Ir J Med Sci DOI 10.1007/s11845-017-1591-2
ABSTRACTS
Proceedings of the RAMI Section of OtoRhinoLaryngology Head and Neck Surgery (ORL HNS) Spring Meeting, Friday 9th December 2016, Education and Research Centre, Royal Victoria Eye and Ear Hospital, Adelaide Road, Dublin 2
Ó Royal Academy of Medicine in Ireland 2017
Nasopharyngeal oncocytoma: an incidental finding M Sefen, N Patil
levels. An important feature of this disease is it can masquerade as a malignancy in terms of symptoms, radiological findings and even preliminary pathological analysis. Correct diagnosis is paramount as this disease is highly sensitive to corticosteroids.
Sligo University Hospital Oncocytomas are largely benign tumours that occur commonly in the kidneys, salivary and endocrine glands. They are composed of oncocytes—epithelial cells characterized by an excessive amount of mitochondria. We present a 67 year-old female patient who attended the Emergency Department with ear ache and tinnitus. An examination of the postnasal space showed fullness, and biopsies were taken from the fossae of Rosenmueller. Histology showed a completely excised oncocytoma. We discuss the presentations and management of this unusual pathology that may be associated with malignant changes, that was detected at a rare site.
Ku¨ttner’s tumour E O’Reilly, P Sheahan Department of Head and Neck Surgery, South Infirmary Victoria University Hospital, Cork A 76 year-old man presented with a 3 week history of unilateral parotid swelling, facial palsy and enlarged level 2 neck nodes. Initial Ultrasound and biopsy was suspicious for an oncoytic epithelial neoplasm. CT and MRI showed a well defined, lobulated and likely oncocytic mass. Of note the patient had hypereosinophilia on pre operative full blood counts. He underwent a Parotidectomy as per MDT discussion. Histopathological analysis of the specimen yielded surprising results. Immunoglobulin G4 (IgG4)—related disease is a rare systemic disease that is characterized by infiltration of IgG4-positive plasma cells and lymphocytes. This causes fibrosis and associated organ dysfunction. It commonly affects head and neck structures such as the salivary glands (Kuttner’s Tumour), lymph nodes, lacrimal glands, orbits, thyroid, sinonasal cavities, and rarely the larynx. It prevails in elderly males and often with elevated serum eosinophils and IgG4
Non-cutaneous secondary primary in a melanoma patient: a reminder to be mindful N Kharytaniuk1, L Skinner1, P Calvert2, M Donnelly1 1 Departments of Otolaryngology, Head and Neck Surgery; 2Medical Oncology, University Hospital Waterford
BRAF inhibitor therapy has significantly changed treatment protocols for malignant melanoma. However, RAS-associated malignancies have been reported in clinical trials with BRAF inhibitor therapy, in particular, chronic myelomonocytic leukaemia and non-cutaneous squamous cell carcinoma of the head and neck. In vitro experiments have demonstrated paradoxical activation of mitogen activated protein kinase (MAP kinase) signalling in BRAF cells with RAS mutations when exposed to BRAF inhibitors. We present a case of a 59 year old gentleman, who was referred to our unit with cervical lymphadenopathy two years following commencement of BRAF inhibitor for treatment for T4N2b malignant melanoma. He was diagnosed with a p16 positive oropharyngeal squamous cell carcinoma and was treated with chemoradiotherapy. Although absolute cause and effect cannot be proven, this case highlights the difficulties with emerging oncological therapies.
Tonsillectomy for PANDAS R O’Shea, R Gaffney Beaumont Hospital Background: Paediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections (PANDAS) was first proposed
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Ir J Med Sci as a unique diagnostic entity in 1998. This refers to the abrupt onset of obsessive compulsive disorder (OCD), tic disorder or associated behavioural disturbance which bears a temporal relationship with group-A-beta-haemolytic streptococcal (GABHS) infections. Case report: We present the case of a previously healthy 9-year old girl who demonstrated new onset behavioural disturbance characterised by inattention/hyperactivity and compulsive traits of a fluctuating nature. The patient was found to have recurrent episodes of streptococcal pharyngitis confirmed on repeat throat cultures. She was assessed by community paediatric services who referred her for otolaryngological assessment with a view to consider tonsillectomy as a potential treatment. Conclusion: PANDAS is a rare phenomenon, however one which may encountered in the otolaryngological OPD. Tonsillectomy has been shown to be an effective therapy in cases where antibiotic therapy alone has failed to show signs of improvement.
