online journal of otolaryngology jorl volume 2 issue 3

http://www.jorl.scopemed.org/

Review Article

Volume 2 Issue 3 2012 ISSN 2250-0359

Retrospective analysis of Dyshormongenetic Goitre

* Chandrasekaran Maharajan Sucharitha Vedachalam

* Madras Medical College

Abstract:

Dyshormonogenetic goitre is a rare thyroid entity which occurs due to enzymatic

deficiency in the physiological process of thyroxin synthesis resulting in goitre formation. This has

to be differentiated from iodine deficiency goitres for their similarity in clinical presentation,

hormonal profile and on scintigraphy studies. This differentiation is vital for the reason that

Dyshormonogenetic goitre (DHGG) needs to be treated with thyroxin while Iodine deficiency

disorder (IDD) requires simple dietary iodine supplementation.

Key Words

Dyshormonogenetic goitre, Hypothyroidism, Perchlorate discharge test, Pendred

syndrome, Iodine deficiency disorder, Tc99 scan

Materials and Methods

52 DHGG patients were identified and diagnosed out of 2364 patients treated

between December 2001 to December 2011 in our department a referral centre for whole of South

India for thyroid disorders. Details collected include age, sex, grade of goitre, nodularity, associated

deafness, The tests done include Thyroid function tests, Perchlorate discharge test, USG neck,

Scintigraphy study, Fine needle aspiration cytology & histopathological examination. In these 52

patients, fifty patients were between 15 and20 years of age; 30 patients were males and 22 patients

were females. Siblings belonging to 3 different families showed features of DHGG. All the 52

presented with grade III goitres. All patients had hypothyroidism at the time of presentation. USG

showed nodularity in all cases. 1 Patient presented with mental retardation. This was present in the

families were siblings were affected. One patient had associated deafness, Pendred syndrome. None

of them had malignancy.I-131 scan was done in 35 patients and Tc 99 scan was done in 17 patients.

Scintigraphy study showed increased uptake. I131 scan also showed low liver counts. In order to

differentiate DHGG from IDD perchlorate discharge test and 24 hour urinary iodine measurements

were done. 24 hour urinary iodine was above 200 ug/day. These specific investigations revealed the

defect to be at the organification level. None of these patients showed iodine deficiency status thus

clearly showing the distinction from iodine deficiency goitre.

All 52 patients were subjected to Total thyroidectomy after one month preparation

with thyroxin. Thyrotherapy not only corrects the hypothyroid status but also helps to reduce the

vascularity of the gland.

Discussion:

In DHGG there is defect in the hormone synthesis (1) indicated by low T3, T4 and

high TSH. Scintigraphy shows high uptake (2) except DHGG due to trapping defect. There are

three important steps in thyroxin synthesis: 1) Trapping - Iodide is trapped by the thyroid gland 2)

Organification – trapped iodide is converted to iodine and with thysine Monoiodothyrosine (MIT)

and diiodothyrosine (DIT) are formed. 3) Coupling - MIT and DIT couple to form T3 and

T4.Trapping defect DHGG has low uptake in scintigraphy studies. It also shows a low salivary:

plasma radioiodide ratio of 1:1 (Normal: 10:1) (3). Organification defect is confirmed by perchlorate

discharge test (4). This is done in the following way; radiotracer is given and an uptake test is done,

following which 1 Gm of potassium perchlorate is given orally and an uptake is repeated after 2

hours. A fall in uptake between 10-20% indicates organification defect. Coupling defect will show

MIT and DIT in plasma whereas it is normally absent. They are usually present in the first or

second decade with or without a family history. When DHGG runs in families it is associated with

mental retardation (5) and Pendred syndrome (

6, 7). DHGGs are due to TG gene mutation (

8) or

DHGG presents with huge goiters (9), soft and highly vascular.

Differential diagnosis of IDD should be thought of when there is hypothyroidism

with increased uptake by scintigaphy studies. IDD has a low 24 hour urinary iodine level. Aa a

result of long standing hypothyroidism with sustained high levels of TSH in DHGG the thyroid

gland shows a highly cellular picture in FNAC and a HPE of such a gland shows papillary

proliferation with papillary fronds, nuclear atypia and minimal amount of colloid and hence it is

mistaken for thyroid cancer (10

). There is increased incidence of malignancy due to overexpression

of EGF and EGF-R m RNAs in DHGG (11

).

Conclusion:

Whenever Dyshormonogenetic goitres present as diffuse goitres they must be treated

with thyrotherapy. Only when they present as nodular goitres surgery is indicated. Carcinomatous

change can occur if DHGGs are not treated with thyrotherapy. Surgery of choice is total

thyroidectomy. After thyroidectomy they require lifelong replacement with thyroxine.

References

1. J.S.Kennedy J Path (1969) The pathology of dyshormonogenetic goitre 99(3):251

2. R.F Harvey,etal. Proceedings of Royal college of Medicine (1971) Dyshormono genetic goitre

with high circulating levels of TSH 64(3): 299

3. Fukate S,etal. Thyroid (2010) Diagnosis of iodine transport defect: do we need to measure

salivary/serum radioactive iodide to diagnose iodide transport defect 20(12):1419

4. J Clerk,H Mfnpeyssen,etal. Hormone research in Paediatrics (2008) Scintigraphic imaging of

paediatric thyroid dysfunction 70(1)

5. J Maenpaa Arch Dis Child(1972) Congenital Hypothyroidism-Aetiology and clinical aspects

47:914

6. Bangkova K ,etal. Cas Lek Usk (2008) Pendred syndrome among patients with hypothyroidism-

genetic diagnosis ,phenotypic variability and occurence of phenocopies 147(12) :616

7. Borch G etal. J Clin Endocrinol Metab (2009) Genetic cause of goitre and deafness 94(6):2106

8. Rubio,Ileana G S ,etal. Cuur Opinion Endocrinol, Diab & Obesity(2009) Mutation of Tg gene

and its relevance to thyroid disorders.16(5):373

9. B C Reynolds,etal. Acta Padiatrica(2006) Goitrous congenetal hypothyroidism in a twin

http://www.jorl.scopemed.org/

pregnancy causing respiratory obstruction at birth: implication for management 95(11):1345

10. Ronald A Ghossein ,etal. Endocrine Path (1997) Dyshormonogenetic goitre: a

clinicopathological study of 65 cases 8(4):283

11. Fillipo Pedrinolo,etal. Thyroid (2004) Overexpression of EGF,EGF-R mRNAs in

Dyshormonogenetic goitre 11(1):15

Images:

Image showing perchlorate discharge test

Www.jorl.scopemed.org

ISSN 2250- 0359

Volume 2 Issue 3 2012

Infected Haller cell

1 Balasubramanian Thiagarajan 2 Venkatesan Ulaganathan

1 Stanley Medical College 2 Meenakshi Medical College

Abstract:

This article discusses the role played by Haller cell in infundibular blocks. Haller cells

(infraorbital cells) are not so uncommon. They have been identified in 40% of normal

individuals. This article traces the history of Haller cell anatomy and its role in paranasal

sinus infections.

Introduction:

Haller cells are also known as infraorbital ethmoidal cells / maxilla ethmoidal cells. These

cells extend into the inferomedial portion of orbital floor. They are seen in 40% of patients.1

Coronal CT scan of nose and sinus showing a large Haller cell on the right side with

evidence of infection


CT scan lateral view showing Haller cell below the orbit

In majority of patients Haller cells may be asymptomatic.2. This air cell is actually named

after Albrect von Haller the Swedish Anatomist who described these air cells.

Problems caused by a Large Haller cell:

1. When infected it can cause narrowing of OMC

2. Can involve orbit

3. During Endoscopic sinus surgery it could push the natural ostium of maxillary sinus


downwards and anteriorly causing difficulties during surgery

4. If this condition is not recognized preoperatively the surgeon may inadvertently enter

orbit

Classification of Haller cells: 3

Radiologically Haller cells may be classified into:

Small

Medium

Large

References:

1. Yousem DM. Imaging of sinonasal inflammatory disease. Radiology. 1993;188 (2): 303-

14. Radiology (abstract) [pubmed citation]

2. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to

nasal septal deviation and paranasal sinus disease. AJNR Am J Neuroradiol. 2004;25 (9):

1613-8.

3. Anatomic relevance of Haller cells in sinusitis Stackpole SA American J of Rhinology

1997 May- June

www.jorl.scopemed.org

ISSN 2250- 0359 Volume 2 Issue 3 2012

Yahya Basith * Balasubramanian Thiagarajan*

*Stanley Medical College

ROLE OF ANATOMICAL OBSTRUCTION IN THE

PATHOGENESIS OF CHRONIC SINUSITIS

A case series study based on radiological assessment

Abstract Sinusitis is a commonly diagnosed condition in the general population.

This article is a study to asses the role of anatomical obstruction in the

pathogenesis of chronic sinusitis, based on symptomatology and radiological

findings of the patients. The frequency of major anatomical variants like deviated

nasal septum, concha bullosa, and paradoxical middle turbinate leading to chronic

sinusitis has been analyzed. In majority of cases the obstruction at osteomeatal

complex is found to be caused by more than one factor.

Chronic rhinosinusitis Definition: Group of disorders characterized by inflammation of the mucosa

of the nose and para nasal sinuses of at least 12 consecutive weeks

duration.Patients with CRS may have acute flare-ups, in such conditions the

disorder is called acute exacerbation of chronic sinusitis.[1,2]

Since it involves inflammation of the mucosa of nasal cavities as well as the

paranasal sinuses, its more aptly termed as rhinosinusitis. There are several

etiological factors leading to the development of chronic sinusitis.They are broadly

classified in to three main groups i.e 1)genetic/physiological factors 2)

environmental factors 3) structural factors.[3]


Role of anatomical obstruction Patency of the pathways through which the sinuses drain is crucial of

adequate mucociliary function and subsequent sinus drainage. Nasal and sinus

mucosa produces approximately 1 L of mucus per day [4]

, which is cleared by

mucociliary transport. Osteal obstruction may lead to fluid accumulation and

stagnation, creating a moist, hypoxemic environment ideal for growth of pathogens

[4]

Major anatomic variants leading to osteo meatal obstruction are

deviated nasal septum, concha bullosa, paradoxical middle turbinate and infra

orbital (Haller) cell [5]

.

Deviated nasal septum: Deviated nasal septum at the level of middle

turbinate is one of the main causes of anatomical obstruction at osteo meatal

complex.

Figure: 1 Cottle classified septal deviation in to 3 types i.e

1) Simple deviation: only mild deviation with no obstruction and it is the most

common type seen.

2) Obstruction: here the deviated septum touches the lateral wall, but on

decongestion with vasoconstrictors the turbinate shrinks and the obstruction is

relieved.

3) Impaction: massive angulation of the septum with a spur [6]


Patients with significant deviation i.e type 2 & 3, who is having CT evidence of

sinusitis have been included in the study.

Figure 2: Coronal CT scan of a patient showing deviated nasal


Figure 3: axial cut of the same patient showing deviated septum.

Septum leading to OMC obstruction.

Concha bullosa: concha bullosa is pneumatisation of the concha, usually the

middle turbinate and is one of the most common anatomic variation in nose.Bolger

et al classified pneumatisation of the concha based on the location as lamellar

concha bullosa, bulbous concha bullosa, and extensive concha bullosa.[7]

There are

many studies in the literature suggesting the role of concha bullosa in sinus disease

etiology. If the concha is expanded significantly, it leads to deviation or

compression of the uncinate process to the lateral wall of nose leading to

obstruction of the ethmoid infundibulum.

Figure 4: CT scan of a patient showing concha bullosa


l

Figure 5: CT image of another patient with extensive pneumatization of the right middle

turbinate.

