Otosclerosis: Experience With Stapes Surgery.

Introduction Otosclerosis is a disorder in which the footplate of the stapes is replaced by an abnormal bone, thereby affecting sound transmission to the inner ear at the level of the oval window. The solution to this condition is to reestablish this mechanism back to normal via the ossicular chain to the inner ear. The aim of stapes surgery is to improve the hearing level to thresholds appropriate enough to obviate the need for hearing aid. The hearing improvement achieved after surgery often lasts for many years. The purpose of the current study was to review our experience and find out the rate of success related to hearing outcomes after stapedotomy. Methods The patients who were operated for otosclerosis between January 2000 and December 2010 at Aga Khan University Hospital, Karachi, Pakistan were included in the study. The charts were reviewed to collect clinical data regarding stapes surgery. The values of speech reception threshold (SRT) were recorded, and the preoperative and postoperative means were compared with a t-test. The bone conduction (BC) and air conduction (AC) thresholds were evaluated at 0.5 kHz, 1.0 kHz, 2.0 kHz, and 3.0 kHz. The preoperative and postoperative means of air-bone gap (AB-gap) were compared with a t-test. The descriptive frequency was calculated to evaluate postoperative AB-gap in individual patients; patients were grouped with a difference of 10 dB of AB-gap. The SPSS Statistics software (IBM, Armonk, NY) was used for statistical analysis. Results A total of 46 patients were included in the study. There were 15 males and 31 females. The mean age was 35 years (range: 20-56). Thirty-three patients had bilateral otosclerosis; two patients had surgery for both ears, taking the total number of ears operated to 48. The mean preoperative AB-gap was 39, while the mean postoperative AB-gap was 11. The means were compared with a t-test and a p-value of <0.05 was considered significant. The means of preoperative and postoperative SRT were 56.25 and 24.27 respectively. Both means were compared with a t-test, and a p-value of <0.05 was considred significant. Postoperatively, 34 ears had AB-gap of 10 dB (70.8%), 11 (22.9%) had within 20 dB, and three (6.3%) had within 30 dB. Conclusions The success rate related to hearing outcomes in patients operated for otosclerosis was excellent and comparable to that found in the current literature. The wide AB-gap noticed in the majority of our patients may represent a delayed presentation to otolaryngologists, which requires further evaluation.

Organ Preservation for Advanced Laryngeal Cancer: Experience with Concurrent Chemoradiation Therapy.

Introduction The larynx is a part of the upper respiratory tract that performs many essential functions including breathing, speaking, and swallowing. For this reason, the quality of life is significantly affected by laryngeal cancer and its treatment. Therefore, the focus of management for the last few decades has been on preserving the function of a larynx without compromising survival. This study was done with the purpose of reviewing our experience of organ preservation approach with concurrent chemoradiation therapy (CCRT) for locally advanced cancers of larynx. Methods A retrospective chart review was carried out for the data of pathology reports and clinical notes of the patients who were diagnosed with laryngeal squamous cell carcinoma and primarily treated with CCRT at our tertiary care institute from November 2010 to June 2015. Results Of 25 patients included in the study, there were 19 males and six females. The mean age was 56 years. On comparison of post-treatment CT scan following eight weeks of completion of therapy, 21 patients showed complete resolution of the disease and four patients had persistent disease who were later treated with salvage laryngectomy. The speech was understandable in 18 patients and poor or not understandable in seven patients. Three patients had chronic aspiration and breathing difficulties necessitating permanent tracheostomy. Three patients required permanent gastrostomy due to chronic dysphagia, one of them belonged to those who were also tracheostomized. Conclusions Our experience with CCRT as an organ preservation approach for advanced laryngeal cancers was promising. When considering the functional organ preservation, the proportion of success is remarkably less; however, the overall impression is worthy enough to uphold the sentiment in favor of non-surgical organ preservation. The debate is ongoing in the quest of finding a balanced approach with acceptable toxicity and decent functional outcome with adequate speech, breathing, and swallowing.

Effect of Montelukast on the Symptom Severity Score of Allergic Rhinitis.

