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.

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 3rd­5th 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.

Negative pressure pulmonary oedema following adenoidectomy under general anaesthesia: a case series.

BACKGROUND: Negative pressure pulmonary oedema (NPPE) is a potentially life-threatening complication of laryngospasm that occurs during or after general anaesthesia. It is a complication of poorly treated or unrecognized laryngospasm occurring at extubation or later in the postoperative period. OBJECTIVE: To emphasize prompt recognition of laryngospasm during or after general anaesthesia and to prevent its progression to NPPE in a resource-challenged environment. METHODS: Three children aged two to four years, one of whom was a known sickle cell anaemia patient presented with adenoid hypertrophy. Surgery was postponed on account of upper respiratory tract infection in each of them. RESULTS: Following treatment of upper respiratory tract infection, they had adenoidectomy under general anaesthesia. They all developed severe laryngospasm at extubation. This progressed to NPPE which was diagnosed on clinical parameters. The children were subsequently admitted to the intensive care unit (ICU) for mechanical ventilation with high FiO2 (0.7-1) and PEEP between 12-24hours. While two of the children survived, the child with sickle cell anaemia died in the ICU. CONCLUSION: Negative pressure pulmonary oedema is a self limiting complication of laryngospasm if it is well managed. However, its outcome may not be good in a patient with intercurrent medical illness such as sickle cell anaemia in which hypoxaemia is deleterious.

Nasal osteogenic chondrosarcoma: a case report.

BACKGROUND: Osteosarcomas and chondrosarcomas are the most common malignancies of the jaw bones. Nasal osteogenic chondrosarcoma is rarely reported. OBJECTIVE: To draw attention to a rare tumour, osteogenic chondrosarcoma. METHODS: A middle aged woman presented with a three month history of nasal blockade and mucopurulent discharge. She was fully clinically evaluated including anterior rhinoscopy and plain radiograph. RESULTS: Detailed history, physical examination and plain radiography showed features suggestive of antrochoanal polyp with differential diagnoses of sino nasal and nasopharyngeal tumour. At emergency tracheostomy, examination under anaesthesia, meticulous nasal and nasopharyngeal tumour clearance was done. Histopathological examination of the mass revealed osteogenic chondrosarcoma. CONCLUSION: Though rare, osteogenic chondrosarcoma affects nasal bones. Clinically the tumour mimicks an antro-choanal polyp and is associated with the challenge of recurrence.

Challenges of Otolaryngologic Referral in a Nigerian Tertiary Hospital

Background: The referral system offers one strategy for making the best use of hospitals and tertiary healthcare services. The aim of this study was to analyze the referral system of patients to the otorhinolaryngologist and to examine the use of in-house referral system in the teaching hospital set up. Methods: This was a retrospective review of all patients referred to the ENT Department between January 2000 and December 2007. Data retrieved from all referral notes included the review of referral letter; demographic; referral status; clinical presentations and examination findings. These data were entered into the SPSS computer software version 11.0 and analysed Results: A total of 1402 cases were analyzed. The patients' ages ranged from 3weeks to 90yrs; with 70.4of cases being below 40yrs of age while 25.9were between 40-64yrs and 3.7were above 65yrs. The Male to female sex ratio was 1:1. The majority (70.4) of the patients had at least primary school education. The rest (29.6) had no formal education. Slight over half (51.5) of the patients were unemployed. The rest were either civil servants or self employed. Out of the 1402 patients that were referred to the hospital; in-house referral accounted for 74.1; 7.2of came from private health facility and 4.3were self referrals. Out of the 1038 in-house referrals; 42.8were from GOPD; 5.0from Staff clinic; 13.3from surgery; 4.7from medicine; 3.5from Obstetrics and Gynaecology; 10from paediatrics and 10.4from ophthalmology and 10.3from ENT staffs such as residents; ENT Nurse Practitioner and ENT supporting staffs such as speech therapist and audiologist. Conclusion: The challenges of referral to the otolaryngologists are enormous thus the need to organize continuous medical education for the family physician; to make patients have confidence in the primary care physician; early referral of patients and to allow the otorhinolaryngologist to focus on the cutting edge issues of the specialty

Day case adenoidectomy: is it safe?