Paradoxical middle turbinate: another anomaly of the nasal cavity leading

to air way obstruction and chronic sinusitis is a paradoxical turbinate. A middle

turbinate that is concave medially rather than laterally is called paradoxical.

Usually paradoxical turbinates occur where the maxillary sinus is hyperplastic. The

overgrowth causes the mucosa to to buckle and fold inwards, with the resultant

curve pointing towards the septum. An exagerrately curved paradoxical turbinate

compreeses the uncinate procees leading to meatal obstruction.


Figure 6: CT scan of a patient showing paradoxical middle turbinates

Aim of study: Is to assess the role of anatomical obstruction in the pathogenesis of chronic

sinusitis. Anatomical obstruction due to deviated nasal septum, concha bullosa, and

paradoxical middle turbinate are included in the study.

Materials and methods After the advent of endoscopic sinus surgery, pre operative evaluation of the

osteomeatal complex has gained very importance in the management of sinus

disorders.Computed tomography (CT) is the method of choice for the

morphological evaluation of the osteomeatal complex. Coronal plane is the most

commonly used plane by endoscopic surgeons because of its similarity with

surgical orientation. In this study we have used patient symptomatology, anterior

rhinoscopic findings and radiological evidence in to consideration.

Inclusion criteria Patients who presented to the department of E.N.T and Head & neck surgery,

Stanley medical college, during a one month periode with symptoms suggestive of

chronic rhinosinusitis were subjected to undergo coronal CT scan of the para nasal


sinuses. 40 Patients who have symptoms of chronic rhinosinusitis (>12 wks

duration) and whose CT scan shows mucosal thickening of paranasal sinuses

suggestive of chronic sinusitis were included in the study.

Study results Among the 40 patints studied, CT image of 32 (40%) cases showed septal

deviation to either right or left. Concha bullosa was seen in 17 (42.5%) cases and

paradoxical turbinates in 11 (27.5%) cases. Considering isolated variants, 15

(37.5%) cases had septal deviation alone as an anatomical variation, 5 (12.5%) had

concha bullosa alone and 3 (7.5%) cases had paradoxical middle turbinate alone in

their CT images. Most of the cases of concha bullosa was associated with a septal

deviation i.e out of the 17 cases 12 (70.5%) cases had an associated septal

deviation as anatomical variation.

Anatomical

variation

No.of patients Percentage

Deviated septum 32 80%

Concha bullosa 17 42.5%

Paradoxical

turbinate

11 27.5%

Figure 7: table showing the aggregate frequency of anatomical variations studied.

Anatomical

variation

no.of

patients

Percentage

Deviated septum 15 37.5%

Concha bullosa 5 12.5%

Paradoxical

turbinate

3 7.5%

Mixed variation 17 42.5%


Figure 8: table showing isolated frequencies of anatomical variations studied.

DNS

37%

CB

13%

PMT

8%

MIXED

42%

DNS

CB

PMT

MIXED

Figure 9: A pie chart showing the distribution of the major anatomical varients included in

The study. DNS: deviated nasal septum, CB : concha bullosa, PMT : paradoxical middle

turbinate.

Conclusion: Most of the cases of chronic sinusitis caused by anatomical obstruction in the

nose are found to be due to a deviated nasal septum leading to obstruction of

osteomeatal complex.Other major causes are concha bullosa and paradoxical

middle turbinate. Many a time more than one anatomical variation occurs in the

same individual, rather than occurring as isolated single variation i.e a deviated

septum with a concha bullosa or a deviated septum with a paradoxical turbinate. A

concha bullosa of the nose is usually associated with a septal deviation in majority

of the patients. Most common sinus affected due to anatomical obstruction at osteo

meatal complex was maxillary sinus.

References: 1.. Lanza DC, Kennedy DW: Adult rhinosinusitis defined. Otolaryngol Head Neck surg 1997;

117:S1-S7.


2.. Benninger MS, Ferguson BJ, Hadley JA, et al: Adult chronic rhinosinusitis: definitions,

diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003; 129:S1-

S32.

3. Byron J bailey & jonas T.Johnson,Head and Neck surgery,p406, 4th

ed.

4. Byron J Bailey & Jonas T.Johnson, Head and Neck surgery,p406,4th ed.

5. Byron J Bailey & Jonas T.Johnson, Head and Neck surgery, p408, 4th ed

6. Devated nasal sepyum, drtbalu’s otolaryngology online , www.drtbalu.co.in/dns.html

7. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal

abnormalities: CT analysis for

endoscopic sinus surgery. Laryngoscope 1991; 101:56-64.

8.Levin HL: The office diagnosis nasal and sinus disorders using rigid nasal

endoscopy.Otolaryngol Head Neck Surg 102:370-373,1990.

9.May M, Mester SJ, O’ Daniel TG, Curtin HD:Decreasing the risk of endonasal endoscopic

nasal surgery by imaging techniques. Op Tech Otolaryngol Head Neck Surg 1:89-91,1990.

10.Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis:Definitions,

diagnosis, epidemiology and pathophysiology. Otolaryngol Head Neck Surg 2003; 129(3 sppl)

11.Hwang PH, Irwin SB, Griest SE, et al.Radiologic correlates of symptom based diagnostic

criteria for chronic rhinosinusitis. Otolaryngol Head Neck Surg 2003:128(4):489.

12.Zoumalan RA, Lebowitz RA, Wang E, Yung K, Babb JS, Jacob JB. Flat panel cone beam

computed tomography of the sinuses. Otolarungol Head Neck Surg, 2009,140(6):841-4.

13.Zinriech S: Imaging of inflammatory sinus disease. Otolaryngol Clin Am 1993 ; 26:535.

http://www.drtbalu.co.in/dns.html


* SriKamakshi Kothandaraman *Balasubramanian Thiagarajan



ARE LEFT HANDED SURGEONS LEFT OUT?

THE SINISTRAL:

“ If by chance I touched a pencil, a pen or a needle, I was bitterly rebuked, and more than once I have

been beaten for being awkward and wanting a graceful manner.”

These were the words of Benjamin Franklin, noted left-handed American inventor, scientist, printer,

statesman and philosopher, who had a miserable childhood. His words reflect the exact state of affairs

and consequently, the state of mind of the lonely left-hander in this right-dominated world.

Studies have revealed that left-handers are generally more inhibited and anxious, and this doesn’t go

without reason. The scientific reason is that, in left-handers the right half of the brain dominates, and it

is the same side that controls the negative aspect of emotion. As a result, in an attempt to relieve their

anxiety, left-handers like to colour code things, and make lists whenever possible. The more practical

and logical reason is that, the environment of our world strongly favours the right handed majority.

Although sinistrals are considered to be more intellectual and artisitic, (studies have revealed higher

levels of IQ among left-handers) it has also been documented that they are more prone to unintentional

injuries, sports injuries and accidents. In fact, even the rate of finger amputation has been found to be

higher among left handed industrial workers. Even items of everyday usage, such as scissiors and can-

openers are biased towards the right-handed. The saving grace in this distressing situation for the left-

hander is that, Nature has made him/her a born fighter. A review of literature and history reveals that

left-handers from time immemorial have shown a natural talent and inborn skill in games of combat

such as fencing and tennis. In fact, research analysed data shows that societies which were rather quite


violent and aggressive, had a higher proportion of left-handers. Thus, left-handedness which has been

proved to develop in the womb, brings along with it an inborn endurance and strength to survive tough

situations and living circumstances, such as it already is in our world at large for the sinistral.

Coming to familiar waters, and more relevantly to this article, studies have shown that 80% of left-

handed surgeons believe that endoscopic surgery needs to be modified for the left-handed endoscopic

surgeon, though 66% feel that they experience no difficulty in handling the custom-made endoscopy

instruments. Left handed surgeons lack access to left handed instruments while training, receive little

mentoring about their left handedness, and are more prone to needle stick injuries than their right

handed colleagues. By and large, laterality-related comfort has its impact on endoscopic surgery, and

technical modifications are warranted to suit the needs of the left-handed surgeon.

What follows next is a launch into what exactly I have been facing ever since I started taking baby steps

into the skill-dominated field of Otorhinolaryngology, and what in my opinion needs to be done in each

of those challenging situations by the budding left-handed ENT surgeon.

BEING A LEFT-HANDED ENT SURGEON..

Being a left-handed surgeon, more specifically a left-handed ENT surgeon, presents a unique pattern of

difficulties.

The problems start right at the OPD itself. When I sit down at a cubicle with the patient ata distance of

less than 8 inches in front of me & the Bull’s eye lamp at 6 inches above and behind the left shoulder of

the patient, focus the light into the patient’s ear/nose/throat and try to examine the parts, I find that

irritatingly, something keeps blocking the light from falling on the patient’s parts. It took me a few

exasperating days in the OPD, to realize, that that “something” was my very own right upper limb!


To overcome this problem, for a left handed ENT practitioner, the Bull’s eye lamp needs to be placed

above and behind the right shoulder of the patient, at the level of the right ear.

The next confusion arises when a left-hander tries to wield the endoscope. I had carefully observed that

my seniors, while doing endoscopic examination, stand to the right side of the patient and hold the

endoscope in their left hand. While performing an endoscopic surgery, they follow the same discipline

and proceed with the steps of surgery, with the instrument held in their right hand. So when I was given

the opportunity to learn endoscopy, I diligently followed the same principles. (Frankly, I didn’t have a

choice anyway, as the arrangement in the endoscopy room demanded that we carry out the procedure

in that particular orientation. In other words, the arrangement is always such as to suit the right-handed

majority! Ideally, for a left hander, standing to the left of the patient would be comfortable.) So

faithfully standing to the right of the patient, I hesistantly and carefully took the endoscope in my left

hand, adjusted the focus, white balance and position of the camera and haltingly introduced the

endoscope into the anaesthetized and decongested patient’s nasal cavity. Much to my surprise, it

seemed to be quite easy. I was delighted! Maybe being left-handed is an advantage with respect to

endoscopy, I mused. But alas, my happiness was short-lived. Only when I started operating

endoscopically, did I realize my shortcomings. I was not able to control the movements of the

instrument I was using and synchronize it with the endoscope. Though this difficulty is quite common

with beginners, the problem was that, though I was holding the endoscope comfortably in my left hand,

the instrument, with which I need to make the finest of maneuvers, was in my non-dominant hand. This

would not do. This realization pushed me to start learning to use the endoscope with my right hand, so

that my left would be free to handle the instruments.


A left handed surgeon cannot cut with the commonly available scissors. As simple as this

statement is, as humiliating it is, until you discover where the problem actually lies.


The blades of the commonly available scissors are oriented in such a way, that they approximate and cut

well only when used with the right hand and the right hander can see the cutting line. When you try to

use it with the left hand, the blades instead of approximating actually move away from each other, and

you are actually cutting blindly.

This picture shows left hander’s scissors to the left and the usual right

hander’s scissors to the right.


This really alarmed me! So I also started making efforts to make my right hand work atleast half as well

as my left, since I realized that a naturally left-handed ENT surgeon needs to become ambidextrous, if

he/she wishes to prove his mettle in this field. My seniors and teachers kept encouraging me to do this.

I give my right hand exercises in the form of writing, cutting shapes on paper, cutting vegetables and

cooking.

Being a minority, the left-handers are at a disadvantage even in the operation theatre. The operating

table and the Boyle’s apparatus are arranged in such a fashion that the anaesthesiologist stands to the

left of the patient, while the ENT surgeon is to the right. Once I started learning septal correction

surgeries, I realized that standing to the right of the patient and using my left hand to operate was very

uncomfortable. So I requested to be allowed to stand to the left of the patient so that I could operate

comfortably. Though this was quite a relief for me in one sense, the flip side was that I ended up having

to share working space with the anaesthesiologists, which turned out to be irritating for both of us.

