Review Article Volume 2 Issue 3 2012 ISSN 2250-0359

Retrospective analysis of Dyshormongenetic Goitre
* Chandrasekaran Maharajan Sucharitha Vedachalam * Madras Medical College

Abstract: Dyshormonogenetic goitre is a rare thyroid entity which occurs due to enzymatic deficiency in the physiological process of thyroxin synthesis resulting in goitre formation. This has to be differentiated from iodine deficiency goitres for their similarity in clinical presentation, hormonal profile and on scintigraphy studies. This differentiation is vital for the reason that Dyshormonogenetic goitre (DHGG) needs to be treated with thyroxin while Iodine deficiency disorder (IDD) requires simple dietary iodine supplementation. Key Words Dyshormonogenetic goitre, Hypothyroidism, Perchlorate discharge test, Pendred syndrome, Iodine deficiency disorder, Tc99 scan Materials and Methods 52 DHGG patients were identified and diagnosed out of 2364 patients treated between December 2001 to December 2011 in our department a referral centre for whole of South India for thyroid disorders. Details collected include age, sex, grade of goitre, nodularity, associated deafness, The tests done include Thyroid function tests, Perchlorate discharge test, USG neck, Scintigraphy study, Fine needle aspiration cytology & histopathological examination. In these 52 patients, fifty patients were between 15 and20 years of age; 30 patients were males and 22 patients were females. Siblings belonging to 3 different families showed features of DHGG. All the 52 presented with grade III goitres. All patients had hypothyroidism at the time of presentation. USG showed nodularity in all cases. 1 Patient presented with mental retardation. This was present in the families were siblings were affected. One patient had associated deafness, Pendred syndrome. None of them had malignancy.I-131 scan was done in 35 patients and Tc 99 scan was done in 17 patients. Scintigraphy study showed increased uptake. I131 scan also showed low liver counts. In order to differentiate DHGG from IDD perchlorate discharge test and 24 hour urinary iodine measurements were done. 24 hour urinary iodine was above 200 ug/day. These specific investigations revealed the defect to be at the organification level. None of these patients showed iodine deficiency status thus http://www.jorl.scopemed.org/

clearly showing the distinction from iodine deficiency goitre. All 52 patients were subjected to Total thyroidectomy after one month preparation with thyroxin. Thyrotherapy not only corrects the hypothyroid status but also helps to reduce the vascularity of the gland.

Discussion: In DHGG there is defect in the hormone synthesis (1) indicated by low T3, T4 and high TSH. Scintigraphy shows high uptake (2) except DHGG due to trapping defect. There are three important steps in thyroxin synthesis: 1) Trapping - Iodide is trapped by the thyroid gland 2) Organification – trapped iodide is converted to iodine and with thysine Monoiodothyrosine (MIT) and diiodothyrosine (DIT) are formed. 3) Coupling - MIT and DIT couple to form T3 and T4.Trapping defect DHGG has low uptake in scintigraphy studies. It also shows a low salivary: plasma radioiodide ratio of 1:1 (Normal: 10:1) (3). Organification defect is confirmed by perchlorate discharge test (4). This is done in the following way; radiotracer is given and an uptake test is done, following which 1 Gm of potassium perchlorate is given orally and an uptake is repeated after 2 hours. A fall in uptake between 10-20% indicates organification defect. Coupling defect will show MIT and DIT in plasma whereas it is normally absent. They are usually present in the first or second decade with or without a family history. When DHGG runs in families it is associated with mental retardation (5) and Pendred syndrome (6, 7). DHGGs are due to TG gene mutation (8) or DHGG presents with huge goiters (9), soft and highly vascular. Differential diagnosis of IDD should be thought of when there is hypothyroidism with increased uptake by scintigaphy studies. IDD has a low 24 hour urinary iodine level. Aa a result of long standing hypothyroidism with sustained high levels of TSH in DHGG the thyroid gland shows a highly cellular picture in FNAC and a HPE of such a gland shows papillary proliferation with papillary fronds, nuclear atypia and minimal amount of colloid and hence it is mistaken for thyroid cancer (10). There is increased incidence of malignancy due to overexpression of EGF and EGF-R m RNAs in DHGG (11). Conclusion: Whenever Dyshormonogenetic goitres present as diffuse goitres they must be treated with thyrotherapy. Only when they present as nodular goitres surgery is indicated. Carcinomatous change can occur if DHGGs are not treated with thyrotherapy. Surgery of choice is total thyroidectomy. After thyroidectomy they require lifelong replacement with thyroxine. References 1. J.S.Kennedy J Path (1969) The pathology of dyshormonogenetic goitre 99(3):251 2. R.F Harvey,etal. Proceedings of Royal college of Medicine (1971) Dyshormono genetic goitre with high circulating levels of TSH 64(3): 299 3. Fukate S,etal. Thyroid (2010) Diagnosis of iodine transport defect: do we need to measure salivary/serum radioactive iodide to diagnose iodide transport defect 20(12):1419 4. J Clerk,H Mfnpeyssen,etal. Hormone research in Paediatrics (2008) Scintigraphic imaging of paediatric thyroid dysfunction 70(1) 5. J Maenpaa Arch Dis Child(1972) Congenital Hypothyroidism-Aetiology and clinical aspects 47:914 6. Bangkova K ,etal. Cas Lek Usk (2008) Pendred syndrome among patients with hypothyroidismgenetic diagnosis ,phenotypic variability and occurence of phenocopies 147(12) :616 7. Borch G etal. J Clin Endocrinol Metab (2009) Genetic cause of goitre and deafness 94(6):2106 8. Rubio,Ileana G S ,etal. Cuur Opinion Endocrinol, Diab & Obesity(2009) Mutation of Tg gene and its relevance to thyroid disorders.16(5):373 9. B C Reynolds,etal. Acta Padiatrica(2006) Goitrous congenetal hypothyroidism in a twin

pregnancy causing respiratory obstruction at birth: implication for management 95(11):1345 10. Ronald A Ghossein ,etal. Endocrine Path (1997) Dyshormonogenetic goitre: a clinicopathological study of 65 cases 8(4):283 11. Fillipo Pedrinolo,etal. Thyroid (2004) Overexpression of EGF,EGF-R mRNAs in Dyshormonogenetic goitre 11(1):15

Images:

Image showing perchlorate discharge test

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ISSN 2250- 0359

Volume 2 Issue 3 2012

Infected Haller cell
1

Balasubramanian Thiagarajan
1

2

Venkatesan Ulaganathan

Stanley Medical College

2

Meenakshi Medical College

Abstract: This article discusses the role played by Haller cell in infundibular blocks. Haller cells (infraorbital cells) are not so uncommon. They have been identified in 40% of normal individuals. This article traces the history of Haller cell anatomy and its role in paranasal sinus infections. Introduction: Haller cells are also known as infraorbital ethmoidal cells / maxilla ethmoidal cells. These cells extend into the inferomedial portion of orbital floor. They are seen in 40% of patients. 1

Coronal CT scan of nose and sinus showing a large Haller cell on the right side with evidence of infection

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CT scan lateral view showing Haller cell below the orbit

In majority of patients Haller cells may be asymptomatic.2. This air cell is actually named after Albrect von Haller the Swedish Anatomist who described these air cells. Problems caused by a Large Haller cell: 1. When infected it can cause narrowing of OMC 2. Can involve orbit 3. During Endoscopic sinus surgery it could push the natural ostium of maxillary sinus

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downwards and anteriorly causing difficulties during surgery 4. If this condition is not recognized preoperatively the surgeon may inadvertently enter orbit Classification of Haller cells: 3 Radiologically Haller cells may be classified into: Small Medium Large

References: 1. Yousem DM. Imaging of sinonasal inflammatory disease. Radiology. 1993;188 (2): 30314. Radiology (abstract) [pubmed citation] 2. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004;25 (9): 1613-8. 3. Anatomic relevance of Haller cells in sinusitis Stackpole SA American J of Rhinology 1997 May- June

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ISSN 2250- 0359

Volume 2 Issue 3 2012

Yahya Basith * Balasubramanian Thiagarajan* *Stanley Medical College

ROLE OF ANATOMICAL OBSTRUCTION IN THE PATHOGENESIS OF CHRONIC SINUSITIS
A case series study based on radiological assessment Abstract
Sinusitis is a commonly diagnosed condition in the general population. This article is a study to asses the role of anatomical obstruction in the pathogenesis of chronic sinusitis, based on symptomatology and radiological findings of the patients. The frequency of major anatomical variants like deviated nasal septum, concha bullosa, and paradoxical middle turbinate leading to chronic sinusitis has been analyzed. In majority of cases the obstruction at osteomeatal complex is found to be caused by more than one factor.

Chronic rhinosinusitis
Definition: Group of disorders characterized by inflammation of the mucosa of the nose and para nasal sinuses of at least 12 consecutive weeks duration.Patients with CRS may have acute flare-ups, in such conditions the disorder is called acute exacerbation of chronic sinusitis.[1,2] Since it involves inflammation of the mucosa of nasal cavities as well as the paranasal sinuses, its more aptly termed as rhinosinusitis. There are several etiological factors leading to the development of chronic sinusitis.They are broadly classified in to three main groups i.e 1)genetic/physiological factors 2) environmental factors 3) structural factors.[3]

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Role of anatomical obstruction
Patency of the pathways through which the sinuses drain is crucial of adequate mucociliary function and subsequent sinus drainage. Nasal and sinus mucosa produces approximately 1 L of mucus per day [4], which is cleared by mucociliary transport. Osteal obstruction may lead to fluid accumulation and stagnation, creating a moist, hypoxemic environment ideal for growth of pathogens
[4]

Major anatomic variants leading to osteo meatal obstruction are deviated nasal septum, concha bullosa, paradoxical middle turbinate and infra orbital (Haller) cell [5].

Deviated nasal septum: Deviated nasal septum at the level of middle
turbinate is one of the main causes of anatomical obstruction at osteo meatal complex.

Figure: 1
Cottle classified septal deviation in to 3 types i.e 1) Simple deviation: only mild deviation with no obstruction and it is the most common type seen. 2) Obstruction: here the deviated septum touches the lateral wall, but on decongestion with vasoconstrictors the turbinate shrinks and the obstruction is relieved. 3) Impaction: massive angulation of the septum with a spur [6]
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Patients with significant deviation i.e type 2 & 3, who is having CT evidence of sinusitis have been included in the study.

Figure 2: Coronal CT scan of a patient showing deviated nasal www.jorl.scopemed.org

Figure 3: axial cut of the same patient showing deviated septum. Septum leading to OMC obstruction.

Concha bullosa: concha bullosa is pneumatisation of the concha, usually the
middle turbinate and is one of the most common anatomic variation in nose.Bolger et al classified pneumatisation of the concha based on the location as lamellar concha bullosa, bulbous concha bullosa, and extensive concha bullosa.[7] There are many studies in the literature suggesting the role of concha bullosa in sinus disease etiology. If the concha is expanded significantly, it leads to deviation or compression of the uncinate process to the lateral wall of nose leading to obstruction of the ethmoid infundibulum.

Figure 4: CT scan of a patient showing concha bullosa

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l Figure 5: CT image of another patient with extensive pneumatization of the right middle turbinate.

