SURGICAL MANAGEMENT OF VOCAL CORD PARALYSIS: THE NEED FOR CAREFUL PATIENT SELECTION.

BACKGROUND: Vocal cord paralysis is one of the challenging laryngeal clinical entities confronting the Laryngologist and indeed, the Phono-surgeon. The ability to maintain an effective balance between voice and airway function to ensure good quality of life requires expertise. This study is therefore designed to highlight our experience on surgical management of vocal cord paralysis. METHOD: Clinical notes of all patients that met the inclusion criteria for this study on vocal cord paralysis over a ten-year period were analysed. Data was generated from patients' case files retrieved using standard codes according to the International Classification of Diseases (ICD-10). RESULTS: From the 7,941 new ENT cases seen, 26 patients had vocal cord paralysis (VCP) giving a prevalence of 0.3%. The male to female ratio was 1: 4.2 with a mean age of 45.7years ± 6.3. Their ages ranged from 21-80 years. Thyroidectomy was the main causal factor in 46.2% while idiopathic causes was documented in 23.1%. Twenty-three patients (88.5%) had unilateral VCP from which 21(91.3%) were abductor paralysis. The ratio of Left: Right VCP was 3:1. All the 3 bilateral cases were abductor paralysis. Neurotropic agents only, were effective in cases of unilateral VCP. However, in those with bilateral paralysis, two had tracheostomy only, while the third had a laryngo-fissure, arytenoidoplasty and endo-laryngeal stenting in addition. All were successfully decannulated with good voice quality. CONCLUSION: With these observations, we suggest the choice of appropriate surgical technique, timing and careful patient selection in order to preserve voice, curtail operative sequelae and achieve good quality of life (QoL) which is the overall management strategy, be borne in mind.

Routine Electrocardiography Request in Adenoidectomy: Is it necessary?

To evaluate the relevance of routine electrocardiographic request in pre-operative work-up of children undergoing adenoidectomy. This is a two year prospective study of children with obstructive adenoid that had adenoidectomy. This is a tertiary hospital based study at the Otorhinolaryngology Department of University College Hospital, Ibadan. Children (≤12 years) with clinical and radiological evidence of an obstructive adenoid were investigated. Information obtained with an interviewer assisted questionnaire included the biodata, clinical presentation of the patients, ECG findings, echocardiographic findings, cardiothoracic ratio, palatal airway and ratio of adenoid diameter to the nasopharyngeal diameter. The adenoid volume was measured after adenoidectomy. The results were analyzed using SPSS version 14 and level of statistical significance was P < 0.05. There were seventy four patients; 45 (60.8%) males and 29 (39.2%) females with a mean age of 38.35 months, S.D ± 30.32 (range 5-144 months). All the patients presented with mouth breathing and recurrent mucopurulent rhinorrhea. Mild snoring was detected in 18 (25%) patients, moderate snoring in 39 (54.17%) patients and severe snoring in 15 (20.83%) patients. Mild apnea was observed in 55 (74.32%) patients and moderate in 19 (25.68%) patients. Only seven (9.46%) patients had abnormal electrocardiographic findings but their ejection fraction on echocardiography ranged from 63 to 72% with a mean value of 68.17%, S.D ± 3.22. Cardiac complications of enlarged obstructive adenoid appear not to be common. Routine preoperative electrocardiography should therefore be restricted to only the high risk patients.

Recurrent nasal polyp and pansinus mucopyocele associated with bilateral blindness: a case report.

A 39 year old female with 24-month history of recurrent mucoid rhinorhea associated with progressive bilateral nasal blockage, headache, anosmia and bilateral impaired vision is reported. There was a past history of sinus surgery. The neuro-ophthalmic examination revealed left non-axial proptosis and visual acuity of nil light perception in both eyes at 3 meters. CT scan of the paranasal sinuses and brain showed markedly expanded left frontal sinus with sclerotic walls and expanded mixed density lesion in all the sinuses. She had surgery via trans-nasal, external and skull base approaches for effective clearance of the polypoidal masses and drainage of the sinus mucopyocele. Histological examination confirmed chronic inflammatory polyp. She remains stable to date although visual impairment and anosmia remained persistent. Patients with nasal polyposis require frequent follow-up even after surgical treatment for the early detection and management of complications to avoid consequences such as visual loss.