Introduction Rhinitis is a common respiratory disorder that can be broadly defined as an inflammation of nasal mucosa. Allergic rhinitis is the most common form of chronic rhinitis characterized by one or more symptoms including sneezing, nasal itching, nasal congestion, postnasal drip, and rhinorrhea. Montelukast is an antagonist to the leukotriene receptor. It is non-sedating, dosed once daily, and has a safety profile similar in adults and children, with approval down to six months of age. The purpose of the study was to see the improvement in the severity of symptoms of the patients with allergic rhinitis treated with montelukast. Methods The symptom severity score for allergic rhinitis was calculated by asking the patient to evaluate the severity of individual symptoms (sneezing, nasal congestion, rhinorrhea, and postnasal drip) against the 4-point scoring scale over the last 24 hours. After explaining the scoring system to the patient, a proforma was filled before starting the treatment. A dose of 10 mg of montelukast once daily was prescribed. On the follow-up visit after four weeks of therapy, compliance was ensured and then the symptom severity score was recorded again on the proforma. The total nasal symptom severity score (TNSSS) was calculated as a sum of all four nasal symptoms. Pre- and post-treatment mean of TNSSS was compared using a t-test. P-value of less than 0.05 was considered significant. Results A total of 140 patients were included in the study. The mean age was 30 years. The minimum age was 15 years and the maximum age was 45 years. There were 93 males and 47 females. The difference between pre- and post-mean values of TNSSS was 5.82. Both pre- and post-mean of TNSSS were compared using the t-test, and P-value was significant, i.e., <0.005. Conclusions The common symptoms of allergic rhinitis evaluated in the study showed improvement in response to the treatment with montelukast. The improvement in symptom severity score was maximum in sneezing and least in rhinorrhea. In light of recent developments on neuropsychiatric adverse effects and FDA warnings, caution needs to be exercised to reserve the use of montelukast for the selected patients.

Readmissions After Day Care Surgery In Ent: A Tertiary Care Experience.

BACKGROUND: Re-admission following day care surgery in ENT (Ear, Nose & Throat) results in significant morbidity to patient & massive load to hospital & also raises the question on the safety of day care surgery. Only a small number of published studies emphases on return to hospital within 30 days following day care surgery in otorhinolaryngology especially from our region. This study was carried out to determine the frequency of re-admission after day care surgery in ENT. METHODS: We prospectively studied consecutive patients who underwent ENT procedures [i.e., septoplasty, tympanoplasty type I & functional endoscopic sinus surgery (FESS) for deviated nasal septum (DNS), chronic suppurative otitis media tubotympanic (CSOM TT) variety & ethmoidal nasal polyposis (ENP) respectively] as day care surgery case under general anaesthesia at the Section of Otorhinolaryngology and Head & Neck Surgery, Aga Khan University Hospital & Liaquat National Hospital, Karachi from January 2015 to December 2016. All patients aged 20- 60 years of both genders were included in the study. SPSS software version 20 was used for data compilation and analysis. p-value less than or equal to 0.05 was taken as significant. RESULTS: In the phase of 24 months, total 317 cases met the inclusion criteria & were included in the study. There were 205 males & 112 females in the study population. One hundred & twenty-two patients having DNS, 128 having CSOM TT & 67 suffering from ENP & underwent septoplasty, tympanoplasty type I & FESS respectively. Complications were observed in a total of 7 (2.2%) patients in our study group & required re-admission within 1 month of surgery. Stratification was done between re-admission & all effect modifiers, with all showing insignificant results. CONCLUSIONS: Our results demonstrate that ENT surgeries (septoplasty, tympanoplasty type I & FESS) are safe procedures which can be performed as a day care case with acceptably low readmission rates.

Ameloblastoma: Management and Outcome.