Paradoxical middle turbinate: another anomaly of the nasal cavity leading
to air way obstruction and chronic sinusitis is a paradoxical turbinate. A middle turbinate that is concave medially rather than laterally is called paradoxical. Usually paradoxical turbinates occur where the maxillary sinus is hyperplastic. The overgrowth causes the mucosa to to buckle and fold inwards, with the resultant curve pointing towards the septum. An exagerrately curved paradoxical turbinate compreeses the uncinate procees leading to meatal obstruction.

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Figure 6: CT scan of a patient showing paradoxical middle turbinates

Aim of study: Is to assess the role of anatomical obstruction in the pathogenesis of chronic
sinusitis. Anatomical obstruction due to deviated nasal septum, concha bullosa, and paradoxical middle turbinate are included in the study.

Materials and methods
After the advent of endoscopic sinus surgery, pre operative evaluation of the osteomeatal complex has gained very importance in the management of sinus disorders.Computed tomography (CT) is the method of choice for the morphological evaluation of the osteomeatal complex. Coronal plane is the most commonly used plane by endoscopic surgeons because of its similarity with surgical orientation. In this study we have used patient symptomatology, anterior rhinoscopic findings and radiological evidence in to consideration.

Inclusion criteria
Patients who presented to the department of E.N.T and Head & neck surgery, Stanley medical college, during a one month periode with symptoms suggestive of chronic rhinosinusitis were subjected to undergo coronal CT scan of the para nasal
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sinuses. 40 Patients who have symptoms of chronic rhinosinusitis (>12 wks duration) and whose CT scan shows mucosal thickening of paranasal sinuses suggestive of chronic sinusitis were included in the study.

Study results
Among the 40 patints studied, CT image of 32 (40%) cases showed septal deviation to either right or left. Concha bullosa was seen in 17 (42.5%) cases and paradoxical turbinates in 11 (27.5%) cases. Considering isolated variants, 15 (37.5%) cases had septal deviation alone as an anatomical variation, 5 (12.5%) had concha bullosa alone and 3 (7.5%) cases had paradoxical middle turbinate alone in their CT images. Most of the cases of concha bullosa was associated with a septal deviation i.e out of the 17 cases 12 (70.5%) cases had an associated septal deviation as anatomical variation.
Anatomical variation Deviated septum Concha bullosa Paradoxical turbinate No.of patients 32 17 11 Percentage 80% 42.5% 27.5%

Figure 7: table showing the aggregate frequency of anatomical variations studied.

Anatomical variation Deviated septum Concha bullosa Paradoxical turbinate Mixed variation

no.of patients 15 5 3 17

Percentage 37.5% 12.5% 7.5% 42.5%

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Figure 8: table showing isolated frequencies of anatomical variations studied.

MIXED 42% PMT 8% CB 13%

DNS 37%

DNS CB PMT MIXED

Figure 9: A pie chart showing the distribution of the major anatomical varients included in The study. DNS: deviated nasal septum, CB : concha bullosa, PMT : paradoxical middle turbinate.

Conclusion:
Most of the cases of chronic sinusitis caused by anatomical obstruction in the nose are found to be due to a deviated nasal septum leading to obstruction of osteomeatal complex.Other major causes are concha bullosa and paradoxical middle turbinate. Many a time more than one anatomical variation occurs in the same individual, rather than occurring as isolated single variation i.e a deviated septum with a concha bullosa or a deviated septum with a paradoxical turbinate. A concha bullosa of the nose is usually associated with a septal deviation in majority of the patients. Most common sinus affected due to anatomical obstruction at osteo meatal complex was maxillary sinus.

References:
1.. Lanza DC, Kennedy DW: Adult rhinosinusitis defined. Otolaryngol Head Neck surg 1997; 117:S1-S7.

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2.. Benninger MS, Ferguson BJ, Hadley JA, et al: Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003; 129:S1S32. 3. Byron J bailey & jonas T.Johnson,Head and Neck surgery,p406, 4th ed. 4. Byron J Bailey & Jonas T.Johnson, Head and Neck surgery,p406,4th ed. 5. Byron J Bailey & Jonas T.Johnson, Head and Neck surgery, p408, 4th ed 6. Devated nasal sepyum, drtbalu’s otolaryngology online , www.drtbalu.co.in/dns.html 7. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991; 101:56-64. 8.Levin HL: The office diagnosis nasal and sinus disorders using rigid nasal endoscopy.Otolaryngol Head Neck Surg 102:370-373,1990. 9.May M, Mester SJ, O’ Daniel TG, Curtin HD:Decreasing the risk of endonasal endoscopic nasal surgery by imaging techniques. Op Tech Otolaryngol Head Neck Surg 1:89-91,1990. 10.Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis:Definitions, diagnosis, epidemiology and pathophysiology. Otolaryngol Head Neck Surg 2003; 129(3 sppl) 11.Hwang PH, Irwin SB, Griest SE, et al.Radiologic correlates of symptom based diagnostic criteria for chronic rhinosinusitis. Otolaryngol Head Neck Surg 2003:128(4):489. 12.Zoumalan RA, Lebowitz RA, Wang E, Yung K, Babb JS, Jacob JB. Flat panel cone beam computed tomography of the sinuses. Otolarungol Head Neck Surg, 2009,140(6):841-4. 13.Zinriech S: Imaging of inflammatory sinus disease. Otolaryngol Clin Am 1993 ; 26:535.

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* SriKamakshi Kothandaraman

*Balasubramanian Thiagarajan

*Stanley Medical College

Volume 2 Issue 3 2012

ISSN 2250-0359

ARE LEFT HANDED SURGEONS LEFT OUT? THE SINISTRAL:
“ If by chance I touched a pencil, a pen or a needle, I was bitterly rebuked, and more than once I have been beaten for being awkward and wanting a graceful manner.” These were the words of Benjamin Franklin, noted left-handed American inventor, scientist, printer, statesman and philosopher, who had a miserable childhood. His words reflect the exact state of affairs and consequently, the state of mind of the lonely left-hander in this right-dominated world. Studies have revealed that left-handers are generally more inhibited and anxious, and this doesn’t go without reason. The scientific reason is that, in left-handers the right half of the brain dominates, and it is the same side that controls the negative aspect of emotion. As a result, in an attempt to relieve their anxiety, left-handers like to colour code things, and make lists whenever possible. The more practical and logical reason is that, the environment of our world strongly favours the right handed majority. Although sinistrals are considered to be more intellectual and artisitic, (studies have revealed higher levels of IQ among left-handers) it has also been documented that they are more prone to unintentional injuries, sports injuries and accidents. In fact, even the rate of finger amputation has been found to be higher among left handed industrial workers. Even items of everyday usage, such as scissiors and canopeners are biased towards the right-handed. The saving grace in this distressing situation for the lefthander is that, Nature has made him/her a born fighter. A review of literature and history reveals that left-handers from time immemorial have shown a natural talent and inborn skill in games of combat such as fencing and tennis. In fact, research analysed data shows that societies which were rather quite www.jorl.scopemed.org

violent and aggressive, had a higher proportion of left-handers. Thus, left-handedness which has been proved to develop in the womb, brings along with it an inborn endurance and strength to survive tough situations and living circumstances, such as it already is in our world at large for the sinistral. Coming to familiar waters, and more relevantly to this article, studies have shown that 80% of lefthanded surgeons believe that endoscopic surgery needs to be modified for the left-handed endoscopic surgeon, though 66% feel that they experience no difficulty in handling the custom-made endoscopy instruments. Left handed surgeons lack access to left handed instruments while training, receive little mentoring about their left handedness, and are more prone to needle stick injuries than their right handed colleagues. By and large, laterality-related comfort has its impact on endoscopic surgery, and technical modifications are warranted to suit the needs of the left-handed surgeon. What follows next is a launch into what exactly I have been facing ever since I started taking baby steps into the skill-dominated field of Otorhinolaryngology, and what in my opinion needs to be done in each of those challenging situations by the budding left-handed ENT surgeon.

BEING A LEFT-HANDED ENT SURGEON..
Being a left-handed surgeon, more specifically a left-handed ENT surgeon, presents a unique pattern of difficulties. The problems start right at the OPD itself. When I sit down at a cubicle with the patient ata distance of less than 8 inches in front of me & the Bull’s eye lamp at 6 inches above and behind the left shoulder of the patient, focus the light into the patient’s ear/nose/throat and try to examine the parts, I find that irritatingly, something keeps blocking the light from falling on the patient’s parts. It took me a few exasperating days in the OPD, to realize, that that “something” was my very own right upper limb!

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To overcome this problem, for a left handed ENT practitioner, the Bull’s eye lamp needs to be placed above and behind the right shoulder of the patient, at the level of the right ear. The next confusion arises when a left-hander tries to wield the endoscope. I had carefully observed that my seniors, while doing endoscopic examination, stand to the right side of the patient and hold the endoscope in their left hand. While performing an endoscopic surgery, they follow the same discipline and proceed with the steps of surgery, with the instrument held in their right hand. So when I was given the opportunity to learn endoscopy, I diligently followed the same principles. (Frankly, I didn’t have a choice anyway, as the arrangement in the endoscopy room demanded that we carry out the procedure in that particular orientation. In other words, the arrangement is always such as to suit the right-handed majority! Ideally, for a left hander, standing to the left of the patient would be comfortable.) So faithfully standing to the right of the patient, I hesistantly and carefully took the endoscope in my left hand, adjusted the focus, white balance and position of the camera and haltingly introduced the endoscope into the anaesthetized and decongested patient’s nasal cavity. Much to my surprise, it seemed to be quite easy. I was delighted! Maybe being left-handed is an advantage with respect to endoscopy, I mused. But alas, my happiness was short-lived. Only when I started operating endoscopically, did I realize my shortcomings. I was not able to control the movements of the instrument I was using and synchronize it with the endoscope. Though this difficulty is quite common with beginners, the problem was that, though I was holding the endoscope comfortably in my left hand, the instrument, with which I need to make the finest of maneuvers, was in my non-dominant hand. This would not do. This realization pushed me to start learning to use the endoscope with my right hand, so that my left would be free to handle the instruments.

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A left handed surgeon cannot cut with the commonly available scissors. As simple as this statement is, as humiliating it is, until you discover where the problem actually lies.

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The blades of the commonly available scissors are oriented in such a way, that they approximate and cut well only when used with the right hand and the right hander can see the cutting line. When you try to use it with the left hand, the blades instead of approximating actually move away from each other, and you are actually cutting blindly. This picture shows left hander’s scissors to the left and the usual right

hander’s scissors to the right.

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This really alarmed me! So I also started making efforts to make my right hand work atleast half as well as my left, since I realized that a naturally left-handed ENT surgeon needs to become ambidextrous, if he/she wishes to prove his mettle in this field. My seniors and teachers kept encouraging me to do this. I give my right hand exercises in the form of writing, cutting shapes on paper, cutting vegetables and cooking. Being a minority, the left-handers are at a disadvantage even in the operation theatre. The operating table and the Boyle’s apparatus are arranged in such a fashion that the anaesthesiologist stands to the left of the patient, while the ENT surgeon is to the right. Once I started learning septal correction surgeries, I realized that standing to the right of the patient and using my left hand to operate was very uncomfortable. So I requested to be allowed to stand to the left of the patient so that I could operate comfortably. Though this was quite a relief for me in one sense, the flip side was that I ended up having to share working space with the anaesthesiologists, which turned out to be irritating for both of us. For tonsillectomies, when the patient is intubated nasally, the usual practice of the anaesthesiologist is to introduce the endotracheal tube through the left nostril of the patient and fix all the tubings in such a way that they come to the left side of the patient and the ENT surgeon at the head end of the table, which serves to be convenient to the anaesthesiologist and the right handed ENT surgeon. A similar arrangement for a left handed ENT surgeon, is not only irritating for him/her as all the anaesthetic tubings keep coming in the way of his/her dominant hand, but more alarmingly also places the patient at risk for an accidental extubation due to the very same reasons. So when a left-handed ENT surgeon is blessed with the liberty to arrange the operating room to his/her convenience, he/she should first thing, place the anaesthetic equipment and the anaesthesiologists to the right side of the patient. The most depressing problem my handedness leads me to face, is the confusion and difficulty that my teachers and seniors have when they try to teach me surgical steps. They need to first get oriented to my orientation and then teach me!

