Beware of the master masquerader- A case series of cavitary lung disease with hearing loss.

Granulomatosis with polyangiitis (GPA) is an etiologically unknown systemic disease characterized by necrotizing granulomatous inflammation. Additionally, it is accompanied by vasculitis of small and medium-sized blood vessels. It manifests clinically as a triad involving the lungs, upper airways, and kidneys. It is estimated that 90% of patients will exhibit upper or lower airway symptoms and around 80% develops the renal disease. In this article, we describe three case scenarios with varying presentations. GPA should be considered among the possible etiologies of cavitary pulmonary lesions with ear manifestations including hearing loss with poor response to unusual treatment.

To investigate the knowledge, attitude and practices regarding tuberculosis case notification among public and private doctors practicing of modern medicine in South Delhi.

In India, tuberculosis (TB) notification has been required since 2012. Notwithstanding, notification rates remain low. Non-reporting of tuberculosis cases not only results in an underestimation of cases, but also impedes the country's TB control strategy. Our research aims to assess practitioners' awareness, perception, and practice of tuberculosis case notification, as these factors can help reduce the TB burden. A cross-sectional study of 142 physicians was conducted between August 2018 and December 2019. Doctors were interviewed and given evaluation forms. Seventy-seven percent of the 142 physicians polled worked in medicine-related specialties, while 33% worked in surgery. Public sector physicians (64.7%) knew more about the Nikshay App than private practitioners (40.8%). The vast majority of public-sector doctors were only notified through their hospital's National Tuberculosis Elimination Programme (NTEP) center. However, the majority of private practitioners (47.8%) notified cases directly through the hospital, the local District Tuberculosis Officer (DTO) or NTEP medical officer (24 percent), or the Nikshay portal (28%), whereas the majority of public sector doctors notified only through the hospital NTEP center (85.9%). The primary reasons for non-notification are the high patient load on doctors, a lack of understanding about Nikshay App and its functionality, technological difficulties in using the Nikshay App, and the stigma associated with tuberculosis. The Nikshay App must be popularized as a notification mechanism through the NTEP program. To increase notification rates, practitioners must overcome the challenges they face. In terms of notification, more seminars and training, particularly hands-on training, should be held on a regular basis.

Effect of wearing an N95 respirator on the internal nasal valve and the association with external nasal anatomy - a cohort study.

OBJECTIVES: To determine whether: the N95 respirator affects nasal valve patency; placement on the bony vault improves patency; and external nasal anatomy affects the outcome. METHODS: A prospective study with 50 participants was conducted. Nasal patency was measured by the minimal cross-sectional area via acoustic rhinometry, and using the Nasal Obstruction Symptom Evaluation survey, before and after wearing the N95 respirator and after adjustment. RESULTS: The minimal cross-sectional area was narrowed by 27 per cent when wearing the N95 respirator (p < 0.001), and improved by 9.2 per cent after adjustment (p = 0.003). The total Nasal Obstruction Symptom Evaluation score increased from 10.2 to 25.4 after donning the N95 respirator (p < 0.001), and decreased from 25.4 to 15.6 after adjustment (p < 0.001). There was no correlation with external nasal anatomy parameters. CONCLUSION: Wearing the N95 respirator causes narrowing of the nasal valve, and adjustment onto the bony vault improves symptoms. The findings were not affected by external nasal anatomy.

Combined lateral orbitotomy and endoscopic transnasal orbital decompression in a case of orbital aspergillosis with impending intracranial invasion.