Day case adenotonsiletomy: experience of two private clinics in Nigeria.

BACKGROUND: adenoidectomy and tonsillectomy are among the common surgeries perform in children in otorhinoryngological practice. It was the aim of this study to evaluate the post operative mobility in patients undergoing day-case adenoidedtomy/tonsillectomy or adenotonsillectomy. METHODOLOGY: All pediatrics cases requiring adenoidectomy, tonsillectomy or both who presented at HANSA clinics Enugu (January 1990 to June 2004) and GENIKS specialist clinics Ibadan (January 2000 to June 2004) were counseled for day case surgery. The inclusion criteria were: Patients certified fit for surgery-ASA grade I or II for general anaesthesia and had no intercurrent CVS disease or bleeding diathesis among others. RESULTS: A total number of 144 patients requiring adenoidectomy Tonsillectomy or both were seen at the study centers with only sixty six (45.8%) meeting the inclusion criteria. Adenoidectomy constituted 47% of the surgeries with over 80 of the patient age less than 7 years reactionary haemorrhage was noted in 3 (4.5%) of the patient, the other complications were non-persistent vomiting 13 (19.7%), low grade fever 5 (7.6%) and pain at time of discharge 23 (34.8%). There were no fatalities. CONCLUSION: The complication rates were low. Day-case Adenoidectomy/tonsillectomy or adenotonsillectomy is safe and the presence or closeness of the family members contributed greatly to patients/post recovery as this as this had a soothing/calming effect on the patient/s.

Day case adenotonsiletomy: experience of two private clinics in Nigeria

Background: adenoidectomy and tonsillectomy are among the common surgeries perform in children in otorhinoryngological practice. It was the aim of this study to evaluate the post operative mobility in patients undergoing day-case adenoidedtomy/tonsillectomy or adenotonsillectomy. Methodology: All pediatrics cases requiring adenoidectomy; tonsillectomy or both who presented at HANSA clinics Enugu (January 1990 to June 2004) and GENIKS specialist clinics Ibadan (January 2000 to June 2004) were counseled for day case surgery. The inclusion criteria were: Patients certified fit for surgery- ASA grade I or II for general Anaesthesia and had no intercurrent CVS disease or bleeding diathesis among others. Results: A total number of 144 patients requiring adenoidectomy; Tonsillectomy or both were seen at the study centers with only sixty six (45.8) meeting the inclusion criteria. Adenoidectomy constituted 47of the surgeries with over 80 of the patient age less than 7 years reactionary haemorrhage was noted in 3 (4.5) of the patient. the other complications Were non-persistent vomiting 13 (19.7); low grade fever 5 (7.6) and pain at time of discharge 23 (34.8). There were no fatalities. Conclusion: The complication rates were low. Day-case Adenoidectomy/tonsillectomy or denotonsillectomy is safe and the presence or closeness of the family members contributed greatly to patients/ post recovery as this as this had a soothing/calming effect on the patient/s

Surgical management of advanced hypopharyngeal carcinoma: a case report and literature review.

BACKGROUND: Surgical resection of advanced primary head and neck cancers especially of the upper aerodigestive tract like hypopharyngeal cancer, usually leave a very big defect, which has to be reconstructed in order to maintain the gastropharyngeal continuity. This oncological surgery is best performed at the same sitting as a one staged procedure. STUDY DESIGN: A clinical case of a 56-year-old female with advanced hypopharyngeal cancer who had a single stage total pharyngolaryngectomy and partial oesophagectomy with reconstruction of the upper aerodigestive tract using pectoralis major pedicled flap and post operative adjunct chemo-radiation therapy. RESULT: Functionally, our patient had good swallowing reflex, fed on normal diet free of feeding tube and no gastric reflux. There was clinical evidence of weight gain. No evidence of flap complications post surgery. CONCLUSION: The rarity of this procedure and its advantages in the management of an advanced hypopharyngeal cancer in this environment are discussed.