The right attitude for the left!:
Inspite of all these issues surrounding the left handed surgeon, he/she has the unique capability to use his/her left hand exceptionally well. While a left hander can with some struggle manage to make his/her right hand usable, the same cannot be said of a natural right hander. In this right-oriented world, a right hander cannot that easily make his/her left hand work as well as his/her right. Like my HOD, Professor.Dr.T.Balasubramanian,MS,DLO, rightly puts it, being a left-handed ENT surgeon is like a double edged sword. It can make or break you depending on your attitude and how you deal with the issues associated with it. The right approach for a left-handed surgeon is to make himself/herself ambidextrous! That way, he/she can get the best of both worlds (left and right), if I may put it that way!

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REFERENCES:
1. Makay O et al. Surgeon’s view on the limitation of left-handedness during endoscopic surgery. J Laparoendosc. Adv Surg Tech A 2008 April; 18(2):217-21. 2. New Scientist Print Edition 22nd July 2004, Lisbon. 3. Cardiff Western Mail, July 2001. 4. Adrian E Flatt MD FRCS. Is being left-handed a handicap? The short nd useless answer is “yes and no”.Proc (Bayl Univ Med Cent) 2008 July; 21(3):304-307. 5. Adusimilli PS et al. left handed surgeons:are they left out? Curr Surg 2004;61(6):587-591. 6. Coren S. left-hander: everything you need to know about left-handedness. London: John Murray, 1992.

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Volume 2 Issue 3 2012

ISSN 2250 - 0359

Ophthalmic disorders among students of School for the Deaf, Akure By C.O.Omolase FWACS, FMCOph 1, O.O.Komolafe FWACS, FMCOph 1 A.O.Adeniji FWACS,2 O.Adetan FWACS,FMCS3.B.O.Omolase M.B.B.S 4, A.K.Akinwalere M.B.B.S,1 E.O.Omolade M.B.B.S 1 1) Department of Ophthalmology, Federal Medical Centre , Owo. 2) Department of ENT, Federal Medical Centre, Owo 3) Department of Orthopaedics, Federal Medical Centre, Owo. 4) Department of Radiology, Federal Medical Centre, Owo.

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Correspondence to:

Dr. Charles Oluwole Omolase Consultant Ophthalmologist, Federal Medical Centre, Owo. Ondo State E mail address: omolash2000@yahoo.com

ABSTRACT Aim: This study aimed at determining the prevalence and pattern of ophthalmic disorders among students of School for the Deaf, Akure, Ondo State, Nigeria. Methodology: This is a cross sectional descriptive study was conducted in October, 2011 as part of activities marking the Annual Physicians’ week of Nigerian Medical Association (NMA), Ondo State. Ethical clearance was obtained from the Ethical Review Committee of Federal Medical Centre, Owo prior to commencement of this study. The permission of the School Authority was also obtained before the commencement of this study. The respondents were selected by simple random sampling technique. All enrolled participants were interviewed with the aid of the study instrument (questionnaire) by the authors and interpreters (school teachers). Results: The respondents comprised of 91(56.9%) Males and 69 Females (43.1%). Nearly all the respondents;158(98.8%) were deaf and dumb. Most respondents; 116(72.5%) had ocular examination in the past. Few respondents; 118(73.75%) had ophthalmic disorder. The
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commonest ophthalmic disorder was refractive error which was found in 16 respondents (38.1%). Myopia was diagnosed in 9 respondents. CONCLUSION: Most of the respondents were deaf and dumb. Few respondents had ophthalmic disorder. The commonest ophthalmic disorder was refractive error. Myopia was the most predominant refractive error. There is need for periodic ocular screening and treatment at the School for the Deaf. Key words: Ophthalmic Disorders, Deaf and Dumb, Nigeria.

INTRODUCTION Deaf children tend to rely on their visual cues to explore and adapt to their environment. Thus visual impairment in a deaf child is likely to worsen the handicap of the child. There is a strong association between the functions of the eyes and ears (1). Deafness is a common challenge in West Africa and it is often associated with measles, deafness and meningitis(2). Deafness is a high risk factor for visual problems (3,4). The high rate of ocular pathology in deaf patients is related to the fact that the retina and cochlear have the same embryonic origin during the sixth and seventh weeks of embryonic development (5). Oculoauditory syndromes have also been reported(6,7). Genetic and environmental factors may affect both the ear and eye (8,9). The prevalence of ocular abnormalities tend to generally increase with the severity of hearing impairment. As the degree of hearing impairment becomes more pronounced, the compensatory role of the other sense organs becomes more prominent. It had also been observed that rubella syndrome may account for the high prevalence of refractive errors and ocular disorders in

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hearing impaired children (10). A mild refractive error may lead to a reduction in the visual cues available to the deaf child (6,11). Studies have shown higher prevalence of ophthalmic disorders among deaf children compared with children of the same age group without hearing impairment (5). The prevalence of ophthalmic disorders among hearing children ranges between 17% to 30% (8) as opposed to 44% to 65% among deaf children(6,12-15). A review of the literature on ophthalmic disorders carried out in Greece revealed paucity of literature on ophthalmic disorders in deaf children (16).The situation in Nigeria in this regard is also the same as only few studies have been carried out on ophthalmic disorders in Nigerian deaf children. Screening and detection of ophthalmic disorders in deaf children is of utmost importance (2). Early detection of such abnormalities, diagnosis and treatment would enhance the adjustment of the deaf children. In view of this fact, this study was designed to determine the prevalence and pattern of ophthalmic disorders among students of School for the Deaf, Akure. It is hoped that the findings of this study shall be utilized by policy formulators to evolve strategies to promote the ocular health of deaf students.

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Methodology This is a cross sectional descriptive study conducted in October, 2011 at the School for the Deaf, Akure as part of activities marking the Annual Physicians’ week. Ethical clearance was obtained from the Ethical Review Committee of Federal Medical Centre, Owo prior to commencement of this study. The permission of the School Authority was also being obtained before the commencement of this study. A total number of one hundred and sixty(160) consenting students out of the six hundred and eighty students of the School for the Deaf selected by simple random sampling technique were enrolled in this study. Informed consent was obtained from all the respondents. All enrolled participants were interviewed with the aid of the study instrument (questionnaire) by the authors and interpreters(school teachers).They responded by sign language which was interpreted by the school teachers(interpreters).The authors also learnt the sign language during the process of data collection. The information obtained from the respondents included their bio data and history of previous ocular examination. The visual acuity of the participants was assessed with the aid of kay pictures and Snellen E chart depending on their age. The respondents matched the direction of the arm of the ‘E’ with their fingers. Detailed ocular examination was carried out on the respondents by the Ophthalmologists with the aid of pen torch and Direct Ophthalmoscope. In cases of poor view of the posterior segment, the pupils were dilated with the aid of 1% tropicamide for dilated funduscopy. Respondents with refractive error were refracted to determine the type and degree of refractive error. Respondents who needed further
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examination and treatment were referred to Federal Medical Centre, Owo for further Management. The data obtained was collated and analyzed with the aid of SPSS 15.0.1 statistical soft ware.

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RESULTS One hundred sixty (160) respondents participated in this study. They comprised of 91males(56.9%) and 69 females(43.1%).Their ages ranged between 5 years and 23 years with a mean age of 15.4 years ± 3.4 years. Most respondents;142(88.75%) were Christians while the remaining ones;18(11.25%) were Muslims. The ethnicity of the respondents showed that 146(91.3%) were Yorubas, 11(6.9%) were Ibos and the remaining 3(1.9%) were Hausas. Most respondents; 158(98.75%) were deaf and dumb while the remaining 2(1.25%) were deaf. Nearly all the respondents; 159(99.4%) had congenital deafness while only one (0.6%) had acquired deafness. The vision of the respondents as detailed in table 1 revealed that only one (0.6%) was blind. Majority of the respondents; 116(72.5%) had previous ocular examination and the remaining 44(27.5%) did not have previous ocular examination. Most respondents 156(97.5%) had normal colour vision while colour vision could not be ascertained in the remaining 4(2.5%) due to poor vision and failure of the respondents to respond convincingly to sign language. Few respondents; 42(26.25%) had ophthalmic disorder while the remaining 118 (73.75%) did not have ophthalmic disorder. Those who had ophthalmic disorder comprised of 27 males (64.3%) and 15 females (35.7%) As detailed in table 2 most respondents with ophthalmic disorder had refractive error; 16(38.1%). Myopia was the commonest refractive error as this was
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present in 9 respondents (21.4%). Few; 5(11.9%) had hypermetropia and the remaining 2(4.8%) had astigmatism.

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DISCUSSION There was a preponderance of males in our study population and this is in tandem with the fact that there were more males in the school at the time of this study. Most of our respondents were Christians and this may be related to the fact that Christianity was the predominant religion in the study community. Majority of the participants were Yorubas and this may be due to the fact that the study community is a Yoruba community in South-West Nigeria. Most of the respondents had congenital deafness and this may be a pointer to less prominent role of acquired deafness in this part of the World. It is quite remarkable that most our respondents had previous ocular examination. This finding is however at variance with that of another Nigerian study by Onakpoya et al which reported that 70.5% of their study population had no previous ocular examination (17).However previous ocular examination was more common among students with ophthalmic abnormalities (17). The relatively high rate of uptake of previous ocular examination in our study population is a pointer to the fact that efforts may have been made in the past to appraise their ocular status. However there is need for all concerned to build on this and thereby put in place necessary machinery to promote ocular health of this category of people. Vision plays a prominent role in the acquisition of skills such as sign language which most deaf and dumb persons rely on. Thus visual impairment in deaf and dumb people could adversely affect their adaptation to the environment. This may make such people unduly irritable thus adversely affecting their interpersonal relationship. Most of our respondents had good vision and this may explain their adjustment to the school environment. Only one of our respondents was

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blind. This finding is similar to that of Onakpoya et al (17) which reported that 2(1.3%) of their study population were blind. The prevalence of ophthalmic disorders among deaf children tends to vary widely in different population world wide. A study done in Kaduna, Nigeria revealed that 20.9% of the study population had ophthalmic disorder and refractive error was the commonest presentation (1). The finding of this former study is in keeping with our own as refractive error was the commonest ophthalmic disorder in our study population. However the study by Abah et al (1) identified hypermetropia as the commonest refractive error in their study population as opposed to our own in which myopia was the commonest refractive error. The finding of Abah et al (1) is also consistent with a study done in Turkey (5) which reported that hypermetropia was the commonest refractive error in the study population. It is worthy of note that only one of our respondents with refractive error had spectacle correction. This brings to fore the urgent need for those affected to have spectacle correction so as to prevent development of amblyopia. Another study done in Benin City revealed that 73.26% of the study population had visual disorder (18). The females in the study population were affected more than males (18). This latter finding is consistent with a previous study which reported higher prevalence of females with ophthalmic disorders in school of disabilities (19). However this finding is at variance with our own as most of the respondents with ophthalmic disorder were males. Studies done in Oregon, USA (3), Nepal, (19) and Turkey (5) reported prevalence rates of ophthalmic disorders of 48%,23% and 40.4% respectively among deaf children.