Intranasal mass in a neonate: when its not a polyp or a turbinate
Case history: A 52 year-old female presented with sore throat, dysphagia and intermittent hoarseness over a two year period, progressing to necrotising epiglottis then HLH. From initial presentation to her unfortunate death she had multiple biopsies and a large multidisciplinary team contributing to her care. The underlying cause for her deterioration was probably a T-cell lymphoma disrupting her immune system followed by necrotising epiglottitis. There was possibly an Epstein Barr viral trigger for HLH, however, as definitive evidence of malignancy was never found. Clinical significance: This case required input from multiple ENT consultants as well as respiratory, rheumatological, infectious disease, haematological and eventually critical care colleagues. Each input instigated a new diagnostic path/treatment plan with little headway made. Our learning from this case has been to recognise and set up more formal multi-disciplinary forums for such complex cases that require it. Unfortunately, the mortality rate of HLH is high and despite appropriate treatment, remission in this case was not possible.
Incidental finding of medullary thyroid carcinoma metastasis to a lymph node
A Gyan-Baffour, K Davies, M Colreavy ENT Department, Temple Street Children’s University Hospital Background: Congenital nasal masses are rare malformations and occur in one in 20,000–40,000 live births. Neonates presenting with nasal congestion and/or obstruction are rare and therefore be a cause for diagnostic uncertainty. Management of these cases is made easier with a good understanding of the classification of paediatric nasal masses and the principles of assessment and treatment. Case presentation: We present a case of a 4 week old baby boy presenting to our Emergency department with intermittent noisy breathing, inability to feed, weight loss and increased work of breathing. He was admitted by our paediatric colleagues with a working diagnosis of an URTI. However, an ENT consult was sought for the noisy breathing, where a unilateral nasal mass completely obstructing the right nostril was found. CT and MRI revealed a soft tissue mass entirely within the nasal cavity with a medially placed tract extending as far as the anterior cranial fossa. Differential diagnosis on imaging suggested the possibility of a nasal dermoid. The case was brought to our local MDT to include neurosurgery due to the cranial extension. We are planning a joint procedure in the coming weeks. Conclusion: Due to it’s rarity, the general Otolaryngologist will have little direct experience with these unusual nasal masses. Intranasal masses with no intracranial communication can be removed often endoscopically aided by the microdebrider. More complex masses with intracranial extension require MDT discussion, joint care and imaging is crucial.
G Thong1, J Doody2, C Barry3, C Timon1,2, P Lennon1,2 1 Department of Otorhinolaryngology/Head and Neck Surgery, Royal Victoria, Eye and Ear Hospital; 2Departments of Otorhinolaryngology/Head and Neck Surgery; 3Maxillofacial Surgery, St James’ Hospital, Dublin
We present a case of a 64-year-old male, who underwent a modified radical neck dissection as part of his management of an oropharyngeal SCC. Histopathological examination revealed an incidental finding of medullary thyroid carcinoma metastasis in a lymph node. Subsequent total thyroidectomy revealed C cell hyperplasia only with no primary focus of carcinoma. MTC is a rare tumour of neuroendocrine origin and may be sporadic or hereditary. Incidental well differentiated thyroid carcinoma metastasis in the neck dissection specimens have previously been reported. However, a case of incidental MTC has not yet been published to our knowledge. We present this case to illustrate an extremely rare case of an incidental MTC metastasis to the cervical lymph chains, and to discuss the challenges that have arisen in this patient’s management.
Does the pharyngeal pouch fit? M Lau, D McCartan, N McCluney Department of ENT, Altnagelvin Area Hospital
A fatal case of haemophagocytic lymphohistiocytosis presenting with progressive necrotising epiglottitis DC Dick1, W Primrose1, S Napier2 1
Departments of Otolaryngology, Head and Neck Surgery; Pathology, Royal Victoria Hospital, Belfast
2
Introduction: Haemophagocytic lymphohistiocytosis (HLH) is a rare ‘cytokine storm’ disorder often triggered by T-cell lymphoma or viral (Epstein Barr) infection. Even more rare is a trigger originating in the larynx.