For tonsillectomies, when the patient is intubated nasally, the usual practice of the anaesthesiologist is

to introduce the endotracheal tube through the left nostril of the patient and fix all the tubings in such a

way that they come to the left side of the patient and the ENT surgeon at the head end of the table,

which serves to be convenient to the anaesthesiologist and the right handed ENT surgeon. A similar

arrangement for a left handed ENT surgeon, is not only irritating for him/her as all the anaesthetic

tubings keep coming in the way of his/her dominant hand, but more alarmingly also places the patient

at risk for an accidental extubation due to the very same reasons. So when a left-handed ENT surgeon is

blessed with the liberty to arrange the operating room to his/her convenience, he/she should first thing,

place the anaesthetic equipment and the anaesthesiologists to the right side of the patient.

The most depressing problem my handedness leads me to face, is the confusion and difficulty that my

teachers and seniors have when they try to teach me surgical steps. They need to first get oriented to

my orientation and then teach me!

The right attitude for the left!:

Inspite of all these issues surrounding the left handed surgeon, he/she has the unique capability to use

his/her left hand exceptionally well. While a left hander can with some struggle manage to make his/her

right hand usable, the same cannot be said of a natural right hander. In this right-oriented world, a right

hander cannot that easily make his/her left hand work as well as his/her right. Like my HOD,

Professor.Dr.T.Balasubramanian,MS,DLO, rightly puts it, being a left-handed ENT surgeon is like a double

edged sword. It can make or break you depending on your attitude and how you deal with the issues

associated with it. The right approach for a left-handed surgeon is to make himself/herself

ambidextrous! That way, he/she can get the best of both worlds (left and right), if I may put it that way!


REFERENCES:

1. Makay O et al. Surgeon’s view on the limitation of left-handedness during endoscopic surgery. J

Laparoendosc. Adv Surg Tech A 2008 April; 18(2):217-21.

2. New Scientist Print Edition 22nd July 2004, Lisbon.

3. Cardiff Western Mail, July 2001.

4. Adrian E Flatt MD FRCS. Is being left-handed a handicap? The short nd useless answer is “yes

and no”.Proc (Bayl Univ Med Cent) 2008 July; 21(3):304-307.

5. Adusimilli PS et al. left handed surgeons:are they left out? Curr Surg 2004;61(6):587-591.

6. Coren S. left-hander: everything you need to know about left-handedness. London: John

Murray, 1992.


Volume 2 Issue 3 2012 ISSN 2250 - 0359

Ophthalmic disorders among students of School for the Deaf, Akure

By C.O.Omolase FWACS, FMCOph 1, O.O.Komolafe FWACS, FMCOph

1 A.O.Adeniji

FWACS,2

O.Adetan FWACS,FMCS3.B.O.Omolase M.B.B.S

4, A.K.Akinwalere M.B.B.S,

1

E.O.Omolade M.B.B.S 1

1) Department of Ophthalmology,

Federal Medical Centre ,

Owo.

2) Department of ENT,

Federal Medical Centre,

Owo

3) Department of Orthopaedics,


Owo.

4) Department of Radiology,


Owo.


Correspondence to: Dr. Charles Oluwole Omolase

Consultant Ophthalmologist,


Owo.

Ondo State

E mail address: [email protected]

ABSTRACT

Aim: This study aimed at determining the prevalence and pattern of ophthalmic disorders among

students of School for the Deaf, Akure, Ondo State, Nigeria.

Methodology: This is a cross sectional descriptive study was conducted in October, 2011 as

part of activities marking the Annual Physicians’ week of Nigerian Medical Association (NMA),

Ondo State. Ethical clearance was obtained from the Ethical Review Committee of Federal

Medical Centre, Owo prior to commencement of this study. The permission of the School

Authority was also obtained before the commencement of this study. The respondents were

selected by simple random sampling technique. All enrolled participants were interviewed with

the aid of the study instrument (questionnaire) by the authors and interpreters (school teachers).

Results: The respondents comprised of 91(56.9%) Males and 69 Females (43.1%). Nearly all the

respondents;158(98.8%) were deaf and dumb. Most respondents; 116(72.5%) had ocular

examination in the past. Few respondents; 118(73.75%) had ophthalmic disorder. The


commonest ophthalmic disorder was refractive error which was found in 16 respondents

(38.1%). Myopia was diagnosed in 9 respondents.

CONCLUSION: Most of the respondents were deaf and dumb. Few respondents had

ophthalmic disorder. The commonest ophthalmic disorder was refractive error. Myopia was the

most predominant refractive error. There is need for periodic ocular screening and treatment at

the School for the Deaf.

Key words: Ophthalmic Disorders, Deaf and Dumb, Nigeria.

INTRODUCTION

Deaf children tend to rely on their visual cues to explore and adapt to their environment. Thus

visual impairment in a deaf child is likely to worsen the handicap of the child. There is a strong

association between the functions of the eyes and ears (1). Deafness is a common challenge in

West Africa and it is often associated with measles, deafness and meningitis(2). Deafness is a

high risk factor for visual problems (3,4

). The high rate of ocular pathology in deaf patients is

related to the fact that the retina and cochlear have the same embryonic origin during the sixth

and seventh weeks of embryonic development (5). Oculoauditory syndromes have also been

reported(6,7

). Genetic and environmental factors may affect both the ear and eye (8,9

). The

prevalence of ocular abnormalities tend to generally increase with the severity of hearing

impairment. As the degree of hearing impairment becomes more pronounced, the compensatory

role of the other sense organs becomes more prominent. It had also been observed that rubella

syndrome may account for the high prevalence of refractive errors and ocular disorders in


hearing impaired children (10

). A mild refractive error may lead to a reduction in the visual cues

available to the deaf child (6,11

).

Studies have shown higher prevalence of ophthalmic disorders among deaf children compared

with children of the same age group without hearing impairment (5).

The prevalence of ophthalmic disorders among hearing children ranges between 17% to 30% (8)

as opposed to 44% to 65% among deaf children(6,12-15

). A review of the literature on ophthalmic

disorders carried out in Greece revealed paucity of literature on ophthalmic disorders in deaf

children (16

).The situation in Nigeria in this regard is also the same as only few studies have been

carried out on ophthalmic disorders in Nigerian deaf children. Screening and detection of

ophthalmic disorders in deaf children is of utmost importance (2). Early detection of such

abnormalities, diagnosis and treatment would enhance the adjustment of the deaf children. In

view of this fact, this study was designed to determine the prevalence and pattern of ophthalmic

disorders among students of School for the Deaf, Akure. It is hoped that the findings of this

study shall be utilized by policy formulators to evolve strategies to promote the ocular health of

deaf students.


Methodology

This is a cross sectional descriptive study conducted in October, 2011 at the School for the Deaf,

Akure as part of activities marking the Annual Physicians’ week. Ethical clearance was obtained

from the Ethical Review Committee of Federal Medical Centre, Owo prior to commencement of

this study. The permission of the School Authority was also being obtained before the

commencement of this study.

A total number of one hundred and sixty(160) consenting students out of the six hundred and

eighty students of the School for the Deaf selected by simple random sampling technique were

enrolled in this study. Informed consent was obtained from all the respondents. All enrolled

participants were interviewed with the aid of the study instrument (questionnaire) by the authors

and interpreters(school teachers).They responded by sign language which was interpreted by

the school teachers(interpreters).The authors also learnt the sign language during the process of

data collection. The information obtained from the respondents included their bio data and

history of previous ocular examination. The visual acuity of the participants was assessed with

the aid of kay pictures and Snellen E chart depending on their age. The respondents matched the

direction of the arm of the ‘E’ with their fingers. Detailed ocular examination was carried out

on the respondents by the Ophthalmologists with the aid of pen torch and Direct

Ophthalmoscope. In cases of poor view of the posterior segment, the pupils were dilated with the

aid of 1% tropicamide for dilated funduscopy. Respondents with refractive error were refracted

to determine the type and degree of refractive error. Respondents who needed further


examination and treatment were referred to Federal Medical Centre, Owo for further

Management. The data obtained was collated and analyzed with the aid of SPSS 15.0.1 statistical

soft ware.


RESULTS

One hundred sixty (160) respondents participated in this study. They comprised of

91males(56.9%) and 69 females(43.1%).Their ages ranged between 5 years and 23 years with a

mean age of 15.4 years ± 3.4 years.

Most respondents;142(88.75%) were Christians while the remaining ones;18(11.25%) were

Muslims. The ethnicity of the respondents showed that 146(91.3%) were Yorubas, 11(6.9%)

were Ibos and the remaining 3(1.9%) were Hausas.

Most respondents; 158(98.75%) were deaf and dumb while the remaining 2(1.25%) were deaf.

Nearly all the respondents; 159(99.4%) had congenital deafness while only one (0.6%) had

acquired deafness.

The vision of the respondents as detailed in table 1 revealed that only one (0.6%) was blind.

Majority of the respondents; 116(72.5%) had previous ocular examination and the remaining

44(27.5%) did not have previous ocular examination.

Most respondents 156(97.5%) had normal colour vision while colour vision could not be

ascertained in the remaining 4(2.5%) due to poor vision and failure of the respondents to respond

convincingly to sign language.

Few respondents; 42(26.25%) had ophthalmic disorder while the remaining 118 (73.75%) did

not have ophthalmic disorder. Those who had ophthalmic disorder comprised of 27 males

(64.3%) and 15 females (35.7%) As detailed in table 2 most respondents with ophthalmic

disorder had refractive error; 16(38.1%). Myopia was the commonest refractive error as this was


present in 9 respondents (21.4%). Few; 5(11.9%) had hypermetropia and the remaining 2(4.8%)

had astigmatism.


DISCUSSION

There was a preponderance of males in our study population and this is in tandem with the fact

that there were more males in the school at the time of this study. Most of our respondents were

Christians and this may be related to the fact that Christianity was the predominant religion in the

study community. Majority of the participants were Yorubas and this may be due to the fact that

the study community is a Yoruba community in South-West Nigeria. Most of the respondents

had congenital deafness and this may be a pointer to less prominent role of acquired deafness in

this part of the World.

It is quite remarkable that most our respondents had previous ocular examination. This finding is

however at variance with that of another Nigerian study by Onakpoya et al which reported that

70.5% of their study population had no previous ocular examination (17

).However previous

ocular examination was more common among students with ophthalmic abnormalities (17

). The

relatively high rate of uptake of previous ocular examination in our study population is a pointer

to the fact that efforts may have been made in the past to appraise their ocular status. However

there is need for all concerned to build on this and thereby put in place necessary machinery to

promote ocular health of this category of people.

Vision plays a prominent role in the acquisition of skills such as sign language which most deaf

and dumb persons rely on. Thus visual impairment in deaf and dumb people could adversely

affect their adaptation to the environment. This may make such people unduly irritable thus

adversely affecting their interpersonal relationship. Most of our respondents had good vision and

this may explain their adjustment to the school environment. Only one of our respondents was


blind. This finding is similar to that of Onakpoya et al (17

) which reported that 2(1.3%) of their

study population were blind.

