Prognosticators of Excision of Giant Intra-Oral Tumors in a Resource-Challenged Setting: A Case Report.

Minor salivary glands are widely distributed in the mucosal surface of the lips, palate, nasal cavity, pharynx, and larynx, thus can arise from any of these primary sites. Intra-oral minor salivary gland tumors (IMSGTs), while considered rare in the general population are relatively more common when compared to all the other extra-oral sites. Pleomorphic adenoma, as seen in the index patient, is the most commonly diagnosed benign IMSGT. Intra-oral minor salivary gland tumors are not uncommon and depending on their size, nature, and location can be associated with severe limitation of the Patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality. In addition to these deleterious effects, they present a major surgical challenge to the surgeon, who has to determine the safest, most feasible access to ensure complete, or near-complete excision, as well as to the anesthetist, who needs to secure a definitive airway through the nose or mouth, both of which could be significantly restricted by the presence of the tumor. The aim is to present our successful management of one of the largest intra-oral minor salivary gland tumors documented in the literature, highlighting the specific measures we undertook to tackle the peculiar surgical and anesthetic challenges we faced. It had been two years since surgery and the patient is thriving with a markedly improved quality of life and no features of recurrence. The patient is a 50-year-old male with a slowly growing painless, left palatal mass in the roof of the mouth of 10 years duration with recurrent spontaneous bloody discharge effluent and snoring. There was an associated history of dysphagia to solid with associated choking spells, a left-sided facial asymmetry with no cheek swelling, odynophagia, sore throat, or difficulty with breathing. There was ipsilateral loss of upper incisors and dental anarchy about two years before presentation. No other nasal, otologic, or ophthalmic symptoms were present. No neck swelling, stiffness, cough, or chest symptoms. The oropharyngeal physical examination was highly restricted due to the intra-oral size of the mass. Figure 1. There was facial asymmetry with a bulge of the left maxilla, left-sided levels 1b and 2 non-tender lymph node enlargements, freely mobile, not adhered to the skin. A craniofacial CT scan revealed extensive isodense heterogeneously enhancing intra-oral soft tissue mass occupying the entire palate/oral cavity and encroaching laterally on the masticator and the parapharyngeal space with erosion of the left maxillary floor and hyoid bone Figure 2. The patient had an excision biopsy of the palatal mass with a free margin. No frozen section at the time of surgery. Histology revealed Pleomorphic adenoma and was followed up for 2 years with no evidence of recurrence. Prognosticators are delay in presentation leading to an increase in size of the mass and severe limitation of the patient's ability to breathe, speak clearly, and/or swallow and consequent severe morbidity and even mortality, the surgeon not being overwhelmed, the skillful Anaesthesist that could maneuver the nasal cavity without us doing tracheostomy and the successful outcome of the surgery.