A 64-year-old man with a known history of diabetes and hypertension presented to the Accident and Emergency Department with a 2-day history of sudden decreased vision in the right eye. Temporal arteritis was suspected with an elevated erythrocyte sedimentation rate (71 mm/h), and oral prednisolone was started immediately. Four days later, the patient's right eye vision deteriorated from 0.6 to 0.05, with a grade-4 relative afferent pupillary defect and ophthalmoplegia. Computed tomography showed a contrast-enhancing orbital apex mass in the right orbit abutting the medial and lateral portions of the optic nerve with extension to the posterior ethmoid and sphenoid sinuses. A transethmoidal biopsy was performed which yielded septate hyphae suggestive of Aspergillus infection. Ten days later, the patient's right eye vision further deteriorated to hand movement with total ophthalmoplegia. MRI of the orbit showed suspicion of cavernous sinus thrombosis. A combined lateral orbitotomy and transethmoidal orbital apex drainage and decompression were performed to eradicate the orbital apex abscess. Drained pus cultured Aspergillus. The patient was prescribed systemic voriconazole for a total of 22 weeks. The latest MRI scan, performed 8 months after surgery, showed residual inflammatory changes with no signs of recurrence of the disease. To our knowledge, this is the first case report which describes the use of a combined open and endoscopic approach for orbital decompression and drainage in a case of orbital aspergillosis. We believe the combined approach gives good exposure to the orbital apex, and allows the abscess in this region to be adequately drained.

Natural history and predictors for progression of mild childhood obstructive sleep apnoea.

AIMS: The natural history of mild childhood obstructive sleep apnoea (OSA) was examined and factors associated with disease progression were identified. METHODS: Subjects were recruited from an epidemiological study which examined the prevalence of OSA in Chinese children aged 6-13 years. The first 56 consecutive children identified with mild OSA (apnoea-hypopnoea index 1-5) were invited for a repeat assessment 2 years after the diagnosis. RESULTS: 45 children participated in the follow-up study, in 13 of whom (29%) the OSA was found to have worsened. Compared with those in whom OSA had not worsened, the worsened OSA group had a greater increase in waist circumference, a higher prevalence of large tonsils (occupying > or =50% of the airway) at both baseline and follow-up, and a higher prevalence of habitual snoring at both baseline and follow-up. The presence of large tonsils had a positive predictive value of 53% and a negative predictive value of 83% for worsening OSA over a 2-year period. Multivariate linear regression analysis showed that the change in obstructive apnoea-hypopnoea index was associated with age at baseline (beta (SE) = -0.92 (0.34), p = 0.009), gender (male = 1; female = 0) (beta (SE) = 4.69 (1.29), p<0.001), presence of large tonsils at baseline (beta (SE) = 4.36 (1.24), p = 0.001), change in waist circumference (beta (SE) = 0.30 (0.09), p = 0.002) and persistently large tonsils (beta (SE) = 5.69 (1.36), p<0.001) over the 2-year period. CONCLUSIONS: Mild OSA in the majority of children does not resolve spontaneously. Subjects with tonsillar hypertrophy, especially boys, should be closely monitored to allow early detection of worsening OSA. Weight control should be stressed in the management of childhood OSA.

'Steam-boat' supraglottic laryngoplasty for treatment of chronic refractory aspiration: a modification of Biller's technique.

OBJECTIVE: The surgical treatment of intractable aspiration usually requires sacrifice of the patient's natural voice to prevent food entering the airway. Biller described a tubed supraglottic laryngoplasty to control aspiration while allowing patients to phonate with their larynx. Our preliminary experience with this technique in Chinese patients has been disappointing, as tension in the mucosa on wound closure led to wound dehiscence. Our objective was to modify Biller's technique in order to achieve a better outcome. METHOD: We modified Biller's technique by trimming the epiglottic cartilage and by inserting a tibial periosteal graft to reinforce closure of the mucosa, creating an arrangement resembling a Chinese steam boat. RESULTS: Three Chinese patients underwent the modified Biller's technique. No wound dehiscence occurred, the surgery controlled aspiration, and the patients were able to phonate with their own larynx. All patients resumed oral feeding, and previously placed gastrostomy tubes were removed. CONCLUSION: The 'steam-boat' supraglottic laryngoplasty is a viable surgical alternative to total laryngectomy or tracheal diversion for controlling intractable aspiration, and preserves a phonating larynx.

