Osteomyelitis of the temporal bone: terminology, diagnosis, and management.

Objectives To review the terminology, clinical features, and management of temporal bone osteomyelitis. Design and Setting Prospective study in a tertiary care center from 2001 to 2008. Participants Twenty patients visiting the outpatient department diagnosed with osteomyelitis of the temporal bone. Main Outcome Measures The age, sex, clinical features, cultured organisms, surgical interventions, and classification were analyzed. Results Of the 20 cases, 2 (10%) were diagnosed as acute otitis media. Eighteen (90%) had chronic otitis media. Nineteen (95%) were classified as medial temporal bone osteomyelitis and one (5%) as lateral temporal osteomyelitis. The most common clinical features were ear discharge (100%), pain (83%), and granulations (100%). Facial nerve palsy was seen in seven cases (35%) and parotid involvement in one case. Ten patients (56%) had diabetes mellitus. The organisms isolated were Pseudomonas aeruginosa (80%) and Staphylococcus aureus (13.33%). Histopathology revealed chronic inflammation in 20 patients (100%) and osteomyelitic bony changes in 14 (70%). Surgical debridement was the most preferred modality of treatment (87%). Conclusion A new classification of temporal bone osteomyelitis has been proposed. Bacterial cultures must be performed in all patients. Antibiotic therapy is the treatment of choice. Surgical intervention is necessary in the presence of severe pain, complications, refractory cases, or the presence of bony sequestra on radiology.

Primary otomycosis in the Indian subcontinent: predisposing factors, microbiology, and classification.

Objective. To define otomycosis and determine the predisposing factors and microbiology in primary otomycosis. Study Design. Prospective study of two years and review of the literature. Setting. Academic Department of Otolaryngology in a coastal city in India. Patients. 150 immunocompetent individuals of whom 100 consecutive patients with a clinical diagnosis of otomycosis are considered as the study group and 50 consecutive patients with no otomycosis are considered as the control group. Results and Observations. Instillation of coconut oil (42%), use of topical antibiotic eardrops (20%), and compulsive cleaning of external ear with hard objects (32%) appeared to be the main predisposing factors in otomycosis. Aspergilli were the most common isolates (80%) followed by Penicillium (8%), Candida albicans (4%), Rhizopus (1%), and Chrysosporium (1%), the last being reported for the first time in otomycosis. Among aspergilli, A. niger complex (38%) was the most common followed by A. fumigatus complex (27%) and A. flavus complex (15%). Bacterial isolates associated with fungi in otomycosis were S. aureus, P. aeruginosa, and Proteus spp. In 42% of healthy external ears fungi were isolated. Conclusion. Aspergillus spp. were the most common fungi isolated, followed by Penicillium. Otomycotic ears are often associated with bacterial isolates when compared to normal ears. Fungi are also present in a significant number of healthy external auditory canals and their profiles match those in cases of otomycosis. The use of terms "primary" and "secondary" otomycosis is important to standardize reporting.

Branchial anomalies: diagnosis and management.

Objective. To find out the incidence of involvement of individual arches, anatomical types of lesions, the age and sex incidence, the site and side of predilection, the common clinical features, the common investigations, treatment, and complications of the different anomalies. Setting. Academic Department of Otolaryngology, Head and Neck Surgery. Design. A 10 year retrospective study. Participants. 30 patients with clinically proven branchial anomalies including patients with bilateral disease totaling 34 lesions. Main Outcome Measures. The demographical data, clinical features, type of branchial anomalies, and the management details were recorded and analyzed. Results and Observations. The mean age of presentation was 18.67 years. Male to female sex ratio was 1.27 : 1 with a male preponderance. Of the 34 lesions, maximum incidence was of second arch anomalies (50%) followed by first arch. We had two cases each of third and fourth arch anomalies. Only 1 (3.3%) patients of the 30 presented with lesion at birth. The most common pathological type of lesions was fistula (58.82%) followed by cyst. 41.18% of the lesions occurred on the right side. All the patients underwent surgical excision. None of our patients had involvement of facial nerve in first branchial anomaly. All patients had tracts going superficial to the facial nerve. Conclusion. Confirming the extent of the tract is mandatory before any surgery as these lesions pass in relation to some of the most vital structures of the neck. Surgery should always be the treatment option. injection of dye, microscopic removal and inclusion of surrounding tissue while excising the tract leads to a decreased incidence of recurrence.