Spectrum of otorhinolaryngology emergencies in the elderly in Ibadan, Nigeria.

BACKGROUND: The elderly (65 years and above) are a special group of patients whose illnesses and management are modified by the process of aging. It is thus the aim of this study to evaluate the spectrum of ear, nose, throat, head and neck emergencies among the elderly in Ibadan, Nigeria. METHOD: This is an eight-year (April 1996-March 2004) retrospective study of 87 geriatric patients who presented with otorhinolaryngological emergencies at our centre. RESULTS: Eighty-seven emergency cases studied constituted about 20% of the total geriatric cases seen within this period. There were 55 (63.2 per cent) males and 32 (36.8 per cent) females. The pharyngolaryngeal emergencies with upper airway obstruction constituted 55 per cent of the cases, a majority being a result of malignant lesions of the larynx and pharynx. Others were nasal 20.7 per cent, otological 11.5 per cent, oesophageal 9.7 per cent and head and neck 3.1 per cent. Most of the patients had emergency tracheostomy (54 per cent), as a prelude to their definitive management while 24 per cent were managed medically. CONCLUSION: Prevalence of emergency otorhinolaryngology cases among the elderly appears high. Most of the throat diseases with upper airway obstruction were due to malignancy. There is thus the need for increased awareness of the people through social campaigns and health education on the merits of early detection and seeking appropriate treatment for these tumours.

Retropharyngeal abscess: a clinical experience at the University College Hospital Ibadan.

BACKGROUND: Infection within the retropharyngeal space could progress on to an abscess formation resulting into retropharyngeal abscess (RPA), which can either be acute or chronic. RPA can be a life-threatening emergency, with potential for airway compromise and other catastrophic complications. This review is aimed at highlighting our experience with patients with a diagnosis of retropharyngeal abscess. METHODS: Retrospective review of thirty patients with a confirmed diagnosis of retropharyngeal abscess, who were admitted and managed within an eleven-year period (1993 to 2003) in the Otolaryngology department of the University College Hospital Ibadan. RESULTS: There were fifteen males and females each with M:F ratio of 1:1, consisting of twenty-five children and five adults and their median age was 21 months and twenty three (77%) were younger than 5 years. It was observed that while the adult patients presented early for specialist treatment, the paediatric patients presented late. The major complaints were fever (87%), respiratory distress or stridor (57%), cough (53%), neck pain/swelling (43%), and refusal of feeds (30%). Other minor complaints were throat pain, difficulty in swallowing, anorexia, and weight loss. The commonest associated symptoms seen especially among the younger age group were nasal discharge, nasal blockage, tooth-ache, snoring and limitation of neck movement. CONCLUSION: The treatment of retropharyngeal space infections in children and adults should include accurate clinical diagnosis, empirical usage of broad-spectrum antibiotics, and timely surgical drainage.

An unusual rhino-pharyngeal foreign body.

BACKGROUND: Foreign bodies of the upper aerodigestive tract are commonly seen in the paediatric population; however adult patients with nasal foreign bodies in particular are much less common and when sharp foreign bodies are present there is a great risk of developing complications. STUDY DESIGN: This is a case report of a 20-year-old male magician with impacted rhino-pharyngeal foreign body. He intentionally inserted two long sewing needles into the right nasal cavity during a magical act. RESULTS: The impacted foreign bodies were located in his nose/pharynx and removal was achieved per orally under general anaesthesia. Only a minimal evidence of retropharyngeal abscess was noted despite the prolonged stay of the foreign bodies. CONCLUSION: This case highlights the fact that both a deliberate and an accidental foreign body in an adult nasal cavity can get impacted as well as the significance for its early removal.

Recurrent respiratory papillomatosis in Ibadan, Nigeria.

