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.

Indications and outcome of tracheostomy in Ilorin, North Central Nigeria: 10 years review.

BACKGROUND: The study aims to highlight common indications as well as outcome of treatment among patients with tracheostomy in Ilorin, North-Central Nigeria. METHODS: A review of clinical records of all patients with tracheostomy over a period of ten years (2002-2011), using the Theatre, Ward, ICU and the emergency register after approval from the ethical review committee. Data retrieved included; demographic profile, primary diagnosis, indication for tracheostomy, surgical technique, hospital admission and care outcome of management. All information retrieved input and analysed using an SPSS version 17.0 and data analyzed descriptively. RESULTS: Seventy-six patients had complete data for analysis, age range from 1-89yrs, and mean age of 41.9yrs. There are 48males and 28 females with M:F ratio of 1.6:1. Majority of the patients were in the 3rd-5th decade. About 47.4% had temporary tracheostomy. The commonest indication for tracheostomy is upper airway obstruction secondary to aerodigestive tract tumors in 60.5%, then trauma in 26.3%. The complications are higher among the under tens'. Out of the 36 temporary tracheostomy only 18 were successfully decannulated. The mean hospital stay was 22±2days. Overall 15% mortality was recorded. CONCLUSION: Common reason for tracheostomy is essentially same earlier documentation in developing countries, common among males, emergency type still most common, neoplasm, prolonged intubation and trauma are the commonest indications, its complication is still high among the under tens'. The outcome is good with 15% mortality due to the primary disease and not from tracheostomy.

Clinical Presentation and Outcome of Sinonasal Tumors in a Nigerian Tertiary Hospital - 6-year Review.

BACKGROUND: Sinonasal tumor is an uncommon tumor in Nigeria, but the burden of the disease in terms of morbidity and mortality is on the increase. The aim of this study is to evaluate the pattern of presentation and outcome of sinonasal tumor in our center. METHODOLOGY: This was a retrospective review of all the patients with sinonasal cancer seen in Ear, Nose, and Throat Department of the hospital between January 2008 and December 2013. The patients' biodata, clinical presentation, stage of the disease at presentation, identifiable risk factors, histopathological findings, and outcome were presented. RESULTS: A total of 22 patients were diagnosed with sinonasal cancer out of 71 patients (31%) with head/neck cancers during the period of study. There were 12 males (54.5%) and 10 females (45.5%) with a mean age of 51 ± 2.1 years. Epistaxis, nasal blockage, and discharge were seen in all patients though 41% of patients presented first to the ophthalmologist due to proptosis. Identifiable risk factors were exposure to wood dust (29%) and petrochemical products in (11%). Most patients presented first at advanced stages of the disease (82%). Histologically, well-differentiated squamous cell carcinoma was the most common (54.6%) followed by nonintestinal well-differentiated adenocarcinoma in 18.2% and plasmacytoma (9.1%). Chemoradiation was the mainstay of management in (38%) though 13.6% had total maxillectomy with postsurgical chemoradiation and 50.4% defaulted due to cost of management. CONCLUSION: Health education on early presentation and efforts at early detection of the disease are needed to achieve cure. Exposure to the identifiable risk factors should be reduced by protective measures. Easy access to radiotherapy at affordable price will surely improve the outcome of this disease.

Accidental Decannulation OF TRACHEOSTOMY TUBES - Case Series.

Tracheostomy tube (TT) is usually removed in a planned manner once the patient ceases to have the condition that necessitated the procedure. Accidental decannulation or extubation refers to inadvertent removal of tracheostomy tube out of the stoma. It could prove fatal in an otherwise stable patient. We review a variety of unexpected and often-overlooked causes of accidental decannulation with suggestions on preventive measures. We therefore present three cases of accidental decannulation of tracheostomy tubes in order to report our experiences in the management of the condition. CONCLUSION: Accidental decannulation occurs both in hospitalized and patient on home care of their tracheostomy tubes. Reduction in neck circumference due to weight loss predisposes to accidental decannulation, which could be prevented by suturing the flange to the skin.

INTRAMEDULLARY TUBERCULOMA OF THORACIC SPINAL CORD IN AN APPARENTLY HEALTHY NIGERIAN: CASE REPORT.

Spinal intramedullary is an uncommon form of tuberculosis causing spinal cord injury in this environment. We report a case of thoracic intramedullary tuberculoma in an immunocompetent male Nigerian with negative screening for tuberculosis. He presented with 8 months history of back pain and 2 months history of progressive weakness in both lower limbs. Physical examination revealed a well-nourished man with spastic paraplegia. Chest radiograph and CT scan were normal but Magnetic resonance imaging (MRI) of the thoracolumbar region showed cord oedema and circumscribed intramedullary lesions at D12 and L1 levels with target sign. The patient was promptly prepared and had D12 and L1 laminectomy and posterior myelotomy with excision of the intramedullary lesion. Histology showed granulomatous lesion with central caseation in keeping with a tuberculoma. He was treated with a 4-drug antituberculous regimen with physiotherapy and he made complete neurological recovery 8 months post-operatively. Intramedullary tuberculoma should be considered in differential diagnosis of intramedullary tumors in this environment. Treatment with antituberculous drugs results in good outcome.

Prevalence of snoring and symptoms of sleep disordered breathing among primary school pupils in Ilorin, Nigeria.

BACKGROUND/AIM: Snoring is the production of sound from the upper aero-digestive tract during sleep due to turbulent airflow This study is to determine the prevalence, pattern, night and daytime symptoms of snoring among nursery and primary school pupils in Ilorin, Nigeria due to its public health importance. MATERIALS AND METHODS: This cross sectional survey was carried out among nursery /primary school pupils in Ilorin, Kwara state between April and September, 2010. Ten schools were selected randomly from 100 schools sited within the 3LGAs of Ilorin municipality. Also private and public schools with different parental social economic status were selected. The pupils were selected from nursery 2 to primary 6 in each school using the class registers with the aid of a table of random numbers with 1500 children assessed. The parents/guardians were made to fill the questionnaires and same returned with visitations to the schools twice weekly and reminders sent via phone calls. Data were analyzed using EPIINFO 2002 version 2 software. RESULTS: 1500 questionnaires were given out but 909 were completely filled and returned (response rate of 61%.). There were 598(65.8%) non snorers (NSn) and 311(34.2%) snorers (Sn) at different scales with 153 male snorers to 158 female snorers. The ages of the children ranges from 3 to 16 years (mean ± SD, 8.3 ± 4.8 years. The mean age for the Sn was 8.2 and 8.3 for NSn (range 3-6 years). No statistical difference in age, gender or socio-economic status between Sn and NSn. 598(65.8%) were non snorers (NSn) and 311(34.2%) were snorers (Sn) especially in the age groups 3-6 years, 121(38.9%) and above 6 years of age 101(32.7%) and below 3 years were 89(28%). CONCLUSION: Snoring is an important health problem among the pupils as a significant percentage snores and most of them are between third and sixth year of life.