ROYAL ACADEMY OF MEDICINE IN IRELAND IRISH JOURNAL OF MEDICAL SCIENCE
Proceedings of the RAMI Section of OtoRhinoLaryngology Head and Neck Surgery (ORL HNS) Winter Meeting Friday 11th December 2015 Education and Research Centre, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2
Irish Journal of Medical Science Volume xxx Supplement x DOI 10.1007/s11845-016-1499-2
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Disclosure Statement
This supplement has received no external funding or sponsorship
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Ir J Med Sci DOI 10.1007/s11845-016-1499-2
Proceedings of the RAMI Section of OtoRhinoLaryngology Head and Neck Surgery (ORL HNS) Winter Meeting, Friday 11th December 2015, Education and Research Centre, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2
References: 1. Chandler JR. Pathogenesis and treatment of facial paralysis in malignant external otitis. Ann Otol Rhinol Laryngol. 1972;81: 648–658. 2. Ridder GJ, Breunig C, Kaminsky J and Pfeiffer J. Eur Arch Otorhinolaryngol. 2015;272: 1269–1276. 3. Malone DG, O’Boynick PL, Ziegler DK et al. Osteomyelitis of the skull base. Neurosurgery. 1992;30;3: 426–431.
When the Skull Base Goes Bad D Hogan1, A O’Connor1, D Rawluk2, R McConn-Walsh1 1 Department of Otolaryngology, Beaumont Hospital, Dublin, Ireland and The Royal College of Surgeons in Ireland (RCSI); 2Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
Background: Necrotising otitis externa is a diagnosis that should not be far from the ENT surgeons mind when presented with an immunocompromised or diabetic patient, with otalgia out of proportion to the clinical findings and external auditory canal granulation tissue. A life threatening condition left untreated, it was previously associated with a 50 % mortality according to Chandler [1]. A rarer clinical entity exists in the form of central skull base osteomyelitis that can masquerade as numerous different skull base pathologies on imaging and will often present in immunocompetent patients. A recent case series published by Ridder et al. [2] showed that of their 20 patients, less than half of them were diagnosed diabetics with up to 1/3 of patients having no identifiable risk factors. We present a recent case report of central skull base osteomyelitis that proved a diagnostic dilemma. Aims: The aim of this paper is to present a rare case of central skull base osteomyelitis and highlight the difficulties in diagnosis and treatment that ultimately required craniotomy for confirmatory histopathology and culture. Our case report highlights the variability in presentation, the rapid progression of the untreated disease process, and the remarkable recovery that can be achieved with appropriate treatment. We aim to highlight that timely diagnosis of central skull base osteomyelitis is important in achieving optimal clinical outcomes. Methods: A pubmed search was undertaken to identify publications in English over the last 10 years that examined central skull base osteomyelitis, its diagnosis, treatment and imaging characteristics. This was used to highlight important elements of our case report. Results: As described by Malone et al.3, the typical findings on MRI of central skull base osteomyelitis are centered around the clivus and include marrow hypointensity on T1 imaging and hyperintensity on T2 imaging. Unfortunately this pattern can be seen in multiple pathologies encountered in the skull base. Once the diagnosis was achieved and correct treatment was commenced our patient made a remarkable recovery, with complete resolution of his pain and normalization of his inflammatory markers. Changes seen on imaging rapidly improved, with resolution of his bilateral glue ear slower to occur. Conclusions: Central skull base osteomyelitis is a rare condition that has a different presentation compared with the typical necrotizing otitis externa that is more commonly seen by otorhinolaryngologists. It will often present with lower cranial nerve palsies and headache and lacks an obvious external ear cause. Imaging findings can mimic many other potential pathological processes, and thus the diagnosis must be kept in mind in the differential of central skull base pathology.
Ortner’s Variant: a Novel Cause for Vocal Cord Paralysis? ´ Catha´in, M Donnelly C Fitzgerald, S Emmett, E´ O Department of Otolaryngology, University Hospital Waterford, Dunmore Road, Waterford Background: An 86-year-old female patient, with past medical history was of gastro-oesophageal reflux and angina, presented to ENT with persistent hoarseness. Results: Flexible laryngoscopy revealed a paralysed left vocal cord. CT scan of neck and thorax highlighted a thoracic aortic aneurysm in the presence of a giant hiatus hernia containing stomach, small, and large bowel causing displacement of the heart and great vessels. Conclusion: Dramatic imaging accompanies this interesting case of vocal cord paralysis in the presence of a thoracic aortic aneurysm and giant, displacing hiatus hernia.