Les glandes salivaires mineures sont largement réparties à la surface muqueuse des lèvres, du palais, de la cavité nasale, du pharynx et du larynx, et peuvent donc survenir à partir de l'un de ces sites primaires. Les tumeurs des glandes salivaires mineures intra-orales (TGSMIO), bien que considérées comme rares dans la population générale, sont relativement plus courantes par rapport à tous les autres sites extra-oraux. L'adénome pléomorphe, tel que celui observé chez le patient index, est la TGSMIO bénigne la plus fréquemment diagnostiquée. Les tumeurs des glandes salivaires mineures intra-orales ne sont pas rares et, en fonction de leur taille, de leur nature et de leur emplacement, peuvent être associées à une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère et même une mortalité. Outre ces effets délétères, elles présentent un défi chirurgical majeur pour le chirurgien, qui doit déterminer l'accès le plus sûr et le plus faisable pour assurer une excision complète ou presque complète, ainsi que pour l'anesthésiste, qui doit assurer une voie aérienne définitive par le nez ou la bouche, tous deux pouvant être significativement restreints par la présence de la tumeur. L'objectif est de présenter notre prise en charge réussie de l'une des plus grandes TGSMIO documentées dans la littérature, mettant en évidence les mesures spécifiques que nous avons prises pour relever les défis chirurgicaux et anesthésiques particuliers auxquels nous avons été confrontés. Deux ans après l'intervention, le patient se porte bien avec une nette amélioration de sa qualité de vie et aucune manifestation de récurrence. Le patient est un homme de 50 ans présentant une masse palatine gauche en croissance lente et indolore dans le palais depuis 10 ans, avec des écoulements sanguins spontanés récurrents et des ronflements. Il y avait une histoire associée de dysphagie aux solides avec des épisodes d'étouffement, une asymétrie faciale du côté gauche sans tuméfaction de la joue, une odynophagie, un mal de gorge ou des difficultés respiratoires. Il y avait une perte ipsilatérale des incisives supérieures et une anarchie entaire environ deux ans avant la présentation. Aucun autre symptôme nasal, otologique, ophtalmique n'était présent. Aucun gonflement du cou, raideur, toux ou symptômes thoraciques. L'examen physique de l'oropharynx était fortement limité en raison de la taille intra-orale de la masse. Figure 1. Il y avait une asymétrie faciale avec une bosse du maxillaire gauche, des ganglions lymphatiques non douloureux des niveaux 1b et 2 du côté gauche, mobiles librement, non adhérents à la peau. La tomodensitométrie craniofaciale a révélé une masse tissulaire molle intraorale extensive, hétérogène, rehaussée de manière isodense occupant l'ensemble du palais/cavité buccale et empiétant latéralement sur les muscles masticateurs et l'espace parapharyngé, avec érosion du plancher du maxillaire gauche et de l'os hyoïde. Figure 2. Le patient a subi une biopsie d'excision de la masse palatine avec une marge libre. Aucune section congelée n'a été réalisée lors de la chirurgie. L'histologie a révélé un adénome pléomorphe et un suivi de 2 ans n'a montré aucun signe de récurrence. Les facteurs pronostiques comprennent le retard de la présentation entraînant une augmentation de la taille de la masse et une limitation sévère de la capacité du patient à respirer, à parler clairement et/ou à avaler, avec une morbidité sévère voire une mortalité, le chirurgien ne se laissant pas dépasser, l'anesthésiste compétent pouvant manœuvrer dans la cavité nasale sans avoir recours à une trachéotomie, et le succès de l'intervention chirurgicale. MOTS-CLÉS: Intraoral; Glande salivaire mineure; Excision; Tumeur; Pronostiqueurs.

Correlation of sonographic inferior vena cava and aorta diameter ratio with dehydration in Nigerian children.

BACKGROUND: Accurate assessment of the degree of dehydration is essential in the management and fluid therapy of dehydrated children. The invasiveness of central venous pressure limits its routine clinical use. Fortunately, some studies have suggested that ultrasonographic measurement of inferior vena cava (IVC) diameter: aorta diameter ratio (IADR) is an objective method of assessing intravascular volume. OBJECTIVES: To determine the clinical usefulness of ultrasound measurement of IADR in assessment of children with dehydration. METHODOLOGY: This was a cross-sectional study which compared dehydrated children to age- and sex-matched euvolemic healthy children as controls. The maximum anteroposterior diameter of the abdominal aorta (at peak systole) and maximum IVC diameter (in expiration) were measured. RESULTS: A total of 120 subjects and 120 controls were evaluated. The mean age was 21.73 ± 20.89 months for subjects and 21.19 ± 22.13 months for control. The mean IADR for children with mild, moderate, and severe dehydration was 0.75 ± 0.07, 0.55 ± 0.07, and 0.33 ± 0.05, respectively. The mean IADR for controls was 0.99 ± 0.06. IADR had an inverse relationship with the degree of dehydration in the subjects. A cut-off point of 0.86, with a sensitivity and specificity of 96.7% in predicting dehydration, was derived, with the sensitivity and specificity increasing with increasing level of dehydration. CONCLUSION: IADR is sensitive and specific for assessing moderate and severe dehydration in Nigerian children.

