Subcutaneous Nasal Schwannoma in a Pediatric Patient: A Rare Case Report with Emphasis on Histopathology's Role in Differential Diagnosis.

BACKGROUND Schwannomas are rare and benign tumors of the nerve sheath, composed of Schwann cells, and they are extremely rare in the nasal area. Here, we report a case that presented to our clinic as a growing nasal mass and was found to be a unilateral subcutaneous schwannoma. There have been a few previous cases reported of such patients having nasal obstruction, epistaxis, or other symptoms, but our patient did not. We stress the importance of considering schwannoma in the differential diagnosis of nasal masses, even in pediatric patients, and the role of histopathology differentiating it from other diagnoses such as neurofibroma. CASE REPORT Our patient was a 9-year-old girl with a painless nasal swelling on the nasal bridge that she first noticed 2 years ago, which started growing gradually and began to become firm. She was otherwise asymptomatic and had no relevant family history. Histopathology revealed an encapsulated spindle cell tumor with both hypo- and hyper-cellular areas, and immunohistochemistry showed that the tumor was strongly positive for S-100 and negative for both desmin and CD34, with blood vessels marking. A final diagnosis of schwannoma was made. CONCLUSIONS We presented a case of nasal septal schwannoma, emphasizing the importance of considering schwannoma in the differential diagnosis of nasal masses, and the role of histopathology to rule out other possible diagnoses.

Congenital Diaphragmatic Hernia as a Presentation of Mucopolysaccharidosis in a 3-year-old child: A Case Report.

Background: Mucopolysaccharidoses (MPS) are rare, metabolic lysosomal storage disorders caused by the deficiency of enzymes required for the stepwise breakdown of glycosaminoglycans (GAGs). We report a case that was discovered to be Mucopolysaccharidosis Type II and was presented to the hospital with signs and symptoms of congenital diaphragmatic hernia. The hernia was repaired, and the patient was discharged on BiPAP and High-flow Oxygen. Case Presentation: A vaginally delivered male child was presented to the hospital with a fever, cough, and shortness of breath. He has a history of recurrent chest infections treated as pneumonia. The child was born to a mother with a pregnancy complicated with gestational diabetes and the presence of polyhydramnios. Screening tests during the pregnancy reported no congenital anomalies. The patient was admitted, and a chest X-ray was performed and revealed cardiomegaly, pulmonary infiltrates consistent with pneumonia and bowel herniation noted through the right hemidiaphragm. A Computed Tomography (CT) scan of the thorax and Barium swallow was done, and Pneumonia and Congenital diaphragmatic hernia was confirmed. Genetic testing was done because the patient has coarse facial features, developmental delay, hypotonia and skeletal abnormalities. Iduronate-2-sulfatase enzyme levels were significantly low, all the other enzymes were normal in range, and the diagnosis of Type II Mucopolysaccharidosis was established. The patient was stabilized and operated on for diaphragmatic hernia repair. No enzyme-replacement therapy (ERT) was given because it is not available in Jordan. He was discharged on high-flow Oxygen and bilevel positive airway pressure (BiPAP). Conclusion: Depending on the typical presentation to suspect Mucopolysaccharidosis is not always the key to diagnose it. MPS is a multi-organ disorder and rare presentations should not be disregarded.

Predictors of Dehydration Following Adenotonsillectomy in Jordanian Pediatric Cases.