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Other studies done in India,(20) UK,(21) and Australia (22) reported prevalence rates of ophthalmic disorders in their study population of 24%,43.6% and 33% respectively. A study done in China reported ocular problems in 35.8% of deaf mute students (23). Nearly all the participants had normal colour vision. However this could not be ascertained in very few of them who were yet to fully acquire the language skill and one of them who was blind. The predicament of the deaf-blind in our study population draws attention to the plight of deaf-blind persons in general. The respondents with ectopia lentis were promptly referred to a Cardiologist in view the cardiac defect they had as a result of their underlying Marfans syndrome. Their referral reinforces the need for multidisciplinary approach to the Management of deaf persons most especially in childhood. The need for comprehensive medical examination prior to enrolment in School for the Deaf cannot be overemphasized so as to detect and treat any coexisting anomaly which may be life threatening. Carrying out institutional based studies in our area of interest may however introduce bias as obviously not all deaf and dumb children attend the School for the Deaf. Thus it is imperative to interpret the findings of the study cautiously so as to avoid generalization. However in spite of the obvious limitation of this study, it is important for eye care providers to pay special attention to ocular abnormalities in deaf children.

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CONCLUSION Majority of the respondents had ocular examination in the past. Most of the respondents were deaf and dumb. Few respondents had ophthalmic disorder. The commonest ophthalmic disorder was refractive error. Recommendation 1) All students enrolled in Schools for the Deaf should undergo comprehensive ocular examination at the point of admission to the School. 2) Routine ophthalmic screening and treatment should be carried out periodically in Schools for the Deaf so as to promote the ocular health of the students. 3) Recommended glasses should be dispensed free of charge to Students of Schools for the Deaf who are in need so as to prevent amblyopia and also to enhance their adjustment to the environment. 4) The Government should ensure adequate electric power supply to Schools for the Deaf most especially in the night so that the students can communicate through sign language without difficulty.

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ACKNOWLEDGEMENT We are grateful to the respondents for graciously accepting to participate in this study. Special thanks and appreciation to the Authority and Teachers of School for the Deaf, Akure for their cooperation. The authors are greatly indebted to Dr.K. Ilegbusi and Mr.E.B.Olanitori of Department of Ophthalmology, Federal Medical Centre, Owo for their immense contribution to this study. The support of Nigerian Medical Association, Ondo State branch is hereby acknowledged.

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REFERENCES 1)Abah ER,Oladigbolu KK,Samaila E,Merali H,Ahmed AO,Abubakar TH. Ophthalmic abnormalities among deaf students in Kaduna, Northern Nigeria .Annals of African Medicine 2011;10(1):29-33. 2)Holborow C, Martinson F, Anger N. A study of deafness in West Africa. Int J Pediatr Otorhinolaryngol 1982; 2:115-35. 3) Brinks L.Ophthalmic screening of deaf students in Oregon.J Pediat Ophthalmol Strabis 2001;38(1):11-5. 4) Gilbert CE, Anderson L. Prevalence of visual impairment in children Ophthalmic Epidemiol 1999; 6:73-82. 5) Hanioðlu-Kargi S, Köksal M, Tomaç S, Uðurba SH, Alpay A. Ophthalmologic abnormalities in children from a Turkish school for the deaf. Turk J Pediatr 2003; 45:39-42. 6) Rogenbogen L,Godel V.Ocular deficiencies in deaf children.J Pediatr Ophthalmol Strabismus 1985;22:231-3. 7) Leguire LE,Fishman C.A prospective study of ocular abnormalities in hearing impaired and deaf student ENT J 1986;7:64-5. 8) Coleman HM. An analysis of the visual status of an entire school population. Am Optom Assoc 1970;41:341-7. 9) Rogers F. Screening of school age hearing impaired children. J Pediat Opthalmol 1988; 22(5):230-2.
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10)Roizen NJ,Mets MB. Ophthalmic disorder with Downs syndrome .Dev Med Child Neurol 1994;36:594-600. 11)Murdoch H,Russell –Eggitt I. Visual screening in school for hearing –impaired children. Child Care Health Dev 1990;16:253-61. 12) Siatkowski RM,Flynn JT,Hodges AV et al.Ophthalmologic abnormalities in the Pediatric cochlear implant population.Am J Ophthalmol 1994;118:70-6. 13) Leguire LE, Fillman RD, Fishman DR, Bremor DL, Rogers GL. A prospective study of ocular abnormalities in hearing impaired and deaf students. Ear Nose Throat J 1992;71:643-6. 14)Woodruff ME.Diffrential effects of various causes of deafness on the eyes, refractive errors and vision of children.Am J Optom Physiol Opt 1986;63:668-675. 15) Mohindra I.Vision profile of deaf children.Am J Optom Physiol Opt 1976;53:412-19. 16) Nikolopoulos TP, Lioumi D, Stamataki S, O'Donoghue GM, Guest M, Hall A. Evidencebased overview of ophthalmic disorders in deaf children, A literature update. Otol Neurotol 2006;27:1-24 17) Onakpoya OH,Omotoye OJ. Screening for ophthalmic disorders and visual impairment in a Nigerian school for the deaf.Eur J Ophthalmol 2010;20(3):596-600. 18)Osiayuwu AB,Ebeigbe JA.Prevalence of visual disorders in deaf children in Benin city JNOA 2009;15:20-2. 19) Sapkota K. Visual status of deaf school students in Kathmandu, Nepal. Community Eye Health 2005;18:129.
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20) Gogate P, Rishikeshi N, Mehata R, Ranade S, Kharat J, Deshpande M. Visual impairment in hearing-impaired students. Indian J Ophthalmol 2009;57:451-3. 21) Guy R,Nicholson J,Pannu SS,Holden R. A clinical evaluation of ophthalmic assessment in children with sensori-neural deafness. Child Care Health Dev 2003;29:377-84. 22) Nicoll AM, House P. Ocular abnormalities in deaf children; A discussion of deafness and retinal pigment changes. Aust N Z J Ophthalmol 2007;16:205-8. 23)Ma QY,Zeng LH,Chen YZ,Li ZY,Guo XM,Dai ZY, et al.Ocular survey of deaf and mute children.Yan Ke Xue Bao 1989;5:44-6.

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Table 1:

Visual acuity of respondents

Visual acuity

Right eye Frequency(Percentage%)

Left eye Frequency(Percentage%)

<6/18 3/60-6/60 <3/60 –PL NPL

149(93.1) 8(5) 1(0.6) 2(1.3)

146(91.25) 11(6.9) 2(1.25) 1(0.6)

Total

160(100)

160(100)

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Table 2: Ophthalmic disorders among the respondents

Ophthalmic disorder

Frequency

Percentage(%)

Refractive error Juvenile Glaucoma Vernal conjunctivitis Early lens opacity Ectopia lentis Pthisis bulbi Optic atrophy Uveitis Pseudophakia Heterochromia iridis Retinitis pigmentosa Keratopathy

16 7 4 3 3 2 2 1 1 1 1 1

38.1 16.7 9.5 7.1 7.1 4.8 4.8 2.4 2.4 2.4 2.4 2.4

Total

42

100

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Volume 2 Issue 3 2012

ISSN: 2250-0359

ROLE OF TISSUE ADHESIVE IN OTORHINOLARYNGOLOGY
* Karthikeyan Arjunan * Balasubramanian Thiagarajan *Seethalaksmi Narashiman

*Stanley Medical College

Abstract: This paper summarises the effectiveness of tissue adhesives in otorhinolaryngology. Although the adhesion system cannot and should not replace surgical suture, it provides valuable assistance in tissue synthesis and in local haemostasis, particularly in cases where conventional suture methods are especially difficult to apply. In addition to good adhesion, an elastic consistency, and good tissue compatibility, the adhesive is completely absorbed. The system has been used successfully in myringoplasty, laryngectomy during pharyngeal closure, repair of CSF leak, laryngocele, and ossiculoplasty. Introduction: The idea to use adhesives for wound closure or to stabilize and fix tissues can be traced back to many centuries. After the use of different adhesives and glutinous substances (pitch, bee wax, natural rubber) for wound cover with more or less good results, the development of fibrin glues (1940) and the later cyanoacrylates (1960) offered new ways in tissue adhesion. The gold standard of wound closure, the suture, becomes less possible because of Continuous miniaturisation and the development of minimally invasive surgery methods, particularly in mucosal areas. But a sufficient wound closure, a secured fixation of skin grafts, transplants and implants can be of vital importance for the success of a surgical therapy. In these areas, tissue adhesives virtually present themselves as method of choice. Gluing ensures a constant laminar force spreading. Unevenness of the material can be

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compensated by the adhesive. Additionally to mechanical and chemical basics of adhesion, the characteristics of a living system must be considered for medical application. The requirements of medical tissue adhesive: Biocompatibility: -Biodegradation and resorbability in a defined period -no local or systemic toxicity, carcinogenicity or teratogenicity of the adhesives or its degradation products -marginal heat development during hardening. Compound strength: -high bond strength in wet environment with immediate functional stress -adequate elasticity Application: -easy preparation -adequate flow characteristics and curing times -application systems for different areas of application -miniaturisation (microscopic and endoscopic surgical methods) Others: -Sterilisability -Stable to storage

Materials and methods: A study was conducted in Stanley medical college and hospital from 2009 to 2011. Tissue glue was used in various surgeries like myringoplasty, total laryngectomy (pharyngeal closure), repair of CSF leak and laryngocele and the effectiveness was evaluated. We used Biologic tissue adhesive, ‘Tisseel’ a two component fibrin sealant.

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Tisseel kit contains: Tisseel, lyophized, stream treated sealer protein concentrate, human 1 ml of Tisseel solution contains Clottable protein Thereof fibrinogen Plasma fibrinogen (CIG) Factor XIII Plasminogen 75- 115 mg 70-110 mg 2-9 mg 10-15 IU 40-120 ug

Aprotinin solution bovine, 3000 KIU/ml Thrombin 4 lyophized, human 1 ml of thrombin solution contains Thrombin 4 IU Thrombin 500 lyophized, human 1 ml of thrombin solution contains Thrombin 500 IU Calcium chloride solution 40 mmol/l Kits for reconstruction and application.

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Image showing TISSEEL KIT

Image showing syringe used for tissue glue application

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Mechanism of adhesion: 1 The components thrombin and fibrinogen cause, analogue to the last phase of blood coagulation, the formation of cross-linked fibrin. Here, the concentration of fibrinogen is 15 to 25 times higher than in circulating plasma. Therefore, fibrin is formed much faster. The other key factor is factor XIII, which causes an indissoluble fibrin matrix. Besides, most fibrin glues contain anti-fibrinolytic substances (tranexamic acid, aprotinin), which are responsible for stabilisation of the adhesion by inhibition of fibrinolysis. 1,2 It is elaborated in detail in discussion.