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Foreign bodies in pharyngeal pouches are rare. A literature search has captured nine case reports, of which six were capsule endoscopies. We present a case of a sixty-four year old lady with a plastic foreign body (FB) within a pharyngeal diverticulum. This transpired to be a size marker cube commonly seen on clothes hangers. The patient initially presented with acute dysphagia after swallowing a tablet. She was observed for 48 h and her symptoms regressed and she resumed a normal diet. She was followed up in clinic where she complained of a persistent ‘‘feeling of something in her throat (FOSIT).’’ A barium swallow was requested which showed a nonmetallic FB in a pharyngeal pouch. A rigid oesophagoscopy was undertaken in an attempt to remove the FB which proved difficult due to its’ smooth surface and the surrounding mucosal inflammatory
Ir J Med Sci process. We were concerned about causing a perforation and a second attempt was undertaken with a head and neck surgeon. The second attempt was successful and the patient was fasted for 24 h and commenced on antibiotics as a precaution. The patient was discharged home 48 h later. This case highlights an interesting and rare cause of dysphagia and a FOSIT.
‘Can you hear me? A tale of progressive dysphonia’ F Kavanagh, C Fahy, O Young Department Otolarygnology, Galway University Hospital, Newcastle Road, Galway SC, a 16 year old female presented with worsening dysphonia 4 weeks after an uneventful surgical and anaesthetic course for an elective tonsillectomy for recurrent tonsillitis. Her symptoms were persistent and progressive since her operation leading to almost complete aphonia. No risk factors for pre-existing laryngeal pathology were identified. Oral cavity and cervical examination were unremarkable. Flexible nasoendoscopy demonstrated bilateral large fleshy masses partially occluding the posterior glottis and preventing adduction of the vocal cords. She was anaesthetised electively using a total intravenous anaesthesia technique (TIVA) and transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) without intubation. The polyps were excised trans-orally by micro dissection and mitomycin c was applied topically. Clinically her dysphonia instantly resolved. Laryngeal injury post intubation is common and most frequently is subclinical rarely requiring surgical intervention [1]. Given the subclinical nature of the condition exact prevalence is disputed. We present a rare and interesting case of endotracheal intubation related injury. Reference: 1. Laryngeal complications by orotracheal intubation: Literature review (2012) Luiz Alberto Alves Mota, Glauber Barbosa de Cavalho and Valeska Almeida Brito. Int Arch Otorhinolarygo 16(2):236–245
Two’s company, threes a crowd R Stewart, L McCadden, D McCaul Craigavon Area Hospital Background: Pleomorphic adenoma is the most common benign salivary gland neoplasm though its occurrence in the submandibular gland is uncommon, 5% of cases [1]. A number of theories exist for the development of branchial cysts. Previously thought to be due to failed obliteration during embryonic development [2]; now largely accepted to be cystic transformation of cervical lymph nodes [3]. Case presentation: A 49-year-old female presented to ENT with a right-sided level 2 swelling of six weeks duration but reducing in size. A watchful waiting approach was adopted and the swelling resolved within 3 months.