Cardiac remodelling and dysfunction in children with obstructive sleep apnoea: a community based study.

BACKGROUND: Childhood obstructive sleep apnoea (OSA) is suggested to be associated with cardiac structural abnormalities and dysfunction but existing evidence is limited and the treatment effect on echocardiographic outcome remains controversial. OBJECTIVE: To examine the presence of subclinical cardiac abnormalities in childhood OSA and the effects of treatment on cardiac changes. METHODS: Polysomnography (PSG) and echocardiographic examinations were performed in 101 children aged between 6 and 13 years who were invited from a community based questionnaire survey. They were classified into a reference group (apnoea-hypopnoea index (AHI) <1, n = 35), mild OSA group (AHI 1-5, n = 39) and moderate to severe group (AHI >5, n = 27) based on the PSG results. Treatments, including adenotonsillectomy or nasal steroids, were offered to the mild and moderate to severe OSA groups. RESULTS: The moderate to severe OSA group had greater right ventricular (RV) systolic volume index (RVSVI), lower RV ejection fraction (RVEF) and higher RV myocardial performance index (RVMPI) than the reference group. They also had more significant left ventricular (LV) diastolic dysfunction and remodelling with larger interventricular septal thickness index (IVSI) and relative wall thickness than those with lower AHI values. The moderate to severe OSA group had an increased risk of abnormal LV geometry compared with the reference group (odds ratio 4.21 (95% CI 1.35 to 13.12)). Log transformed AHI was associated with RVSVI (p = 0.0002), RVEF (p = 0.0001) and RVMPI (p<0.0001), independent of the effect of obesity. Improvement in RVMPI, IVSI and E/e' were observed in those with a significant reduction in AHI (>50%) comparing 6 month with baseline data. CONCLUSIONS: OSA is an independent risk factor for subclinical RV and LV dysfunction, and improvement in AHI is associated with reversibility of these abnormalities.

Ex-utero intrapartum treatment: a controlled approach to the management of anticipated airway problems in the newborn.

Airway problems in an unborn foetus that may cause obstruction can be safely managed using an ex-utero intrapartum technique. Advanced technology now allows many congenital airway problems to be diagnosed in the prenatal period. Careful prenatal planning of an ex-utero intrapartum treatment allows safe airway control while the foetus remains on uteroplacental support. It avoids the need for emergent intervention of an acutely obstructed airway in a neonate that often has disastrous consequences.

Video sleep nasendoscopy: the Hong Kong experience.

Video sleep nasendoscopy is a valuable technique for the study of upper airway dynamics in obstructive sleep apnea syndrome. The authors' 10-year experience with its use in Hong Kong has allowed technique refinement for safety and optimal evaluation. Its use in the evaluation of patients who snore, patients with obstructive sleep apnea syndrome, and continuous positive airway pressure titration is presented.

A case of neonatal stridor.

A case is reported of a retropharyngeal abscess in a neonate who presented with increasing stridor since birth. Group B streptococcus was cultured from the abscess contents and the maternal birth tract.

Internal carotid artery hemorrhage after irradiation and osteoradionecrosis of the skull base.

OBJECTIVE: To evaluate the clinical presentation and management of internal carotid artery rupture after irradiation and osteoradionecrosis of the skull base. STUDY DESIGN AND SETTING: A retrospective review of the patients in an otorhinolaryngology-head and neck secondary and tertiary referral center. METHODOLOGY: From January 1993 to December 1996, patients with hemorrhage from internal carotid artery as a complication of irradiation and osteoradionecrosis of skull base were reviewed and analyzed. RESULTS: Four patients with internal carotid arterial rupture were included in this study. Angiography was performed in all cases. Embolization of the aneurysm was performed on 2 patients and the remaining 2 patients underwent occlusion of their internal carotid arteries. Three of the 4 patients did not survive. The fourth is currently alive and well 18 months after embolization of 1 internal carotid artery. CONCLUSION: Skull base osteoradionecrosis with bleeding from internal carotid artery is a potentially fatal complication of irradiation. Angiography was the mainstay of diagnosis with embolization of the aneurysm and embolization or ligation of the internal carotid artery being the management options. Internal carotid artery occlusion is the definitive treatment provided cross circulation is adequate. SIGNIFICANCE: The advantages and disadvantages of the treatment options are discussed and a management protocol is proposed.