OBJECTIVE: To document the Clinical outcome of Day Case Adenoidectomy in Children in a Nigerian tertiary health Institution and a private Ear, Nose and Throat Consultant Cinic. METHODOLOGY: This is a prospective study of twenty eight children without any co-morbid condition operated for adenoidectomy between June 2002 and May 2004. The patients were admitted on the day of surgery and discharged within 12 hours post surgery. RESULT: A total number of 28 patients were operated for adenoidectomy. 16 children were treated as planned day cases and 12 were treated as inpatients. 50% of the patients were in the age group of 2-4 years. There were 12 males and 4 females with a M:F ratio of 3: 1. All the parents of the patients had access to cars and 75% resided within 30 minutes of travelling time from the hospital. CONCLUSION: Day case adenoidectomy is relatively safe and may prove advantageous considering long surgical waiting lists, preventing Hospital acquired infection and minimizing cost of hospitalization.

Parental satisfaction with post-adenotonsillectomy in the developing world.

AIM/BACKGROUND: Tonsillectomy with or without adenoidectomy is one of the most commonly performed surgical procedures by the otolaryngologists in the pediatric population. The aim of this study is to evaluate parental expectation and satisfaction following tonsillectomy with or without adenoidectomy. MATERIALS AND METHODS: Hospital-based prospective study of all consented parents whose children had tonsillectomy with or without adenoidectomy over a period of 13 months (February 2008 to February 2009) using a cross-sectional method. Pre- and post-surgical questionnaire-based Interview was conducted for them and information retrieved included biodata, pre- and post-surgical symptoms on follow-up in the clinic of obstructive sleep apnoea, snoring, mouth breathing and rhinorrhea, parental expectation and satisfaction after surgery. All data were entered into statistical data using SPSS version 11 and analyzed and the results are presented in tables and figures. RESULTS: A total of 29 patients had adenotonsillar surgery, who were within the age range of 1.50-14 years with a mean age of 5.50 (SD=4.06+/-0.75). M:F ratio was found to be 3:1 (22 males and 7 females). Parents were satisfied with the expected outcome in terms of symptoms post-operatively in 96.6% while only one 3.4% were not satisfied. CONCLUSION: Majority of the parents (96.6%) were satisfied with the expectation of immediate resolution of symptoms; however, obstructive adenotonsillar hypertrophy remains an important problem to be solved to achieve total parental satisfaction in adenotonsillar operations.

Neuro-ophthalmic manifestation of nasopharyngeal carcinoma at Ilorin: a five year review.

BACKGROUND: Patients with Nasopharyngeal Carcinoma (NPC) may present with neuro-ophthalmic symptoms including visual loss. Involvement of the cranial nerves have been found to impact significantly on the individual's 5 year survival rate, which makes an early diagnosis of this condition of great importance in the management of NPC. MATERIAL AND METHODS: A retrospective review of all patients with clinical and histological diagnosis of NPC over a five year period between 1999 and 2003 was carried out. Information retrieved from the records include their age, symptoms and signs with emphases on neuro-ophthalmic at presentation. Data were analysed using SPSS statistical package. RESULT: Twenty records out of the 23 patients with a diagnosis of NPC seen during this period were available for review. The age range was between 20 and 60 years, the Mean was 38.9 years, SD 11.62. Sixty percent of the patients had neuroophthalmic manifestation with symptoms such as ocular pain, double vision, loss of vision and eye protrusion and signs such as ophthalmoplegia, exposure keratopathy and proptosis in various combinations. CONCLUSION: Neuro-ophthalmic manifestations were commonly found among patients diagnosed as NPC at Ilorin. A high index of suspicion of NPC whenever a patient presents with neuro-ophthalmic signs and symptom is advocated.

