The Varied Presentations of Sinonasal Region Schwannomas: Apropos of Four Cases.

Schwannomas of the sinonasal compartment are rare benign neoplasms of peripheral nerve sheath origin and constitute ~ 4% of all head and neck schwannomas. The presentation may simulate a range of benign and intermediate grade pathologies. Management involves surgical excision via open or endoscopic approach. To describe the clinico-epidemiological characteristics and surgical outcomes in sinonasal region schwannoma patients operated at our institute. The study is a descriptive case series of patients with sinonasal region schwannomas treated at our institution. A retrospective search of electronic database of the Department of ENT and Head and Neck Surgeries and Department of Pathology was conducted from January 2013 to January 2019. The various demographic and clinical details of the patients were extracted. A total of four patients operated for sinonasal region schwannoma were identified. The involved sites were nasal dorsum, nasal cavity, pterygopalatine fossa and infratemporal fossa. The mild, non-specific symptoms resulted in patients ignoring their symptoms for a while initially and presenting late. The nasal dorsum lesion was revealed as a surprise during open rhinoplasty for correction of nasal deformity. Complete excision was achieved in all the cases and no recurrence has been noticed during the follow up (varying from 6 months to 6 years) till date. The diverse clinical manifestations and approaches to the treatment of schwannomas in this specific region are discussed. The surgical excision is the standard of care in dealing with these neoplasms. This series highlights the rarity of this pathology in the sinonasal area, diagnostic surprises and the decision making to choose the correct surgical approach for complete excision. Once excised completely, recurrence is not expected.

Unusual cause of recalcitrant epistaxis.

Nosebleeds are among the most familiar presentations to the emergency department as well as otorhinolaryngologic outpatient services. Bleeding from nasal septal branches of the anterior ethmoid artery (AEA) is common and can be effectively controlled endoscopically. However, the bleeding from a pseudoaneurysm involving the nasal septal branches of AEA is extremely rare and can be troublesome to control using endoscopic methods. We report an adult patient presenting with profuse nasal bleeding postroad traffic accident due to the formation of AEA septal branch pseudoaneurysm. The patient required repeated nasal packing, and the diagnosis was revealed using digital subtraction angiography. Since profuse active bleeding precluded endoscopic visualisation, an external approach had to be adopted to ligate the AEA to control the bleeding. We discuss the management options and nuances for this rare cause of the troublesome nasal bleeding.

Unusual cause of dysphagia and dysphonia.

Forestier's disease is an idiopathic noninflammatory condition associated with enthesopathy leading to hyperostosis of the vertebrae and peripheral skeletal system. The disease tends to affect elderly individuals and remains asymptomatic in most of the cases. Uncommonly, the patient may present with upper aerodigestive symptomatology, usually dysphagia. In elderly individuals, the disease may closely mimic upper aerodigestive tract malignancy, which should be actively excluded. In our patient, the hypopharyngeal soft tissue distortions created by the bony hypertrophy shifted the clinicoradiological suspicion towards malignant pathology. The current case presents the diagnostic dilemma associated with the disease and the need to keep the possibility of severe cervical bony hypertrophy as a cause of upper aerodigestive symptoms in mind.

Idiopathic Isolated Nasal Amyloidosis: Report of a Rare Case with Review of Literature.

Deposition of amyloid in localized form is rare and most often involves head and neck region. Localized amyloidosis carries good prognosis with surgical debridement offering symptomatic benefit. We present an adolescent male presenting with localized sinonasal amyloidosis managed previously with conservative surgical debridement. The patient was symptomatic from early childhood and the previous histopathological reports were non-specific inflammation. A repeat biopsy revealed features of amyloidosis and retrospective review of past slides revealed the same. On explaining the course of the disease and prognosis, the patient opted for regular follow up. A pertinent comprehensive literature review of the condition is discussed.

A randomized study to compare palonosetron with ondansetron for prevention of postoperative nausea and vomiting following middle ear surgeries.

BACKGROUND AND AIMS: Postoperative nausea and vomiting (PONV) has multifactorial etiology. It is a commonly encountered morbidity after anesthesia specially following middle ear surgery. Various antiemetic medications have been tried with mixed responses. Palonosetron is a newer 5-hydroxytryptamine (5-HT3) receptor antagonist marketed for PONV prophylaxis. This study was designed to compare the efficacy of palonosetron and ondansetron in preventing PONV after middle ear surgeries. MATERIAL AND METHODS: One hundred patients of ASA class 1 or 2, aged 18 years and above, weighing between 40 and 90 kg scheduled for elective middle ear surgeries were randomly assigned into palonosetron group (n = 50) and ondansetron group (n = 50). Palonosetron was administered in dose of 1 mcg/kg maximum up to 75 mcg and ondansetron in dose of 0.1 mg/kg maximum up to 8 mg. Intraoperative monitoring of QTc interval was also done to see any significant change after the antiemetic administration. The incidence of nausea, vomiting, and side effects were recorded over 2, 12, and 24 hours postoperatively. All parameters were compared between the two groups as mean ± standard deviation and as count (%). Two sided P values of <0.05 were considered significant. RESULTS: The incidence of PONV (P = 0.002), nausea (P = 0.0002) and vomiting (P = 0.006) was significantly lower in palonosetron group than in ondansetron group in 2- to 12-hour period. QTc interval prolongation, a known side effect of ondansetron was not found in palonosetron group intraoperatively. CONCLUSION: Palonosetron was found to be superior to ondansetron up to 12 hours after the surgery with no significant effect on QTc interval.