Introduction Ameloblastoma is a locally destructive tumor with a propensity for recurrence if not entirely excised. Management of ameloblastoma poses a challenge for all involved in the field of head and neck surgery because successful treatment requires not only adequate resection but also a functional and aesthetically acceptable reconstruction of the residual defect. Methods Patients who had histologically proven ameloblastoma between 1991 and 2009 were identified from the database of Aga Khan University Hospital. A review of all medical records, radiological images, operative reports and pathology reports was undertaken. Results A total of 15 patients with histologically confirmed ameloblastoma were identified. Out of 15 patients nine were males and six were females with age range from 20 to 60 years (mean age 43 years). The most common symptom found in our patient group was painless facial swelling. In 13 patients the origin of tumor was mandible and in the remaining two the tumor originated from maxilla. Eleven out of 15 patients underwent segmental mandibulectomy, two had maxillectomy and two had enucleation. All patients who underwent segmental mandibulectomy required reconstruction. Reconstruction was done with microsurgical free tissue transfer in eight patients, non-vascularized iliac crest bone graft was used in one patient and two had plating only. All free flaps survived with no evidence of flap loss. The mean follow-up was eight years. There was no evidence of graft failure which was used in one patient. Complication was seen in only one of our patients in the form of plate exposure. Recurrence was seen in two of our cases who primarily underwent enucleation. All patients had satisfactory speech, cosmesis and mastication. Conclusion The management of ameloblastoma still poses a big challenge in spite of being the most common odontogenic tumor. In our study we have found that segmental mandibulectomy with disease-free margin of around 1 cm and immediate reconstruction with free tissue transfer have shown good results.

Metachronous second primary malignancy in head and neck cancer patients: is five years of follow-up sufficient?

OBJECTIVES: The aim of this study was to determine the incidence and characteristics of second primary malignancy (SPM) in patients with head and neck squamous cell carcinoma treated at a tertiary care hospital. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 221 patients who underwent surgery with or without adjuvant treatment for head and neck cancer from 2000 to 2002. Data of age, sex, risk factors, sites of primary and SPM, TNM stage of primary tumor, incidence of SPM, and survival were collected from medical charts. RESULTS: Eighteen patients developed SPM during a median follow-up of 67 months, with an overall incidence of 8.14%. In addition, 77.7% of SPMs occurred in the oral cavity, followed by 11% in the lungs. The 5-year overall survival after the diagnosis of SPM in the head or neck was 70%, compared to 30% for SPM in other body regions. CONCLUSION: Considering a high incidence of SPM, i.e., 8.14%, in a mean follow-up period of 67 months suggests the need for long-term follow-up. Since treatment of SPM has shown an acceptable survival rate, early detection and curative therapy should be emphasized.

Clinicopathological Behavior and Treatment-related Outcome of Rare Salivary Duct Carcinoma: The Shaukat Khanum Memorial Cancer Hospital Experience.

Background Salivary gland tumors are rare salivary gland malignancies with resemblance to ductal breast carcinoma. We have described clinicopathological behavior and treatment outcomes of this rare malignancy. Methods Salivary duct carcinoma patients treated from 2010 to 2015 were retrospectively analyzed for clinicopathological characteristics and treatment-related outcomes of the disease. Results A total of 12 patients with salivary duct carcinoma were included in the study. All were males with mean age of 52.58 ± 13.43. Parotid gland was the most commonly involved major salivary gland while buccal mucosa and anterior tongue were most common oral cavity sub-sites involving minor salivary glands. The disease-free survival was 75% at 10 months and 25% at 20 months. The mean follow-up time was 12 months. There were three local recurrences and one distant metastasis. Conclusion Salivary duct carcinoma is a locally aggressive tumor with tendency for local recurrence and distant metastasis. Adverse features such as perineural invasion, extra-capsular spread and advanced nodal disease may worsen prognosis.

An Overview of Laryngeal Cancer Treatment at a Tertiary Care Oncological Center in a Developing Country.

Introduction Development of laryngeal cancer is multifactorial, and management is surrounded with controversies. Recent reports suggest a decline in the survival of these patients. We conducted a study to analyze the clinicopathological parameters and compute the outcomes in terms of survival in patients with laryngeal cancer treated at our institution. Methods Electronic charts of 515 patients with Laryngeal cancer treated at our Hospital and Research Center from 2004 to 2014 were retrospectively reviewed. Results Median age was 62 years. Male: female ratio 91%: 9%. Sixty-two percent were smokers. Histologically, all were squamous cell carcinoma. Most common subsite was glottis (88%). Treatment was non-surgical in 92% and surgical in 8%. The five-year overall survival (OS), disease-specific survival (DSS), disease-free survival (DFS) and locoregional control (LRC) were 67%, 74%, 59% and 70%, respectively. OS, DSS, DFS and LRC for early stage (I-II) and advance stage (III-IV) were 81 and 54%, 86 and 63%, 75 and 45%, and 83 and 57%, respectively. Twenty-two percent recurred locally. Of these failures, 19% were inoperable, 36% were surgically salvaged and 34% refused laryngectomy. Conclusions Our survival rates are comparable with published data. The high refusal rate for salvage total laryngectomy is concerning and needs further study to evaluate the reasons.