A Case of Mammary Analog Secretory Carcinoma of the Left Parotid S Boyle, P Sheahan ENT Department South Infirmary Victoria University Hospital Background: A rare salivary gland neoplasm that relates to the morphology and genetics of an equally rare carcinoma-breast secretory carcinoma. The parotid glands are the most frequently involved gland of the salivary glands. It is typically a painless, slow growing carcinoma which rarely metastasis. Aim: Study of a case of mammary analog secretory carcinoma. Methods: A chart review and literature review was conducted on mammary analog secretory carcinoma. Real time RT-PCR performed using Taq Man Gene Expression Assays was used to confirm diagnosis. Results: JB 70-year male presented with a pre-auricular swelling, present for 3/12. No tenderness, otherwise well. Ex heavy smoker, C2H5OH Excess. O/E Hard, smooth, mobile 1 cm 9 1cm mass over left parotid region, facial nerve intact, FNE normal. Initial FNAC was suggestive of carcinoma possibly mucoepidermoid type. He proceeded to have left parotidectomy and neck dissection and a 2.3 9 2.2 cm tumour was excised which had extremely dense fibrous adhesions. There was no extraglandular extension. Perineural invasion was present and histology was suspicious for lymphovascular space invasion. No lymph node involved. Histology was referred to Our Lady’s Hospital Crumlin confirmed the T(12;15)ETV6-NTRK3 fusion transcript mutation. Following discussion at H&N MDT agreed to undergo post-op radiotherapy-60 Gy. Last seen 6/10/15, no signs of recurrence, his main issues is xerostomia post radiotherapy. Conclusions: A rare carcinoma which one should consider as part of the differential diagnosis of parotid carcinomas.
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Granuloma Gravidarum S Ahern, A Ionescu, V Vaivockaite, N Considine Department of Otorhinolaryngology, Sligo Regional Hospital We report the case of a 32-year-old female who presented with a bleeding nasal polyp, in the third trimester of pregnancy, which was excised in the early puerperium. Histology confirmed a lobular capillary haemangioma. We discuss excision, etiology, manifestations and the controversial nosology of this, and related, phenomena.
sinus and IJV thrombosis. Microbiological analysis of right hip aspirate revealed Fusobacterium necrophorum. Antibiotic therapy was adjusted accordingly and to date he is clinically well. Conclusion: We present an unusual case of Lemierre’s syndrome arising from acute mastoiditis in an 8-month old infant, which resulted in osteomyelitis of the humerus and microabscesses of the liver. These complications are infrequently seen, but potentially serious if not recognised promptly. We hope this case will raise awareness of Lemierre’s and potential for systemic manifestation.
A Joint Decision Sublingual Trichilemmal Cyst: the First Reported Case?
´ Catha´in1, C Fitzgerald1, M Farrell2, M Donnelly1 E´ O 1
C Hevican, K Davies, I Keogh Department of Otolaryngology, University College Hospital, Galway Introduction: We present the first documented case of a Trichilemmal cyst in the sublingual region. Case history: A 39-year-old lady presented acutely to our department with a right submandibular sialolithiasis. A large firm painful mass was palpate in the sublingual area. Radiologically, a well circumscribed mass was identified. After the acute phase settled an intra oral exploration of the right Wharton’s duct was undertaken. The specimen was large (23 9 7 9 10 mm), and calcified. These findings were consistent with a stone in the duct. However, histolopathology, demonstrated skin and underlying dermis, consistent with a benign Trichilemmal cyst. There was central dystrophic calcification. Excision of the cyst led to a complete resolution of the patient’s symptoms. Clinical significance: Trichilemmal cysts are common intradermal or subcutaneous cysts. They arise from outer root sheath epithelium and are usually found in hair bearing areas, (90 % on the scalp). While the majority of these are benign in nature, they do exhibit the potential for malignant transformation. Intraoral presentation is exceptional, with two documented cases in the oral labial mucosa. We can find no other documented case of a sublingual Trichilemmal cyst.
