The Role of Surgery in the Treatment of Cervical Lymph Node Tuberculosis.

Cervical lymph node tuberculosis is a public health problem in Morocco and the rest of the world. Its paucibacillary nature makes diagnosis and treatment difficult. This is a descriptive-analytical retrospective study presenting 104 cases of patients with manifestations of cervical lymph node tuberculosis confirmed by pathological examination (100%), associated in some cases with positive bacteriology (40.6%), treated and followed up in the otolaryngology (ENT) department of the Cheikh Khalifa International University Hospital (HUICK) over a period of 5 years and 9 months (from January 01, 2017, to September 30, 2022). In our study, 14 patients (i.e., 13.5%) had a history of tuberculosis (all locations); only four (i.e., 3.8%) of them had confirmed cervical lymph node tuberculosis, of which three were still under treatment: two of them presented for treatment failure (i.e., 1.9%) and one patient for a paradoxical reaction (i.e., 1%). Three pulmonary locations (i.e., 2.9%) and one mediastinal location (i.e., 1%) were found. Surgery associated with histological study was the key to the diagnosis of tuberculosis in our study. Its procedures were: excisional biopsy for 26 patients (i.e., 25%), adenectomy for 54 patients (i.e., 51.9%), lymph node dissection for 15 patients (i.e., 14.4%), and lymphadenectomy for nine patients (i.e., 8.7%). In some cases, drainage (+/- curettage) was recommended in addition to the surgical procedure in 14 patients (i.e., 13.5%). All our patients benefited from post-surgical anti-bacillary treatment. Lymphorrhea was the only operative complication and it affected two patients (i.e., 1.9%). Meanwhile, the relapse rate was 10.6% (i.e., 11 patients), the treatment failure rate was 3.8% (i.e., four patients), and the paradoxical reaction affected 2.9% (i.e., three patients). The latter had all benefited from a simple biopsy. This indicates that a more extensive surgical procedure gives better results with a better healing rate. In conclusion, anti-bacillary treatment remains the reference treatment for lymph node tuberculosis. However, surgery holds great promise as the first-line treatment in case of fistula or abscess or in the event of failure or if complications occur.

Influence of the Size and Location of the Perforation on the Anatomical Results of Myringoplasty.

INTRODUCTION: Type 1 tympanoplasty (myringoplasty) is the surgical closure of a perforated eardrum. Its purpose is to restore the integrity of the tympanic membrane and to improve hearing in the affected ear. Nowadays, we note the increasing use of cartilage as material for the reconstruction of the tympanic membrane. The main objective of our study is to evaluate the influence of size and perforation site on the results of type 1 tympanoplasties performed in our department. MATERIALS AND METHODS:  We carried out a retrospective study of a series of myringoplasties spread over a period of four years and five months from January 1, 2017, to May 31, 2021. For every patient, we collected data regarding age, sex, perforation size, location, and closure of the tympanic membrane after myringoplasty. The audiological results for air conduction (AC) and bone conduction (BC), as well as air-bone gap reduction following surgery, were noted. Follow-up audiograms were performed at the following intervals: two months, four months, and eight months postoperatively. The frequencies tested included 250, 500, 1000, 2000, and 4000 Hz. Similarly, the air-bone gap was estimated on the mean of all frequencies. A chi-squared test and Mann-Whitney test were used to compare qualitative and quantitative variables, respectively. RESULTS: A total of 123 myringoplasties were included in this study. Closure of the tympanic membrane was achieved successfully in 85.7% for one-quadrant-size perforations (24 cases), and in 76.2% for two-quadrant-size perforations (16 cases). When 50-75% of the tympanic membrane was absent at the time of diagnosis, full repairment was achieved in 89.6% of the patients (n = 24), and in 85.0% (n = 34) when the perforation was subtotal. Recurrences have not happened more significantly for one location of the tympanic defect compared to another. Indeed, failures for anterior quadrant perforations were 14 whereas other sites represented 19 cases of non-integrated grafts. The audition was significantly improved from pre-operatively (AC mean of 48.7 dBs with ranges from 24 to 90 dBs) to post-operatively (30.7 dBs AC with ranges from 10-80 dBs) (p = 0,002). The average postoperative audiometric Rinne was 18 dBs with a gain of 15.37 dBs. DISCUSSION: Patients with bilateral perforations (tubal dysfunction, allergic rhinitis) are more likely to develop recurrences. Thus, the series considering many patients operated on twice has high failure rates. Good compliance with anti-allergic treatment and with hygiene rules (in particular ear sealing) is essential for the closure of anterior perforations. CONCLUSION:  It seems through our study that there is no correlation between the size and location of the perforation and its postoperative closure. Risk factors such as smoking, anemia, intraoperative bleeding, and gastroesophageal reflux are important and determining in the healing process.