The prevalence of ophthalmic disorders among deaf children tends to vary widely in different

population world wide. A study done in Kaduna, Nigeria revealed that 20.9% of the study

population had ophthalmic disorder and refractive error was the commonest presentation (1). The

finding of this former study is in keeping with our own as refractive error was the commonest

ophthalmic disorder in our study population. However the study by Abah et al (1) identified

hypermetropia as the commonest refractive error in their study population as opposed to our own

in which myopia was the commonest refractive error. The finding of Abah et al (1) is also

consistent with a study done in Turkey (5) which reported that hypermetropia was the commonest

refractive error in the study population. It is worthy of note that only one of our respondents with

refractive error had spectacle correction. This brings to fore the urgent need for those affected to

have spectacle correction so as to prevent development of amblyopia. Another study done in

Benin City revealed that 73.26% of the study population had visual disorder (18

). The females in

the study population were affected more than males (18

). This latter finding is consistent with a

previous study which reported higher prevalence of females with ophthalmic disorders in school

of disabilities (19

). However this finding is at variance with our own as most of the respondents

with ophthalmic disorder were males. Studies done in Oregon,

USA (3), Nepal, (19) and Turkey (5) reported prevalence rates of ophthalmic disorders of

48%,23% and 40.4% respectively among deaf children.


Other studies done in India,(20) UK,(21) and Australia (

22) reported prevalence rates of

ophthalmic disorders in their study population of 24%,43.6% and 33% respectively. A study

done in China reported ocular problems in 35.8% of deaf mute students (23

).

Nearly all the participants had normal colour vision. However this could not be ascertained in

very few of them who were yet to fully acquire the language skill and one of them who was

blind. The predicament of the deaf-blind in our study population draws attention to the plight of

deaf-blind persons in general. The respondents with ectopia lentis were promptly referred to a

Cardiologist in view the cardiac defect they had as a result of their underlying Marfans

syndrome. Their referral reinforces the need for multidisciplinary approach to the Management

of deaf persons most especially in childhood. The need for comprehensive medical examination

prior to enrolment in School for the Deaf cannot be overemphasized so as to detect and treat any

coexisting anomaly which may be life threatening.

Carrying out institutional based studies in our area of interest may however introduce bias as

obviously not all deaf and dumb children attend the School for the Deaf. Thus it is imperative to

interpret the findings of the study cautiously so as to avoid generalization. However in spite of

the obvious limitation of this study, it is important for eye care providers to pay special attention

to ocular abnormalities in deaf children.


CONCLUSION

Majority of the respondents had ocular examination in the past. Most of the respondents were

deaf and dumb. Few respondents had ophthalmic disorder. The commonest ophthalmic disorder

was refractive error.

Recommendation

1) All students enrolled in Schools for the Deaf should undergo comprehensive ocular

examination at the point of admission to the School.

2) Routine ophthalmic screening and treatment should be carried out periodically in Schools for

the Deaf so as to promote the ocular health of the students.

3) Recommended glasses should be dispensed free of charge to Students of Schools for the Deaf

who are in need so as to prevent amblyopia and also to enhance their adjustment to the

environment.

4) The Government should ensure adequate electric power supply to Schools for the Deaf most

especially in the night so that the students can communicate through sign language without

difficulty.


ACKNOWLEDGEMENT

We are grateful to the respondents for graciously accepting to participate in this study. Special

thanks and appreciation to the Authority and Teachers of School for the Deaf, Akure for their

cooperation. The authors are greatly indebted to Dr.K. Ilegbusi and Mr.E.B.Olanitori of

Department of Ophthalmology, Federal Medical Centre, Owo for their immense contribution to

this study. The support of Nigerian Medical Association, Ondo State branch is hereby

acknowledged.


REFERENCES

1)Abah ER,Oladigbolu KK,Samaila E,Merali H,Ahmed AO,Abubakar TH. Ophthalmic

abnormalities among deaf students in Kaduna, Northern Nigeria .Annals of African Medicine

2011;10(1):29-33.

2)Holborow C, Martinson F, Anger N. A study of deafness in West Africa. Int J Pediatr

Otorhinolaryngol 1982; 2:115-35.

3) Brinks L.Ophthalmic screening of deaf students in Oregon.J Pediat Ophthalmol Strabis

2001;38(1):11-5.

4) Gilbert CE, Anderson L. Prevalence of visual impairment in children Ophthalmic Epidemiol

1999; 6:73-82.

5) Hanioðlu-Kargi S, Köksal M, Tomaç S, Uðurba SH, Alpay A. Ophthalmologic abnormalities

in children from a Turkish school for the deaf. Turk J Pediatr 2003; 45:39-42.

6) Rogenbogen L,Godel V.Ocular deficiencies in deaf children.J Pediatr Ophthalmol Strabismus

1985;22:231-3.

7) Leguire LE,Fishman C.A prospective study of ocular abnormalities in hearing impaired and

deaf student ENT J 1986;7:64-5.

8) Coleman HM. An analysis of the visual status of an entire school population. Am Optom

Assoc 1970;41:341-7.

9) Rogers F. Screening of school age hearing impaired children. J Pediat Opthalmol 1988;

22(5):230-2.


10)Roizen NJ,Mets MB. Ophthalmic disorder with Downs syndrome .Dev Med Child Neurol

1994;36:594-600.

11)Murdoch H,Russell –Eggitt I. Visual screening in school for hearing –impaired children.

Child Care Health Dev 1990;16:253-61.

12) Siatkowski RM,Flynn JT,Hodges AV et al.Ophthalmologic abnormalities in the Pediatric

cochlear implant population.Am J Ophthalmol 1994;118:70-6.

13) Leguire LE, Fillman RD, Fishman DR, Bremor DL, Rogers GL. A prospective study of

ocular abnormalities in hearing impaired and deaf students. Ear Nose Throat J 1992;71:643-6.

14)Woodruff ME.Diffrential effects of various causes of deafness on the eyes, refractive errors

and vision of children.Am J Optom Physiol Opt 1986;63:668-675.

15) Mohindra I.Vision profile of deaf children.Am J Optom Physiol Opt 1976;53:412-19.

16) Nikolopoulos TP, Lioumi D, Stamataki S, O'Donoghue GM, Guest M, Hall A. Evidence-

based overview of ophthalmic disorders in deaf children, A literature update. Otol Neurotol

2006;27:1-24

17) Onakpoya OH,Omotoye OJ. Screening for ophthalmic disorders and visual impairment in a

Nigerian school for the deaf.Eur J Ophthalmol 2010;20(3):596-600.

18)Osiayuwu AB,Ebeigbe JA.Prevalence of visual disorders in deaf children in Benin city JNOA

2009;15:20-2.

19) Sapkota K. Visual status of deaf school students in Kathmandu, Nepal. Community Eye

Health 2005;18:129.


20) Gogate P, Rishikeshi N, Mehata R, Ranade S, Kharat J, Deshpande M. Visual impairment in

hearing-impaired students. Indian J Ophthalmol 2009;57:451-3.

21) Guy R,Nicholson J,Pannu SS,Holden R. A clinical evaluation of ophthalmic assessment in

children with sensori-neural deafness. Child Care Health Dev 2003;29:377-84.

22) Nicoll AM, House P. Ocular abnormalities in deaf children; A discussion of deafness and

retinal pigment changes. Aust N Z J Ophthalmol 2007;16:205-8.

23)Ma QY,Zeng LH,Chen YZ,Li ZY,Guo XM,Dai ZY, et al.Ocular survey of deaf and mute

children.Yan Ke Xue Bao 1989;5:44-6.


Table 1: Visual acuity of respondents

Visual acuity Right eye Left eye

Frequency(Percentage%) Frequency(Percentage%)

<6/18 149(93.1) 146(91.25)

3/60-6/60 8(5) 11(6.9)

<3/60 –PL 1(0.6) 2(1.25)

NPL 2(1.3) 1(0.6)

Total 160(100) 160(100)


Table 2: Ophthalmic disorders among the respondents

Ophthalmic disorder Frequency Percentage(%)

Refractive error 16 38.1

Juvenile Glaucoma 7 16.7

Vernal conjunctivitis 4 9.5

Early lens opacity 3 7.1

Ectopia lentis 3 7.1

Pthisis bulbi 2 4.8

Optic atrophy 2 4.8

Uveitis 1 2.4

Pseudophakia 1 2.4

Heterochromia iridis 1 2.4

Retinitis pigmentosa 1 2.4

Keratopathy 1 2.4

Total 42 100


Volume 2 Issue 3 2012 ISSN: 2250-0359

ROLE OF TISSUE ADHESIVE IN OTORHINOLARYNGOLOGY

* Karthikeyan Arjunan * Balasubramanian Thiagarajan *Seethalaksmi Narashiman


Abstract:

This paper summarises the effectiveness of tissue adhesives in otorhinolaryngology.

Although the adhesion system cannot and should not replace surgical suture, it provides

valuable assistance in tissue synthesis and in local haemostasis, particularly in cases where

conventional suture methods are especially difficult to apply. In addition to good adhesion,

an elastic consistency, and good tissue compatibility, the adhesive is completely absorbed.

The system has been used successfully in myringoplasty, laryngectomy during pharyngeal

closure, repair of CSF leak, laryngocele, and ossiculoplasty.

Introduction:

The idea to use adhesives for wound closure or to stabilize and fix tissues can be traced back

to many centuries. After the use of different adhesives and glutinous substances (pitch, bee

wax, natural rubber) for wound cover with more or less good results, the development of

fibrin glues (1940) and the later cyanoacrylates (1960) offered new ways in tissue adhesion.

The gold standard of wound closure, the suture, becomes less possible because of

Continuous miniaturisation and the development of minimally invasive surgery methods,

particularly in mucosal areas. But a sufficient wound closure, a secured fixation of skin

grafts, transplants and implants can be of vital importance for the success of a surgical

therapy. In these areas, tissue adhesives virtually present themselves as method of choice.

Gluing ensures a constant laminar force spreading. Unevenness of the material can be


compensated by the adhesive. Additionally to mechanical and chemical basics of adhesion,

the characteristics of a living system must be considered for medical application.

The requirements of medical tissue adhesive:

Biocompatibility:

-Biodegradation and resorbability in a defined period

-no local or systemic toxicity, carcinogenicity or teratogenicity of the adhesives or its

degradation products

-marginal heat development during hardening.

Compound strength:

-high bond strength in wet environment with immediate functional stress

-adequate elasticity

Application:

-easy preparation

-adequate flow characteristics and curing times

-application systems for different areas of application

-miniaturisation (microscopic and endoscopic surgical methods)

Others:

-Sterilisability

-Stable to storage

Materials and methods:

A study was conducted in Stanley medical college and hospital from 2009 to 2011. Tissue

glue was used in various surgeries like myringoplasty, total laryngectomy (pharyngeal

closure), repair of CSF leak and laryngocele and the effectiveness was evaluated. We used

Biologic tissue adhesive, ‘Tisseel’ a two component fibrin sealant.


Tisseel kit contains:

Tisseel, lyophized, stream treated sealer protein concentrate, human 1 ml of Tisseel solution

contains

Clottable protein 75- 115 mg

Thereof fibrinogen 70-110 mg

Plasma fibrinogen (CIG) 2-9 mg

Factor XIII 10-15 IU

Plasminogen 40-120 ug

Aprotinin solution bovine, 3000 KIU/ml

Thrombin 4 lyophized, human 1 ml of thrombin solution contains

Thrombin 4 IU

Thrombin 500 lyophized, human 1 ml of thrombin solution contains

Thrombin 500 IU

Calcium chloride solution 40 mmol/l

Kits for reconstruction and application.


Image showing TISSEEL KIT

Image showing syringe used for tissue glue application


Mechanism of adhesion: 1

The components thrombin and fibrinogen cause, analogue to the last phase of blood

coagulation, the formation of cross-linked fibrin. Here, the concentration of fibrinogen is 15

to 25 times higher than in circulating plasma. Therefore, fibrin is formed much faster. The

other key factor is factor XIII, which causes an indissoluble fibrin matrix. Besides, most fibrin

glues contain anti-fibrinolytic substances (tranexamic acid, aprotinin), which are responsible

for stabilisation of the adhesion by inhibition of fibrinolysis. 1,2 It is elaborated in detail in

discussion.