A Wolf in Sheep's Clothing: Keratosis Obturans Causing Facial Nerve Palsy - A Case Report with Review of the Literature.

Keratosis obturans is a benign disease caused by layered impaction of wax within the external auditory canal. It presents with acute onset of pain and ear blockade. The current report discusses a 24-year-old male patient with recurrent unilateral keratosis obturans associated with facial canal erosion and resulting in facial palsy. A detailed review of the literature is presented. Keratosis obturans can behave aggressively, resulting in significant erosion of the bone and intratemporal structural damage and complications. Timely intervention is vital.

Oral Cysticercosis: A Case Series and Review of Literature.

The cysticercus is the larval form of the pork tapeworm. Oral cavity involvement of cysticercosis is rare but frequently reported from developing countries. This report presents 3 cases of oral cysticercosis involving the tongue and buccal mucosa in isolation. All 3 patients were treated with surgical excision and had an uneventful postoperative course. A brief review of the PubMed English-language literature search is presented. Oral cavity involvement with cysticercosis presents a diagnostic dilemma. Management is primarily surgical and carries an excellent prognosis.

Bilateral Tonsillar Enlargement as a First Manifestation of Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma with an Unusual Interfollicular Pattern of Infiltration.

Tonsillar lymphoma usually presents as unilateral or bilateral enlargement or as an ulcerative or fungating lesions. Most lymphomas that involve the tonsils are diffuse large B-cell lymphomas and primary low grade lymphomas are exceptional. We report a case of primary B-cell chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) affecting tonsils with interfollicular pattern of infiltration in a 54-year-old female who clinically presented with bilateral tonsillar enlargement, sore throat, dysphagia and respiratory difficulty, unresponsive to the conservative treatment. To the best of our knowledge, till date only six cases of CLL/SLL infiltrating tonsils have been reported in the English literature, three of these were known cases of CLL/SLL prior to tonsillectomy. In the present case diagnosis of CLL/SLL was first time established on tonsillar histomorphology and that too with an unusual interfollicular pattern of infiltration.

Large pedunculated fibrovascular polyp of oesophagus in a young woman.

A 25-year-old female patient with a history of progressive dysphagia of one year duration was detected to have intraluminal polypoidal mass in the oesophagus on barium contrast study and computed tomography. Direct laryngoscopy and flexible endoscopy confirmed the origin from pharyngo-oesophageal junction. Lateral cervical oesophagotomy and excision of a polypoidal mass of 15x6.5x3 cm size was done. Histopathology revealed fibrovascular polyp (FVP) arising from submucosa of oesophagus. FVP is a benign tumour-like condition which can attain an enormous size inside the lumen of the oesophagus. It predisposes the patient to aspiration due to incomplete vocal cord adduction and asphyxia due to possible laryngeal inlet block and thus, threatening life. Complete surgical excision through lateral oesophagotomy is the standard treatment and provides cure in the majority of cases.

Variable extent of emperipolesis in the evolution of Rosai Dorfman disease: Diagnostic and pathogenetic implications.

This study examines variation of morphologic features, including emperipolesis, during the evolution of a case of Rosai Dorfman Disease (RDD). A 44-year-old male patient with RDD affecting the salivary glands, cervical lymph nodes, nasal and maxillary sinus mucosa had a waxing and waning course over two and a half years, with episodic sudden increase in size followed by involution and then a static course with moderate sized swellings. Multiple aspirations and biopsies were performed, which form the basis of this study. Four classical cases of RDD on aspirates and another four on biopsy were analyzed for comparison, with quantification of the number of lymphocytes engulfed by histiocytes (emperipolesis). Three nasal biopsies and one salivary gland excision of the index case, performed during acute exacerbation, showed chronic inflammation and foamy histiocytes without emperipolesis, the aspirate showing emperipolesis nil in 45%, 1-3 lymphocytes in 15%, 4-10 in 36% and > 10 in 4%. Two aspirations and one lymph node biopsy done from static phase showed classical features of RDD with extensive emperipolesis, the aspirate from left cervical lymph node showing emperipolesis nil in 2%, 1-3 in 5%, 4-10 in 35% and > 10 in 58% while right cervical lymph node aspirate showed emperipolesis nil in 9%, 1-3 in 21%, 4-10 in 29% and > 10 in 41%. A biopsy performed from involuting cervical lymph node showed extensive apoptosis and vasculitis without foamy histiocytes or emperipolesis. For comparison, eight classical RDD cases showed abundant emperipolesis with mild variation. Emperipolesis is variable in RDD depending on disease activity, which has differential diagnostic relevance and demonstrates the natural history of this rare disease.