Depth of invasion (DOI) as a predictor of cervical nodal metastasis and local recurrence in early stage squamous cell carcinoma of oral tongue (ESSCOT).

BACKGROUND: The new AJCC staging system (8th edition) incorporates depth of invasion to stage oral cancers. It is a recognized predictor for neck nodal metastasis and local recurrence, the associated risk is not well defined. The aim of this study was to explore the risk of occult neck nodal metastasis and local recurrence in relation to depth in early stage squamous cell carcinoma of oral tongue. METHODS: We have evaluated records of 179 patients with early tongue cancer treated in our unit from 2006-2015 with a mean age of 57.92 ± 11.93 years. Treatment modalities used were surgery (26%), surgery followed by radiotherapy (64%) and chemo-radiation (10%). Neck dissection was ipsilateral in 94% and bilateral in 6% of the patients. Patients were grouped according to the AJCC cut off points in 8th edition for depth; group A: 1-5 mm (35%), group B: 6-10 mm (47%) and group C: > 10 mm (18%). RESULTS: Risk of local recurrence and nodal metastasis for Group A was 15% (10/63) and 23% (15/63), group B 20% (17/84) and 34% (29/84), and group C 40% (13/32) and 53% (17/32). CONCLUSIONS: Depth more than 10 mm is associated with significantly increased risk of recurrence and nodal metastasis. Elective neck dissection should be a consideration for tumors having depth less than 5mm.

Clinicopathological Behavior and Oncological Outcomes of Malignant Parotid Tumors in a Pakistani Population.

Introduction The incidence of salivary gland tumors is influenced by geographical and racial factors resulting in diverse histology.  While salivary gland tumors account for a low proportion of head and neck cancers, most malignant tumors of the salivary gland are located in the parotid gland. The goals of this study are to describe the clinicopathological behavior of malignant parotid tumors and explore oncological outcomes related to survival in our Pakistani tertiary care cancer hospital. Methods We conducted a retrospective analysis of 209 patients diagnosed with malignant parotid tumors from 2004 to 2016. Data such as demographics, age, gender, histology, grade, clinical and pathological stage, surgical treatment types and adjuvant modalities used were analyzed using SPSS software version 20. We used Kaplan Meier curves to analyze survival data. Results The median patient age at diagnosis was 40 years, and the ratio of men to women was 1.2:1. Mucoepidermoid carcinoma was the most common histological variant (with a 50% incidence rate) followed by adenoid cystic carcinoma (13%), and adenocarcinoma (10%). Histology has further categorized these malignant tumors into low (34%), intermediate (28%), and high (21% ) grades. The American Joint Committee on Cancer, seventh edition, clinical staging was Stage I (21%), II (28%), III (15%), and IV (34%). The 5-year survival was 68%, and the 10-year survival was 45%. Conclusion Mucoepidermoid carcinoma is the most common malignant parotid histology in our patient population. Advanced age, increased T stage (size > 4 cm), high-grade histology, and cervical nodal involvement decrease overall survival. Open biopsies, piecemeal excisions, and delayed presentation for radiotherapy post-surgery may also have role in adverse outcomes in these malignancies.

Small cell neuroendocrine carcinoma of nose and paranasal sinuses: The Shaukat Khanum Memorial Cancer Hospital experience and review of literature.

Small cell neuroendocrine carcinoma (SCNEC) is a rare disease of nose and paranasal sinuses. In contrast to other regions SCNEC of this region has been reported to be recurrent and locally aggressive. No definite treatment has been established till date because of rarity of this disease. The purpose of this descriptive study is to present the series of 8 cases with SNEC of nose and paranasal sinuses. Retrospective review of 8 patients presenting with Small cell neuroendocrine carcinoma of nose and paranasal sinuses, from January, 2005 to December, 2014 treated at Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore was performed to determine the clinical characteristics and outcome of this disease. The subjects were 7 males and 1 female with a mean age of 45±15 years (range 24 to 59 years). Tumours were present in nasal cavity (n=4), ethmoid sinus (n=3) and maxillary sinus (n=1). Almost 50% of patients presented with AJCC stage IV-A. All patients had immunohistochemistry proven diagnosis. All patients (08) received radiotherapy with mean doses 58±Gy (Range 54-66Gy). Surgery was performed in 2 while chemotherapy was administered in 4 patients. Recurrence occurred in 3 patients, one each with loco-regional, distant and both. At a median follow up of 38 months, 5 patients were alive with no evidence of disease. SCNEC is a rare but aggressive neoplasm. Current standard of care varies but multi-modality approach should be the cornerstone in management of SCNEC. Early diagnosis and intervention improve the final outcome.