Peripheral vascular surgical procedures in Ilorin, Nigeria: indications and outcome.

BACKGROUND: Data on peripheral vascular surgical interventions from Nigeria is scanty. Reports form Western and Eastern Nigeria dates back about two decades. This study therefore analyses the various etiological conditions necessitating intervention, and their outcome. METHODS: A retrospective analysis of patients requiring surgical intervention on peripheral vessels from a prospectively collected single surgeon database over a two-year period was conducted. Data were analysed using SPSS version 15.0 windows statistical package. RESULTS: Fourteen peripheral vascular surgical procedures were performed. The age range was 2-70 years (24.4 ± 16.3) with five cases (35.7%) in 20-29 year group. Trauma accounted for 11 (73.3%) cases. Upper limb involvement occurred in 7 (63.6%) of the traumatic cases whereas all 2 true aneurysm occurred in the lower limb. Direct repair was possible in re-establishing anatomic continuity in about 64% of cases. Of the six morbidities, wound infection accounted for 50% followed by failure of re-vascularizaton (33.3%) and there was one mortality. CONCLUSION: Trauma is the leading cause of peripheral vascular condition necessitating surgery from our study. Young adults predominate. Though direct repair are often feasible, there is a need for the availability of graft options. Wound infection constitutes the highest post-operative morbidity.

Unusual cutaneous metastatic follicular thyroid carcinoma.

Follicular thyroid carcinoma (FTC) is the second most common thyroid cancer (TCs) after papillary carcinoma, but it is ranked first in producing distant metastases among TCs. It accounts for 10 - 20% of all thyroid malignancies and is most often seen in patients over 40 years of age. Distant metastases at the time of diagnosis are reported in 11 - 20% of the patients and may be the reason for presentation. There have been less than 30 reported cases of cutaneous metastases from FTC in the English Literature, a majority affecting the scalp. We present an unusual aggressive, hypervascular FTC in a 58-year-old man with a previous diagnosis of multinodular goiter. The difficulty in gaining his acceptability of orthodox management resulted in the development of multiple giant scalp and right facial metastatic masses associated with lytic calvarial destruction and the involvement of frontal and right maxillary sinuses. These imposed serious challenges in managing him in a resource-poor community.

Thyroid cancers amongst goiter population in a Nigerian tertiary hospital: surgical and radiographic perspective.

BACKGROUND: Goiters are commonly benign, but cases of malignancy can develop. Thyroid cancer is known to be commoner in whites than in blacks and in females than in males. Bone metastasis is a common occurrence and may be the initial manifestation in a small subset. We hope to determine the incidence and the cervical radiographic patterns of thyroid cancer amongst goiter population in Nigeria. METHOD: Surgical, histological and radiographic findings in patients with goiter who had thyroidectomy in our hospital from 1999 to 2006 were reviewed. Those with proven cancer were analyzed for sex, age and radiographic changes using SPSS 11.0 for windows. RESULTS: Thirteen (8.2%) cases out of the 160 goiters were malignant and distant metastases were present in 1.3% at presentation. The histological sub-types of malignant goiters were follicular (5.0%), papillary (1.9%) and poorly differentiated or anaplastic thyroid carcinoma (1.3%). As much as 30% of thyroid cancers demonstrated calcification on plain neck radiograph, which were commonly scattered or diffused. CONCLUSIONS: Carcinomatous goiters occurred in 9.3% of the goiter population studied with predominance of follicular variant. Surgery remains the main stay but was inappropriate in about 1.2% of population with goitre. Aside evidence of bony destruction, TC should be suspected in goiters with mixed (diffused or scattered) calcifications.

The relationship between gallstone disease and gall bladder volume.