Strangled by His Nerves-Cervical Plexiform Neurofibroma With Infantile Spinal Neurofibromatosis: Case Report in a 14 Years Old Child.

Background: Neurofibromatoses are a rare group of autosomal dominant tumor suppressor phacomatoses syndromes. Neurofibromatosis type 1 (NF1 or Von Recklinghausen's disease) is the most commonly found type of neurofibromatosis, and constitutes the most commonly found autosomal dominant disease of the nervous system. Case presentation: We report a case of a 14-year-old boy who reported a 3-year-history of a slowly enlarging right lateral cervical mass. He has a medical history of a progressive limping gait disorder with scoliotic attitude. MRI identified a dumb-bell shaped intradural right cervical process through right paravertebral gutter on C2 to C4, a second intradural dorsal mass with the same characteristics through left paravertebral gutter on D4 and D5 and a large tissue-like mass infiltrating the lumbosacral subcutaneous soft tissues. A Surgical excision of the cervical and lumbar masses was performed with a good outcome after surgical excision. Conclusions: This case illustrates the need for a collaboration of both neurological and head and neck surgeons in terms of managing difficulties related to a cervical neurofibroma. Benign plexiform neurofibromas are rapidly growing tumors, particularly in children and adolescents, which makes all the importance of early detection and appropriate treatment. Repeated interventions are usually needed in order to adapt and stabilize the tumors extension.

Squamous Cell Carcinoma of the Submandibular Gland With Cutaneous Fistula: A Case Report and Literature Review.

Squamous cell carcinoma (SCC) of salivary glands, also referred to as epidermoid carcinoma, is a very rare neoplastic tumor. It occurs as metastasis of a cutaneous or mucosal squamous carcinoma of the head and neck or as a primary SCC. In the latter case, the most known risk factor is previous irradiation to the gland. Common clinical symptoms are represented by cervical swelling and hyposialia. The treatment is essentially surgical, most often supplemented by a radical neck dissection and postoperative radiation therapy. A 75-year-old male patient with a history of chronic smoking was consulted for a tumefaction in the right submandibular region evolving for three months. No cervical lymphadenopathy in the submandibular and superior jugulo-carotid areas was palpable. CT scan showed an enhancing heterogeneous process of the right cervical region, invading the mylohyoid and stylohyoid muscles. A biopsy-excision of the lesion has shown a keratinizing tumor with cytonuclear atypia, consistent with SCC. Radical resection of the mass was associated with the removal of the infiltrated skin. The cutaneous defect was repaired with a rhomboid flap. The patient was started on sessions of adjuvant radiotherapy and chemotherapy. Eight months postoperatively, the patient came for follow-up, with no signs of local disease. The EGFR protein is found in ~70% of salivary neoplasms and is considered as a factor of poor prognosis and rapid proliferation. PET CT is currently the best examination to detect the existence of a concomitant malignant lesion. Diagnosis of primary SCC (PSCC) of the submandibular gland is made on histopathology. Differential diagnoses include mucoepidermoid carcinoma, lymphoepithelial carcinoma and submandibular metaplasia. There is an increased prevalence of nodal involvement in the PSCC, which justifies neck dissection (regions I, II and III of the neck). The RAS mutation leading to resistance to anti-EGFR therapies may be assessed. This would allow for a treatment depending on molecular features for metastatic PSCCs. PSCC of major salivary glands is a very rare lesion with local and general aggressiveness. The diagnosis is based on a combination of clinical examination, MRI, fine needle aspiration and histological examination. Immunotherapy constitutes a ground of research to treat metastatic and advanced pathological cases.