BACKGROUND: Recurrent respiratory papilomatosis (RRP), the most common benign neoplasm of the larynx, usually results in upper airway obstruction that is most often misdiagnosed as lower airway disease in children. The prevalence of RRP and various aspects of its clinical course are still unknown with a dearth of literature on this in Nigeria. This study aims at presenting the clinical profile of RRP as seen in the University College Hospital, Ibadan, Nigeria. METHODOLOGY: A retrospective study of 43 cases of histologically confirmed RRP over a fifteen-year period in the Otorhinolaryngology Department of the University College Hospital Ibadan. RESULTS: There were 28 (65.1%) males and 15 (34.9%) females with mean age of 8.7 years (range 2-23 years). Thirty-two patients (74.4%) were between 110 years with the highest incidence occurring at the 6-10 year age group (39.5%). Forty-one patients (95.3%) belonged to low social classes V and IV. Thirty-one patients (72%) presented within 1 year of onset of symptoms. All the patients were hoarse with 70% of those dyspnoeic at presentation having emergency tracheostomy. The lesions involved the vocal cords and anterior commissure mostly. There were no recurrences in 23 patients (53.5%) while twenty patients (46.5%) had 2 to 5 recurrences. CONCLUSION: Sequelae of RRP in Children may be grave, thus a high index of suspicion is needed in a patient with progressive voice change exceeding six weeks and unresponsive to standard medical therapy.

Stomal recurrence post laryngectomy in University College Hospital, Ibadan.

The outcome of laryngeal carcinoma is favourable and cure rate high if detected early. A major complication experienced post surgery for advanced laryngeal carcinoma is recurrence especially at the tracheostome. This study aimed at evaluating the incidence of stomal recurrence post total laryngectomy with respect to the risk factors. This is a retrospective review of eighteen patients (14 males and 4 females) that had total laryngectomy for histologically confirmed laryngeal carcinoma from 1990 - 2002. Seven patients (38.9%) had stomal recurrence. Seven patients (38.9%) had palpable deep cervical nodes at presentation. Fourteen (77.8%) and four (22.2%) patients had emergency and elective tracheostomy procedures respectively. Twelve patients (66.67%) had neck node dissection during surgery. Post-operatively, twelve patients (66.7%) had only radical radiotherapy; four (22.2%) had both radio-/ chemotherapy while two had preoperative and additional postoperative radiotherapy. The mean duration between the preoperative tracheostomy and total laryngectomy was 62.19 +/- 64.56 days while the mean duration between total laryngectomy and development of stomal recurrence was 7.79 +/- 8.57 months. Ten patients (55.6%) died, (seven with and three without stomal recurrence but who died of distant metastases to the lungs and thoracolumbar vertebral bodies). Stomal recurrence post laryngectomy has a grave prognosis. This present study also showed that advanced stage 3 and 4 tumour, transglottic involvement and the presence of preoperative tracheostomy are the likely risk factors that could be associated with recurrence in our environment. There is therefore the need to reevaluate these preventive measures in a prospective study in order to improve the final outcome in our environment.

Hypopharyngeal paraganglioma: a case report.

Paragangliomas are neuroendocrine neoplasms that primarily afflict patients during the fourth and fifth decades of life. The majority of extra-adrenal paragangliomas arise in the head and neck region, notably from the carotid and aortic bodies, jugular bulb and tympanic plexus. Although one-fifth of all parapharyngeal neoplasms are paragangliomas, primary hypopharyngeal paraganglioma is relatively uncommon, only one other case having previously been documented by Filippin et al. (1989). We report a second case of hypopharyngeal paraganglioma in an 18-year-old male as seen in our center.

Hoarseness in adult Nigerians: a University College Hospital Ibadan experience.