Preservation of Hearing and Facial Nerve Function with the Microsurgical Excision of Large Vestibular Schwannomas: Experience with the Retrosigmoid Approach.

Introduction Vestibular schwannomas (VS) are the most common benign neoplasms of a cerebellopontine angle (CPA), which arise from the Schwann cells of the vestibulocochlear nerve. Eighty percent of CPA tumors are VS followed by meningioma as the second common mass lesion in this critical potential space. Treatment options range from watchful waiting with serial imaging studies to radiosurgery or a microsurgical excision or a combination of surgery and radiation therapy. The primary objective of the study was to assess hearing and facial nerve status before and after the surgery via the retrosigmoid approach. Methods The database of Aga Khan University Hospital was searched for diagnoses of vestibular schwannomas between 2000 and 2007. A total of 35 patients were identified; among them, 27 were selected for the study who met the inclusion criteria. The variables of the study were age, gender, presenting symptoms, size of the tumor, surgical approach, hearing levels, and facial nerve function. Hearing loss was categorized according to the Gardener-Robertson hearing classification and the House-Brackmann Scale was used for facial nerve assessment. Results Out of the 27 patients, 18 were male and nine were female. The mean age was 43 years. The most common presenting complaint was hearing loss and tinnitus, seen in 21 patients. Headache was present in six patients, ataxia in five, and vertigo in three. Facial nerve weakness was noticed in six patients. Two patients had Grade-III paralysis, three had Grade-IV paralysis, and one had Grade-V paralysis. The audiogram confirmed the presence of sensorineural hearing loss (SNHL) in all patients. Twelve patients out of 27 had Class II hearing with the threshold between 31 and 50 decibels and a Speech Discrimination Score (SDS) of 50% to 69%. Ten patients had non-serviceable hearing and the remaining five had poor hearing. The audiogram was repeated after surgery for those 12 patients who had Class II hearing and showed that seven out of 12 patients maintained a hearing threshold within the range of Class II at the one-year follow-up (hearing preservation 58%). The facial nerve preservation rate was 56% considering House-Brackmann Grade III or less as acceptable facial nerve function. Conclusion The optimal treatment for small vestibular schwannomas is a matter of controversy; however, the choice of treatment for large vestibular schwannomas in patients without significant comorbidity is generally microsurgical excision. The surgical excision of a large VS with the retrosigmoid approach is found to be safe consistently. The hearing and facial nerve preservation in our study were found comparable with the literature.

The Submental Island Flap in Head and Neck Cancer.

OBJECTIVES: The submental flap provides an alternative technique in orofacial reconstruction, especially in situations where free flap services are not available. The objective of this study is to demonstrate the oncological safety and benefits of this flap in oral cavity reconstruction in a tertiary care cancer hospital. MATERIALS AND METHODS: A total of 27 patients with oral cavity cancers, which underwent submental flap reconstruction from 2015 to 2017 at Shaukat Khanum Cancer Memorial Hospital, were included in the study. We have retrospectively reviewed records of these patients. RESULTS: There were 25 male and 2 female patients with age ranging from 21 to 73 years. Most common primary tumor sites were buccal mucosa (13), tongue (7), and lower alveolus (7). All patients underwent ipsilateral selective neck dissection after flap was harvested. Complete flap loss was observed in three, whereas one patient had flap dehiscence that subsequently healed. Mean follow-up was 11 months. There were four regional recurrences but no local recurrence. On the last follow-up (minimum 6 months), 15 patients were alive without any disease, 4 were alive with disease, and 3 had died. CONCLUSION: Submental flap is a satisfactory option for oral cavity reconstruction. However, preoperative selection of clinically neck node-negative patient is extremely important as it has potential risk of occult metastasis.