Image describing reconstruction process

Reconstruction and application:

Use Tisseel and Thrombin solution within 4 hrs. after reconstitution.

Caution:

Use separate syringes and needles for reconstitution of Tisseel and thrombin.

Use again separate syringes and needles for their application.

Do not inject by the intravenous route.


Application:

Study 1:

This fibrin glue was used in 10 cases of myringoplasty. 7 Myringoplasty was done as

classical underlay technique. Graft was placed lateral to the handle of malleus and fibrin

glue was applied at the margins of the tympanomeatal flap after it was repositioned. And

those cases were followed up for a period of 6 months (once in every month) and the cases

were evaluated by otoendoscopy and pure tone audiometry.

Otoendoscopy was done and the following features were assessed:

Graft taken up or not.

Graft medialisation.

Graft lateralisation.

Results: Graft was taken up in 9 out of 10 cases. There is neither lateralisation nor

medialisation of the graft. Pure tone audiometry was showed there was improvement in air

bone gap.

Study 2:

Fibrin glue was applied in a case of total laryngectomy after closure of the pharynx.8

Especially here it was applied not to replace the surgical suture but to provide valuable

assistance to the tissue synthesis and for local haemostasis.

Figure showing glue being applied in a patient with total laryngectomy


Sutures were first removed alternatively, and completely removed at 18th post-operative

day. There was no pharyngo cutaneous fistula. Case was followed up once in a month for 3

months. There is neither fistula formation nor inflammatory reaction.

Study 3:

Fibrin glue was also used in cleft palate repair. It was applied after closure of the muscle

layer and mucosal layer. During post-operative follow up the wound was found to be

healthy and there is no palatal fistula.

Application of tissue glue in cleft palate repair

Study 4:

Tissue glue is used in external laryngocele surgery. Laryngocele was resected from its

attachments near the thyrohyoid membrane and tissue glue is applied to seal the defect in

the thyrohyoid membrane. No recurrence was noted in the one year follow up period.


Image showing tissue glue being applied after laryngocele excision

Study 5:

CSF leak repaired through bicoronal approach. Bicoronal approach was used to expose

anterior table of the frontal sinus. A window was created in the anterior table of the frontal

sinus using the fissure burr. The interior of the frontal sinus was visualised and the leak site

was identified over the posterior table of the left frontal sinus which was sealed using tissue

glue and abdominal fat. No recurrence was noted in the 6 months follow up period.


Tissue glue used in CSF leak repair

Discussion:

Fibrin glues are used since 1940. These are the most commonly used tissue adhesives.

Mechanism of adhesion:


The principle of biological sealing:

In the last step of the coagulation cascade fibrinogen is transformed to fibrin monomers

which aggregate and form a gel. Concomitantly, thrombin transforms factor XIII to factor

XIIIa in the presence of calcium ions. Factor XIIIa crosslinks the aggregated fibrin monomers

to a high molecular weight polymer. The resulting fibrin clot seals off surrounding tissue and

provides early haemostasis.

FIBRIN GLUE REPRODUCES THE LAST STEP OF THE COAGULATION CASCADE:

In natural conditions the fibrin clot is degraded after 1-2 days in most tissues. Fibrin glue

contains aprotinin- the most effective exogenous antifibrinolytic (clot stabilizer) known to

inhibit not only plasminogen activation and plasmin binding but most proteases involved in

clot degradation. It is added to fibrin glue to prolong its stability in vivo up to 9-10 days.

Factor XIII crosslinks fibrin monomers and also fibrin and fibronectin with the collagen of the

tissue to which the sealant was applied.


The fibrin glue clot contains 30 times the fibrinogen concentration, provides high elasticity

and 4-5 times greater tensile strength than a normal blood clot.

Fibrinogen concentration is directly proportional to:

- Elasticity of the fibrin clot

- Increased tensile strength

- Increased adhesive strength


Blood clot Fibrin glue clot

All components of a fibrin glue matrix are involved in the process of wound healing.

Advantages of these biologic tissue adhesives:

- Good adhesion in wet environment

- Minimal tissue irritation

- Good sealing without heat development

- Curing time is better

Disadvantages:

- There is a minimal risk of transmission of prions by aprotinin with bovine origin 1,3

- Cannot be used in arterial bleeding (even heavy venous bleeding is contraindicated)

- Cannot be used in persons with allergic heparin induced thrombocytopenia, and who are

intolerance to bovine products.


SPECIAL WARNINGS AND SPECIAL PRECAUTIONS FOR USE:

1. For epilesional use only. Soft tissue injection carries the risk of an anaphylactoid

reaction and /or local tissue damage

2. Life threatening anaphylactiod reactions and/or thromboembolic complications may

occur if the preparation is unintentionally applied intravascularly.

3. It should be applied as a thin layer. Excessive clot thickness may negatively interfere

with the products efficacy and wound healing process.

4. Fibrin glue contains bovine protein (aprotinin). Even in the strict local application,

there is a risk of anaphylactoid reaction, linked to the presence of bovine aprotinin.

The risk seems higher in case of previous exposure even it was well tolerated.

5. Therefore any use of aprotinin containing products should be recorded in the

patient’s records.

6. In case of shock, standard medical treatment for shock should be implemented.

7. Signs of hypersensivity reactions include hives, generalised urticaria, and tightness

of the chest, wheezing, hypotension, and anaphylaxis. If these symptoms occur the

administration has to be discontinued immediately.

8. Thrombin and factor XIII are made from human plasma. Standard measures to

prevent infections resulting from the use of medicinal products prepared from

human blood or plasma include selection of donors, screening of individual

donations.

9. Despite this, the possibility of transmitting infective agents cannot be totally

excluded. this also applies to unknown or emerging viruses or other pathogens. The

measures taken are considered effective for enveloped viruses such as HIV, HBV and

HCV. The measures taken may be of limited value against small non-enveloped

viruses such as parvovirus B 19 AND HAV.

10. The hypersensitive and anaphylactoid reactions especially may be seen, if the

preparation is applied repeatedly, or administered to patients known to be

hypersensitive to aprotinin or any other constituents of the products. Even if the

second treatment with fibrin glue was well tolerated, a subsequent administration

may result in severe anaphylactoid reactions.


Other than biologic tissue adhesives some other adhesives also in use. They are

- Synthetic adhesives (cyanoacrylates)

- Gelatine resorcinol formaldehyde/glutaraldehyde glues

- Albumin glutaraldehyde glue

Synthetic adhesives:

This has been described for the first time in 1959. 1,4.

But the first short chain cyanoacrylates turned out to be histotoxic and caused distinct

foreign body reactions. The long chain cyanoacrylates of the second generation are more

biocompatible. 5,6 With raising chain length ,toxicity and adhesion strength decrease,

elasticity and polymerisation time increase.

First generation:

- Methyl cyanoacrylate

Second generation:

- Ethyl 2 cyanoacrylate

- n butyl cyanoacrylate

- 2 octyl cyanoacrylate

- Isobutyl cyanoacrylate

- N butyl 2 cyanoacrylate + methacryloxysulphone


In contact with hydroxide ions (liquids like blood or water, air humidity) the cyanoacrylates

form long, strong waterproof chains in an exothermic reaction. The resulting polymer leads

to a stable adhesive bond. The polymerisation time is 20 sec to 2 min. with too much

moisture the reaction runs too fast for a tissue adhesion.

Advantages:

- Good adhesion in moderate wet environments.

- Strong adhesion.

Disadvantages:

- Toxic degradation products.


- Heat generation during polimerization.

Gelatin resorcinol formaldehyde/glutaraldehyde glues:

These were introduced on 1966.


Resorcinol and dialdehyde react to a 3 dimensional network. Gelatine serves as filler.

Polimerisation time is 2 min, the degradation products are much less toxic as those of the

cyanoacrylates.

Note: this is not used in otorhinolaryngology widely due to difficult application.

Albumin glutaraldehyde:


The glutaraldehyde molecules band together by covalent bond with the added albumin as

well as with the proteins of the tissue. The polymerisation time starts immediately after

mixture of the components. The entire adhesive strength is achieved after 2 min.

Note: because of its adhesion attributes in wet environments, this adhesive seems to be

appropriate in otorhinolaryngology.

Role in ENT:

Role in otology:

- Myringoplasty 7, readaptation of the edges after traumatic rupture

- Ossiculoplasty (for both fixation of transplants (cartilage, ossicles) and

Implants (TORP,PORP)

- Fixation of implantable hearing system

- Otoplasty

Role in rhinology:

- Septoplasty (sealing of mucosa) ,closure of septal perforations, turbinoplasty, epistaxis.

- Fixation of transplants (cartilage, bone) and implants (stents) in repair of CSF leak and

other surgeries.

- Dural plasty .


Role in laryngology:

- Closure of fistula. 8

- Fixation of transplants and implants.

References :

1. Schneider 2001 ,march 10. Tissue adhesives in otorhinolaryngology

2. Pursifull NL,Morey AF, Tissue glues and nonsuturing techniques. Curr opin urol 2007; 17,

396-401 DOI-10. 1097/ MOU ob013e3282f0d683

3. Petersen B, Barkun A, Carpenter S, et al. Tissue adhesives and fibrin glues.Gastrointest

Endosc.2004.60. 327-333, DOI: 10, 1016/S0016-5107 (04) 01564-0

4. Coover H. Joyner ,shearer N, Wicker T. Chemistry and performance of cyanoacrylate

adhesives. Special technical papers.1959; 413-417.

5.Alamouti D, Von Kobyletzki G, Allard P, Hoffmann K. Ein prospektiver Vergleich von

octyanoacrylat –Gewebekleberund konventionellen wundverschlussen. Hautarzt. 1999; 50:

58-59.DOI 10.1007/S001050050867.

6. Leggat PA ,Smith DR, Kedjarune U. surgical applications of cyanoacrylate adhesives: a

review of toxicity. ANZ J Surg 2007; 77:209-213.DOI: 10.1080/19338240903241291.

7. Samuel PR, Roberts AC, Nigam A. The use of indermil (n-butyl cyanoacrylate) in

otorhinolaryngology and head and neck surgery. A preliminary report on the first 33

patients. J Laryngol Otol. 1997; 111;536-540.DOI:10.1017/S0022215100137855.

8. Wiseman S, Hicks W, lr, Loree, kasspooles M, Ringual N. Fibrin glue reinforced closure of

postlaryngectomy pharyngocutaneous fistula.



DEPARTMENT OF OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY , SMHS

HOSPITAL GOVERNMENT MEDICAL COLLEGE SRINAGAR,J&K SRINAGAR INDIA

DR.ANEESA.A.MIRZA( P.G SCHOLAR),DR.IRFAN IQBAL(REGISTRAR)

,DR.K.KISHORE(LECTURER),DR.SAJAD.M.QAZI(ASST.PROF.)DR.SHEETAL .K.

LINGUAL SCHWANNOMA: OUR EXPERIENCE

ABSTRACT

Schwannomas are benign tumors of nerve sheath and quite uncommon in oral cavity. The

case of a 15 yr old male is presented who had a 4 months history of swelling on right lateral

border of tongue associated with disturbance in mastication. Examination revealed a 2x2 cm

globular and smooth swelling on right lateral border of tongue. Complete excision with

primary closure was carried out. Histopathological examination of the surgical specimen was

consistent with schwannoma.

INTRODUCTION

A Schwannoma is a benign, encapsulated, slow growing tumor arising from the neural

sheath’s Schwann cells of the peripheral, cranial or autonomic nerves.1It was first identified

by Virchow in 1908.2 About 25-40% of these tumors occur in head and neck region. A rare

site for schwannoma is the oral cavity, it accounts for only 1% of all head and neck region

tumors.3

A 15 yr old male patient (fig.1) presented with 4 months history of a slowly progressive

painless swelling on right lateral border of tongue associated with disturbance in

mastication without any pain or bleeding.