Six months later, a swelling developed in the region of her right submandibular gland. USS suggestive of a necrotic lymph node. Contrast MRI showed a benign colloid thyroid nodule, a 1.2 cm submandibular swelling in keeping with a pleomorphic adenoma and a prominent level 2 lymph node. Excision of the right submandibular gland and suspected node in proximity was performed. Histopathology confirmed the submandibular swelling to be a pleomorphic adenoma but surprisingly the second mass was a small branchial cyst. Conclusion: As ENT surgeons we will deal with branchial cysts and pleomorphic salivary adenomas frequently but rarely in the same patient and it is unreported in the same operation! References: 1. Spiro RH (1986) Salivary neoplasms: overview of a 35-year experience with 2807 patients. Head Neck Surg 8(3):177–184 2. Gnepp DR (1993) Malignant mixed tumors of the salivary glands: a review. Pathol Annu 28(Pt 1):279–328 3. Gollege J (1994) The aetiology of lateral cervical (branchial) cysts: past and present theories. J Laryngol Otol 108(8):653–659
Facial palsy after Cochlear Implant Programming: an unusual complication H Petersen, P Walshe, F Glynn, L Viani Cochlear Implant Programme, Beaumont Hospital Introduction: Although Cochlear implantation (CI) is considered as an effective and relatively safe procedure for adults and children with severe-profound hearing loss, revision surgery due to medical complications or device failure are reported in several studies. Case description: This is a report of a 24-year old female patient who received a right-sided CI (Cochlear, Nucleus CI24RE) at 21 years of age due to progressive congenital profound hearing loss bilaterally. Preoperative radiological assessment revealed that the second turn of the cochlear was dilated, as was the vestibule bilaterally. However, the surgery went well without any complications and the postoperative followup was initially satisfactory. Approximately 4 years after surgery, following an upper respiratory tract infection she heard a ‘‘burst sound’’ from the implant and subsequently loss of function. The ear examination was unremarkable. However, immediately after reprogramming of the CI device the patient developed a sudden grade 5 House-Brackmann facial palsy. The device was switched off again and the palsy improved to grade 3 after 1 h and eventually back to normal facial nerve function 3 weeks following antimicrobial and anti-inflammatory treatment. However, she developed two further episodes of tingling with transient facial nerve palsy. The diagnostic imaging included: a CT Temporal Bone, CT Angiogram and in situ Integrity Testing of the device. All of these tests were normal, suggesting no fault with the implant. A decision was made to explant and reimplant on the same side with a new device. Again, the surgery was uneventful. Intraoperative the tympanic portion of the facial nerve showed good bony covering. Since revision surgery the CI is working normally with no further episodes of facial nerve palsy. The explanted device passed all electrical tests in the ex vivo investigation by the company confirming apparent normal device function. Conclusion: Despite intensive literature research as well as exchange of information with the company and international experts no reasonable explanation for the CI triggered facial palsy could be found.
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Vincristine induced vocal cord paralysis
Eosinophilic angiocentric fibrosis
C Dorris, J Wauchope, C Leonard, A O’Kane, C Jackson
B Lang, J Lang
Department of Paediatric Otorhinolaryngology, Royal Belfast Hospital for Sick Children
ENT Department, University Hospital Galway
Background: Vincristine is a chemotherapy agent with commonly reported adverse effects. Peripheral neuropathy is well recognised; however, bilateral paralysis of the vocal cords is rare. Presentation: A 2-year-old girl with Beckwith-Weidman syndrome presented with unilateral proptosis. CT and MRI demonstrated a tumour arising from the left orbit, invading the middle cranial fossa but with no evidence of either Chiari malformation or mediastinal metastasis. Endonasal biopsy confirmed rhabdomyosarcoma. After completing an initial cycle of RMS 2005 protocol chemotherapy, including vincristine, the child developed significant stridor. Awake fibreoptic endoscopy suggested bilateral vocal cord palsy. Microlaryngoscopy confirmed the diagnosis and absence of other pathology. Age appropriate endotracheal tube was passed, and the child ventilated. Stridor continued after extubation but neither respiratory distress nor fatigue was observed. The multi-disciplinary team, after discussion with the parents, elected for conservative management, rather than proceed with tracheostomy. Vincristine was removed from the protocol, and the clinical condition improved. Discussion: We report a rare complication following commencement of Vincristine. The case highlights the importance of considering both common and rare causes of vocal cord paralysis, and the role of MDT and parental wishes in complex airway cases.
Eosinophilic angiocentric fibrosis (EAF) is a rare, benign, slow growing condition, of unknown etiology which affects the upper respiratory tract. It most commonly affects the nasal cavity and midfacial soft tissues, although it rarely can involve the sub glottis and orbits. The condition is characterised histologically by perivascular inflammatory cell infiltration with progressive fibrosis around small vessels, leading to a characteristic ‘‘onion skin’’ type pattern. Since the condition was first described by Holmes and Panje in 1983 there have only been two case reports of subglottic involvement. We report a case of a 56 year old woman who presented with hoarseness and stridor. She underwent microlaryngoscopy and subglottic sub mucosal debulking. The histology was pathognomonic with a diagnosis of EAF. In recent years emerging evidence suggests that EAF may belong to the IgG4 related systemic disease spectrum. Due to the rarity of this condition, consensus has not yet been reached regarding optimal treatment of EAF. Historically, complete surgical excision was regarded as the treatment of choice, however, as in our case, this is often not possible. To our knowledge we are the first case to successfully use the monoclonal antibody rituximab with oral steroids as an alternative to complete surgical resection in patients with subglottic EAF.