Treatment Outcomes of Rare Retromolar Trigone Squamous Cell Carcinoma Using Combined Modalities.

BACKGROUND: Retromolar trigone squamous cell carcinoma is relatively uncommon and due to its complex anatomy has always remained a challenge in terms of loco-regional control and survival. Surgery, radiotherapy, and chemotherapy as combined modalities have been used but high recurrence rates result in poor outcome. METHODS: We have retrospectively evaluated records of 62 patients treated in Head and Neck Oncology unit of Shaukat Khanum Memorial Cancer Hospital and Research Centre (SKMCH and RC), Lahore, Pakistan from 2004 to 2014 who were included based on the criteria of histopathological proven squamous cell carcinoma of retromolar trigone (RMT) treated with radical intent. Diagnostic workup for all patients involved clinical examination, imaging modalities usually magnetic resonance imaging (MRI), computerized tomography (CT), Orthopantomogram (OPG), and chest x-ray (CXR) to evaluate regional and distant metastasis, respectively. Kaplan-Meier survival curves were used to depict survival. RESULTS: The study was comprised of 36 male and 26 female patients. Treatment modalities used are surgery only (n = 1), radiotherapy alone (n = 13), radiotherapy followed by surgery (n = 10), chemoradiotherapy (n = 16), induction chemotherapy followed by concurrent chemoradiotherapy (n = 19), induction chemotherapy followed by surgery, and radiotherapy (n = 2). Surgical interventions include wide local excisions (n = 6), marginal mandibulectomy (n = 4), and segmental mandibulectomy (n = 4). Surgical margins were clear in 54%, close in 38%, and involved in 8% of patients. AJCC 7th edition showed cT1 8%, cT2 22%, cT3 14%, and cT4 56% while pT1 2%, pT2 3%, and pT4 8%. During follow-up, 18% patients have come up with local recurrence, 22% showed persistent disease while 9% have presented with distant metastasis. The five-year and overall survivals are 38% and 22%, respectively. CONCLUSION: Retromolar trigone involvement poses many vital structures at risk of involvement. Late presentation results in involvement of masticator space compromising both mouth opening and surgical outcomes. Surgery and radiotherapy have shown comparable results in disease control. Bone invasion has shown poor outcome in terms of loco-regional control and overall survival.

An Unusual Case of Cauda Equina Secondary to Spinal Metastasis of Thyroid Cancer.

INTRODUCTION: Cauda equina secondary to metastatic follicular thyroid cancer of the lumbosacral area is a rare entity. CASE REPORT: We report an unusual case of a 52-year-old male who presented with backache, lower limb weakness, and perianal numbness. A CT-scan of the lumbosacral area showed an enhancing mass at the L4, L5 and S1 vertebrae. Histopathology after excision revealed a metastatic thyroid cancer. Hence, a CT scan of the neck and chest was performed which showed a nodule in the left lobe of the thyroid and a mass in the left chest wall. A total thyroidectomy and excision of the chest wall lesion was undergone, which was diagnosed as a follicular carcinoma of the thyroid. CONCLUSION: Metastatic workup of spinal metastasis should include evaluation of the thyroid gland.

Squamous cell carcinoma of oral tongue in young patients - A 10 years tertiary care experience.

OBJECTIVE: To evaluate the clinical and pathological profile of young patients with squamous cell carcinoma of tongue. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and comprised record of patients <35 years presenting with squamous cell carcinoma of tongue between 2001 and 2011. Data was extracted from the electronic database of the hospital for site and age. Clinico-pathological variables were analysed using SPSS 20. RESULTS: Of the 29 patients, 17(58.6%) were men and 12(41.3%) were women. The overall mean age at presentation was 29.6+/-4.4 years. All patients (100%) had some sort of addiction, with 15(51.7%) having more than one addiction. Of the total, 20(68.9%) patients had moderately differentiated carcinoma. At presentation, 20(68.9%) had advanced stage (III-IV) disease. Surgery was the primary modality used in all the patients (100%). Median follow-up period was 36 months (range: 1-6 years). During follow-up, 7(24.1%) patients developed recurrence. CONCLUSIONS: Squamous cell carcinoma of the tongue was more commonly seen in males, and multiple addictions were a common risk factor.