Background: Dehydration is a well-established complication of adenotonsillectomy. This study aims to measure the prevalence of dehydration among pediatric adenotonsillectomy patients in a tertiary hospital in Amman and to identify the risk factors that could be associated with it. Methods: This is an observational single-center study. Data were collected by reviewing the health records of patients who underwent adenotonsillectomy between January 2015 and June 2020 at Ibn Al-Haytham Hospital. Inclusion criteria were any patient between 1 and 12 years old that has undergone routine adenotonsillectomy. Exclusion criteria were any adenotonsillectomy for neoplasm purposes, patients with reported developmental delay, and patients who underwent adenoidectomy or tonsillectomy alone. Collected data included patients' demographics, indication for adenotonsillectomy, type of surgical technique, and history of dehydration in the following two weeks post adenotonsillectomy. The data were then imported into an SPSS statistical spreadsheet and analyzed. Descriptive statistics analysis of the demographic characteristics of the cases was prepared. Numerical data were expressed as percentages or means ± standard deviation (SD). Results: Three hundred and eighty-four patients met the inclusion criteria of this study. 234 patients (62.2%) were male, and the majority of the cases (223 patients) were between 5 and 6 years old, accounting for 58.8% of the population. The prevalence of post-adenotonsillectomy dehydration was 5.7%. Point estimation with a 95% confidence interval falls between 5.17 and 5.63. Dehydration was more prevalent in children aged under three years old. Dependence-type Multivariate analysis revealed that age and gender remained significantly associated with dehydration with P values > 0.001 and 0.004, respectively, after adjusting for the other variables. Conclusion: Dehydration is a serious yet rare complication post adenotonsillectomy. Screening for dehydration pre- and post-discharge is highly recommended. There is a need for further multi-center and population-based studies to examine the full extent of dehydration complications. It is in the best interest of surgeons and all caregivers to provide the best quality of care for adenotonsillectomy cases. Avoiding dehydration and all other surgical complications would be part of the standards of high-quality health care.

Role of pre-incisional external bilateral ultrasound guide glossopharyngeal nerve block with diluted bupivacaine mixture in pain management in oropharyngeal surgery: A randomized control trial.

The glossopharyngeal nerve block (GNB) was evaluated for pain control together with the magnitude of obtunded gag reflex as a useful clinical sign of GNB. METHODS: 400 patients scheduled for oropharyngeal surgery were randomly allocated into 2 groups (200 patients in each group), Group1 patients received bilateral GNB with 0.125% bupivacaine, 0.5 xylocaine, and 4 mg dexamethasone, while Group 2 patients were enrolled as a control group. Throat pain was evaluated using the visual analog scale at 0.5, 8, and 24 h after surgery, and the degree of gag reflex response was evaluated at the same time points. RESULTS: Postoperative pain scores at rest and during swallowing were significantly lower in Group 1 versus Group 2. The analgesic efficacy of GNB was intensely interrelated with the magnitude of the obtunded gag reflex (P 0.01). CONCLUSIONS: GNB is beneficial for pain control in oropharyngeal surgery. An obtunded gag reflex could be a useful clinical sign for a successful GNB analgesic outcome.

Myxoma of urinary bladder (case report).

Bladder myxoma is a very rare tumor that happens in a benign manner. The mesenchymal origin is typically the supply of these tumors. This tumor is usually diagnosed by the excisional biopsy due to the difficulty of diagnosis preoperatively as different bladder tumors' types. During this paper, we tend to represent a case report of this terribly rare mesenchymal growth within the urinary bladder which is an unusual location for myxoma tumors to occur. A 48-year-old feminine was hospitalized because of obscure abdominal pain. The patient underwent partial cystectomy, and the histopathology reported the presence of myxoma of urinary bladder.

Efficacy of pillar implants to reduce snoring and daytime sleepiness.

OBJECTIVE: To measure the efficacy of pillar implants in reducing snoring. MATERIALS AND METHODS: A total of 30 adult patients who underwent pillar implants were assessed preoperatively and at 1, 3, 6 and 12 months after the implantation. Improvement was measured using snoring frequency, visual analog scale for snoring loudness, and Epworth sleepiness scale for daytime sleepiness. RESULTS: The mean snoring frequency, loudness and Epworth score were reduced from 6.9, 9.2 and 7.4 at the baseline to 5, 5.9 and 5.6, respectively, at 12 months postoperatively (all p < 0.03). The partial implant extrusion rate was 6.7%. CONCLUSION: We suggest that a pillar implant procedure should be considered before proceeding to more morbid surgeries in patients with snoring and daytime sleepiness.

Congenital Hairy Polyp Causing Severe Upper Airway Obstruction in a Newborn: A Case Report.