BACKGROUND: Hoarseness is a major symptom of laryngeal disease. Persistent hoarseness may be an early warning of such sinister lesions as cancer of the larynx and nasopharynx, hence the need for increased awareness of this symptom and its causes. METHODS: This is a retrospective study of all hoarse adult patients seen in the Otorhinolaryngology clinics of the University College Hospital Ibadan over an 8-year period (1995-2002). RESULTS: The total study population of 124 patients consisted of 72 (58.06%) males and 52 (41.94%) females with an overall mean age of 46.98 years and age range 16-84 years. The mean duration of hoarseness before presentation was 23.29 months; 56 (45.2%) patients presented within 6 months of onset of hoarseness. Chronic non-specific laryngitis including vocal cord nodules was the most common cause of hoarseness (55.6%). Chronic non-specific laryngitis patients had a mean age of 45.05 years. Fourteen point forty-nine percent (14.49%) of patients with chronic non-specific laryngitis smoked cigarette and drank alcohol, 60.88% were professional voice users. The other causes of hoarseness included laryngeal cancer (24.2%), recurrent laryngeal nerve palsy (8.1%) and laryngeal papilloma (6.5%). The patients with laryngeal cancer had a mean age of 57.63 years. The two male patients with laryngeal tuberculosis were all secondary to pulmonary phthisis. CONCLUSION: The causes of hoarseness are varied and late presentation may worsen the prognosis. Persistent hoarseness of more than three weeks should have detailed Otolaryngological evaluation.

Recurrent respiratory papillomatosis mimicking retropharyngeal abscess in a Nigerian child.

UNLABELLED: Recurrent respiratory papillomatosis (RRP) is not an uncommon disease of the aero-digestive tract, usually involving points of narrowing. Involvement of the oropharynx, particularly when florid, may be easily confused with a retropharyngeal abscess. STUDY DESIGN: Case report of a 1 1/2 year-old child with florid pharyngeal RRP. RESULTS: The clinical presentation and features on radiography of this patient mimicked retropharyngeal abscess. The patient successfully had a preoperative tracheosomy and excision of the RRP. CONCLUSION: There was a diagnostic dilemma in this patient because of the identical features of the two conditions. A high index of suspicion and painstaking, careful clinical and radiological evaluation is the key to diagnosis and prompt definitive management.

Complications of classical tracheostomy and management.

Tracheostomy can prevent many deaths in otherwise fatal airway diseases and problems but has numerous complications that are mostly avoidable if the procedure is carefully performed together with strict postoperative management. This is a retrospective review of tracheostomy complications over a 10 year period (1991-2002) in the Department of Otorhinolaryngology (ORL), University College Hospital, Ibadan. A total of 179 tracheostomies performed on 168 patients with 69 complications (38.6%) were documented. There was a significantly greater number of complications in the 43 emergency cases (54%) than in the 26 elective cases 1(46%), P = 0.0002]. The overall mortality rate was 2.2%. The most common complications of tracheostomy were infective in origin, representing 43% of all complications. This study highlights the complications and mortality and gives details of management that will prevent or minimize their occurrences. Those who require long-term tracheostomy must be on regular follow-up and taught home-care of the tracheostomy before discharge from the hospital.

Primary extranodal non-Hodgkin's lymphoma of the upper aerodigestive tract--a descriptive analysis of the pattern seen in the University College Hospital, Ibadan.

This retrospective review highlights primary extranodal non-Hodgkin's lymphoma (NHL), of the upper aerodigestive tract as seen in Ibadan over a ten-year period. There was a male preponderance (m:f ratio of 2:1), with a mean age of 42.5 years and a bimodal age presentation at the fourth and fifth decades. The Waldeyer's ring was the commonest affected site while the tonsil is the highest involved subsite. Sixty-eight percent of the patients had regional lymphadenopathy and thirty eight percent also 'B' symptom at presentation. The peculiar presentations of this NHL are the short duration (10 months) of symptoms, mainly intermediate/high grade diffuse large cell lymphoma especially in the Waldeyer's ring and sinonasal region with absence of low-grade small cell lymphoma. The majority of patients (64.3%) presented with Stage IV disease, which shows that the disease has an aggressive course with high mortality and generally poor outcome with 53.6% of the patients dead within one-year onset of symptoms. The overall mean survival period was 14 months. Comparison of the median survival of the patients that died when matched with the site, Ann Arbor staging, histological grade/subtype and treatment modality yielded no significant differences. These further confirm the aggressive nature of the disease in our environment.