Image describing reconstruction process

Reconstruction and application: Use Tisseel and Thrombin solution within 4 hrs. after reconstitution. Caution: Use separate syringes and needles for reconstitution of Tisseel and thrombin. Use again separate syringes and needles for their application. Do not inject by the intravenous route.

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Application: Study 1: This fibrin glue was used in 10 cases of myringoplasty. 7 Myringoplasty was done as classical underlay technique. Graft was placed lateral to the handle of malleus and fibrin glue was applied at the margins of the tympanomeatal flap after it was repositioned. And those cases were followed up for a period of 6 months (once in every month) and the cases were evaluated by otoendoscopy and pure tone audiometry. Otoendoscopy was done and the following features were assessed: Graft taken up or not. Graft medialisation. Graft lateralisation. Results: Graft was taken up in 9 out of 10 cases. There is neither lateralisation nor medialisation of the graft. Pure tone audiometry was showed there was improvement in air bone gap.

Study 2: Fibrin glue was applied in a case of total laryngectomy after closure of the pharynx.8 Especially here it was applied not to replace the surgical suture but to provide valuable assistance to the tissue synthesis and for local haemostasis.

Figure showing glue being applied in a patient with total laryngectomy
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Sutures were first removed alternatively, and completely removed at 18th post-operative day. There was no pharyngo cutaneous fistula. Case was followed up once in a month for 3 months. There is neither fistula formation nor inflammatory reaction. Study 3: Fibrin glue was also used in cleft palate repair. It was applied after closure of the muscle layer and mucosal layer. During post-operative follow up the wound was found to be healthy and there is no palatal fistula.

Application of tissue glue in cleft palate repair

Study 4: Tissue glue is used in external laryngocele surgery. Laryngocele was resected from its attachments near the thyrohyoid membrane and tissue glue is applied to seal the defect in the thyrohyoid membrane. No recurrence was noted in the one year follow up period.

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Image showing tissue glue being applied after laryngocele excision

Study 5: CSF leak repaired through bicoronal approach. Bicoronal approach was used to expose anterior table of the frontal sinus. A window was created in the anterior table of the frontal sinus using the fissure burr. The interior of the frontal sinus was visualised and the leak site was identified over the posterior table of the left frontal sinus which was sealed using tissue glue and abdominal fat. No recurrence was noted in the 6 months follow up period.

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Tissue glue used in CSF leak repair

Discussion: Fibrin glues are used since 1940. These are the most commonly used tissue adhesives. Mechanism of adhesion:

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The principle of biological sealing: In the last step of the coagulation cascade fibrinogen is transformed to fibrin monomers which aggregate and form a gel. Concomitantly, thrombin transforms factor XIII to factor XIIIa in the presence of calcium ions. Factor XIIIa crosslinks the aggregated fibrin monomers to a high molecular weight polymer. The resulting fibrin clot seals off surrounding tissue and provides early haemostasis.

FIBRIN GLUE REPRODUCES THE LAST STEP OF THE COAGULATION CASCADE: In natural conditions the fibrin clot is degraded after 1-2 days in most tissues. Fibrin glue contains aprotinin- the most effective exogenous antifibrinolytic (clot stabilizer) known to inhibit not only plasminogen activation and plasmin binding but most proteases involved in clot degradation. It is added to fibrin glue to prolong its stability in vivo up to 9-10 days. Factor XIII crosslinks fibrin monomers and also fibrin and fibronectin with the collagen of the tissue to which the sealant was applied.

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The fibrin glue clot contains 30 times the fibrinogen concentration, provides high elasticity and 4-5 times greater tensile strength than a normal blood clot. Fibrinogen concentration is directly proportional to: - Elasticity of the fibrin clot - Increased tensile strength - Increased adhesive strength

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Blood clot

Fibrin glue clot

All components of a fibrin glue matrix are involved in the process of wound healing.

Advantages of these biologic tissue adhesives: - Good adhesion in wet environment - Minimal tissue irritation - Good sealing without heat development - Curing time is better Disadvantages: - There is a minimal risk of transmission of prions by aprotinin with bovine origin 1,3 - Cannot be used in arterial bleeding (even heavy venous bleeding is contraindicated) - Cannot be used in persons with allergic heparin induced thrombocytopenia, and who are intolerance to bovine products.

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SPECIAL WARNINGS AND SPECIAL PRECAUTIONS FOR USE: 1. For epilesional use only. Soft tissue injection carries the risk of an anaphylactoid reaction and /or local tissue damage 2. Life threatening anaphylactiod reactions and/or thromboembolic complications may occur if the preparation is unintentionally applied intravascularly. 3. It should be applied as a thin layer. Excessive clot thickness may negatively interfere with the products efficacy and wound healing process. 4. Fibrin glue contains bovine protein (aprotinin). Even in the strict local application, there is a risk of anaphylactoid reaction, linked to the presence of bovine aprotinin. The risk seems higher in case of previous exposure even it was well tolerated. 5. Therefore any use of aprotinin containing products should be recorded in the patient’s records. 6. In case of shock, standard medical treatment for shock should be implemented. 7. Signs of hypersensivity reactions include hives, generalised urticaria, and tightness of the chest, wheezing, hypotension, and anaphylaxis. If these symptoms occur the administration has to be discontinued immediately. 8. Thrombin and factor XIII are made from human plasma. Standard measures to prevent infections resulting from the use of medicinal products prepared from human blood or plasma include selection of donors, screening of individual donations. 9. Despite this, the possibility of transmitting infective agents cannot be totally excluded. this also applies to unknown or emerging viruses or other pathogens. The measures taken are considered effective for enveloped viruses such as HIV, HBV and HCV. The measures taken may be of limited value against small non-enveloped viruses such as parvovirus B 19 AND HAV. 10. The hypersensitive and anaphylactoid reactions especially may be seen, if the preparation is applied repeatedly, or administered to patients known to be hypersensitive to aprotinin or any other constituents of the products. Even if the second treatment with fibrin glue was well tolerated, a subsequent administration may result in severe anaphylactoid reactions.

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Other than biologic tissue adhesives some other adhesives also in use. They are - Synthetic adhesives (cyanoacrylates) - Gelatine resorcinol formaldehyde/glutaraldehyde glues - Albumin glutaraldehyde glue Synthetic adhesives: This has been described for the first time in 1959. 1,4. But the first short chain cyanoacrylates turned out to be histotoxic and caused distinct foreign body reactions. The long chain cyanoacrylates of the second generation are more biocompatible. 5,6 With raising chain length ,toxicity and adhesion strength decrease, elasticity and polymerisation time increase. First generation: - Methyl cyanoacrylate Second generation: - Ethyl 2 cyanoacrylate - n butyl cyanoacrylate - 2 octyl cyanoacrylate - Isobutyl cyanoacrylate - N butyl 2 cyanoacrylate + methacryloxysulphone Mechanism of adhesion: In contact with hydroxide ions (liquids like blood or water, air humidity) the cyanoacrylates form long, strong waterproof chains in an exothermic reaction. The resulting polymer leads to a stable adhesive bond. The polymerisation time is 20 sec to 2 min. with too much moisture the reaction runs too fast for a tissue adhesion. Advantages: - Good adhesion in moderate wet environments. - Strong adhesion. Disadvantages: - Toxic degradation products.

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- Heat generation during polimerization. Gelatin resorcinol formaldehyde/glutaraldehyde glues: These were introduced on 1966. Mechanism of adhesion: Resorcinol and dialdehyde react to a 3 dimensional network. Gelatine serves as filler. Polimerisation time is 2 min, the degradation products are much less toxic as those of the cyanoacrylates. Note: this is not used in otorhinolaryngology widely due to difficult application. Albumin glutaraldehyde: Mechanism of adhesion: The glutaraldehyde molecules band together by covalent bond with the added albumin as well as with the proteins of the tissue. The polymerisation time starts immediately after mixture of the components. The entire adhesive strength is achieved after 2 min. Note: because of its adhesion attributes in wet environments, this adhesive seems to be appropriate in otorhinolaryngology. Role in ENT: Role in otology: - Myringoplasty 7, readaptation of the edges after traumatic rupture - Ossiculoplasty (for both fixation of transplants (cartilage, ossicles) and Implants (TORP,PORP) - Fixation of implantable hearing system - Otoplasty Role in rhinology: - Septoplasty (sealing of mucosa) ,closure of septal perforations, turbinoplasty, epistaxis. - Fixation of transplants (cartilage, bone) and implants (stents) in repair of CSF leak and other surgeries. - Dural plasty .

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Role in laryngology: - Closure of fistula. 8 - Fixation of transplants and implants.

References : 1. Schneider 2001 ,march 10. Tissue adhesives in otorhinolaryngology 2. Pursifull NL,Morey AF, Tissue glues and nonsuturing techniques. Curr opin urol 2007; 17, 396-401 DOI-10. 1097/ MOU ob013e3282f0d683 3. Petersen B, Barkun A, Carpenter S, et al. Tissue adhesives and fibrin glues.Gastrointest Endosc.2004.60. 327-333, DOI: 10, 1016/S0016-5107 (04) 01564-0 4. Coover H. Joyner ,shearer N, Wicker T. Chemistry and performance of cyanoacrylate adhesives. Special technical papers.1959; 413-417. 5.Alamouti D, Von Kobyletzki G, Allard P, Hoffmann K. Ein prospektiver Vergleich von octyanoacrylat –Gewebekleberund konventionellen wundverschlussen. Hautarzt. 1999; 50: 58-59.DOI 10.1007/S001050050867. 6. Leggat PA ,Smith DR, Kedjarune U. surgical applications of cyanoacrylate adhesives: a review of toxicity. ANZ J Surg 2007; 77:209-213.DOI: 10.1080/19338240903241291. 7. Samuel PR, Roberts AC, Nigam A. The use of indermil (n-butyl cyanoacrylate) in otorhinolaryngology and head and neck surgery. A preliminary report on the first 33 patients. J Laryngol Otol. 1997; 111;536-540.DOI:10.1017/S0022215100137855. 8. Wiseman S, Hicks W, lr, Loree, kasspooles M, Ringual N. Fibrin glue reinforced closure of postlaryngectomy pharyngocutaneous fistula.

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Volume 2 Issue 3 2012

ISSN 2250-0359

DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY , SMHS HOSPITAL GOVERNMENT MEDICAL COLLEGE SRINAGAR,J&K SRINAGAR INDIA
DR.ANEESA.A.MIRZA( P.G SCHOLAR),DR.IRFAN IQBAL(REGISTRAR) ,DR.K.KISHORE(LECTURER),DR.SAJAD.M.QAZI(ASST.PROF.)DR.SHEETAL .K.

LINGUAL SCHWANNOMA: OUR EXPERIENCE
ABSTRACT
Schwannomas are benign tumors of nerve sheath and quite uncommon in oral cavity. The case of a 15 yr old male is presented who had a 4 months history of swelling on right lateral border of tongue associated with disturbance in mastication. Examination revealed a 2x2 cm globular and smooth swelling on right lateral border of tongue. Complete excision with primary closure was carried out. Histopathological examination of the surgical specimen was consistent with schwannoma.