A rare case of suppurative aspergillosis of the thyroid.

Suppurative fungal infection of the thyroid is an extremely rare condition even more so in an immunocompetent patient. Fungal infections of the thyroid usually occur in immunocompromised patients with hematological malignancies, recipients of bone marrow and solid organ allografts on immunosuppression, and patients with AIDS. A 65-year-old male presented with swelling in the front of the neck for 2 years. Examination revealed a 4 × 4 cm non-tender, firm swelling of the right lobe of the thyroid. The patient was taken up for a subtotal thyroidectomy. Intra-operatively, an abscess cavity with pus was found in the right lobe of the thyroid. Histopathology revealed features of fungal abscess and staining demonstrated fungal hyphae characteristic of Aspergillus ssp.

Grievous temporal and occipital injury caused by a bear attack.

Bear attacks are reported from nearly every part of the world. The chance of a human encountering a bear increases as the remote bear territory diminishes. The sloth bear is one of the three species of bears found in India, which inhabits the forests of India and its neighboring countries. Here we describe a teenager who came to us with a critical injury involving the face, temporal and occipital bones inflicted by a sloth bear attack. He underwent a temporal exploration, facial nerve decompression, pinna reconstruction, and occipital bone repair to save him from fatality.

Carcinoma ex pleomorphic adenoma of the maxillary sinus: a case report.

A 52-year-old woman presented to the ENT clinic with a huge swelling on the right side of her face that had originated 6 years earlier. The mass was ultimately diagnosed as a carcinoma ex pleomorphic adenoma of the maxillary sinus. Carcinoma ex pleomorphic adenoma itself is uncommon, and its origin in the maxillary sinus is very rare. We discuss the presentation, histopathologic picture, and management of this case.

Osteomyelitis of the temporal bone in identical twin infants.

Osteomyelitis of the skull base almost always occurs in elderly patients with diabetes; however, it may occur in patients with compromised immune function regardless of their age. We present the cases of a pair of immunocompetent, 2-year-old identical twins who experienced osteomyelitis of the temporal bone almost exactly 1 year apart. An incident such as this, in this age group, has never been reported in the literature.

Assessment of Operative Blood Loss and the Factors Affecting it in Tonsillectomy and Adenotonsillectomy.

To estimate the average operative blood loss in tonsillectomy and adenotonsillectomy and the various factors affecting it. A prospective study of estimation of blood loss in 100 patients who underwent tonsillectomy and adenotonsillectomy. Data collected included the age, sex, operative indication, clotting time, Hb levels and usage of pre-operative antibiotics. Cold knife dissection method for tonsillectomy and curettage method for adenoidectomy were used. Measurement by calorimetric method of estimation being simple and accurate was used for estimation. Study undertaken at a tertiary referral hospital catering to an urban, semi-urban and rural populace. Blood loss was more in males and increases as age advances both in adenotonsillectomy and tonsillectomy. Blood loss was more in fibrosed tonsils, at lower hemoglobin levels and at higher clotting times. It was less in cases who received pre-operative antibiotics. The average blood losses in males and females during tonsillectomy were 106.91 and 96.26 ml respectively. In adenotonsillectomy, the average blood losses in males and females were 81.44 and 76.82 ml respectively. In our series we found that blood loss in tonsillectomy and adenotonsillectomy depended on various factors like age, sex, the type of tonsillitis, method of dissection, hemoglobin concentration, clotting time and the use of antibiotics. All these factors must be taken into consideration while taking up patients especially those who cannot tolerate blood loss, for surgery.

Spontaneous arteriovenous malformation of the ear.