Examination of the oral cavity showed a swelling of 2x2cm on right lateral border of

tongue. The swelling was non tender with a smooth surface and well demarcated margins.

Examination of the rest of oral cavity revealed no other lesion. No regional lymphadenitis

was detected. The patients’ medical history was unremarkable.

Results of routine laboratory tests were within normal limits. MRI of the tongue (fig2)

and oral cavity was performed and revealed a well-defined lobulated mass lesion exhibiting

isointense signal on T1 and hyper intense on T2 images along the lateral border of the

tongue. Other structures of the tongue and oral cavity were without pathomorphological

signs. Fine needle aspiration cytology of the mass was suggestive of the lingual

schwannoma.

Excision if the swelling was planned under general anaesthesia. The lesion was

completely excised by intraoral approach(fig3) and surgical defect was closed. The patient

had an uneventful postoperative recovery. Histopathological examination of the surgical

specimen was suggestive of schwannoma.

DISCUSSION

Schwannomas or neurilemmomas are benign slow growing solitary and encapsulated

tumors originating from Schwann cells of the nerve sheath1.Schwannoma usually occurs in

adults and although they can involve children but are not commonly seen in younger age

group. There is no gender preference4.The presenting feature of a tongue schwannoma is

usually a tumour mass. Other symptoms include dyspnoea or dysphagia and depend on the

location and size of the tumor.5

Schwannomas in the head and neck regions constitute 25% of all extracranial schwannomas

but only 1% show intraoral origin6,7.The intraoral lesions have a predilection for the tongue

followed by the palate, floor of mouth, buccal mucosa and mandible8.In the tongue, base of

tongue is commonly affected3 and the tip is least affected part.9

Identification of the originating nerve may be difficult. In more than 50% of intraoral

lesions, it is not possible to differentiate between tumors of the lingual, hypoglossal and

glossopharyngeal nerves.10

Diagnostic investigations include ultrasound scan, computerised tomography, magnetic

resonance imaging and fine needle aspiration cytology. MRI is best choice in detecting the

extent of the tumour and correlates well with operative findings.11 Diagnosis is confirmed by

histopathology showing the presence of Antoni A and Antoni B cells, nuclear palisading,

whorling of cells and verocay bodies. Malignant lesions such as squamous cell carcinomas

and sarcoma and benign lesions such as granular cell tumors, salivary gland tumours,

leiomyoma, rhabdomyomas, lymphangiomas, haemangioma, dermoid cysts, lipomas,

inflammatory lesions and lingual thyroid are the differential diagnosis of this entity.12


Treatment is always surgical and usually requires only an excision or enucleation of the

tumor.9 Radiation therapy is not indicated because schwannomas exhibit a high degree of

radioresistance.13 Prognosis is excellent as malignant transformation of schwannoma is an

exceptionally rare event and can safely be disregarded.

Figure 1

fig3

Figure 2

REFERENCES

1. Cunningham LL Jr, Warner MR: Schwannoma of the vagus nerve first diagnosed as a

parotid tumour. J oral maxillofacsurg 2003; 61:141-4

2. Mosharrafa TM, Kupper Smith RB, Porter JP, Donavan DT: Malignant peripheral

nerve sheath tumour of the ethmoidal sinus. Arch otolaryngol head neck surg 1997;

123:654,656-7

3. Pfeifle R, Baur DA, Pantino A, Helman J: Schwannoma of the tongue: report of 2

cases. J oral maxillofacsurg 2001; 59: 802-4

4. Chiapasco M, Ronchi P, Scola G: Neurilemmoma (Schwannoma) of the oral cavity: A

report of 2 clinical cases. Minerva stomatol 1993; 42:173-8

5. DeBree R, Westerveld GJ, Smiele LE: Submandibular approach of a large schwanniom

in base of tongue. Eur Arch otorhinolaryngol 2000; 257: 283-6


6. Bansal R, Trivedi P, Patel S: Schwannoma of the tongue. Oral oncol extra 2005;

41:15-17

7. Lopez Jornet P, Bermejo Fenoll A: Neurilemmoma of the tongue. Oral oncol extra

2005; 4:154-7

8. Krolls SO, McGinnis JP Jr, Quon D: Multinodular versus plexiformneurilemmoma of

the hard palate. Report of a case. Oral surg Oral med Oral pathol 1994; 77:154-7

9. Gallesio A, Berrone S. Schwannoma located in the tongue-A clinical case report.

Minerva stomatol 1992; 41:583-90

10. Gutmann R, Grevers G: Extracranialschwannoma of the ENT region. Review of the

literature with a case report of benign schwannoma of the base of tongue. HNO

1997;45:468-71

11. Karaca CT, Habesoglu TE, Naboglu B, Habesoglu M, Oysu C, Egeli E et all.

Schwannoma of a tongue in a child. Am J Otolaryngol 2010: 31: 46-8

12. Nelson W, Chuprevich T, Galbraith DA: Enlarging tongue mass. J oral maxillofacsurg

1998; 56:224-7

13. Gallo WJ, Moss M, Shapiro DN, Gaul JV: Neurilemmoma: Review of the literature

and report of five cases. J Oral surg 1997;35:235-6



Actinomycosis and aspergillosis in the nose of a diabetic: A case report

1Meenu Khurana Cherian

1*, Rajarajeswari

2

1Department of ENT, Gulf Medical College Hospital and Research Centre, Ajman, UAE;

2Department of Pathology,

3Department of Medicine, Pondicherry Institute of Medical Sciences,

Pondicherry, India.

*Presenting Author

Corresponding Author Dr. Meenu Cherian Department of ENT Gulf Medical College Hospital & Research Centre Ajman, UAE. Email Id: [email protected] Phone: +971 67431333 Fax: +971 67431222


ABSTRACT

This is a rare case of an elderly diabetic with a short duration of nasal discharge and

obstruction due to an infection of actinomycosis and aspergillosis on the inferior turbinate

and floor of the nose.

Keywords: nose, turbinate, Actinomycosis, Aspergillosis, diabetes

INTRODUCTION

Actinomycosis of the nose and turbinate is extremely rare1, and a combined infection

with aspergillus is even more so2. The possible cause for this condition is discussed. The

management of the particular patient is described.

CASE REPORT

An 80 year old physician, a diabetic on treatment, was admitted with a productive cough

of two weeks’ duration. The patient had earlier undergone aortic valve replacement on

two occasions and coronary artery bypass grafting. Five months ago he suffered a left

basal ganglia infarct and was on regular physiotherapy for the resulting hemiplegia.

Suspecting microaspiration the chest physician started the patient on Levofloxacin 500

mg. Two days later he complained of nasal obstruction and purulent discharge. This

persisted even after completion of the antibiotic course. A diagnostic nasal endoscopy

was performed which showed yellow colored debris and discharge on the floor of the

nose and adjacent inferior turbinate on the right. The rest of the nose was normal. The

discharge was subjected to microbiological examination which showed 1-2


polymorphs/HP field with occasional Gram positive bacilli and cocci. There was no

growth on culture.

A week later the nasal endoscopy was repeated as the patients problem persisted. A thick

encrusted plaque was found on the posterior part of the medial surface of the inferior

turbinate and on the adjacent floor of the nose. This showed granules which were bright

yellow in colour. On removing the crusts there was bleeding from the underlying mucosa.

The particular colour of the lesion led us to suspect actinomycosis, and the material was

sent for histopathological examination. The biopsy was reported as actinomycosis and

aspergillosis. The patient was then treated with oral Penicillin for 3 months and

Itraconazole for one month after all the mucosal lesions were removed endoscopically

from the nose.

DISCUSSION

Actinomycosis involving the nasal cavity is extremely rare1. Actinomyces sp. are a

common commensal in the oral cavity, rectum and vagina. Infections caused by this

organism are due to penetrating injury and immunocompromised states. Actinomyces are

microaerophilic and these infections are generally deep giving rise to abscesses and

osteomyelitis. Cervicofacial infections manifest commonly as odontogenic infections and

rarely sinusitis and a nasopharyngeal mass. This patient had suffered a cerebrovascular

accident a few months earlier and the mucosal trauma associated with a nasogastric tube

may be the cause for the actinomycotic infection. A mixed infection of actinomycosis and

aspergillosis has only been reported in the lung3. Aspergillus in the nose and paranasal


sinuses manifests as AFRS, invasive or non-invasive granulomatous infection. In this

particular case it is likely that the actinomycosis was the primary infection and the fungal

infection secondary to the antibiotic therapy. Isolated Actinomycosis and actinomycosis

along with a fungal infection are rare in the nose and paranasal sinuses. Both can present

as a granular mass, a discharging sinus or similar to osteomyelitis.

CONCLUSION

In our case only debris and a plaque were visible. It is difficult to differentiate the two

conditions clinically4. A history of concomitant dental infection in a diabetic or

immunocompromised patient is usually present5. In our case an indwelling nasogastric

tube causing trauma to the nasal mucosa in a diabetic was probably the cause. Even

though fine needle aspiration cytology plays some role in the diagnosis of actinomycosis

in a granular mass6, the diagnosis is confirmed only on histopathology.


Figure 1. Endoscopic view of a thick encrusted plaque seen in the posterior part of the

medial surface of the inferior turbinate and on the adjacent floor of the nose


Figure 2. The section shows multiple actinomycotic colonies charecterized by

radiating filaments with the periphery showing eosinophilic Splendore-Hoeppli

reaction. These are surrounded by an abscess with acute on chronic inflammatory

infiltrate. Embedded in the abscess are aspergillus colonies, the fungal filaments show

septate hyphae and branching at acute angles. Fruiting bodies are also seen

(Heamtoxylin & Eosin stain-100x)


Figure 3. [H&E 400X]

Figure 4. Section shows actinomycotic colonies sorrounded by aspergillus colonies

(Periodic Acid Schiff stain 400x)


Figure 5. (PAS stain 100X)

Figure 6. Section shows aspergillus colonies with septate hyphae, branching at acute

angles. Some fruiting bodies are also seen (Gomori Methanamine silver Stain 400x)


Figure 7. Section shows actinomycotic colonies along with aspergillus colonies (Gomori

Methanamine silver Stain 100x)


References

1. Ozcan C, Talas D, Görür K, et al. Actinomycosis of the middle turbinate: an

unusual cause of nasal obstruction. Eur Arch Otorhinolaryngol

2005;262(5):412-5.

2. Huang CW, Lee MA, Lu RH, et al. A case of pulmonary aspergilloma and

actinomycosis. J MJ Med Microbiol 2011;60(4):543-6.

3. Hiroyoshi T, Shunsuke E, Kohzo S, et al. Endobronchial aspergillosis and

actinomycosis associated with broncholithiasis. Eur J Cardiothorac Surg

2007;31:1144-1146.

4. Bhatia PL, Obafunwa JO. Rare infections of nose and paranasal sinuses.

Trop Geogr Med 1990;42(3):289-93.

5. Weston V. Microorganisms. In, Gleeson M, Browning GG, Burton MJ, et

al. (ed). Scott-Brown’s Otorhinolaryngology: Head and Neck surgery, 7th

ed.

London, Hodder and Arnold 2008;195-203.

6. Gupta N, Kaur J, Srinivasan R, et al. Fine needle aspiration cytology in

lesions of the nose, nasal cavity and paranasal sinuses. Acta Cytol

2011;55(2):135-41.