BACKGROUND Hairy polyps are rare tumors mainly comprising fatty tissues covered by skin and hair follicles, with varied localizations and sizes. Early excision of the polyps by surgery is an effective treatment resulting in a permanent cure. We present a case of successful management of severe obstruction of the oropharynx in a newborn who presented with a large mass of congenital hairy polyp. CASE REPORT A vaginally delivered infant, weighing 3 kg, presented immediately after birth with cyanosis symptoms, failure of the first cry, and respiratory distress signs. The newborn was born to a mother with an uneventful pregnancy. Screening tests during the pregnancy reported no congenital anomalies. The newborn's hematological and biochemical test results were normal. After presenting these symptoms, the newborn was immediately intubated and put on a nasogastric feeding tube, which revealed a small portion of a polyp-like mass. A computed tomography (CT) scan further confirmed a large pedunculated mass, measuring 3×2 cm, arising from the soft palate, and obstructing the oropharynx. Histopathological examination confirmed the presence of a hairy polyp. The polyp was wholly removed transorally using the Covidien LigaSure device without the need for endoscopy. This procedure allowed safe extubation, and the baby was discharged home without symptoms 4 days after birth. CONCLUSIONS This case sheds light on the importance of considering hairy polyp in the differential diagnosis of pharyngeal mass with respiratory distress in pediatric patients. This report also describes our experience using the LigaSure surgical device without needing endoscopic visualization to successfully resect the hairy polyp without complications.

Otitis media with effusion: The role of Helicobacter Pylori in its pathogenesis.

BACKGROUND: Otitis Media with Effusion (OME) is the most common disease of the middle ear. Different factors play a role in its pathogenesis, such as viral and bacterial infections, allergy, morphological and functional changes of nasal passage, Eustachian Tube (ET), and cleft palate. This study aims to investigate the Helicobacter Pylori presence in middle ear effusions from patients with OME through RT-PCR and compare our results with results from other published articles. METHODS: The study was carried out from October 2007 to February 2009, in the Department of Otorhinolaryngology of SS. Annunziata Hospital, Chieti, Italy. 132 consecutive patients with OME were included in the study. Fluid in the middle ear was assessed for the presence of Helicobacter Pylori through RT-PCR. RESULTS: 132 consecutive patients with OME were included in the study. The patients were between ages 8 and 78 (median 50); 62 were males (47%), 70 were females (53%), and 53 patients had bilateral OME (40%). 185 samples were collected from 132 patients. Of the 185 samples taken from the ear, 21 (11.35%) were not adequate for the correct execution of the DNA extraction procedure. The remaining 167 samples, subjected to RT-PCR, did not show in any case an increase in fluorescence linked to the FAM fluorophore, thus demonstrating the complete absence of Helicobacter Pylori. CONCLUSION: Based on the results obtained, we can affirm that although a third of the cases of OME is correlated to the presence of reflux, Helicobacter Pylori does not seem to play any role in the pathophysiology of OME as it cannot be found in endo-tympanic exudate.

Prevalence and Predictors of Thyroid Dysfunction Among Type 2 Diabetic Patients: A Case-Control Study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) and thyroid disorders are common endocrine disorders. This case-control study aims to determine the prevalence and predictors of thyroid disorders in T2DM patients. METHODS: A total of 998 T2DM patients attending a tertiary hospital were included and underwent investigations for thyroid function: thyroid-stimulating hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3); and glycated hemoglobin (HbA1c). They were compared with 343 non-diabetic subjects as controls. RESULTS: A total of 1341 participants were included in the study. The mean age ± SD was 60.14 ± 12.21, and 47.9% were females. Among T2DM patients, 140 (14%) were known to have thyroid disorders; and as a direct result of screening, 126 (12.6%) new cases of thyroid disorder were diagnosed. Thus, the overall prevalence of thyroid disorders was found to be 26.7% in T2DM patients which significantly higher than the controls (13.7%), (p˂0.001). Subclinical hypothyroidism was the most common one. Using logistic regression, after adjusting for age, gender, obesity, smoking, anemia, presence of goiter, disease duration, and poorly controlled, the risk factors for thyroid dysfunction among T2DM patients were an age of ≥50 years with an adjusted OR of 3.895 (95% CI 2.151-7.052, p<0.001); female gender (OR 1.757, 95% CI 1.123-2.747, p=0.013); goiter (OR 2.904, 95% CI 1.118-7.547, p=0.029), and HbA1c>7% (OR 2.553, 95% CI 1.472-4.429, p=0.001). However, there were no significant associations between thyroid disorders and complications or duration of diabetes (p>0.050). CONCLUSION: A high prevalence of thyroid disorders was reported in T2DM patients. Therefore, we suggest that diabetic patients should be routinely screened for thyroid dysfunction. Old age, female gender, goiter, and poorly controlled diabetes found to be risk factors for thyroid dysfunction among T2DM patients. Consequently, appropriate management and control of diabetes may lower the risk of thyroid dysfunction and vice versa.