Lemierre’s Syndrome: a Not Very Humerus Complication A O’Kane, S Leonard, S Kapur, S Christie, S Hampton Department of ENT Surgery, Royal Victoria Hospital, Belfast Background: Lemierre’s syndrome commonly affects young adolescences. Purulent thrombophlebitis of the internal jugular vein results from an infection of the head and neck, pharyngitis in 87 %. Migration of septic emboli, most frequently to the lungs, can occur. Case discussion: An 8-month old infant boy presented to A&E with right mastoid abscess and sepsis, preceeded by a 7-day history of pyrexia, malaise and pulling at his right ear. He was transferred to theatre for surgical drainage. MRI the next day revealed thrombosis of the right sigmoid sinus extending to the internal jugular vein. With no positive culture results from surgery, paediatric infectious disease physicians, neurosurgery and microbiologists helped guide antibiotic treatment. On day 21 his mother noticed reduced left arm movement and right hip tenderness. Plain X-ray of the left shoulder showed destruction of the humeral head and he had a right hip effusion on ultrasound scanning. MRI confirmed osetomyelitis of the left proximal humerus, a micro-abscess of his liver and persistent right sigmoid
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Department of Otolaryngology, University Hospital Waterford, Dunmore Road, Waterford; 2Department of Radiology, University Hospital Waterford, Dunmore Road, Waterford A 46 year old man with a 24 h history of progressively worsening anterior left neck pain and cellulitis tracking down the anterior chest wall was referred to our service. A CT of neck revealed a multiloculated deep neck abscess underlying the left sternocleidomastoid. This was incised and drained and treated with intravenous antibiotics. Group A Streptococcus was confirmed as the causative organism. Ten days later the patient developed a boggy swelling of the left sternoclavicular joint. A second CT scan in conjunction with an MRI revealed left sided sternoclavicular joint osteomyelitis. A multi-disciplinary approach ensured complete resolution of this infection. We present this case to illustrate the possible unusual complications of a deep neck space infection.
A Journey Through Cowden Syndrome C Brophy, CB Heffernan, M Amin ENT Department, Mater Misericordiae University Hospital, Dublin Cowden syndrome is a rare cancer predisposition syndrome inherited in an autosomal-dominant fashion. The syndrome is characterized by hamartomatous polyps that affect multiple organs: skin, mucous membranes, thyroid, breast, gastrointestinal tract, endometrium and brain. It is also associated with an increased risk of developing malignancy in many tissues but especially breast, thyroid and endometrium. We present the case of a 47 year old lady with multiple manifestations of Cowdens syndrome. The most life threatening of these manifestations was extensive aerodigestive tract hamartomas. She presented to the ENT service at the Mater hospital with new onset stridor and underwent emergency tracheostomy and required a number of further procedures. This case highlights the multiple presentations of Cowden syndrome specifically the important ENT manifestations.
A Rare Cause of Anosmia E Keane, AM Ionsecu, H Khan, N Patil Department of ENT Surgery, Sligo Regional Hospital, The Mall, Sligo A 23-year-old male presented with frontal headache, blurred vision and anosmia for 3 months. Flexible nasendoscopy was normal. He was noted to have florid papilloedema, more pronounced on the right.
Ir J Med Sci CT and MRI brain showed a large mass in the frontal region straddling the midline, compressing both frontal horns of the lateral ventricles favouring a large glioma. He underwent resection with adjuvant chemo/radiation. Histology confirmed a Grade III oligodendroglioma. He has ongoing anosmia. Systemic therapy with Temozolomide has been proposed. These tumours rarely cause permanent anosmia but may have an association with Foster Kennedy Syndrome.
A Slip of the Tongue S Emmett1, CW Fitzgerald1, MA Farrell2, LJ Skinner1 1 Departments of Otolaryngology, 2Radiology, University Hospital Waterford
Background: A 12 year old boy presented was referred to our service with a short history of slurred speech. An isolated left hypoglossal nerve palsy was diagnosed. Results: The subsequent investigative pathways for this condition are discussed. Conclusions: This idiopathic cause of hypoglossal nerve palsy highlights the different emphasis and approaches of otolaryngology, neurology, and radiology to this condition, and demonstrates the importance of a combined multi-disciplinary team approach to this often ominous sign.
CSF in the Sigmoid Sinus. A Very Rare Complication of Sigmoid Sinus Thrombosis and Epidural Posterior Cranial Fossa Abscess E Mullen, M Javadpour, Rory McConn-Walsh Neuro-Otology and Skull Base Services, Beaumont Hospital, Dublin Background: Otitis media is a relatively common and usually self limiting inflammatory disease of the middle ear, however, it has the potential to propagate and cause more serious sequelae such as mastoiditis, and rarely intracranial complications such as bacterial meningitis, epidural abscess and sigmoid sinus thrombosis. Sigmoid sinus thrombosis is a rare diagnosis that affects approximately five people per million and accounts for 0.5–1 % of all strokes. Traditionally risk factors have been associated with virchow’s triad and can be subdivided into acquired and genetic causes. Indeed, parameningeal infections ear, sinus, mouth, face, neck only account for 8.2 % of cases. Objective: This report aims to highlight the surgical approach utilised to treat this rare complication. Case report: We would like to present the case of an 11 year old girl who presented to Waterford regional hospital with a yellow/ brown suppurative discharge from her ear with a 3/52 hx of ruptured ear drum. On admission she complained of diplopia and dizziness and was commenced on IV Antibiotics. MRI head in WRH showed extension of the infective process in the right middle ear into the posterior fossa with an abscess present and a fistula between the sigmoid sinus and the dura with CSF in the sigmoid sinus. She was started on IV heparin anticoagulation therapy and a right tympanomastoidectomy evacuation of the epidural abscess and seeding of the dural fistula was undertaken. She has made a full recovery. Conclusion: Although rare, otitis media is associated with life threatening intracranial sequelae; therefore early recognition and management are crucial in avoiding/minimising these complications.