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Ozcan%20C%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Talas%20D%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22G%C3%B6r%C3%BCr%20K%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed/15549341

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Huang%20CW%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lee%20MA%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Lu%20RH%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=actinomycosis%2Caspergillosis%20and%20upper%20respiratory%20tract

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Bhatia%20PL%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Obafunwa%20JO%22%5BAuthor%5D


http://www.ncbi.nlm.nih.gov/pubmed?term=%22Gupta%20N%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Kaur%20J%22%5BAuthor%5D

http://www.ncbi.nlm.nih.gov/pubmed?term=%22Srinivasan%20R%22%5BAuthor%5D




Sphenoethmoidal hemangioma-A rare presentation

* Sundar krishnan * Raghukumaran

*Madras Medical College & Rajiv Gandhi Government General Hospital

ABSTRACT

Hemangiomas do not develop as commonly in the sinonasal cavity, compared with

other head and neck sites. The most common presenting symptom was epistaxis.

Hemangiomas involving multiple sinuses with a atypical clinical presentation is extremely rare.

We present a representative case of sphenoethmoidal hemangioma with atypical clinical

presentation and treated by endoscopic excision yielding excellent outcome in terms of tumor

control and safety.

CASE REPORT

A 37 year old male had c/o referred to ENT OPD with c/o headache past 6months,

diminished vision in right eye 2months & left eye 2weeks and increased frequency of urination

2weeks.


On carefully eliciting the history he revealed his headache was diffuse, compressive nature

continuously present not associated with nausea and vomiting.2months back developed

blurring of vision in right eye for which he attended opthal OPD where he was admitted for 2

days investigated, diagnosed as ?retrobulbar neuritis treated and discharged.

After discharge, for 2weeks he was asymptomatic and had deterioration of vision in right eye &

diminution of vision in left eye with increased frequency of urination 2weeks.patient again

revisited opthal OPD from where he was referred to neurology OPD.

After serial of investigations by neurologists they are still inconclusive in diagnosis and with aid

of radiologists they gave a differential diagnosis of? Fungal granuloma,? ethmoidal carcinoma

and ?pituitary adenoma with dibetes insipidus.

Then patient was referred to our ENT OPD for further management.

CRANIAL NERVE EXAMINATION:

OPTIC NERVE: Rt Lt

Visual acuity only light 6/36

Perception

Colour vision not appreciable +

Field of vision absent +

Other cranial Nr’s examination-Normal; All blood investigations was normal

ENT examination revealed normal except for mild DSL, Deviated septum to left.


CT PNS

MRI BRAIN WITH PNS


DIAGNOSTIC NASAL ENDOSCOPY showed,

Rt side: Accessory ostium + , Middle turbinate medialized

*Lt side-DSL, Accessory ostium + , Sphenoethmoidal recess-normal

# NO MASS VISUALISED IN NASAL CAVITY

We planned for a,

ENDOSCOPIC TRANSNASAL MASS EXCISION, under GA

We had excised the mass and sent for histopathological examination

HPE report showed polypoidal respiratory epithelium lined mucosa with scattered bony spicules

with large dilated thin walled blood vessels lined by endothelial cells and foci of proliferating thin

walled branching closely packed blood vessels wit intervening fibrotic stroma.

Lesion consistent with HEMANGIOMA


HPE PICTURES-CAPILLARY AND CAVERNOUS HEMANGIOMA


PRE OPERATIVE MRI POST OPERATIVE MRI

Post operatively pt had a transient Diabetes Insipidus was on strict fluid management with normal renal

parameters

Within a week DI resolved completely

Nasal pack removed on IVth POD

To our surprise pt had a dramatic improvement in vision in immediate post op period and returned to

6/6 in both eyes.

CONCLUSION:

Thus we conclude sphenoethmoidal hemangioma is extremely rare presenting with

blindness and endoscopic optic nerve decompression proven its complete removal with excellent

outcome in patient improvement and tumor control.


DISCUSSION


REFERENCES



Correlation of fine needle aspiration and final histopathology in thyroid disease: a series

of 702 patients managed in an endocrine surgical unit

*Chandrasekaran Maharajan * Himagirish Rao

*Madras Medical College

Abstract

Introduction: Thyroid nodules are a common clinical entity found among the adult

general population. With increasing use of imaging investigations like ultrasonography, there

has been a significant rise in the detection of non-palpable thyroid nodules that require further

evaluation and management. The routine use of FNAC has reduced the number of

unnecessary surgical procedures for thyroid nodules. Taking a decision as to whether to

operate on a thyroid nodule is dependent on accurate FNAC testing. This study describes the

experience with FNAC in a consecutive series of patients with thyroid nodules who

underwent thyroidectomy at a tertiary care hospital in the department of endocrine surgery.

Patients and methods: Clinical and pathologic data of patients with thyroid nodules or

diffuse goitre who were operated in a single endocrine surgical unit between January 2008

and December 2010 were prospectively collected and retrospectively reviewed. The

anatomical lesion of the thyroid (solitary nodule, STN, multinodular goitre, MNG or diffuse


goitre, DG) was recorded. The functional status of the thyroid was assessed for each patient

at presentation. All patients included in the study underwent fine needle aspiration cytology

(FNAC) followed by surgery. Patients with solitary toxic nodules underwent

hemithyroidectomy, while others underwent total thyroidectomy. Final histopathology (HPE)

was then compared with initial FNAC results.

Results: Out of the total number of 702 patients, 119 (17%) were men and the remaining 583

(83%) were women. With regards to solitary thyroid nodules, FNAC had a sensitivity of

86.9%, specificity of 99.1%, false negative rate of 13.1%, false-positive rate of 0.9%, positive

predictive value of 97,6% and negative predictive value of 94.9% for diagnosis of

malignancy. FNAC had a sensitivity of 76.9%, specificity of 98.8%, false negative rate of

23.1%, false-positive rate of 1.2%, positive predictive value of 94.6% and negative predictive

value of 93.8% for diagnosis of malignancy with respect to diffuse and multinodular goitre.

Overall, FNAC had a sensitivity of 80.2%, specificity of 98.9%, false negative rate of 19.8%,

false-positive rate of 1.1%, positive predictive value of 96.6% and negative predictive value

of 94.1% for diagnosis of malignancy.

Conclusion: FNAC was more accurate in patients with solitary thyroid nodules than in those

with multinodular or diffuse goitre. While false negativity could be due to misrepresentative

sample or misinterpretation of the sample, false positivity could be ascribed to hyperplasia of

thyrocytes in the functioning thyroid as a result of TSH stimulation.


Introduction

Thyroid nodules are a common clinical entity found among the adult general

population. The frequency of non-palpable thyroid nodules may be as high as 50% or more

by the age of 50 years.1,2

With time, ultrasonography has come to be used with increasing

regularity in clinical practice. As a result, there has been a significant rise in the incidence of

non-palpable thyroid nodules that require further evaluation and management. Since 1986,

when fine needle aspiration cytology (FNAC) was first reported from Sweden, it has been

widely accepted as the most accurate, cost-effective, and safe screening test for rapid

diagnosis of thyroid nodules.3, 4, 5

The routine use of FNAC has reduced the number of unnecessary surgical procedures

for thyroid nodules.2, 6

In addition; it has enabled the detection of thyroid cancer at earlier

stages.7, 8

Taking a decision as to whether to operate on a thyroid nodule is dependent on

accurate FNAC testing. Assessment of false positive and false negative FNAC results

assumes importance in this context.9

Indeterminate FNAC results that include follicular and Hurthle cell neoplasms and

those that indicate a suspicion of papillary thyroid cancer (PTC) without actually diagnosing

PTC, represent a continued diagnostic and treatment challenge to pathologists and surgeons

alike. The diagnosis of follicular thyroid carcinoma (FTC) or Hurthle cell carcinoma (HTC)

requires the presence of capsular or vascular invasion on final histopathological examination

(HPE), findings that cannot be assessed by FNAC. Sometimes, patients with indeterminate

thyroid nodules who undergo hemi-thyroidectomy are found to have malignancy on final

pathology. Such cases necessitate completion thyroidectomy.3, 6


This study describes the experience with FNAC in a consecutive series of patients

with thyroid nodules who underwent thyroidectomy at a tertiary care hospital in the

department of endocrine surgery.

Methods

Clinical and pathologic data of 702 consecutive patients with thyroid nodules or

diffuse goitre who were managed in a single endocrine surgical unit between January 2008

and December 2010 were prospectively collected and retrospectively reviewed. The

anatomical lesion of the thyroid (solitary nodule, STN, multinodular goitre, MNG or diffuse

goitre, DG) was recorded. The functional status of the thyroid was assessed for each patient

at presentation with the help of free thyroid hormone (FT3 and FT4) and thyroid stimulating

hormone (TSH) levels. Levels of anti-microsomal and anti-thyroglobulin antibodies (AMA

and ATG) were estimated. Those who were hypothyroid or hyperthyroid at presentation were

started on appropriate drug therapy.

All FNAC slides were classified into 1 of 4 main categories: non-diagnostic, benign,

indeterminate, or malignant. The indeterminate group included specimens further classified

as follicular neoplasm (FN), Hurthle cell neoplasm (HN), or suspicious for papillary thyroid

cancer (SPTC). Specimens were classified as follicular neoplasms when cytology aspirates

were very cellular, with scant or no colloid, and uniform microfollicular cells were present.

The interpretation of Hürthle cell neoplasm was made when FNAC aspirates consisted of

microfollicles formed by cells with abundant eosinophilic cytoplasm lacking lymphocytes.

The diagnosis of ‘suspicious for PTC’ (SPTC) was made when cellular aspirates revealed

nuclear grooving, intranuclear pseudo-inclusions, or Psammoma bodies, but no papillae and

little colloid.


Papillary microcarcinomas, defined as malignant lesions smaller than 1 cm, were considered

in the final analysis of this study.

Patients with non-toxic solitary thyroid nodules (including FN, HN and PTC), DG and

MNG underwent total thyroidectomy. Those with a solitary toxic adenoma underwent

hemithyroidectomy. All patients with pre-operative diagnosis of malignancy underwent total

thyroidectomy (TT) and central compartment neck lymph-node dissection (CCLND), if

indicated. Those patients with lateral cervical node metastases diagnosed preoperatively

underwent a modified radical neck dissection (MRND) of the involved side.

Indications for thyroidectomy when FNAC of the index nodule was benign included

interval growth, obstructive symptoms, cosmetic reasons, adverse ultrasonographic nodule

features, and/or patient preference.

All 702 patients underwent hemithyroidectomy or total thyroidectomy, and final

histopathology (HPE) was then compared with initial FNAC results.

Results

A total of 702 patients, aged between 13 and 78 yrs, with median age of 39 yrs

underwent FNAC of the thyroid followed by thyroidectomy between January 2008 and

December 2010. Out of the total number of patients, 119 (17%) were men and the remaining

583 (83%) were women.

Out of the total number of cases studied on FNAC, 460 (66%) were diagnosed with

benign thyroid disease while 115 patients (16%) were diagnosed to have malignancy (Table

1). 71 (10%) FNAC results were classified as indeterminate and 56 patients had a non-

diagnostic FNAC (Table 1). Out of the 115 patients who were diagnosed with malignancy,

107 (93%) had PTC while 8 (7%) had medullary thyroid cancer (Table 1). Among the


indeterminate reports, 34 patients (48%) were reported to have FN, while 5 (7%) were

diagnosed as HN and the remaining 32 (45%) were suspicious for PTC (Table 1).

Among the 460 patients with benign disease as diagnosed on FNAC, 433 (94%)

patients had benign disease after HPE, while 27 (6%) patients turned out to have malignancy

(Table 1). Out of the 115 patients diagnosed with malignancy on FNAC, 110 (96%) patients

had malignancy on HPE while 5 (4%) patients had benign disease on HPE of the operative

specimen (Table 1). All these 5 patients had been diagnosed with PTC on FNAC. All the

patients diagnosed with MTC on FNAC had MTC on HPE of the operative specimen. Out o

the 71 patients with indeterminate FNAC diagnosis, 32 (45%) had malignancy on HPE, while

39 (55%) patients had benign disease (Table 1).