INNOVATION AND SURGICAL TECHNIQUES
A stiff lower lip; diffuse large cell B cell lymphoma of the lower lip N Elsafty, N Patil, M Choo Department of Otorhinolaryngology, Sligo University Hospital Case: A 93-year-old woman, with an unremarkable past medical history of hypertension and cholelithiasis, was referred by her GP to our outpatient department with a hard, painless, pea-sized lesion on the mucosal surface of the mid lower lip, slowly increasing in size over four months. The patient denied any trauma, lip biting, or secondary changes associated with the swelling. On examination, there was a hard, well-demarcated, one-centimeter lesion present on the inside of the lower lip resembling a fibrosed mucocele. A second, smaller, left lateral lesion on the cutaneous surface of the lower lip was also noted. There were no other palpable swellings of her neck and the remainder of her ENT assessment was unremarkable. Both lesions appeared benign, however she subsequently underwent excision biopsy of the inner lip lesion. The histology revealed a high-grade, diffuse large cell B cell lymphoma and the patient was urgently referred to Haematology for review. Although lymphoma commonly presents in head and neck nodal and sometimes, extranodal tissues, they are exceedingly uncommon primary entities of the oral cavity, constituting less than 2% of primary extranodal Non-Hodgkin’s B cell lineage lymphomas. We report one such case, which if left untreated, may have life-threatening consequences.
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Laryngeal ultrasound in a pictorial of supraglottic cysts N Okonkwo, V Uzomefuna, P Kiely, JE Fenton Departments of ENT/HNS and Radiology UHL and UL GEMS Introduction: A 77 year-old female smoker was admitted with dehydration and on examination she had a right parotid swelling and goitre. Ultrasound of neck demonstrated bilateral lobulated hypoechoic masses at the posterior aspect of the upper thyroid cartilage. Followup computed tomography neck and thorax was performed which confirmed bilateral supraglottic laryngeal cysts with a right parotid swelling consistent with a Warthins tumour. ENT opinion and nasopharyngoscopy confirmed large bilateral benign epiglottic cysts. Discussion: Ultrasound larynx has correctly identified laryngeal cysts with a high degree of specificity. Unexpectedly there are few ultrasound reports for pathologies involving the larynx, probably a direct effect of other imaging techniques, including CT and MRI. Importantly, ultrasound of the larynx could replace CT as the imaging modality of choice in certain instances including paediatric inflammatory masses as it eliminates the risk of exposure to ionising radiation. Conclusion: Ultrasound of larynx although rarely performed should be encouraged as it is proven to be helpful in diagnosing certain laryngeal pathologies while at the same time constitutes very minimal health hazards especially in children.
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How I do it: percutaneous suture to secure stent in laryngotracheal reconstruction
We highlight the unique case of a large schwannoma occurring in the postnasal space, which presented a considerable operative challenge with many learning points.
J Wauchope, C Dorris, A O’Kane, C Leonard, C Jackson Department of Paediatric Otorhinolaryngology, Royal Belfast Hospital for Sick Children
Sialorrhoea: a management challenge S Jaber, K Davies, T O’Dwyer
Background: Laryngotracheal reconstruction (LTR) is the operation of choice for management of isolated symptomatic subglottic stenosis. Which stent to use and how to secure the stent is debated. Removal of the stay suture is often difficult and requires reopening of the neck wound. Our technique, when combined with an ET tube stent, allows quick and easy removal without reopening of the neck wound. Case discussion: An 18-month-old child with recurrent croup was investigated with routine MLB. At intubation, neither age appropriate bronchoscope nor endotracheal tube could be passed and a grade III SGS was diagnosed. Tracheostomy was performed to stabilise airway. A two stage LTR with anterior and posterior cartilage grafts was performed. A modified ET tube was used as a stent and secured with a single prolene suture. The stay suture had over 30 throws placed and ends emerge through the lateral skin wound. At six weeks, the stent was opened endoscopically. This allowed intra-stent division of the stay suture, which is easily identified externally and simply pulled out. The stent is then removed endoscopically. Conclusion: We present a novel and effective technique for stent fixation in LTR. The child has progressed well, and was decannulated successfully six weeks following stent removal.