Amelanotic Malignant Mucosal Melanoma of the Nasal Cavity: Case Report and Literature Review.

Sinonasal malignant melanoma is a rare but aggressive tumor of the head and neck area. It has a poor prognosis. Common symptoms are nasal obstruction, epistaxis, or purulent rhinorrhea. Diagnosis relies on histopathology with immunohistochemistry (IHC) studies. Surgery is the essential treatment, most often supplemented by radiotherapy or immunotherapy. A 63-year-old female patient, with a history of right dacryocystorhinostomy and Parkinson's disease, consulted for symptoms of right nasal obstruction with increasing intensity accompanied by two episodes of mild unilateral epistaxis. Rigid optic examination showed a white-pinkish right obstructive supra-centimetric endonasal tumor. CT revealed an extensive tissue process of the right nasal cavity invading the maxillary sinus, the inferior and middle conchas. A biopsy of the lesion was conducted under local anesthesia. The immunohistochemical study has shown undifferentiated tumor with positive antibody anti PS100 and anti-melan A evoking malignant sinonasal melanoma. The patient underwent two surgeries for maxillectomies as she presented a first local recurrence. She was started on adjuvant radiotherapy. At one year of follow-up, she does not present any local or general signs of disease. Sinonasal melanoma is a particular entity of head and neck mucosal melanomas. The highest incidence is described to be in the seventh and eighth decades of life with no sex difference. IHC profiling of different melanoma subtypes showed the importance of alterations in the KIT gene, this genetic data may constitute a therapeutic target. After surgery, the important local recurrence rates and regional failure justify adjuvant radiotherapy also for resections in free margins. Most authors consider that prophylactic neck dissection is not necessary. Preoperative imaging features (CT scan) are characteristic and helpful for diagnosis. IHC is essential, has a high sensitivity for differentiating achromic melanomas from other neoplasms. Sinonasal achromic melanoma is a very uncommon tumor, invasive, and frequently associated with distant metastasis. Paraclinic examinations are essential for staging and guiding therapeutic management. Immunotherapy is a promising ground of research as it comes to metastatic and advanced disease.

Melatonin is useful alternative for sedation in children undergoing auditory brainstem responses testing.

Auditory brainstem responses testing (ABRs) is frequently required to assess auditory function in children. It is done usually in outpatient fashion and requires deep sleep to avoid artefacts. Sedation method used for the test should allow a deep sleep while avoiding general anaesthesia that requires special monitoring, dedicated staff and operating room availability. For this purpose, several sedation methods have been used, with the risk of respiratory depression and sides effects. We aim to assess the efficacy and the usefulness of melatonin in sedation for children undergoing auditory brainstem responses testing. We calculated success rate of complete bilateral ABR, sleep delay and quality of sleep of 247 children referred for ABR testing. Two hundred six children (83.4%) successfully underwent both ears testing. The delay to sleep was variable with a mean of 32 min. The quality of sleep was described as continuous in 156 infants (75.7%) and discontinuous in 50 infants (24.27%) requiring either simple nursing or a second dose of melatonin 30 min later.Conclusion: Melatonin has the advantages of inducing natural sleep and reducing sleep delay without adverse effects or respiratory depression risk. It is efficient and useful sedation method for ABRs in an outpatient setting. What Is Known? • Auditory brainstem responses test is the most used objective test to assess auditory function in children and requires deep sleep to avoid artefacts. • Melatonin is an endogenous pineal hormone used for sedation in electrophysiological testing and magnetic resonance imaging. What Is New? • 83.4% of children in our study successfully performed a bilateral ABR under melatonin-induced sleep with continuous sleep in 75.7%. • The use of melatonin to induce sleep for ABR tests is useful in an outpatient setting and it is a good alternative to general anaesthesia in Morocco.