Caught Red Handed-Congo Staining in the Oropharynx R Stewart1, R Adair2 Antrim Area Hospital; 2The Ulster Hospital Dundonald, Northern Ireland
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Amyloidosis refers to a heterogeneous group of diseases caused by the presence of extracellular deposits of abnormal protein fibrils (1). The incidence of amyloidosis is approximately 5–10 per million per year, with up to 20 % of these cases involving the head and neck (3). Localised amyloidosis of the oropharynx is rare with only five cases being reported (3). Case presentation: A 74-year-old never smoker and retired mechanic presented with a 2-month history of hoarseness and weight loss. On examination he had a large right-sided pharyngeal mass extending across the soft palate with associated ipsilateral neck gland. Contrast enhanced CT showed 4 9 3 9 6 cm mass extending from the hard palate to the superior border of the hyoid bone without infiltration. It was contiguous and infiltrated the soft palate; bilateral level two adenopathy was noted. Fine needle aspiration of the neck node showed abundant amorphous material which was representative of amyloid on Congo red stain and the washings showed polyclonal population on light chain stain. PET CT confirmed uptake in the oropharynx but nil else in keeping with localised amyloid. He was managed jointly by haematologists who commenced a short course of steroids with good symptomatic effect and had a laser resection under the ENT surgeons. Conclusion: Localised amyloidosis of the oropharynx is a rare condition that can be managed definitively with early surgical resection preventing airway compromise. References: 1. Glenner CG. Amyloid deposits and amyloidosis: The betafibriloses (first part). New Engl J Med 1980;302:1283–92. 2. Penner CR, Muller S. Head and neck amyloidosis: a clinicopathologic study of 15 cases. Oral Oncol. 2006;42(4):421–9. 3. Aono J, Yamagata K & Yoshida H. (2009). Local amyloidosis in the hard palate: a case report. Oral Maxillofac Surg, 13, 2, (2009), pp. 119–22.
Spontaneous Otoacoustic Emissions as a Cause for Unilateral Objective Tinnitus in a Healthy Toddler N Kharytaniuk1, S McMahon2, MH Khan1, P O’Sullivan1 1
Departments of Otolaryngology, Head and Neck Surgery, Audiology, South Infirmary Victoria University Hospital, Cork
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Introduction: Objective tinnitus is an uncommon entity, and can be due to several underlying causes. It is however rare for objective tinnitus to present as audible spontaneous oto-acoustic emissions, and only a handful of such cases are reported in the literature. Case report: A case of unilateral objective tinnitus in a 3-year old healthy bilingual toddler is presented. The parents noticed a highpitched continuous ‘‘buzzing’’ sound coming from the right ear since 6 months of age. Clinical examination of the ear was normal, but the clinician noticed a high-pitched tinnitus, which was matched to a 6 kHz pure tone. The child had passed the newborn screening test. Follow-up audiometry (Visual Reinforcement Audiometry) was satisfactory, and tympanometry results were consistent with normal middle ear
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Ir J Med Sci function bilaterally. Interestingly, spontaneous oto-acoustic emission (OAE) assessment confirmed a large spontaneous emission recordable at 47 dB and 6.7 kHz in the right ear, and secondary masked emission recordable at 20 dB and 5.3 kHz ipsilaterally. These findings fit in with the hypothesis that exists in the literature, that the tinnitus may be due to loud spontaneous oto-acoustic emissions. Conclusion: Our case illustrates a rare cause of objective tinnitus likely secondary to spontaneous oto-acoustic emissions. However, the more common causes for such presentation should be sought for and ruled out.
affected therefore increased understanding is necessary for optimal management.