Arterio-venous (A-V) malformations of the ear are uncommon lesions. While most are secondary to trauma, spontaneous lesions are very rare. A-V malformations anywhere in the body can have a range of clinical effects from mild disfigurement to cardiac failure. Treatment of these lesions poses a challenge to the surgeon due to their extreme vascularity and high incidence of recurrence. Highly selective arterial embolization and surgical resection offer the best chance for cure. In this article, the authors present a case of acquired A-V malformation of the ear, which was treated successfully by surgical excision without pre-operative embolization with no recurrence on follow-up proving that in areas of easy and superficial access, a pre-operative embolization need not be routinely carried out in cases of small to medium sized vascular tumors.

Paragangliomas of the Head & Neck: the KMC experience.

To determine the clinical features, investigations, intra-operative findings, surgical approaches used and the results of the treatment for paragangliomas of the head and neck. Retrospective study of 14 cases of paragangliomas in head and neck seen over a period of 10 years including five carotid body tumors, seven glomus jugulares and two glomus tympanicums. HRCT scans and bilateral carotid angiography were done in all cases of glomus jugulare. Pre-operative embolization was done in most cases. The trans-cervical approach was used for all cases of carotid body. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare tumors. Postaural tympanotomy approach was used for both patients with glomus tympanicum. In one case of extratympanic glomus jugulare tumor with hypoglossal palsy, a neck exploration was done to isolate and excise the tumor. Five patients with carotid body tumors presented as unilateral, painless, pulsatile swelling in the upper neck. Intra-operatively, three of the tumors were classified into Shamlin's Grade II and one each into Grade III and Grade I. A carotid blow-out occurred in one of the patients with Grade II disease, which was managed. ECA resection had to be done in one case. Seven patients were diagnosed to have glomus jugulare and two with glomus tympanicum. Six glomus jugulare tumors presented with hearing loss, ear discharge and obvious swelling. Glomus tympanicums presented with hearing loss but no bleeding from the ear. On examination, tumors presented with an aural polyp with no VII nerve deficits. Both tympanicums were classified as Fisch Type A, three of the jugulares classified as Type B, two as Type D2 and one as Type D1. Tumors were found to be supplied predominantly by the ascending pharyngeal artery. In three cases of Type B jugulare tumors, a post-aural tympanotomy was used. A Fisch Type A approach was done for three cases of Type D jugulare. The transcanal approach was used for both patients with glomus tympanicum. Paragangliomas are uncommon tumors that need accurate diagnosis and skilled operative techniques. Though the surgical approaches may appear complicated, the removal provides good cure rates with minimal morbidity and recurrence. Lateral skull base approaches should be the armamentarium of every head and neck surgeon.

Assessment of eustachian tube function in tympanoplasty.

OBJECTIVE: A clinically useful test for eustachian tube function (ETF) is still lacking. Here we plan to evaluate the mucociliary function of the ET by saccharin and methylene blue test, and compare the outcome of surgery with normal and abnormal ET functions. STUDY DESIGN: Case series with planned data collection. SETTING: Department of Otolaryngology-Head and Neck Surgery, Kasturba Medical College, Mangalore (Manipal University), a tertiary care center in South India. SUBJECTS AND METHODS: This study comprised 86 patients diagnosed with mucosal chronic otitis media in quiescent/inactive stage. All were subjected to a detailed clinical examination and investigations. Preoperative evaluation of ETF was compared with postoperative outcome of surgery, and the results were analyzed. RESULTS: The saccharin test and methylene blue dye test had a good correlation in evaluating ETF. The mean value for saccharin perception time and the clearance time for methylene blue were 17.5 and 8.1 minutes, respectively. ETF was best in anterior, worst among posterior, and intermediate in subtotal perforations. Type 1 tympanoplasty was successful in 94 percent with normal ETF and in 68 percent with partial dysfunction. CONCLUSION: The saccharin test is a simple, cost-effective, and valuable diagnostic tool to assess the mucociliary function of the ET. The outcome of middle ear surgery would be a success in normal ETF, whereas in partial dysfunction the outcome need not necessarily be a failure.

Management of head and neck trauma in a developing country.

