear Cell Renal Cell Cancer.

OBJECTIVE: To study the expression profiles of 5 microRNAs in tissue and serum of patients with clear cell renal cell cancer (ccRCC) and evaluate their diagnostic and prognostic potential. MATERIALS AND METHODS: We prospectively analyzed 30 patients of histologically proven ccRCC and collected 3 mL of serum preoperatively and small pieces of tumor and adjacent non-tumor renal tissue intraoperatively. Control serum samples were obtained from 15 patients of non-renal benign diseases. We analyzed 5 miRNAs-miR-34a, miR-141, miR-200c, miR-1233, and miR-21-2. Freshly collected samples were immediately frozen in liquid nitrogen and total RNA was extracted. cDNA was synthesized by reverse transcription, and quantitative polymerase chain reaction was performed to determine relative miRNA expression. RESULTS: In the renal tissue and serum samples, 3 out of 5 miRNAs were differentially expressed; that is, the expression levels of miR-34a and miR-141 were significantly decreased, whereas that of miR-1233 was significantly increased. Serum miR-34a, miR-141, and miR-1233 were able to diagnose ccRCC with a sensitivity of 80.76%, 75%, and 93.33%, and specificity of 80%, 73.33%, and 100%, respectively, as compared to histopathology. Using a panel of 2 serum miRNAs (miR-141 and miR-1233) ccRCC can be diagnosed with 100% sensitivity and 73.3% specificity. CONCLUSION: miRNAs are differentially expressed in serum of patients with ccRCC and can be used to diagnose ccRCC with high sensitivity and specificity. Diagnostic sensitivity can be further improved by using a panel of miRNAs and has the potential to serve as novel diagnostic markers of ccRCC.

Ipsilateral Dual-Site, Same-Sitting Percutaneous Lung Biopsy: A Feasibility Study.

PURPOSE: Patients with thoracic malignancies often have more than one site of pulmonary, nodal or pleural disease within one hemithorax. In addition, large heterogeneous lesions may comprise distinct, mixed pathological entities. Histological analysis of these lesions can alter tumour staging and treatment options. We investigated the feasibility, safety and benefit of performing image-guided percutaneous lung biopsy (PLB) of two lesions in the same hemithorax at a single sitting. MATERIALS AND METHODS: Ten consecutive outpatients with two or more potential disease foci within the same hemithorax were analysed over a 15-month period. The mean age of the patients was 66 years (range 46-81 years). Patients underwent CT-guided coaxial 20G   core biopsy of both lesions, with separate coaxial punctures for each lesion. Patients were managed as per established local institution ambulatory lung biopsy protocol using small-calibre Heimlich-valve chest drain (HVCD) to treat significant post-PLB pneumothorax in an outpatient setting. Data regarding lesion characteristics, diagnoses and complications were recorded. RESULTS: All 10 patients (n = 20 biopsies, 100% technical success) received informative histological diagnosis on both lesions. This altered management in all cases. Although a high rate of pneumothorax occurred (60%; 6/10), only two of these patients required treatment with HVCD. No other significant complications occurred in those patients with small asymptomatic pneumothoraces or those that required HVCD placement. CONCLUSIONS: Dual-site lung biopsy, performed as a single procedure, is potentially a safe and effective technique for diagnosing patients with multiple thoracic lesions, and can provide useful staging information to guide patient management.

Coronary artery occlusion after arterial switch operation in an asymptomatic 15-year-old boy.

A 15-year-old boy with transposition of the great arteries (TGA) and neonatal arterial switch operation (ASO) presented with complete occlusion of the left main coronary artery (LMCA). Intra-operatively, an intramural left coronary artery was identified. Therefore, since age 7 years he had a series of screening exercise stress tests. At 13 years old, he had 3 to 4 mm ST segment depression in the infero-lateral leads without symptoms. This progressed to 4.2 mm inferior ST segment depression at 15 years old with normal stress echocardiogram. Sestamibi myocardial perfusion scan and cardiac magnetic resonance imaging was inconclusive. Therefore, a coronary angiogram was obtained which showed complete occlusion of the LMCA with ample collateralization from the right coronary artery system. This was later confirmed on a computed tomogram (CT) angiogram, obtained in preparation of coronary artery bypass grafting. The case illustrates the difficulty of detecting coronary artery stenosis and occlusion in young patients with rich collateralization. Coronary CT angiogram and conventional angiography were the best imaging modalities to detect coronary anomalies in this adolescent with surgically corrected TGA. Screening CT angiography may be warranted for TGA patients, particularly for those with known coronary anomalies.

Assessment of Adequacy of Supplementation of Vitamin D in Very Low Birth Weight Preterm Neonates: A Randomized Controlled Trial.

OBJECTIVES: To compare the effect of 400 IU and 1000 IU vitamin D for 6 weeks in very low birth weight preterm neonates. DESIGN: Randomized, double-blinded controlled trial in a teaching hospital. PARTICIPANTS: Fifty very low birth weight preterm neonates. INTERVENTION: Vitamin D 400 IU/day (Group 1) or 1000 IU/day (Group 2). OUTCOME MEASURES: Change in serum calcium, phosphate, alkaline phosphatase (ALP), 25-hydroxy vitamin D (25-OHD), parathormone, incidence of skeletal hypomineralization and growth. RESULTS: After 6 weeks of supplementation, the mean serum calcium and 25-OHD levels were significantly higher (p < 0.001 each), while ALP and parathormone levels significantly lower (p < 0.001 each) in group 2. Skeletal hypomineralization was lesser and growth better in group 2. CONCLUSION: Vitamin D supplementation in a dose of 1000 IU/day is more effective in maintaining serum calcium, phosphate, ALP, 25-OHD and parathormone levels with lower incidence of skeletal hypomineralization and better growth.

Prime Drug Interplay in Dental Practice.

Drug interaction is a negative representation of pharmacotherapy. In order to provide the best patient care possible, a thorough knowledge of how the drug interactions occur is needed for proper application in practice. Possible interactions among current medication and drugs being prescribed should be considered always. A thorough understanding of the mechanism of interactions among drugs is a must for the health care practitioner. Considering the astounding number of drugs patients may be taking, this task seems discouraging. The count of possible interactions in dental practice are less due to few number of drugs utilized and brief period of therapy, but still notable number are to be considered. The aim of present preview is to consider the manifold and multiplex nature of pharmacological drug-drug interaction in the general dental practice setting.

Esthetic dentistry for multiple gingival recession cases: Coronally advanced flap with bracket application.

Treatment of gingival recession is essential to rectify the esthetic and functional deficiencies of the patient and to combat further periodontal destruction. However, treating multiple recession cases is quite challenging, and therefore requires constant modifications of the prevalent treatment strategies as per the severity of the condition. The objective of this case report was to evaluate the effectiveness of coronally advanced flap (CAF) technique without vertical incisions using CAF brackets (CAF+B) for treating a patient presenting with class II gingival recession defects in relation to maxillary anteriors. Complete root coverage was observed, and the results were consistent even after 6 months. The current case report demonstrates good outcomes of the CAF + B technique without the use of any additional soft tissue grafts or vertical incisions, therefore, endorsing the promising potential of the CAF + B technique in multiple gingival recession cases.