How Important is the Multidisciplinary Team (MDT) Approach in Paediatric Oncology? D Brinkman, AM Naude´, M Colreavy M Department of Paediatric Otolaryngology, Temple Street Children’s University Hospital, Dublin
A Case of Complicated Hereditary Hemorrhagic Telangiectasia and Response to Bevacizumab Therapy SL Gillanders, H Savage Jones Department of Otorhinolaryngology, Midlands Regional Hospital Tullamore Osler-Weber-Rendu disease or Hereditary Hemorrhagic Telangictasia (HHT) is a rare autosomal dominant disorder that affects blood vessels throughout the body resulting in a tendency for bleeding. Diagnostic criteria include epistaxis, telangiectasias, visceral lesions and family history. The genetic bases of this condition involves TGFb signalling. We present a severe case of HHT with profound blood loss through epistaxis, heart failure, and a GI bleed requiring bowel resection. Treatment with bevacizumab has shown a major improvement on symptoms and an identifiable decrease in levels of VEGF in serum sam.
Hyperparathyroidism Associated with Long-Term Lithium Therapy for the Management of Bipolar Affective Disease R O’Shea, P Walshe
Introduction: Two cases in Temple Street Children’s hospital recently highlighted the importance of an MDT approach in paediatric oncology: One being a relatively common presentation of a parotid mass, the other an interesting consult requesting an endoscopic guided nasal biopsy. Clinical presentation: The first case is a 2 year old girl that presented to the emergency department with a 3 week history of a parotid swelling and was promptly referred to ENT. An MRI scan revealed multiple lesions in her mandible and zygomatic arch, after which a CT scan located the primary lesion in her abdomen, and a clinical diagnosis of neuroblastoma was made. The second case presented to ophthalmology with visual loss and proptosis. After a large symmetrical anterior skull base tumour was found on MRI invading the sinuses, neurosurgery approached ENT with a view of performing a transnasal biopsy. Management: Both cases show the importance of interdisciplinary communication. The first combined ENT, general medicine, and oncology to diagnose and treat the patient. The second, while initially presenting as an ophthalmology case, required ENT, neurosurgery and oncology to diagnose and manage her condition. Conclusion: The MDT approach to the paediatric oncology patient is imperative as occasionally other specialty input is required to provide prompt high quality patient care, ultimately treating the patient holistically.
Arhinia: Not To Be Sniffed At
Beaumont Hospital, Dublin Background: Despite its significant side-effect profile, lithium has remained a common treatment in the management of bipolar affective disease for over 60 years. While its effects on thyroid function are well described in the literature, less is known about lithium’s relationship with parathyroid function. Hyperparathyroidism secondary to chronic lithium therapy has only been described 90 times in the English literature. The mechanism of action by which lithium exerts these effects on the parathyroid glands remains unclear. Almost counter-intuitively, despite being systemically active, the majority of patients with lithium-associated hyperparathyroidism are found to have parathyroid adenomas and not four-gland hyperplasia. Case report: We present the case of a 72-year-old lady with a longstanding history of bipolar affective disease which was well-controlled on lithium carbonate therapy, who presented to her general practitioner with progressively worsening low mood. Routine bloods revealed elevated serum calcium levels (3.0 mmol/l corrected) with subsequent parathyroid hormone also elevated. DEXA scan showed T scores of -2.7. Sestimibi scan showed increased tracer retention in the right inferior parathyroid gland. On neck exploration the same gland was found to be enlarged and as a result was excised with histology confirming a parathyroid adenoma. The patient’s calcium levels normalised post-operatively and there has been no recurrence. Conclusion: Lithium-associated parathyroidism is under-described in the literature. Cessation of lithium is usually not an option for those
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S Leonard, A O’Kane, KT Trimble, C Jackson ENT Department, Royal Victoria Hospital, Belfast Background: Arhinia is the congenital absence of the nose. It is an extremely rare condition, with only 43 cases reported in the literature since 1931. It results in airway obstruction and feeding difficulties in the obligate nasal-breathing new born. Achieving a secure airway is of primary importance and input from an experienced neonatal airway team essential. Case discussion: A female, term baby was born to non-consanguinous parents. Early pregnancy was unremarkable, however ultrasound at 20 weeks suggested a flattened nasal profile. Arhinia was noted at birth with a flat mid-face, no nasal aperture and hypertelorism. Following transfer to the NICU she was orally intubated. CT scan on day 1 showed the medial orbital walls abutting with minimal nasal cavity and absent septum. A tracheostomy was performed on day 8. Initially fed via NG tube, from 7 weeks of age she was exclusively breast-fed. At 8 months was fitted with a speaking valve providing good voice and has undergone her first nasal implant at 2 years of age. Conclusion: We present a rare case of arhinia causing severe respiratory distress in a newborn. Tracheostomy was helpful in the early management of this patient. Simultaneous sucking and breathing through a tracheostomy is often difficult and hence orogastric feeding
Ir J Med Sci tubes are invariably required. With excellent parental motivation, exclusive breastfeeding was achieved from 7 weeks of age. Controversies include tracheostomy decannulation, nasal airway reconstruction and cosmetic reconstruction.