INTRODUCTION
A Schwannoma is a benign, encapsulated, slow growing tumor arising from the neural sheath’s Schwann cells of the peripheral, cranial or autonomic nerves.1It was first identified by Virchow in 1908.2 About 25-40% of these tumors occur in head and neck region. A rare site for schwannoma is the oral cavity, it accounts for only 1% of all head and neck region tumors.3

A 15 yr old male patient (fig.1) presented with 4 months history of a slowly progressive painless swelling on right lateral border of tongue associated with disturbance in mastication without any pain or bleeding.

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Examination of the oral cavity showed a swelling of 2x2cm on right lateral border of tongue. The swelling was non tender with a smooth surface and well demarcated margins. Examination of the rest of oral cavity revealed no other lesion. No regional lymphadenitis was detected. The patients’ medical history was unremarkable. Results of routine laboratory tests were within normal limits. MRI of the tongue (fig2) and oral cavity was performed and revealed a well-defined lobulated mass lesion exhibiting isointense signal on T1 and hyper intense on T2 images along the lateral border of the tongue. Other structures of the tongue and oral cavity were without pathomorphological signs. Fine needle aspiration cytology of the mass was suggestive of the lingual schwannoma. Excision if the swelling was planned under general anaesthesia. The lesion was completely excised by intraoral approach(fig3) and surgical defect was closed. The patient had an uneventful postoperative recovery. Histopathological examination of the surgical specimen was suggestive of schwannoma.

DISCUSSION
Schwannomas or neurilemmomas are benign slow growing solitary and encapsulated tumors originating from Schwann cells of the nerve sheath1.Schwannoma usually occurs in adults and although they can involve children but are not commonly seen in younger age group. There is no gender preference4.The presenting feature of a tongue schwannoma is usually a tumour mass. Other symptoms include dyspnoea or dysphagia and depend on the location and size of the tumor.5 Schwannomas in the head and neck regions constitute 25% of all extracranial schwannomas but only 1% show intraoral origin6,7.The intraoral lesions have a predilection for the tongue followed by the palate, floor of mouth, buccal mucosa and mandible8.In the tongue, base of tongue is commonly affected3 and the tip is least affected part.9 Identification of the originating nerve may be difficult. In more than 50% of intraoral lesions, it is not possible to differentiate between tumors of the lingual, hypoglossal and glossopharyngeal nerves.10 Diagnostic investigations include ultrasound scan, computerised tomography, magnetic resonance imaging and fine needle aspiration cytology. MRI is best choice in detecting the extent of the tumour and correlates well with operative findings.11 Diagnosis is confirmed by histopathology showing the presence of Antoni A and Antoni B cells, nuclear palisading, whorling of cells and verocay bodies. Malignant lesions such as squamous cell carcinomas and sarcoma and benign lesions such as granular cell tumors, salivary gland tumours, leiomyoma, rhabdomyomas, lymphangiomas, haemangioma, dermoid cysts, lipomas, inflammatory lesions and lingual thyroid are the differential diagnosis of this entity. 12
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Treatment is always surgical and usually requires only an excision or enucleation of the tumor.9 Radiation therapy is not indicated because schwannomas exhibit a high degree of radioresistance.13 Prognosis is excellent as malignant transformation of schwannoma is an exceptionally rare event and can safely be disregarded.

Figure 1

fig3
Figure 2

REFERENCES
1. Cunningham LL Jr, Warner MR: Schwannoma of the vagus nerve first diagnosed as a parotid tumour. J oral maxillofacsurg 2003; 61:141-4 2. Mosharrafa TM, Kupper Smith RB, Porter JP, Donavan DT: Malignant peripheral nerve sheath tumour of the ethmoidal sinus. Arch otolaryngol head neck surg 1997; 123:654,656-7 3. Pfeifle R, Baur DA, Pantino A, Helman J: Schwannoma of the tongue: report of 2 cases. J oral maxillofacsurg 2001; 59: 802-4 4. Chiapasco M, Ronchi P, Scola G: Neurilemmoma (Schwannoma) of the oral cavity: A report of 2 clinical cases. Minerva stomatol 1993; 42:173-8 5. DeBree R, Westerveld GJ, Smiele LE: Submandibular approach of a large schwanniom in base of tongue. Eur Arch otorhinolaryngol 2000; 257: 283-6

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6. Bansal R, Trivedi P, Patel S: Schwannoma of the tongue. Oral oncol extra 2005; 41:15-17 7. Lopez Jornet P, Bermejo Fenoll A: Neurilemmoma of the tongue. Oral oncol extra 2005; 4:154-7 8. Krolls SO, McGinnis JP Jr, Quon D: Multinodular versus plexiformneurilemmoma of the hard palate. Report of a case. Oral surg Oral med Oral pathol 1994; 77:154-7 9. Gallesio A, Berrone S. Schwannoma located in the tongue-A clinical case report. Minerva stomatol 1992; 41:583-90 10. Gutmann R, Grevers G: Extracranialschwannoma of the ENT region. Review of the literature with a case report of benign schwannoma of the base of tongue. HNO 1997;45:468-71 11. Karaca CT, Habesoglu TE, Naboglu B, Habesoglu M, Oysu C, Egeli E et all. Schwannoma of a tongue in a child. Am J Otolaryngol 2010: 31: 46-8 12. Nelson W, Chuprevich T, Galbraith DA: Enlarging tongue mass. J oral maxillofacsurg 1998; 56:224-7 13. Gallo WJ, Moss M, Shapiro DN, Gaul JV: Neurilemmoma: Review of the literature and report of five cases. J Oral surg 1997;35:235-6

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Volume 2 Issue 3 2012

ISSN 2250-0359

Actinomycosis and aspergillosis in the nose of a diabetic: A case report

1

Meenu Khurana Cherian1*, Rajarajeswari2 Department of ENT, Gulf Medical College Hospital and Research Centre, Ajman, UAE; Department of Pathology, 3Department of Medicine, Pondicherry Institute of Medical Sciences,

1

2

Pondicherry, India.

*Presenting Author

Corresponding Author Dr. Meenu Cherian Department of ENT Gulf Medical College Hospital & Research Centre Ajman, UAE. Email Id: researchdivision@gmu.ac.ae Phone: +971 67431333 Fax: +971 67431222

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ABSTRACT This is a rare case of an elderly diabetic with a short duration of nasal discharge and obstruction due to an infection of actinomycosis and aspergillosis on the inferior turbinate and floor of the nose.

Keywords: nose, turbinate, Actinomycosis, Aspergillosis, diabetes

INTRODUCTION Actinomycosis of the nose and turbinate is extremely rare1, and a combined infection with aspergillus is even more so2. The possible cause for this condition is discussed. The management of the particular patient is described.

CASE REPORT An 80 year old physician, a diabetic on treatment, was admitted with a productive cough of two weeks’ duration. The patient had earlier undergone aortic valve replacement on two occasions and coronary artery bypass grafting. Five months ago he suffered a left basal ganglia infarct and was on regular physiotherapy for the resulting hemiplegia. Suspecting microaspiration the chest physician started the patient on Levofloxacin 500 mg. Two days later he complained of nasal obstruction and purulent discharge. This persisted even after completion of the antibiotic course. A diagnostic nasal endoscopy was performed which showed yellow colored debris and discharge on the floor of the nose and adjacent inferior turbinate on the right. The rest of the nose was normal. The discharge was subjected to microbiological examination which showed 1-2

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polymorphs/HP field with occasional Gram positive bacilli and cocci. There was no growth on culture.

A week later the nasal endoscopy was repeated as the patients problem persisted. A thick encrusted plaque was found on the posterior part of the medial surface of the inferior turbinate and on the adjacent floor of the nose. This showed granules which were bright yellow in colour. On removing the crusts there was bleeding from the underlying mucosa. The particular colour of the lesion led us to suspect actinomycosis, and the material was sent for histopathological examination. The biopsy was reported as actinomycosis and aspergillosis. The patient was then treated with oral Penicillin for 3 months and Itraconazole for one month after all the mucosal lesions were removed endoscopically from the nose.

DISCUSSION Actinomycosis involving the nasal cavity is extremely rare1. Actinomyces sp. are a common commensal in the oral cavity, rectum and vagina. Infections caused by this organism are due to penetrating injury and immunocompromised states. Actinomyces are microaerophilic and these infections are generally deep giving rise to abscesses and osteomyelitis. Cervicofacial infections manifest commonly as odontogenic infections and rarely sinusitis and a nasopharyngeal mass. This patient had suffered a cerebrovascular accident a few months earlier and the mucosal trauma associated with a nasogastric tube may be the cause for the actinomycotic infection. A mixed infection of actinomycosis and aspergillosis has only been reported in the lung3. Aspergillus in the nose and paranasal

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sinuses manifests as AFRS, invasive or non-invasive granulomatous infection. In this particular case it is likely that the actinomycosis was the primary infection and the fungal infection secondary to the antibiotic therapy. Isolated Actinomycosis and actinomycosis along with a fungal infection are rare in the nose and paranasal sinuses. Both can present as a granular mass, a discharging sinus or similar to osteomyelitis.

CONCLUSION In our case only debris and a plaque were visible. It is difficult to differentiate the two conditions clinically4. A history of concomitant dental infection in a diabetic or immunocompromised patient is usually present5. In our case an indwelling nasogastric tube causing trauma to the nasal mucosa in a diabetic was probably the cause. Even though fine needle aspiration cytology plays some role in the diagnosis of actinomycosis in a granular mass6, the diagnosis is confirmed only on histopathology.

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Figure 1. Endoscopic view of a thick encrusted plaque seen in the posterior part of the medial surface of the inferior turbinate and on the adjacent floor of the nose

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Figure 2. The section shows multiple actinomycotic colonies charecterized by radiating filaments with the periphery showing eosinophilic Splendore-Hoeppli reaction. These are surrounded by an abscess with acute on chronic inflammatory infiltrate. Embedded in the abscess are aspergillus colonies, the fungal filaments show septate hyphae and branching at acute angles. Fruiting bodies are also seen (Heamtoxylin & Eosin stain-100x)

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Figure 3. [H&E 400X]

Figure 4. Section shows actinomycotic colonies sorrounded by aspergillus colonies (Periodic Acid Schiff stain 400x)

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Figure 5. (PAS stain 100X)

Figure 6. Section shows aspergillus colonies with septate hyphae, branching at acute angles. Some fruiting bodies are also seen (Gomori Methanamine silver Stain 400x)

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Figure 7. Section shows actinomycotic colonies along with aspergillus colonies (Gomori Methanamine silver Stain 100x)

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References
1. Ozcan C, Talas D, Görür K, et al. Actinomycosis of the middle turbinate: an

unusual

cause

of

nasal

obstruction.

Eur

Arch

Otorhinolaryngol

2005;262(5):412-5.
2. Huang CW, Lee MA, Lu RH, et al. A case of pulmonary aspergilloma and

actinomycosis. J MJ Med Microbiol 2011;60(4):543-6.
3. Hiroyoshi T, Shunsuke E, Kohzo S, et al. Endobronchial aspergillosis and

actinomycosis associated with broncholithiasis. Eur J Cardiothorac Surg 2007;31:1144-1146.
4. Bhatia PL, Obafunwa JO. Rare infections of nose and paranasal sinuses.

Trop Geogr Med 1990;42(3):289-93. 5. Weston V. Microorganisms. In, Gleeson M, Browning GG, Burton MJ, et al. (ed). Scott-Brown’s Otorhinolaryngology: Head and Neck surgery, 7th ed. London, Hodder and Arnold 2008;195-203. 6. Gupta N, Kaur J, Srinivasan R, et al. Fine needle aspiration cytology in lesions of the nose, nasal cavity and paranasal sinuses. Acta Cytol 2011;55(2):135-41.