Anatomical variations of nose and para-nasal sinuses; CT scan review.

OBJECTIVE: To determine the frequency of anatomic variations on computed tomography scan of para-nasal sinuses. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised computed tomography scans of 77 patients who had presented between October 2007 and March 2011. All the scans were reviewed using Picture Archiving Communication System computer software. The scans were reviewed for the presence of deviated nasal septum, paradoxical middle turbinate, Haller cell, Onodi cell, and pneumatisation of the middle turbinate and uncinate process. RESULTS: The mean age of the patients was 31 +/- 13.15 years. One or more types of anatomical variants were observed in 40 (51.9%) of the patients; the most frequent being the deviated nasal septum 20 (26%) and the Concha bullosa 14 (18.2%). CONCLUSION: Considering the wide range of variations in the anatomy, each and every para-nasal sinus case should be planned individually and carefully to avoid dreadful complications and maximise patients' benefit.

Asymmetry of lateral lamella of the cribriform plate: a software-based analysis of coronal computed tomography and its clinical relevance in endoscopic sinus surgery.

BACKGROUND: Endoscopic sinus surgery is a known approach for sinonasal pathologies. Due to close proximity of sinuses to orbits and brain, surgeon should be aware of sinonasal anatomy and associated variations. The roof of ethmoid (fovea ethmoidalis) separates the ethmoidal cells from the anterior cranial fossa. Medially the fovea attaches to the lateral lamella of the cribriform plate, which is the thinnest bone of the skull base. Hence, it is at a high risk of getting damaged during surgery. OBJECTIVE: To ascertain the quantitative analysis of height of lateral lamella according to Keros classification in the computed tomographic (CT) images of patients presenting to our clinic. METHODS: It was retrospective review of 77 CT scans using computerized software known as picture archiving and communication system. The height of lateral lamella was examined for both sides and then classified according to Keros classification. Asymmetry between two sides was also reported. RESULTS: Keros type I was seen in 46 sides (29.8%), type II in 75 sides (48.7%) and type III was seen in 33 (21.4%) sides. Keros type I was seen in 38 sides in males and 8 sides in females. Type II was seen in 46 and 29 sides in males and females, respectively. Type III was seen in 18 sides in males and in 15 sides in females. CONCLUSION: Understanding of the anatomy of ethmoid roof with its possible variation is crucial to give the surgeon optimal information about the possible risk that one can face during the surgery. Hence dreadful complications can be avoided.

A case of otogenic tetanus.

The authors are presenting our experience of managing an interesting case of a 12-year-old girl who presented to our clinic with otorrhea for 3 months and trismus for 1 week. Examination showed bilateral ear discharge with central perforations in tympanic membranes, palatal paralysis and trismus. Systemic examination revealed only mild stiffness of hand muscles. CT-scan head and neck was done to look for intracranial complications of otitis media. However; it revealed only decreased pneumatisation of mastoid cells. She was admitted in the hospital and started on intravenous and local antibiotics after sending ear swab and blood cultures. But she showed no improvement in 48 h. So on the clinical suspicion (trismus and stiffness of hands) remote possibility of otogenic tetanus was considered and she was given tetanus toxoid and immunoglobulins. She gradually showed improvement in her symptoms. Thereafter, culture from ear discharge was also reported positive for Clostridium tetani.

Post-traumatic pseudoaneurysm of internal carotid artery: a cause of intractable epistaxis.

In this case report, the authors are presenting a case of a 35-year-old lady who presented to our clinic with recurrent episodes of massive epistaxis and loss of right eye vision for last 6 months following road traffic accident. There was no other significant medical and surgical history. Bleeding episodes were sometimes very severe with loss up to 400-500 cc and would stop spontaneously. She was given multiple blood transfusions after these episodes. A complete otorhinolaryngological examination including rigid endoscopy and coagulation investigation did not reveal any abnormality. CT with contrast of paranasal region showed blood within the right sphenoid sinus with linear fracture of the lateral wall with post-traumatic cavernous pseudoaneurysm of internal carotid artery localised to right sphenoid sinus. That was managed successfully by embolisation using a detachable balloon and a coil. She was followed up in the clinic at 6 weeks and 6 months interval with no symptoms.