Unusual Cause of a Proptosing Eye: Isolated Right Maxillary Neurofibroma D Yap, H Fox, J Addams-Williams Department of ENT, Royal Gwent Hospital, Cardiff Road, Newport, NP20 2UB, Wales
Bad Cancer Bad Outcome W Hasan, P O’Neill Department of Otolaryngology/Head and Neck Surgery, Beaumont Hospital, Dublin Abstract: A 72-year-old male with previous history of heavy smoking and alcohol consumption presented to the plastic service with 8 9 10 cm facial cutaneous squamous cell cancer. The lesion doubled in a space of 4 weeks. CT scan of his neck showed left cheek fungating mass involving skin, subcutaneous tissue extending to the zygomatic arch and inseparable from bone. The tumour also involves the medial aspect of the eyelid and left lateral rectus muscle but remains preseptal. He was then was referred to our head and Head and Neck service. Left suprastructural maxillectomy, orbital enucleation, radical parotidectomy, modified radical neck dissection with Anterio-Lateral Thigh flap reconstruction was performed. He was admitted to ICU for overnight observation where a tense right sided hemiplegia emerged. CT brain showed no intracranial infarction or bleeding. He was kept intubated and subsequently developed pyrexia and atrial fibrillation. MRi brain showed 1 cm focus of parietal lobe infarction. 48 h post-op he RIP following a myocardial infarction. Tissue histology showed completely excised tumour with clear margins.
Introduction: Neurofibroma is a slow growing benign tumour of the peripheral nerve sheath which is frequently associated with neurofibromatosis type 1 [1]. It can present as a solitary lesion or generalized syndrome of neurofibromatosis (von Recklinghausen disease) [2]. Isolated solitary occurrence of neurofibroma in the maxillary sinus is rare with only 15 reported cases in the English literature. Case report: We present a case of a 70 year old gentleman who was referred to ENT with a right maxillary sinus neurofibroma with extension into the right inferior orbit. He has significant proptosis, ptosis and limitation in abduction of the right eye. He has a complicated past history of multiple neurofibroma which were completely excised. Radiological findings: MRI craniofacial show a large mass filling the right maxillary antrum extending anteriorly into subcutaneous tissue towards nasal ala and posterolaterally into inferior temporal fossa. Superiorly into orbit and cavernous sinus involvement. Histological findings: Biopsy of the right maxillary mass revealed cellular spindle cell tumour with wavy collagen bundles within myxoid stroma which is consistent with a neurofibroma. Management: Patient’s case were discussed in the Skull-base MDT and he have been referred to a specialist centre for surgical removal of the neurofibroma with reconstructive surgery. Conclusion: We present a rare case of isolated right maxillary neurofibroma. Despite the rarity of this disease, otorhinolaryngologist should consider a possibility of neurofibroma of the paranasal sinuses. References:
First Branchial Cleft Anomaly Presenting with a Complete Duplication of the External Auditory Canal: a Photo Anatomic Review P Roche1, CD Robson2, KR Whittemore1 1 Department of Otolaryngology and Communication Enhancement, Boston Children’s Hospital and Harvard Medical School; 2 Department of Radiology, Boston Children’s Hospital and Harvard Medical School, Boston, USA
Abstract: First branchial cleft anomalies are an uncommon group of congenital malformations. Anatomically complex in origin, they may present with an impressive array of signs and symptoms. There are a number of different classification systems available, which renders them challenging to both surgeons and patients in terms of preoperative assessment and surgical planning. The objective of this report is to describe the presentation, surgical treatment, and outcome of a child presenting with a large complex cerumen containing duplication of the external ear canal running medial to the main trunk of the facial nerve. Diagnostic and management pitfalls in the approach to pediatric patients with first branchial cleft anomalies are outlined and a review of the literature is presented.
1. Prakash, Mylanahalli Doddarangiah, Borlingegowda Viswanatha, and Glen Edwin D’Souza. A Rare Case of Isolated Nasal Neurofibroma Mimicking Sinonasal Polyp. Research in Otolaryngology 3.3 (2014): 49–51. 2. Solomon, Monica C., et al. Intra-Osseous Neurofibroma in The Maxilla of A Young Girl-A Report of A Rare Case. Innovative Journal of Medical and Health Science 3.5 (2013).