Resuming elective surgery in the time of COVID-19: a safe and comprehensive strategy.

The 2019 novel corona virus and the disease it causes (COVID-19) is a public health crisis that has profoundly modified the way medical and surgical care is delivered. Countries around the globe had a variable initial response to the COVID-19 pandemic from imposing massive lock downs and quarantine to surrendering to herd immunity. However, healthcare bodies worldwide recognized early on that a triumph against COVID-19 could only be achieved by maintaining the infrastructure of healthcare systems and their capacity to accommodate a potentially overwhelming increase in critical patient care needs. Therefore, they reacted by restricting medical care to emergency cases and postponing elective surgical procedures in all disciplines. The priority was made for treatment of COVID-19 patients and emergency cases. Nevertheless, the battle against the COVID-19 pandemic is still ongoing. In the absence of vaccines or effective drug treatments, its timeline remains uncertain and it cannot be forecast how long healthcare systems will need to cope with it in managing inpatient and outpatient services. Accordingly, extreme measures and restriction may become a recipe for a disaster in the context of the potential adverse health implications imposed by delaying timely medical and surgical care. Therefore, restrictive measures should be substituted with a comprehensive surgical and medical care strategy. One that provides a safe balance between the prevention of COVID-19 and the delivery of essential surgical care. This article provides an overview on how to safely deliver essential surgical care in the time of COIVD-19.

Guidelines for the orthopedic surgeon in the era of COVID-19.

Amid the current pandemic of coronavirus disease 2019 (COVID-19), orthopaedic surgery was one of the fewer specialties that remained active managing emergent and urgent orthopaedic and trauma cases. On the other hand, with the continued spread of this pandemic and its associated socioeconomic confinement and unpredictability of the pandemic curve; many health care facilities were forced into halting all elective and non-urgent activities including orthopaedic specialties. This in part was to help in reallocation of required resources and focusing on the proper management of COVID-19 patients, and to prevent the transmission of infection among health care workers and patients. In this article we analyzed developments and recommendations of international reports about the current outbreak and its impact on the practice of orthopaedic surgery. Our aim was to provide comprehensive and easy guidelines for the management of urgent and emergent cases in hot zones and for the process of returning to usual orthopaedic work flow in a balanced strategy to assure safe practice and providing quality care without the risk of exhausting institutional resources or the risk of COVID- 19 transmission among health care workers or patients.

Accuracy of intraoperative electrophysiological testing in confirming correct cochlear implant electrode positions.

Objective: To investigate the accuracy of intraoperative electrophysiological studies in detecting incorrectly positioned electrodes in cochlear implant surgery. Study design: A retrospective chart review. Setting: Tertiary referral centre. Patients: In total, 104 consecutive patients with a mean age of 5 years underwent cochlear implant surgery at our centre between January 2012 and December 2013. All patients were implanted with Cochlear Nucleus Freedom implants. Method: A retrospective study to compare intraoperative neural response telemetry (NRT), impedance and electrode position using Stenver's transorbital plain X-ray view. Results: Intraoperative electrophysiological tests for patients with Cochlear Nucleus Freedom implants showed 97% sensitivity and 100% specificity compared with postoperative X-ray imaging. Conclusion: NRT results for the position of cochlear implants were very accurate when checked by X-ray imaging showing that this technique is sufficient in most cases. Stenver's plain X-ray view is needed in complicated cases with abnormal NRT testing or difficult electrode insertion.