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Volume 2 Issue 3 2012

ISSN 2250-0359

Sphenoethmoidal hemangioma-A rare presentation
* Sundar krishnan * Raghukumaran

*Madras Medical College & Rajiv Gandhi Government General Hospital

ABSTRACT Hemangiomas do not develop as commonly in the sinonasal cavity, compared with other head and neck sites. The most common presenting symptom was epistaxis. Hemangiomas involving multiple sinuses with a atypical clinical presentation is extremely rare. We present a representative case of sphenoethmoidal hemangioma with atypical clinical presentation and treated by endoscopic excision yielding excellent outcome in terms of tumor control and safety.

CASE REPORT A 37 year old male had c/o referred to ENT OPD with c/o headache past 6months, diminished vision in right eye 2months & left eye 2weeks and increased frequency of urination 2weeks.

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On carefully eliciting the history he revealed his headache was diffuse, compressive nature continuously present not associated with nausea and vomiting.2months back developed blurring of vision in right eye for which he attended opthal OPD where he was admitted for 2 days investigated, diagnosed as ?retrobulbar neuritis treated and discharged. After discharge, for 2weeks he was asymptomatic and had deterioration of vision in right eye & diminution of vision in left eye with increased frequency of urination 2weeks.patient again revisited opthal OPD from where he was referred to neurology OPD. After serial of investigations by neurologists they are still inconclusive in diagnosis and with aid of radiologists they gave a differential diagnosis of? Fungal granuloma,? ethmoidal carcinoma and ?pituitary adenoma with dibetes insipidus. Then patient was referred to our ENT OPD for further management.

 CRANIAL NERVE EXAMINATION: OPTIC NERVE: Visual acuity Rt only light Perception Colour vision Field of vision not appreciable absent + + Lt 6/36

Other cranial Nr’s examination-Normal; All blood investigations was normal ENT examination revealed normal except for mild DSL, Deviated septum to left.

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CT PNS

MRI BRAIN WITH PNS

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DIAGNOSTIC NASAL ENDOSCOPY showed, Rt side: Accessory ostium + , Middle turbinate medialized *Lt side-DSL, Accessory ostium + , Sphenoethmoidal recess-normal # NO MASS VISUALISED IN NASAL CAVITY

 We planned for a, ENDOSCOPIC TRANSNASAL MASS EXCISION, under GA  We had excised the mass and sent for histopathological examination  HPE report showed polypoidal respiratory epithelium lined mucosa with scattered bony spicules with large dilated thin walled blood vessels lined by endothelial cells and foci of proliferating thin walled branching closely packed blood vessels wit intervening fibrotic stroma. Lesion consistent with HEMANGIOMA

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HPE PICTURES-CAPILLARY AND CAVERNOUS HEMANGIOMA

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PRE OPERATIVE MRI

POST OPERATIVE MRI

Post operatively pt had a transient Diabetes Insipidus was on strict fluid management with normal renal parameters Within a week DI resolved completely Nasal pack removed on IVth POD To our surprise pt had a dramatic improvement in vision in immediate post op period and returned to 6/6 in both eyes. CONCLUSION: Thus we conclude sphenoethmoidal hemangioma is extremely rare presenting with blindness and endoscopic optic nerve decompression proven its complete removal with excellent outcome in patient improvement and tumor control. www.jorl.scopemed.org

DISCUSSION

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REFERENCES

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Volume 2 Issue 3 2012

ISSN 2250-0359

Correlation of fine needle aspiration and final histopathology in thyroid disease: a series of 702 patients managed in an endocrine surgical unit

*Chandrasekaran Maharajan * Himagirish Rao *Madras Medical College

Abstract Introduction: Thyroid nodules are a common clinical entity found among the adult general population. With increasing use of imaging investigations like ultrasonography, there has been a significant rise in the detection of non-palpable thyroid nodules that require further evaluation and management. The routine use of FNAC has reduced the number of unnecessary surgical procedures for thyroid nodules. Taking a decision as to whether to operate on a thyroid nodule is dependent on accurate FNAC testing. This study describes the experience with FNAC in a consecutive series of patients with thyroid nodules who underwent thyroidectomy at a tertiary care hospital in the department of endocrine surgery.

Patients and methods: Clinical and pathologic data of patients with thyroid nodules or diffuse goitre who were operated in a single endocrine surgical unit between January 2008 and December 2010 were prospectively collected and retrospectively reviewed. The anatomical lesion of the thyroid (solitary nodule, STN, multinodular goitre, MNG or diffuse
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goitre, DG) was recorded. The functional status of the thyroid was assessed for each patient at presentation. All patients included in the study underwent fine needle aspiration cytology (FNAC) followed by surgery. Patients with solitary toxic nodules underwent

hemithyroidectomy, while others underwent total thyroidectomy. Final histopathology (HPE) was then compared with initial FNAC results.

Results: Out of the total number of 702 patients, 119 (17%) were men and the remaining 583 (83%) were women. With regards to solitary thyroid nodules, FNAC had a sensitivity of 86.9%, specificity of 99.1%, false negative rate of 13.1%, false-positive rate of 0.9%, positive predictive value of 97,6% and negative predictive value of 94.9% for diagnosis of malignancy. FNAC had a sensitivity of 76.9%, specificity of 98.8%, false negative rate of 23.1%, false-positive rate of 1.2%, positive predictive value of 94.6% and negative predictive value of 93.8% for diagnosis of malignancy with respect to diffuse and multinodular goitre. Overall, FNAC had a sensitivity of 80.2%, specificity of 98.9%, false negative rate of 19.8%, false-positive rate of 1.1%, positive predictive value of 96.6% and negative predictive value of 94.1% for diagnosis of malignancy.

Conclusion: FNAC was more accurate in patients with solitary thyroid nodules than in those with multinodular or diffuse goitre. While false negativity could be due to misrepresentative sample or misinterpretation of the sample, false positivity could be ascribed to hyperplasia of thyrocytes in the functioning thyroid as a result of TSH stimulation.

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Introduction Thyroid nodules are a common clinical entity found among the adult general population. The frequency of non-palpable thyroid nodules may be as high as 50% or more by the age of 50 years.1,2 With time, ultrasonography has come to be used with increasing regularity in clinical practice. As a result, there has been a significant rise in the incidence of non-palpable thyroid nodules that require further evaluation and management. Since 1986, when fine needle aspiration cytology (FNAC) was first reported from Sweden, it has been widely accepted as the most accurate, cost-effective, and safe screening test for rapid diagnosis of thyroid nodules.3, 4, 5 The routine use of FNAC has reduced the number of unnecessary surgical procedures for thyroid nodules.2, 6 In addition; it has enabled the detection of thyroid cancer at earlier stages.7,
8

Taking a decision as to whether to operate on a thyroid nodule is dependent on

accurate FNAC testing. Assessment of false positive and false negative FNAC results assumes importance in this context.9 Indeterminate FNAC results that include follicular and Hurthle cell neoplasms and those that indicate a suspicion of papillary thyroid cancer (PTC) without actually diagnosing PTC, represent a continued diagnostic and treatment challenge to pathologists and surgeons alike. The diagnosis of follicular thyroid carcinoma (FTC) or Hurthle cell carcinoma (HTC) requires the presence of capsular or vascular invasion on final histopathological examination (HPE), findings that cannot be assessed by FNAC. Sometimes, patients with indeterminate thyroid nodules who undergo hemi-thyroidectomy are found to have malignancy on final pathology. Such cases necessitate completion thyroidectomy.3, 6

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This study describes the experience with FNAC in a consecutive series of patients with thyroid nodules who underwent thyroidectomy at a tertiary care hospital in the department of endocrine surgery.

Methods Clinical and pathologic data of 702 consecutive patients with thyroid nodules or diffuse goitre who were managed in a single endocrine surgical unit between January 2008 and December 2010 were prospectively collected and retrospectively reviewed. The anatomical lesion of the thyroid (solitary nodule, STN, multinodular goitre, MNG or diffuse goitre, DG) was recorded. The functional status of the thyroid was assessed for each patient at presentation with the help of free thyroid hormone (FT3 and FT4) and thyroid stimulating hormone (TSH) levels. Levels of anti-microsomal and anti-thyroglobulin antibodies (AMA and ATG) were estimated. Those who were hypothyroid or hyperthyroid at presentation were started on appropriate drug therapy. All FNAC slides were classified into 1 of 4 main categories: non-diagnostic, benign, indeterminate, or malignant. The indeterminate group included specimens further classified as follicular neoplasm (FN), Hurthle cell neoplasm (HN), or suspicious for papillary thyroid cancer (SPTC). Specimens were classified as follicular neoplasms when cytology aspirates were very cellular, with scant or no colloid, and uniform microfollicular cells were present. The interpretation of Hürthle cell neoplasm was made when FNAC aspirates consisted of microfollicles formed by cells with abundant eosinophilic cytoplasm lacking lymphocytes. The diagnosis of ‘suspicious for PTC’ (SPTC) was made when cellular aspirates revealed nuclear grooving, intranuclear pseudo-inclusions, or Psammoma bodies, but no papillae and little colloid.

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Papillary microcarcinomas, defined as malignant lesions smaller than 1 cm, were considered in the final analysis of this study. Patients with non-toxic solitary thyroid nodules (including FN, HN and PTC), DG and MNG underwent total thyroidectomy. Those with a solitary toxic adenoma underwent hemithyroidectomy. All patients with pre-operative diagnosis of malignancy underwent total thyroidectomy (TT) and central compartment neck lymph-node dissection (CCLND), if indicated. Those patients with lateral cervical node metastases diagnosed preoperatively underwent a modified radical neck dissection (MRND) of the involved side. Indications for thyroidectomy when FNAC of the index nodule was benign included interval growth, obstructive symptoms, cosmetic reasons, adverse ultrasonographic nodule features, and/or patient preference. All 702 patients underwent hemithyroidectomy or total thyroidectomy, and final histopathology (HPE) was then compared with initial FNAC results.