Mater Misericordiae University Hospital A 21-year old male with cerebral palsy, presented with a long history of drooling or sialorrhoea causing skin excoriation and breakdown, affecting him and his parents physically and psychologically. Despite previous treatment with oral anticholinergic and antihistamine agents attempt to decrease saliva production failed. Sialorrhoea is defined as the oral incontinence of saliva, secreted in normal quantities and with normal quality, considered physiological in infants and halts by 18 months of age. This condition is common in neurologically impaired patients, or patients receiving anticonvulsants agents. Surgical management is based on removal or rerouting of major salivary glands and is associated with severe complications. We describe submandibular botulinum toxin injections as an effective procedure in management of sialorrhoea and consider it as alternative to complicated surgical management.
Single-stage cochlear implantation in mastoidectomy cavities Combined-approach resection of nasopharyngeal schwannoma J O’Sullivan, C Fitzgerald, E O’Cathain, F O’Duffy, P Lacy Beaumont Hospital, Dublin We present the case of a 51-year-old female patient who attended our service with an 18-month history of nasal congestion, postnasal discharge, midfacial pressure symptoms and occasional small-volume epistaxis. Following initial review and examination, MRI scan was completed which highlighted a 3.2 cm 9 2.4 cm 9 3.5 cm welldefined lesion in the right perivertebral space at the level of C1. Endoscopic postnasal space biopsy was performed, which confirmed nasopharyngeal schwannoma. Following multidisciplinary discussion and consultation with the patient, a combined-approach, endoscopic transnasal and transoral resection was performed. Pre-operative radiology, as well as intraoperative imaging are utilised to demonstrate the operative approach to this challenging, uncommon pathology. Schwannomas are benign, slow-growing tumours arising from nerve sheath cells. Provided complete resection is obtained, schwannomas can present a low risk of recurrence post-operatively. In this particular case, our patient showed no sign of recurrence after 6 months of close follow-up. Though commonly found in the head and neck region, just 4% of schwannomas occur in the nasal cavity.
S Kennedy, C Fitzgerald, F Glynn, L Viani, P Walshe National Cochlear Implant Program, Beaumont Hospital, Dublin, Ireland Introduction: The current accepted approach to cochlear implantation in the setting of existing mastoidectomy cavity, is obliteration of the cavity followed by re-exploration after six months, provided the cavity is free of cholesteatoma. Here we describe a technique for implantation of a cochlear implant as a single-stage procedure in a patient with previous mastoidectomy. Case report: An 85-year-old gentleman was referred for consideration for cochlear implantation on a background history of gradual hearing loss following bilateral modified radical mastoidectomies at age ten. A two-stage surgical procedure was unfavourable given the patient’s age and co-morbidities and so single stage implantation was carried out. Standard post-auricular incision and approach was taken. Electrodes were placed in the cochlea and brought to the surface. A blind sac closure was performed on the external auditory canal. Post-operatively, the patient developed a post-auricular sinus, which was treated conservatively. At the two-year follow-up, the patient continued to do well, with a small, clean post-auricular pocket, which was asymptomatic. Conclusion: A single stage procedure to place cochlear implants in mastoid cavities is feasible, with excellent acoustic outcome and an acceptable side-effect profile.
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Porcine collagen graft use in revision mastoidectomy: first reported case in Ireland?
medications and scoffs at the documented protocols, which this department adheres to. What would you do?
R Ramli, P Roche, S Hone
Intranasal necrosis, illicit vs autoimmune cause Department of ENT, Royal Victoria Eye and Ear Hospital T Subramaniam, RSR Woods, C Oosthuizen, J Kinsella In revision mastoid surgeries, autologous temporalis fascia or cartilage is the common graft material used. However, in cases of multiple revision surgery, the choice for good quality autologous graft material may be deficient, alternative donor sites or materials have to be considered. Recently, a new bioactive material derived from porcine small intestine sub mucosa (SIS) has been marketed. We present a case of the usage of bioactive material derived from porcine SIS to as a graft to form new mastoid cavity lining in our revision mastoid surgery performed at our institution. Post operatively, patient has shown good recovery and mastoid cavity is healing well and dry. There is no reported complication or rejection of bioactive material graft seen in this patient. Therefore, we believe that this new bioactive material is potentially a viable option in cases where autologous graft material is nonsufficient especially in cases such as revision mastoid surgeries.