BACKGROUND: The role of a large gallbladder volume with regards to a predisposition to gallstones is unknown. It is likely that an increase in gallbladder volume could result in impaired gallbladder motility and bile stasis which may encourage gallstone formation. This study is therefore to determine the relationship between the presence of gallstone disease and gall bladder volume. METHODOLOGY: One hundred type 2 diabetic patients and 100 age and sex-matched controls underwent real time ultrasonography to determine the relationship between the presence of gallstone disease and gallbladder volume. Their demographic characteristics were recorded and compared. The ultrasound examinations was done in the morning following an overnight fast (to prevent gall bladder contraction) without sedation. Longitudinal and transverse scans of the right upper quadrant was done in both the supine and left lateral positions The gallbladder volume was measured. RESULT: The mean gallbladder volume in diabetic patients with gallstone disease 28.4 +/- 18.6 ml was higher than in those without gallstone disease 27.4 +/- 14.8 ml p = 0.844. The mean gallbladder volume in the controls with gallstone disease 26.5 +/- 14.7 ml was also higher than in those without gallstone disease 24.1 +/- 12.7 ml p = 0.189. CONCLUSION: The fasting gallbladder volume tended to be larger in patients with gallstones (i.e. both diabetic patients and controls).

Preoperative staging of rectal carcinoma using transrectal ultrasonography (Trus): experience with 30 Nigerians.

BACKGROUND AND OBJECTIVE: Colorectal cancer is the second most common malignancy; accounting for approximately 155,000 new diagnosed cases each year in the United States. It is about the commonest Gastrointestinal Malignancy in Nigeria. For cancers specifically located in the rectum, various therapeutic options are available including local excision, total mesorectal excision, preoperative radiotherapy etc. These treatment modalities vary in morbidity and chance for cure. The choice of surgery as well as possible outcome largely depends on the depth of tumour infiltration of the rectal wall as well as extent of perirectal tissue involvement. The aim of this study was to assess local fixity clinically and also to assess the ability of transrectal ultrasound (TRUS) to fulfil staging requirements in patients with rectal cancer. The results of these findings were compared with findings at operation and subsequent findings at pathological examination. This is with the aim of evaluating the usefulness of transrectal ultrasound in selecting patients for surgical intervention especially with respect to resectability. MATERIALS AND METHODS: Thirty consecutive patients with histologically confirmed rectal carcinoma at UITH, Ilorin from January 1998 to December 2002 who underwent preoperative TRUS were prospectively studied. After clinical examination including digital rectal examination they all had TRUS, proctoscopy and sigmoidoscopy. Result of findings on clinical examination, TRUS, findings at surgery and histological findings were compared and analysed using SPSS 10.0. RESULTS: There were 30 patients reviewed. Twenty per cent of patients who were thought to have fixation of the tumour on clinical examination were not confirmed on TRUS and at surgery. All the patients that TRUS diagnosed as fixed and therefore not resectable were confirmed at surgery and histopathology. Digital Rectal Examination (DRE) identified four patients with peri-rectal lymph nodes but TRUS picked six; though only five were histologically positive. CONCLUSION: TRUS is a useful preoperative imaging technique especially where CT and MRI are not readily available. This can assist the surgeon in preoperative decision taking as to the resectability of the tumour and possible prognosis.

The role of ultrasound in obstetrics.

Ultrasound contributes immensely to obstetrics and its application and use is now widespread. The clinical applications and uses of ultrasound include confirmation of pregnancy and multiple gestation, estimation of gestational age, localisation of placenta and monitoring of foetal wellbeing. The others are evaluation of caesarean section scar integrity and post partum haemorrhage. Ultrasound is also useful in prenatal diagnosis and foetal therapy. The major limitation of ultrasound is the fact that it is not useful in air/gaseous containing media. Ultrasound is safe and there is no known adverse effect for now on mother, foetus or operator at the intensity used for present obstetric examination. Overdependence and abuse of ultrasound remains a problem and it should be emphasised that ultrasound is to complement and not a substitute to clinical judgement.