PURPOSE: To investigate cases of trauma in head and neck region; to elucidate the characteristic problems in a developing country. DESIGN AND SETTING: Prospective study; 324 patients with trauma related to head and neck analysed in a tertiary care center from August 1999 to August 2005 RESULTS: 33.6% of patients fell in 21-30 year age group. Road traffic accidents (41.4%) were the most common cause of trauma. Nasal bone fractures were the most common fractures. 72.84% presented with bleeding and 72.22% with pain. 92.9% had tenderness. Only 15% of the patients could afford a CT scan. Plain radiograph diagnosed fractures in 83.33% of cases. ORIF was the treatment of choice in cases of fractures of the zygoma, maxilla and mandible. Open reduction and internal fixation (ORIF) gave good long-term results with satisfactory cosmosis. Most of our patients did not have any significant sequelae. Cerebral concussion was the most common associated injury (35.48%). CONCLUSION: In developing countries, one cannot follow the approaches used for RTAs in developed countries. Treating surgeons will have to select investigation tools and treatment options according to the socioeconomical and cultural variations, which differ from country to country, and also within different parts of the country.

Extensive sphenoethmoid mucocele--an endoscopic management.

Sphenoethmoidal mucoceles are rare tumors. They gradually expand in size and rarely produce bony destruction of sinus walls, leading to orbital, ocular, and intracranial involvement. We present a rare case of sphenoethmoidal mucocele with bone destruction and intracranial extension, who presented with nasal blockade and loss of visual acuity. Computed tomographic scan revealed a soft tissue mass, eroding the base of anterior cranial fossa, extending intracranially into the parasellar temporal fossa. The patient was treated successfully by endoscopic excision. Although a transfacial approach is generally preferred in cases of extensive mucoceles with intracranial extensions, a thorough anatomy of the nasal skull base and proficient use of the endoscope can be a good alternative to such lesions.

Laryngoceles - presentations and management.

INTRODUCTION: Laryngoceles usually present as cervical masses with or without hoarseness of voice. They are mostly unilateral and may be symptomatic or asymptomatic. They are classified as internal, external or combined. They have been described to be an occupational hazard among wind instrument players or glass blowers. They also occur in association with neoplasms of the larynx. MATERIALS AND METHODS: Here we report five patients with laryngoceles of whom two had bilateral laryngoceles, which are very rare. One patient had associated laryngeal malignancy for which total laryngectomy was performed. Two cases underwent excision via cervical approach. The rest were managed conservatively. CONCLUSION: Symptomatic cases have to be managed surgically while asymptomatic ones may be managed conservatively.

Endoscopic-assisted excision of esthesioneuroblastoma.

The purpose of this article is to report a case of esthesioneuroblastoma involving the bilateral paranasal sinuses, which was excised using an endoscopic-assisted transfacial approach. A patient presented with nasal swelling and left-sided nasal obstruction, epistaxis, and diplopia. Examination revealed broadening of the nasal dorsum with a fleshy pink mass in both nasal cavities. Computed tomographic scan showed a mass involving the nasal cavity and paranasal sinuses on both sides. The tumor was diagnosed as group C esthesioneuroblastoma. The mass was excised by bilateral medial maxillectomy and bilateral frontoethmoidectomy. Using a 0 degrees endoscope, the attachment of the tumor to the cribriform plate was identified and resected using a motordrill. On Waroff staining, Hispathology slides suggested esthesioneuroblastoma. The patient was asymptomatic for 1 year, following which he developed infection of the nasal cavity for which he had no form of treatment. He subsequently developed maggots in the nasal cavity after which he died. An endoscopic resection of the cribriform plate from the nasal cavity without a formal craniofacial resection can be safely performed with oncologic safety.

Osteomyelitis in the head and neck.