Tracheal intubation using suspension laryngoscopy in an infant with Goldenhar's syndrome.

We present a case of a ten-month-old boy with Goldenhar's syndrome and significant retrognathia in whom a tracheostomy was performed to relieve upper airway obstruction. Tracheal intubation was facilitated by direct suspension laryngoscopy using a slotted rigid laryngoscope. We propose this technique as an alternative method for tracheal intubation in infants and young children with a difficult airway. The management of the difficult airway in children with Goldenhar's syndrome is discussed.

Hereditary angioedema: report of a case.

Hereditary angioedema is caused by an absolute deficiency or the functional inactivity of C1 esterase inhibitor in plasma. A precise diagnosis is important because, unlike allergic forms of mucocutaneous edema, this condition does not respond to epinephrine, antihistamines, or corticosteroids. We report the case of a 24-year-old man who experienced an acute attack after he had stopped taking his prophylactic medication.

Video-assisted interventional bronchoscopy. The Hong Kong experience.

BACKGROUND: Major airway obstruction due to benign or malignant etiology is not uncommon and is always distressing. Intraluminal stenting has been shown to be a safe and effective approach for symptomatic relief in selected patients based on the European and North American experience. METHODS: We reviewed our experience in Hong Kong on airway stenting over a 19-month period. RESULTS: From February 1994 to August 1995, 33 silicone stents (Dumon stent, Cometh, Marseille, France) were placed in 23 patients (20 males, three females with mean age 61.4 years, range from 26 to 81). Eighteen stents were placed in the trachea, nine in the left main stem, five in the right main stem, and one Y-stent over the carina. Twelve patients had esophageal carcinoma involving the airway, seven had bronchial carcinoma, one had metastatic carcinoma, and three had benign strictures (of which two were due to tuberculosis). There was no procedural related mortality. Stent migration occurred in four patients (17%) and required stent change. Symptoms were improved in all patients as documented by the visual analogue scale. CONCLUSION: Our experience represents the "stentable" diseases seen in Hong Kong, where carcinoma of the esophagus (and tuberculosis) remains prevalent. We conclude that intraluminal stenting remains a safe and effective approach in selected patients with critical airway stenosis. Complications, however, do exist and should be realized by the operator, the patients, and their families.

Obstructive sleep apnea syndrome in a family with Crouzon's syndrome.

Craniofacial anomalies are recognized causes of obstructive sleep apnea syndrome (OSAS) in children. Current literature is limited due to rarity of cases. Furthermore, the mechanism of upper airway obstruction is not clearly understood. We would like to report a family (father and 2 sons) who are suffering from Crouzon's syndrome. The two brothers (ages 1 and 3) were found to have significant obstructive sleep apnea syndrome (OSAS) with failure to thrive. Nasal continuous positive airway pressure (CPAP) markedly improved their OSAS and resulted in accelerated weight gain. The nasoendoscopy and magnetic resonance imaging (MRI) scan taken during natural sleep showed that choanal stenosis, maxillary hypoplasia, posteriorly displaced tongue, lengthened soft palate and adenoid tissues were important in the pathogenesis of upper airways obstruction in Crouzon's syndrome. Nasal CPAP improved airway obstruction by opening a narrow slit as demonstrated by MRI. Our results suggest that OSAS occurred in children with Crouzon's syndrome and that nasal CPAP was a useful treatment modality.