Out of the total number, 196 patients had solitary thyroid nodules (Table 2). While

118 patients (60%) had benign diagnosis on FNAC, 41 patients (21%) were diagnosed with

malignancy, 29 (15%) had indeterminate FNAC and 8 patients (4%) had non-diagnostic

results (Table 2). On comparison with final HPE, FNAC had a sensitivity of 86.9%,

specificity of 99.1%, false negative rate of 13.1%, false-positive rate of 0.9%, positive

predictive value of 97.6% and negative predictive value of 94.9% for diagnosis of

malignancy.

The remaining 502 patients had MNG or DG (Table 3). Out of these, 342 (68%) were

diagnosed with benign disease on FNAC, while 74 patients (15%) were diagnosed with

malignancy (Table 3). 42 patients (8%) had indeterminate results, while FNAC was non-

diagnostic in 48 patients (9%). When compared with the final HPE, FNAC had a sensitivity

of 76.9%, specificity of 98.8%, false negative rate of 23.1%, false-positive rate of 1.2%,

positive predictive value of 94.6% and negative predictive value of 93.8% for diagnosis of

malignancy.


Overall, FNAC had a sensitivity of 80.2%, specificity of 98.9%, false negative rate of


value of 94.1% for diagnosis of malignancy.

In all, 179 out of the total of 702 patients (25%) were found to have malignant thyroid

disease on final HPE (Table 4). Out of these, 113 (63%) had PTC, 48 (27%) had follicular

variant of PTC, 8 patients (4%) had MTC, 4 (2%) had follicular carcinoma, 2 (1%) had

Hurthle cell carcinoma and 4 patients had other variants of PTC.

Discussion

In this study, FNAC was conducted with the help of a 24-guage needle. Non-

aspiration cytology was not performed.

In the present study, the overall false negative rate for FNAC was 19.8%. Other

reports in the literature suggest false negative rates ranging from 1% to 17%.6,8-16

On analysis

of FNAC results with respect to the anatomical diagnosis, FNAC had a false negative rate of

13.1% for solitary thyroid nodules and 23.1% for diffuse goitre or multinodular goitre.

This could be due to misrepresentative sample or misinterpretation of the sample.

False negatives in the case of STNs could be due to misinterpretation, while those in patients

with MNG or DG could be misrepresentative samples.

The false positive rate of FNAC was 1.1% in the present study. This incidence is

consistent with other reports that cite false positive FNA results ranging from 0% to 9%.9-13

This could be ascribed to changes in the thyroid as a result of TSH stimulation.

Hypothyroidism is characterised by hyperthyrotropinemia. Cellular hyperplasia is common in

a functioning gland under TSH stimulation, resulting in highly cellular smears with scanty

colloid, resembling malignancy.

Conclusion


Overall, FNAC had a sensitivity of 80.2%, specificity of 98.9%, false negative rate of


value of 94.1% for diagnosis of malignancy. FNAC was more accurate in patients with

solitary thyroid nodules than in those with multinodular or diffuse goitre. While false

negativity could be due to misrepresentative sample or misinterpretation of the sample, false

positivity could be ascribed to hyperplasia of thyrocytes in the functioning thyroid as a result

of TSH stimulation. . On the basis of these findings, we suggest that it is advisable to avoid

FNAC in hypothyroid state.


References

1. Mazzaferri EL. Management of a solitary thyroid nodule. N Engl J Med

1993;328:553–9

2. Davies L,Welch HG. Increasing incidence of thyroid cancer in the United States,

1973–2002. JAMA 2006;295:2164–7

3. Frates M, Benson C, Charboneau J, et al. Management of thyroid nodules detected at

US: Society of Radiologists in Ultrasound consensus conference statement. Radiology

2005;237:794–800

4. Gharib H, Goellner JR. Fine-needle aspiration biopsy of the thyroid: an appraisal.

Ann Intern Med 1993;118:282–9

5. Cooper DS, Doherty GM,Haugen BR, et al. Revised American Thyroid Association

management guidelines for patients with thyroid nodules and differentiated thyroid

cancer. Thyroid 2009;19:1167–1214

6. Lowhagen T, Willems JS, Lundell G, et al. Aspiration biopsy cytology in diagnosis of

thyroid cancer. World J Surg 1981;5:61–73

7. Gharib H. Fine-needle aspiration biopsy of thyroid nodules; advantages, limitations,

and effects.Mayo Clinic Proc 1994;69:44–9

8. Baloch ZW, Sack MJ, Yu GH, et al. Fine-needle aspiration biopsy of thyroid: An

institutional experience. Thyroid 1998;8:565–9


9. Lew JI, Snyder RA, Sanchez YM, Solorzano CC. Fine needle aspiration of the

thyroid: correlation with final histopathology in a surgical series of 797 patients. J Am

Coll Surg 2011;213:188-94

10. Meko JB, Norton JA. Large cystic/solid thyroid nodules: A potential false-negative

fine needle aspiration. Surgery 1995;118:996–1004

11. Amrikachi M, Ramzy I, Rubenfield S, WheelerTM. Accuracy of fine needle

aspiration of thyroid: A review of 6226 cases and correlation with surgical or clinical

outcome. Arch Pathol Lab Med 2001;125:484–8

12. Blansfield JA, Sack MJ, Kukora JS. Recent experience with preoperative fine-needle

aspiration biopsy of thyroid nodules in a community hospital. Arch Surg

2002;137:818–821

13. Yassa L, Cibas ES, Benson CB, et al. Long-term assessment of a multidisciplinary

approach to thyroid nodule diagnostic evaluation. Cancer Cytopathol 2007;111:508-

16

14. Scalbas GM, Staerkel GA, Shapiro SE, et al. Fine-needle aspiration of the thyroid and

correlation with histopathology in a contemporary series of 240 patients. Am J Surg

2003;186:702–10

15. McCoy KL, Jabbour N, Ogilvie JB, et al. The incidence of cancer and rate of false-

negative cytology in thyroid nodules greater than or equal to 4 cm in size. Surgery

2007;142:837–44

16. Yang J, Schnadig V, Logrono R, Wasserman PG. Fine-needle aspiration of thyroid

nodules: A study of 4703 patients with histologic and clinical correlations. Cancer

Cytopathol 2007; 111:305–15


From the Desk

Dear readers,

For quite some time, lots of things are worrying my mind. I would like to share them, with the idea of not only for clearing my doubts, but for getting better information so that an awareness is created for the future improvements in medicine, in particular, Otorhinolaryngology field.

Otorhinolaryngology being the surgical field let me caution that strict and universal application of Evidence Based Medicine need much revision.

Evidence based medicine

First, let me start with Evidence based medicine (EBM). No doubt, it carries the highest preference in research field. It clearly wins in all allied clinical subjects; I mean to say it is more useful in drug therapy, drug modification, newer drug trials, investigational values, etc.

Coming to surgical procedures, emergency management, terminal care, multi system involvement, multi specialty care, and numerous other situations, the decision making depends on many facets of the problem rather than single entity. Usually Otorhinolaryngogical surgeons faces many challenges including monetary limitation of the patients, psychological aspects, resource availability of the institution especially in emergency situations, expertise needs etc.

Constraints for not adhering to EBM in certain situations may be time factor, aesthetics factors, and occupational factors and also include social and individual mental makeup.

Some of the drawbacks of conducting trials in surgical specialty are, (especially with regard to newer or existing surgical method options)

1. Psychological trauma,

2. Anxiety,

3. Desperation,

4. Insecurity

The patients usually think that they could have chosen the option rather than leaving it for the machine or the third person to decide about their future.

Even though they may consent for the trial, everybody agree that they undergo lot of turmoil during as well as after the procedure.

Forough Farrokhyar quotes, “Surgical trials pose many methodological challenges often not present in trials of medical intervention….. Many barriers and issues of surgical trials affecting internal validity can be overcome with proper methodology, and in most cases these issues do not restrict their conduct…..ref 2”

Methodology

Secondly well defined methodology with proven records is available for newer techniques to be accepted easily by all.

Though trials have many phases including animal experimentations, still it may have different adverse reactions’ when it comes to human experimentations, especially, newer surgical techniques are concerned. If the story goes like this, I do accept that there would not have been revolution of Key- hole surgery, Robotic surgery and computer assisted surgeries which are the common day practices in Otorhinolaryngology field.

Further many time tested surgical practice are slowly weaning to give way for the newer trends. It gives more satisfactions, lessons the surgical time, reduces morbidity, which all will agree.

But no patient is willing to bell the cat.

Protocol modules for Clinical situations

I give more emphasis on the development of protocol modules for Clinical situations (symptomatology wise as well as disease wise). In this Endeavour I would like to give special mention on the great initiative taken by Scottish Intercollegiate Guidelines Network, http://www.sign.ac.uk (Ref 1)

Even though much work has to be done there are few organizations including W.H.O., have already contributed much in this field’

Third and finally I have to accept that quality car and improvement has tremendous impact in the surgical field than EBM. Critical evaluation, continuous assessment, and on the spot verification, by internal as well as independent agencies do carry a lot in the implementation of quality care assessment. This system automatically creates awareness, urgency for improvement and acceptance for standardization.

Holistic and situation based management

Here I would like to mention a live situation. Middle aged male was referred for mastoidectomy as he was having swelling and discharge from the mastoid region for one month. Though he is strong at that time he was very sick. The CT and MRI of mastoid and temporal bone showed mastoiditis. Clinically he was having bloody discharge from both ears. Though they gave history of Incision and drainage was done for subperiosteal swelling day before. There was swelling and wound on both post aural regions with bloody discharge. There was hematoma on

http://www.sign.ac.uk/

the soft palate, bloody discharge from both external auditory canal and also epistaxis from both nostrils with clots. Investigations already done showed serum creatinine 3.5 and blood urea 90 mgms . Internist and Nephrologist who referred this patient, informed that the patient is in the Diffuse intravascular coagulatory state due to sepsis. Hence they were of the opinion that emergency mastoidectomy will be beneficial. Routine investigations were omitted. It was found out that there was spreading cellulitis in the mastoid region rather than abscess. This created the suspicion of septic shock and renal failure as well as the wound cannot be approximated, bone work will invite uncontrollable bleeding and the surgery was referred. Further investigations revealed that Haemoglobin level as 4 grams and the patient was HIV strongly positive . Moral of the story is “ decide by the state of the patient rather than reports and recommendations”. Otorhinolaryngologists have to decide on the ENT conditions.

Let me conclude that surgical management especially in Otorhinolaryngology looks similar to 64 squares of the chess board but with 64 billion options widening as the game goes. In fact it is true, disease don’t restrict to Otorhinolaryngological field for any given patient. They may have causative disease, coexisting disease, complicating factors, contributory factors, in addition to the acute attacks, remission phase, as well as impending complications. As experienced surgeon, one has to view with broad outlook and act timely with precision and holistic approach.

BIBLIOGRAPHY:

1. Scottish Intercollegiate Guidelines Network,

2. Randomized Controlled Trials of Surgical Interventions. Forough Farrokhyar et al (Ann Surg 2010;251: 409 – 416)

3. Randomized Controlled Trials for Evaluating Surgical Questions Eric K. Fung, MD & John M. Loré, Jr (Arch Otolaryngol Head Neck Surg. 2002;128(6):631-634. doi:10-1001/pubs.Arch Otolaryngol. Head Neck Surg.-ISSN-0886-4470-128-6-ooa10211)

U. Venkatesan

online journal of otolaryngology jorl volume 2 issue 3

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