‘Combined ENT-Neurosurgical surgery to manage a dizzy patient’ ´ Catha´in, C Fitzgerald, M Javadpour, K Nevin, E´ O R McConn-Walsh ENT Department, Beaumont Hospital A.U., a 45 year old lady presented with a one year history of dizziness, left-sided hearing loss, ipsilateral facial numbness and headaches. MRI revealed a ‘giant’ petroclival meningioma, measuring 6 9 5 cm. Following multi-disciplinary team discussion, she had a combined ENT-Neurosurgical procedure. A translabyrinthine and retrosigmoid approach was used for access to the tumour. We will discuss the case in detail, including preoperative imaging, intra-operative photos and videos. This case highlights the benefit of a combined ENT and Neurosurgical approach in the management of challenging skull base tumours.
What SIGN did not tell us; a psychiatric indication for tonsillectomy: a clinical conundrum C Murphy, C Wijaya, SG Khoo Department of Otorhinolaryngology/Head and Neck Surgery, St. Michael’s Hospital, Dun Laoghaire, Co., Dublin The Scottish Intercollegiate Guidelines Network (SIGN) has clear and defined indications for tonsillectomy, and this is primarily based on the number of attacks of true recurrent episodes of tonsillitis. We present a referral from psychiatry in which a patient who does not fulfill the criteria for surgery vocalizes her wish to deliberately selfharm if she does not have her tonsils removed. She claims her recurrent sore throats limit the effectiveness of her psychiatric
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Department of Otolaryngology, Head and Neck Surgery, St James’s Hospital Dublin Introduction: Differential diagnosis of extensive intranasal necrosis is commonly infection, malignancy and illicit drug use. Rarely, aggressive autoimmune conditions also can cause intranasal mucosal ulceration and breakdown. Case report: A 30 year male patient presents with worsening bilateral nasal blockage and intermittent epistaxis. Clinical examination reveals extensive intra nasal soft tissue and bony necrosis. Initial work up investigates possible underlying malignant cause, however investigative outcomes query a potential autoimmune cause of clinical findings. The clinical conundrum is further complicated by patients delayed admission of illicit drug use. Discussion: Aggressive intra nasal tissue destruction should prompt urgent investigations as guided patient and clinical history. Examination under anaesthesia is also important to determine extent of disease and obtain tissue to aid histological diagnosis. Autoimmune screen can aid diagnosis, however could be falsely positive in cases of illicit drug use.
‘Multidisciplinary team management of advanced middle ear and skull base carcinoma – would we have done anything differently?’ ´ Catha´in, D Rawluk, B O’Sullivan, R McConn-Walsh E´ O Beaumont Hospital, ENT and Neurosurgical Department We present the case of K.R., a 74 year old lady referred to our tertiary Neuro-Otology service, with a progressively worsening hearing loss, vertigo and new onset facial nerve palsy secondary to a tumour involving the right temporal bone. Her background history included significant bilateral lower limb ischaemia. Following multi-disciplinary assessment, a subtotal temporal bone resection was performed by a combined ENT-Neurosurgical team, with trapezius flap reconstruction and static facial reanimation. An excellent tumour clearance was achieved. However, intra-operatively, her trapezius flap failed. A scalp flap was a successful alternative. She developed a seroma of the trapezius flap donor site, requiring needle aspiration. This resulted in iatrogenic pneumothorax at the time of needle aspiration of the seroma, requiring a chest drain. She also developed acute on chronic bilateral lower limb ischaemia, potentially related to compartment syndrome bilaterally. She ultimately required bilateral above-knee amputations. Adjuvant radiotherapy was planned and commenced as the final histology was adenocarcinoma of the middle ear. She is still an inpatient two months later, and is expected to remain in hospital until her radiotherapy is completed. We present this very complicated case, and despite multi-disciplinary management, she has had significant complications, but we are very hopeful of a good outcome. We look forward to comments from colleagues around the country.