CONCLUSION: All bones of the facial skeleton and spine are susceptible to osteomyelitis due to various predisposing conditions. Current radiological tools are sufficient to provide adequate diagnosis. Treatment can be conservative resection of the diseased bone with adequate clearance in all cases except in cases of osteomyelitis due to osteoradionecrosis (ORN) where resection has to be more radical. OBJECTIVE: In today's antibiotic era, osteomyelitis in the head and neck is a rare occurrence. Dealing with osteomyelitis in head and neck bones is not the same as in other bones of the body due to the nature of the bones, complex anatomy of the region, and esthetics. Our purpose was to analyze the behavior of osteomyelitis in the head and neck bones and its management. MATERIALS AND METHODS: A total of 84 cases of osteomyelitis in head and neck were reviewed in a 10-year period. Pus for culture, antibiotic sensitivity, and radiology were the main investigations. A medical line of treatment was effective in acute cases. Surgery was opted for in chronic cases. RESULTS: Mandible, frontal bone, cervical spine, maxilla, temporal bones, and nasal bones were involved, in descending order of frequency, i.e. the mandible was the most common bone affected. Nine patients were diagnosed as having acute osteomyelitis (11%); 75 were diagnosed as having chronic osteomyelitis (89%). Radiation-induced ORN leading to osteomyelitis was the most common cause of osteomyelitis of the mandible (13 of the 32 cases; 41%). Odontogenic infections and chronic sinusitis each gave rise to osteomyelitis in 3 of 10 cases (30%) of the patients with osteomyelitis of the maxilla. Chronic sinusitis was the main cause of frontal bone osteomyelitis in all 20 cases (100%). Tuberculosis (10 of 15 cases; 67%) and malignancy (5 of 15 cases; 33%) were the main predisposing factors in cervical spine osteomyelitis. Malignant external otitis (MEO) with diabetes mellitus was an underlying factor in all four cases of osteomyelitis of the temporal bone. Of the 18 patients with a diagnosis of ORN, the mandible was found to be the most susceptible bone (13 cases; 72%), followed by the maxilla (four cases; 22%) and cervical spine (1 case). Acute osteomyelitis responded to antibiotics. Sequestrectomy was carried out in all chronic cases but in cases of ORN more radical surgery was performed.

Thyroglossal duct cyst: an unusual presentation.

Most thyroglossal duct cysts are located at or very close to the midline. They generally manifest as painless neck swellings, and they move on protrusion of the tongue and during deglutition. We describe a case of thyroglossal duct cyst that was unusual in that the cyst was located far from the midline, it did not move on protrusion of the tongue, and it was associated with symptoms of dysphagia and extensive neck swelling that mimicked a colloid goiter

Early oral feeds in laryngectomized patients.

OBJECTIVES: It is a common practice to start oral feeding after 7 to 10 days in patients who have undergone laryngeal surgeries. It was our observation that when oral feeds were initiated earlier than this period, there was no increase in the incidence of pharyngocutaneous fistulas. This prospective study is about our experience in initiating early oral feeds in the postoperative period (on the 2nd day) in laryngectomized patients. METHODS: Seventy-eight patients underwent laryngectomy with or without partial pharyngectomy over a period of 38 months between October 2001 and December 2004. The oral feeds were initiated on the 2nd postoperative day in 40 patients. Thirty-eight patients served as controls in whom feeds were initiated after the 10th postoperative day. RESULTS: Only 1 patient in the study group and 2 patients in the control group developed pharyngocutaneous fistulas. Most patients in the control group wished to avoid nasogastric intubation in the recovery period because of discomfort, gastric symptoms, and the need to taste food. CONCLUSIONS: With this study we can assume that in a select group of patients, it is possible to initiate oral feeding much earlier in the postoperative period than was formerly thought.

Congenital laryngeal saccular cyst: report of a case in an infant.

Respiratory obstruction and stridor in infants and children are not uncommon. A rare cause of these life-threatening symptoms is congenital saccular cyst. An accurate diagnosis of saccular cyst can be made by eliciting a good history, by endoscopic visualization of the lesion, and by computed tomography. Endoscopic excision is the preferred treatment for infants, whereas an external approach is reserved for older children. It can be difficult for anesthetists to intubate infants when the anatomy of the larynx is distorted, but the choice of tracheotomy for an infant has many drawbacks as well. We discuss the clinical presentation and management of a 3-month-old boy who was brought to us with a congenital laryngeal saccular cyst.