Traumatic vertebral artery pseudoaneurysm: a case report.

A case of traumatic vertebral artery pseudoaneurysm in a 16-year-old Nigerian male following a stab wound is described. Successful surgical treatment by proximal Subclavian artery control and excision of the lesion was achieved. The value of Doppler ultrasonography in the diagnosis is highlighted. This case illustrates and re-emphasises that this rare lesion should be considered in patients with neck mass following penetrating posteriorly located neck injuries.

Inverted papilloma of the nose and paranasal sinuses: a fifteen-year review.

Inverted papilloma is a relatively rare epithelial neoplasm of the nose and paranasal sinuses accounting for 0.5-4% of all primary tumours of the nose. This is a retrospective study of fifteen patients with histologically confirmed I.P. of the nose and paranasal sinuses seen from 1986 to 2000 at the Department of Otorhinolaryngology, University College Hospital, Ibadan. The patients ages range from 14-65 years, with a median age of 39 years. There were twelve males and three females. Five patients had advanced lesions of which four were bilateral. There was associated synchronous and metachronous squamous cell carcinoma (SCC) in two patients respectively. The surgery offered was based on the clinical and radiological evaluations of these patients. Nine patients had conservative surgery (intranasal clearance/antrostomy and external fronto-ethmoidectomy) while the remaining six patients had radical surgery (lateral rhinotomy/medial maxillectomy) at various times. The two patients with SCC had adjunct radiotherapy/chemotherapy in addition. Recurrence was observed in those that had conservative surgery only. We therefore advocate radical surgery in our environment as the treatment of choice for effective limitation of recurrence.

Sensorineural hearing loss in adults with sickle cell anaemia.

Sensorineural hearing loss (SNHL) is one of the known complications of sickle cell disease (SCD). However, there is paucity of information on SNHL as a complication of SCD, especially in sickle cell anaemia (SCA) in our environment, hence this study. This was a prospective study of pure tone audiological assessment of 167 adult SCA patients in stable condition attending the adult Sickle Cell Clinic and 100 apparently healthy Haemoglobin AA adults as control in the University College Hospital, Ibadan. Their ages ranged from 15 to 56 years for SCA and 15 to 65 years for the controls, with a mean age of 24.2 (+/- 8.2) and 28.7 (+/- 11.9) years respectively. There were 94 females (56.3%) and 73 males (43.7%), fifty-two females (52%) and forty-eight males (48%), with a M:F ratio of 1:1.3 and 1:1.1 for SCA and controls respectively. Sensorineural hearing loss (SNHL) was observed in a total of 178 ears in 110 SCA patients and 68 ears in 47 controls with a prevalence of 66% and 47%, respectively. Sixty-eight patients (62%) and twenty-one controls (44.7%) had bilateral impairment, although only 18 SCA patients (11%) perceived hearing impairment. High frequency loss (4000-8000 Hz) was commonly affected in both the SCA patients and controls as compared to other frequency ranges. Low frequency range was involved in ten ears (9%) especially the right ear of some SCA patients. Decibel hearing level (dBHL) loss was in the mild range (26-40 dBHL) in 103 (58%) and 53 (78%) ears in the SCA and controls, respectively. Five patients had severe and profound dBHL loss. The range of dBHL loss was 26-43 dBHL especially in the high frequency range bilaterally for both the SCA and controls. Mean binaural hearing of 13 dBHL was recorded in both the SCA and controls for each octave frequency bilaterally in those with normal hearing while 26 and 23 dBHL were for those with impaired hearing respectively. Also, the mean dBHL for both ears was observed to be progressively worse with increasing age groupings, more especially in SCA patients. There was no significant correlation between the severity of hearing loss and the frequency of vaso-occlusive crisis. It is hoped that this study would have increased the awareness that SNHL is a common complication of SCA in our patients. There is thus the need for periodic evaluation of the auditory function of SCA patients in our environment.