Aural foreign bodies in children.

OBJECTIVE: Foreign body in the ear is commonly encountered in children by primary care givers, emergency department Physicians, Pediatricians and Otolaryngologists worldwide. METHODS: We reviewed cases of aural foreign bodies in children seen in our centre over a five-year period with the aim of auditing our current practice and suggesting possible improvements suited for developing countries. RESULTS: Grains and seeds (27.9%), beads (19.7%), cotton wool (13.6%), paper (8.8%) and eraser (8.2%) formed the bulk of the aural foreign bodies. About 96% was removed without general anesthesia by using Jobson Horne's probe or aural dressing forceps (73.8%) under direct vision; or by syringing (22.1%). Some 4% had to be removed in the operating theatre under general anesthesia. The complications observed include bruise or laceration and bleeding from the external auditory canal (16.3%), otitis externa (6.5%) and traumatic perforation of the tympanic membrane (1.7%). CONCLUSION: Despite a high proportion of cases managed in the office setting, complication rates were within acceptable levels. There is need to develop practical criteria that will be beneficial to primary health care givers to determine which patients could be managed in the primary care setting with acceptable outcome.

Profound bilateral sensorineural hearing loss in nigerian children: any shift in etiology?

Deafness, profound hearing loss, is a global problem. However, the causes of, attitudes toward, and management options for deafness differ considerably from region to region. This study seeks to identify the present causes of profound sensorineural hearing loss in Nigeria, which in our environment is almost synonymous to a life sentence of silence and isolation. This is a retrospective survey of children 15 years and below (M = 6.7 years, SD = 3.2). Of the 115 children included in this study, 64 (55.7%) were males, giving a male:female ratio of 5:4. Age group 1-3 years had the highest proportion of hearing loss, 33 (28.7%), and there was a progressive decline in frequency with advancing age. In about a third (34.8%) of patients, causes were unknown, probably congenital. The main acquired causes were febrile illness (18.3%), measles (13.9%), meningitis (8.7%), mumps (6.9%), or severe birth asphyxia (4.3%). Compared to the findings of two decades ago, we conclude that there is no significant shift yet in the etiology of profound sensorineural hearing loss in our environment.

Acute laryngeal obstruction in a Nigerian Hospital: Clinical presentation and management.

OBJECTIVES: To determine the clinical presentations and management of patients with acute laryngeal obstruction. PATIENTS AND METHODS: A retrospective study of 36 patients with acute laryngeal obstruction to the accident and emergency unit (A&E), emergency paediatric unit (EPU) and the Ear, Nose and Throat diseases clinic (ENT) of the University of Ilorin Teaching Hospital between January 1998 and the December 2002 are presented. RESULTS: The age ranges of the patient were between 1.5 years to 46 years (mean age 29.6 years with male/female ratio of 2:1 Breathlessness (83.3%), hoarseness (66.7%), and noisy breathing (50%) were the main symptoms at presentation. CONCLUSIONS: These 36 patients represented 4.9 % of the in-patients seen by the Otolaryngologists during the period under review and 75% of cases of acute upper airway obstruction managed during this period. The commonest cause of obstruction in this study was laryngeal tumours (47.2%)-laryngeal carcinoma (27.8%) in the adults and juvenile laryngeal papillomas (19.4%) in the paediatric age group; other causes were laryngeal infections (acute and chronic) represented 20% of aetiologic factors. Impacted laryngeal foreign bodies occurred in 5(13.9%) all in the paediatric age group. Eleven (30.6%) were managed conservatively with antibiotics and antikoch's therapy; 12(33.3%) had emergency tracheostomy prior to definitive treatment of direct laryngoscopy in 10 patients (27.8%) for biopsy, removal of foreign bodies and extirpations of juvenile laryngeal papillomas and 3(8.3%) were managed by endotracheal intubations. Health education of the public is recommended to ensure early presentation in hospital as soon as symptoms of laryngeal tumours are noticed and health care providers should refer such cases early.