Results A total of 702 patients, aged between 13 and 78 yrs, with median age of 39 yrs underwent FNAC of the thyroid followed by thyroidectomy between January 2008 and December 2010. Out of the total number of patients, 119 (17%) were men and the remaining 583 (83%) were women. Out of the total number of cases studied on FNAC, 460 (66%) were diagnosed with benign thyroid disease while 115 patients (16%) were diagnosed to have malignancy (Table 1). 71 (10%) FNAC results were classified as indeterminate and 56 patients had a nondiagnostic FNAC (Table 1). Out of the 115 patients who were diagnosed with malignancy, 107 (93%) had PTC while 8 (7%) had medullary thyroid cancer (Table 1). Among the

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indeterminate reports, 34 patients (48%) were reported to have FN, while 5 (7%) were diagnosed as HN and the remaining 32 (45%) were suspicious for PTC (Table 1). Among the 460 patients with benign disease as diagnosed on FNAC, 433 (94%) patients had benign disease after HPE, while 27 (6%) patients turned out to have malignancy (Table 1). Out of the 115 patients diagnosed with malignancy on FNAC, 110 (96%) patients had malignancy on HPE while 5 (4%) patients had benign disease on HPE of the operative specimen (Table 1). All these 5 patients had been diagnosed with PTC on FNAC. All the patients diagnosed with MTC on FNAC had MTC on HPE of the operative specimen. Out o the 71 patients with indeterminate FNAC diagnosis, 32 (45%) had malignancy on HPE, while 39 (55%) patients had benign disease (Table 1). Out of the total number, 196 patients had solitary thyroid nodules (Table 2). While 118 patients (60%) had benign diagnosis on FNAC, 41 patients (21%) were diagnosed with malignancy, 29 (15%) had indeterminate FNAC and 8 patients (4%) had non-diagnostic results (Table 2). On comparison with final HPE, FNAC had a sensitivity of 86.9%, specificity of 99.1%, false negative rate of 13.1%, false-positive rate of 0.9%, positive predictive value of 97.6% and negative predictive value of 94.9% for diagnosis of malignancy. The remaining 502 patients had MNG or DG (Table 3). Out of these, 342 (68%) were diagnosed with benign disease on FNAC, while 74 patients (15%) were diagnosed with malignancy (Table 3). 42 patients (8%) had indeterminate results, while FNAC was nondiagnostic in 48 patients (9%). When compared with the final HPE, FNAC had a sensitivity of 76.9%, specificity of 98.8%, false negative rate of 23.1%, false-positive rate of 1.2%, positive predictive value of 94.6% and negative predictive value of 93.8% for diagnosis of malignancy.

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Overall, FNAC had a sensitivity of 80.2%, specificity of 98.9%, false negative rate of 19.8%, false-positive rate of 1.1%, positive predictive value of 96.6% and negative predictive value of 94.1% for diagnosis of malignancy. In all, 179 out of the total of 702 patients (25%) were found to have malignant thyroid disease on final HPE (Table 4). Out of these, 113 (63%) had PTC, 48 (27%) had follicular variant of PTC, 8 patients (4%) had MTC, 4 (2%) had follicular carcinoma, 2 (1%) had Hurthle cell carcinoma and 4 patients had other variants of PTC.

Discussion In this study, FNAC was conducted with the help of a 24-guage needle. Nonaspiration cytology was not performed. In the present study, the overall false negative rate for FNAC was 19.8%. Other reports in the literature suggest false negative rates ranging from 1% to 17%.6,8-16 On analysis of FNAC results with respect to the anatomical diagnosis, FNAC had a false negative rate of 13.1% for solitary thyroid nodules and 23.1% for diffuse goitre or multinodular goitre. This could be due to misrepresentative sample or misinterpretation of the sample. False negatives in the case of STNs could be due to misinterpretation, while those in patients with MNG or DG could be misrepresentative samples. The false positive rate of FNAC was 1.1% in the present study. This incidence is consistent with other reports that cite false positive FNA results ranging from 0% to 9%.9-13 This could be ascribed to changes in the thyroid as a result of TSH stimulation. Hypothyroidism is characterised by hyperthyrotropinemia. Cellular hyperplasia is common in a functioning gland under TSH stimulation, resulting in highly cellular smears with scanty colloid, resembling malignancy. Conclusion
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Overall, FNAC had a sensitivity of 80.2%, specificity of 98.9%, false negative rate of 19.8%, false-positive rate of 1.1%, positive predictive value of 96.6% and negative predictive value of 94.1% for diagnosis of malignancy. FNAC was more accurate in patients with solitary thyroid nodules than in those with multinodular or diffuse goitre. While false negativity could be due to misrepresentative sample or misinterpretation of the sample, false positivity could be ascribed to hyperplasia of thyrocytes in the functioning thyroid as a result of TSH stimulation. . On the basis of these findings, we suggest that it is advisable to avoid FNAC in hypothyroid state.

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References 1. Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med 1993;328:553–9 2. Davies L,Welch HG. Increasing incidence of thyroid cancer in the United States, 1973–2002. JAMA 2006;295:2164–7 3. Frates M, Benson C, Charboneau J, et al. Management of thyroid nodules detected at US: Society of Radiologists in Ultrasound consensus conference statement. Radiology 2005;237:794–800 4. Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thyroid: an appraisal. Ann Intern Med 1993;118:282–9 5. Cooper DS, Doherty GM,Haugen BR, et al. Revised American Thyroid Association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid 2009;19:1167–1214 6. Lowhagen T, Willems JS, Lundell G, et al. Aspiration biopsy cytology in diagnosis of thyroid cancer. World J Surg 1981;5:61–73 7. Gharib H. Fine-needle aspiration biopsy of thyroid nodules; advantages, limitations, and effects.Mayo Clinic Proc 1994;69:44–9 8. Baloch ZW, Sack MJ, Yu GH, et al. Fine-needle aspiration biopsy of thyroid: An institutional experience. Thyroid 1998;8:565–9

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9. Lew JI, Snyder RA, Sanchez YM, Solorzano CC. Fine needle aspiration of the thyroid: correlation with final histopathology in a surgical series of 797 patients. J Am Coll Surg 2011;213:188-94 10. Meko JB, Norton JA. Large cystic/solid thyroid nodules: A potential false-negative fine needle aspiration. Surgery 1995;118:996–1004 11. Amrikachi M, Ramzy I, Rubenfield S, WheelerTM. Accuracy of fine needle aspiration of thyroid: A review of 6226 cases and correlation with surgical or clinical outcome. Arch Pathol Lab Med 2001;125:484–8 12. Blansfield JA, Sack MJ, Kukora JS. Recent experience with preoperative fine-needle aspiration biopsy of thyroid nodules in a community hospital. Arch Surg 2002;137:818–821 13. Yassa L, Cibas ES, Benson CB, et al. Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer Cytopathol 2007;111:50816 14. Scalbas GM, Staerkel GA, Shapiro SE, et al. Fine-needle aspiration of the thyroid and correlation with histopathology in a contemporary series of 240 patients. Am J Surg 2003;186:702–10 15. McCoy KL, Jabbour N, Ogilvie JB, et al. The incidence of cancer and rate of falsenegative cytology in thyroid nodules greater than or equal to 4 cm in size. Surgery 2007;142:837–44 16. Yang J, Schnadig V, Logrono R, Wasserman PG. Fine-needle aspiration of thyroid nodules: A study of 4703 patients with histologic and clinical correlations. Cancer Cytopathol 2007; 111:305–15

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Volume 2 Issue 3 2012

ISSN 2250-0359

From the Desk
Dear readers, For quite some time, lots of things are worrying my mind. I would like to share them, with the idea of not only for clearing my doubts, but for getting better information so that an awareness is created for the future improvements in medicine, in particular, Otorhinolaryngology field. Otorhinolaryngology being the surgical field let me caution that strict and universal application of Evidence Based Medicine need much revision. Evidence based medicine First, let me start with Evidence based medicine (EBM). No doubt, it carries the highest preference in research field. It clearly wins in all allied clinical subjects; I mean to say it is more useful in drug therapy, drug modification, newer drug trials, investigational values, etc. Coming to surgical procedures, emergency management, terminal care, multi system involvement, multi specialty care, and numerous other situations, the decision making depends on many facets of the problem rather than single entity. Usually Otorhinolaryngogical surgeons faces many challenges including monetary limitation of the patients, psychological aspects, resource availability of the institution especially in emergency situations, expertise needs etc. Constraints for not adhering to EBM in certain situations may be time factor, aesthetics factors, and occupational factors and also include social and individual mental makeup. Some of the drawbacks of conducting trials in surgical specialty are, (especially with regard to newer or existing surgical method options) 1. Psychological trauma, 2. Anxiety, 3. Desperation, 4. Insecurity

The patients usually think that they could have chosen the option rather than leaving it for the machine or the third person to decide about their future. Even though they may consent for the trial, everybody agree that they undergo lot of turmoil during as well as after the procedure. Forough Farrokhyar quotes, “Surgical trials pose many methodological challenges often not present in trials of medical intervention….. Many barriers and issues of surgical trials affecting internal validity can be overcome with proper methodology, and in most cases these issues do not restrict their conduct…..ref 2” Methodology Secondly well defined methodology with proven records is available for newer techniques to be accepted easily by all. Though trials have many phases including animal experimentations, still it may have different adverse reactions’ when it comes to human experimentations, especially, newer surgical techniques are concerned. If the story goes like this, I do accept that there would not have been revolution of Key- hole surgery, Robotic surgery and computer assisted surgeries which are the common day practices in Otorhinolaryngology field. Further many time tested surgical practice are slowly weaning to give way for the newer trends. It gives more satisfactions, lessons the surgical time, reduces morbidity, which all will agree. But no patient is willing to bell the cat. Protocol modules for Clinical situations I give more emphasis on the development of protocol modules for Clinical situations (symptomatology wise as well as disease wise). In this Endeavour I would like to give special mention on the great initiative taken by Scottish Intercollegiate Guidelines Network, http://www.sign.ac.uk (Ref 1) Even though much work has to be done there are few organizations including W.H.O., have already contributed much in this field’ Third and finally I have to accept that quality car and improvement has tremendous impact in the surgical field than EBM. Critical evaluation, continuous assessment, and on the spot verification, by internal as well as independent agencies do carry a lot in the implementation of quality care assessment. This system automatically creates awareness, urgency for improvement and acceptance for standardization. Holistic and situation based management Here I would like to mention a live situation. Middle aged male was referred for mastoidectomy as he was having swelling and discharge from the mastoid region for one month. Though he is strong at that time he was very sick. The CT and MRI of mastoid and temporal bone showed mastoiditis. Clinically he was having bloody discharge from both ears. Though they gave history of Incision and drainage was done for subperiosteal swelling day before. There was swelling and wound on both post aural regions with bloody discharge. There was hematoma on

the soft palate, bloody discharge from both external auditory canal and also epistaxis from both nostrils with clots. Investigations already done showed serum creatinine 3.5 and blood urea 90 mgms . Internist and Nephrologist who referred this patient, informed that the patient is in the Diffuse intravascular coagulatory state due to sepsis. Hence they were of the opinion that emergency mastoidectomy will be beneficial. Routine investigations were omitted. It was found out that there was spreading cellulitis in the mastoid region rather than abscess. This created the suspicion of septic shock and renal failure as well as the wound cannot be approximated, bone work will invite uncontrollable bleeding and the surgery was referred. Further investigations revealed that Haemoglobin level as 4 grams and the patient was HIV strongly positive . Moral of the story is “ decide by the state of the patient rather than reports and recommendations”. Otorhinolaryngologists have to decide on the ENT conditions. Let me conclude that surgical management especially in Otorhinolaryngology looks similar to 64 squares of the chess board but with 64 billion options widening as the game goes. In fact it is true, disease don’t restrict to Otorhinolaryngological field for any given patient. They may have causative disease, coexisting disease, complicating factors, contributory factors, in addition to the acute attacks, remission phase, as well as impending complications. As experienced surgeon, one has to view with broad outlook and act timely with precision and holistic approach. BIBLIOGRAPHY: 1. Scottish Intercollegiate Guidelines Network, 2. Randomized Controlled Trials of Surgical Interventions. Forough Farrokhyar et al (Ann Surg 2010;251: 409 – 416) 3. Randomized Controlled Trials for Evaluating Surgical Questions Eric K. Fung, MD & John M. Loré, Jr (Arch Otolaryngol Head Neck Surg. 2002;128(6):631-634. doi:101001/pubs.Arch Otolaryngol. Head Neck Surg.-ISSN-0886-4470-128-6-ooa10211)

U. Venkatesan

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