Penetrating Neck Injuries: the Point of Plain Films N Hope, G Gray, M Lesay, E Reddy Ward 3 South, Craigavon Area Hospital, Portadown, Northern Ireland Abstract: Penetrating neck injuries are a potentially life threatening emergency with a mortality rate of 6 %. With an incidence of 1–2 per 100,000 per year they are an important group to recognize and treat in the emergency department. The most common cause of mortality in this patient group is exsanguination. Spinal injuries in this patient group are uncommon. Rapid assessment by otolaryngology is essential in managing penetrating injuries due to the risk of major structural damage.
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Ir J Med Sci In this case we present a 27-year-old male who attended the emergency department having sustained a high velocity penetrating injury to the neck with a nail from a nail gun. Given the clinical complexity of the case a plain film X-ray was deferred in favor of high resolution CT imaging with angiography. As a result of the CT findings C-spine immobilization was immediately applied. Plain films were subsequently taken and it was clearly demonstrated that the point of the foreign body lay within the spinal column. The patient required transfer to a regional center for definitive surgical management.
A Very Rare Malignant Tumour in the Posterior Cranial Fossa of a Child. The Value of a Combined Neurosurgical and ENT Approach to Management
The Chalazion-Angelina Jolie-Clamp Effect L McDonald, C Fernando, SG Khoo Department of Otolaryngology/Head and Neck Surgery, St. Vincent’s University Hospital, Dublin 4 Innovations in surgical technique are often borrowed from other distinct specialties. Ophthalmologists confer upon themselves the title of the cre`me de la cre`me of surgical finesse and it is to their credit that they use surgical tools that enable them to work in confined spaces with dry surgical fields. That mirrors the specialty of Otolaryngology in which haemostasis is paramount. The lip is a vascular area in which even minor blood loss can obscure the surgical field, leading to excessive tissue resection and potential damage to the sensory nerve fibres that traverse the surgical site. We present our technique of sublabial lip biopsies and excision of simple lip cysts in a bloodless field using the chalazion clamp popularized by ophthalmology.
J Ryan, M Javadpour, R McConn-Walsh Neuro-Otology and Skull Base Services, Beaumont Hospital Background: Malignant Peripheral Nerve Sheath tumours (MPNSTs) are rare, highly malignant tumours. They carry a poor prognosis with a 30 % incidence of local recurrence or distant metastases at 10 years. Those located in the head and neck are rarer still, with an even worse prognosis—this is mainly due to difficulty gaining local control. The mainstay of treatment is surgery. Objective: The objective of this case is to describe a novel surgical approach to excising a MPNST from the posterior cranial fossa. Case report: The case is a 12 year-old boy who presented with a history of headaches, ataxia, vomiting, dysphagia, and diplopia. An MRI brain showed a mass at the left cerebello-pontine angle, extending through the jugular foramen. He underwent a retrosigmoid craniotomy with subtotal excision of the mass and histology showed a Vestibular Schwannoma. Recurrence of the tumour was noted later that year on MRI. This was excised via a combined retrosigmoid and transmastoid retrolabyrinthine approach. Histology showed a low grade malignant peripheral nerve sheath tumour. A second recurrence the following year was excised using a left translabyrinthine approach with complete extradural excision of the tumour and closure with fascia lata. There has been no recurrence to date. Conclusion: MPNSTs of the head and neck are very rare and recurrence rates are high. Complete resection is an important step in curing these patients; however it is difficult due to the risk of damage to nearby structures.
Otophyma of the External Auditory Meatus S Jaber, B Speaker, T Mackle
Avoiding Craniotomy in Posterior Table Fractures J AlMarzooq1, C Wijaya1, M Javapour2, P Lacy1 Departments of Otolaryngology; 2Neurosurgery, Beaumont Hospital, Dublin, Republic of Ireland 1
Introduction: Frontal sinus fracture constitutes 5–15 % of maxillofacial trauma. The commonest cause is blunt trauma. Left untreated, meningitis, brain abscess, mucopyocele, cerebro-spinal fluid leak (CSF), and osteomyelitis are the common complications. Traditionally, external surgical approach to repair a defect on posterior table of frontal sinus is via bi-coronal craniotomy. Objective: We describe an alternative approach for frontal sinus defect repair, thus avoiding bi-coronal craniotomy. Case report: An 11-year-old boy presented to our institution with history of blunt trauma on his forehead 3 years ago. He was found to have posterior table fracture of frontal sinus with CSF leak. Subsequently, he developed two episodes of bacterial meningitis, requiring admissions to intensive care unit. We describe a unique surgical approach to repair the defect, without subjecting the patient to potential complications of craniotomy. Conclusion: Although bi-coronal craniotomy is a common approach for frontal sinus fracture repair, our approach is a safe and effective alternative.
Just Give It a Shot!: Injectable Bleomycin Therapy as an Alternative to Surgery in the Management of a Complicated Cystic Hygroma
Royal Victoria Eye and Ear Hospital, Dublin A 50-year old male, presented with a history of conductive hearing loss and otitis externa causing complete external canal obstruction secondary to bilateral otophyma. Despite monthly microsuction and medical therapy for 5 years he continued to suffer from otitis externa. Phymas are considered the end stage of rosacea and mostly affect the nose (rhinophyma). They can also affect the cheeks, eyelids and ears. Otophyma is very rare and can only be successfully managed by surgery. We describe the first case of transcanal XPS microdebridement for the management of sebaceous hyperplasia of the external ear and canal. Microdebridement resulted in successful management of his otitis externa, good canal patency and improvement in hearing threshholds.
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C Toale, T Moran, T O’Dwyer ENT, Department of Surgery, Mater Misericordiae University Hospital Case presentation (Surgical): Cystic hygroma is a congenital malformation of the lymphatic system, with an incidence of approximately 1/6000 births worldwide [1]. Although surgical excision remains the treatment of choice [2] the close association of some lesions to vital structures in the neck can render certain cases inoperable. Injectable sclerosants such as Bleomycin, OK 432 and absolute alcohol offer an alternative approach to the management of these lymphatic malformations [3].
Ir J Med Sci We wish to present the case of a 9 year old female with a large macrocystic lymphatic malformation of the neck treated successfully with injectable bleomycin sclerosant therapy, and discuss the benefits and pitfalls of such an approach as compared to established surgical management. Recent developments in the classification, investigation and management of cystic hygromas will also be considered in an effort to shed some light on these trans-illuminable masses.
Increasingly, we are seeing that there is a major need for procedures which obviate the need for open supraglottic laryngectomy in compromised or medically unfit patients facing the dilema of the second primary within a previously irradiated field. Transoral supraglottic laser resection offers an potentially very rewarding way forward, allowing satisfactory control of margins whilst minimizing the effects of more major surgery and reducing the requirement for prolonged in hospital stay.
References: 1. Sannoh S, Quezada E, Merer DM, Moscatello A, Golombek SG. Cystic hygroma and potential airway obstruction in a newborn: a case report and review of the literature. Cases journal. 2009;2(1):48. 2. Eivazi B, Werner JA. Management of vascular malformations and hemangiomas of the head and neck—an update. Current opinion in otolaryngology and head and neck surgery. 2013;21(2):157–63. 3. Wiegand S, Eivazi B, Zimmermann AP, Sesterhenn AM, Werner JA. Sclerotherapy of lymphangiomas of the head and neck. Head and neck. 2011;33(11):1649–55.
TORL in the Management of Second Primaries Within the Irradiated Field: Light at the End of the Tunnel N Elsafty, P Sheahan, G O’Leary Department of Otorhinolaryngology, Head and Neck Surgery, South Infirmary Victoria University Hospital A 57-year-old smoker presented with an invasive poorly differentiated, p16-negative SCC. of the epiglottis. 6 years previously, he had been treated for a left sided buccal SCC with wide local resection, selective left neck dissection and adjuvant radiotherapy to the neck. Transoral, supraglottic, laser resection was performed with delayed second stage revision bilateral neck dissection. The patient retained full functionality of speech and swallow and satisfactory oncologic control was achieved.
Skeletonizing the Laryngeal Mask Airway. An Albatross Case T Subramaniam, J Kinsella, P Casserly Department of Otolaryngology, Head and Neck Surgery, St James Hospital Dublin Introduction: A laryngeal mask airway (LMA) offers is an intermediate level of securing the airway, lying with the hypopharynx [1, 2]. The LMA offers a time saving benefit and is suitable in a select number of otolaryngology procedures. Aims: We present a case report whereby the of a laryngeal mask airway resulted distortion of neck anatomy leading to an unexpected complication and morbidity. Methods: A case report of a single case performed in St James Hospital Dublin. We review the procedure indications, surgical method, complication, subsequent management and outcomes. Conclusion: Communication between otolaryngologist and anesthesiologist is key due to shared airway and symbiotic relationship during surgical procedures. References: 1. Jefferson N, Riffat F, McGuinness J, Johnstone C. The laryngeal mask airway and otorhinolaryngology head and neck surgery. The Laryngoscope. 2011;121(8):1620–6. 2. Nair I, Bailey PM. Review of uses of the laryngeal mask in ENT anaesthesia. Anaesthesia. 1995;50(10):898–900.
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