Sudden Onset Auditory Neuropathy Spectrum Disorder: A Rare Case Report of Brown Vialetto Van Laere Syndrome

Brown Vialetto Van Laere syndrome is a rare disorder characterized by progressive pontobulbar palsy with bilateral sensorineural hearing loss and lower cranial nerve palsies. Fifty-eight cases have been reported in the last hundred years. As the most common presenting complaint of this disorder is hearing loss, audiological evaluation plays a vital role in pointing towards and narrowing its diagnosis. We present a case report of a 12-year male child affected by this disorder.

Malignant Chondroid Syringoma With Nose and Paranasal Sinus Extension: A Case Report

Chondroid syringoma is a rare, skin appendageal tumor. It is also known as mixed tumor of skin, as it histologically resembles mixed tumor of salivary gland (pleomorphic adenoma). It is most commonly a benign tumor, but a few malignant counterparts have been described in history. It usually presents as a solid, slow-growing, solitary, and painless nodule in the head and neck region. Malignant counterpart is rare and commonly affects trunk and extremities. Early diagnosis and surgery by wide local excision are the most reliable treatments to date. Recurrences are common and hence close follow-up is advised. In this study, we present a case of malignant chondroid syringoma of face with extensive extension into nose and paranasal sinuses, which was recurrent and managed by surgical excision and radiotherapy. To the best of our knowledge, this is the first reported case with extension and bone destruction into nose and sinuses.

Validity and Reliability of Tamil translated University of Washington Quality of Life Questionnaire for Head and Neck Cancers

Background:

Quality of life is an important outcome measure used both in research and patient care across all cultural healthcare settings.

Objective:

This study is aimed to evaluate the validity and reliability of interviewer-administered Tamil translated University of Washington Quality of Life Questionnaire (Version 4) in a setting with low literacy.

Methods:

The study was done in a tertiary care teaching institute in Puducherry, South India. The translation was done by using ‘forward-backward translation method.’ A hundred subjects diagnosed with head and neck cancer (HNC) were interviewed before the initiation of treatment. The Tamil version of University of Washington Quality of Life Questionnaire (UWQOL) questionnaire was validated using the Tamil version of the World Health Organization Quality of Life-Brief questionnaire (WHOQOL-BREF) version. Inter-rater reliability and test-retest reliability was also assessed. Item-total correlation and Cronbach alpha were calculated for assessing validity and internal consistency respectively.

Results:

In the Tamil version of UWQOL, social-emotional subscale was more affected than physical subscale. The domains such as mood, anxiety, and pain were most affected. The subscale scores were significantly different between those with early and late cancer. Tamil version of UWQOL showed moderate correlation with WHOQOL-BREF. The Tamil version of UWQOL had good test-retest and inter-rater agreement. Item-total correlation for the subscales was >0.80. The internal consistency of the Tamil Questionnaire was acceptable with Cronbach Alpha of 0.69.

Conclusion:

The Tamil version of UWQOL questionnaire is a short, valid and reliable for HNC patients of low literacy.

Microbiological Profile of Chronic Tonsillitis in the Pediatric Age Group

Introduction

Tonsillitis is a very common disease in children. Understanding the microbiology and pathology of chronic tonsillitis is an important step in its management. The aim of the study was to describe the microbiological profile of core tonsillar tissue in chronic tonsillitis in children.

Materials and methods

Children under 16 years of age with chronic tonsillitis were recruited in the descriptive study. Children with recurrent tonsillitis and recurrent tonsillitis with obstructive symptoms were included. Children who underwent tonsillectomy for obstructive symptoms alone and those who received antibiotics for at least one month prior to surgery were excluded from the study. Dissection and the snare method of tonsillectomy were done on all children. The operated specimen was cut into two halves in a sterile container. The core of the tonsillar tissue was swabbed with two sterile cotton-tipped swabs and sent for the microbiological evaluation of aerobes and anaerobes. The tonsillar tissue was sent for a histopathological examination.

Results

A total of 106 children were operated for chronic tonsillitis in one year. The mean age of children included in this study was 9.4 years. The duration of symptoms due to tonsillar disease ranged from four weeks to 28 months. There were 48 males and 58 females. Recurrent tonsillitis was the most common indication for tonsillectomy in all children. A total of 301 aerobes and 171 anaerobic microorganisms were isolated from 106 children with chronic tonsillitis. The aerobic bacterial species most often isolated was Streptococcus viridans, which was present in 83 children followed by Group A, β-hemolytic Streptococci in 67 children. The anaerobic bacterial most often isolated was Peptococcus species in 49 children. Polymicrobial aerobic and anaerobic flora were present in all tonsillar specimens, yielding an average of 4.1 isolates per specimen. The histopathological examination revealed chronic tonsillitis with reactive follicular hyperplasia in all (100%) children. Actinomycosis was associated with non-specific reactive follicular hyperplasia in four specimens.

Conclusion

Polymicrobial aerobic and anaerobic flora are identified in deep tonsillar tissue in children with tonsillitis. The identification of bacterial isolates from the core tissue in recurrent tonsillitis could dictate the management of chronic tonsillitis. The histopathological examination of the core tissues of the tonsils helps in an accurate identification of organisms that are difficult to culture.

Management of Laryngotracheal Trauma: A Five-Year Single Institution Experience

INTRODUCTION

Laryngotracheal trauma is a rare life-threatening emergency that requires early identification and immediate intervention. Here, we present 26 patients with laryngotracheal trauma from a tertiary hospital in India. The aim was to describe the clinical presentation and management of laryngotracheal trauma patients.

MATERIALS AND METHODS

This was a retrospective study of laryngotracheal trauma patients treated between January 2011 and March 2016. Patients who presented with a breach in the laryngotracheal framework were included, while those who had penetrating neck injuries superficial to strap muscles/platysma, burn injuries, caustic ingestion, or endotracheal injuries were excluded from the study.

RESULTS

Of 253 patients with neck injury, 26 (23 adults, three children; 21 males, five females; age range, 5-60 years) presented with a breach in the laryngotracheal framework (15 blunt neck-trauma patients and 11 penetrating neck-trauma patients). The most common cause of neck injury was road traffic accidents, seen in 12 patients (46.2%). Computed tomography (CT) was performed in all blunt trauma cases and in four patients with penetrating trauma. All penetrating trauma patients underwent neck exploration. Twelve blunt trauma patients (46.1%) were managed conservatively, while three (11.5%) required surgical intervention. The most common neck exploration finding noted in patients with a penetrating injury was fracture of the thyroid cartilage, which was seen in eight patients (30.8%). Twenty patients (76.9%) had a normal voice, five patients (19.2%) had a hoarse voice, and one patient (3.8%) had a breathy voice post treatment.

CONCLUSION

Early intervention of laryngotracheal trauma is crucial. The role of a CT scan is essential in decision making in blunt trauma cases.

Role of Heparin Irrigation in the Management of Superficial Burns with Special Reference to Pain Relief and Wound Healing: A Pilot Study

Introduction

The objective of this study was to assess the effect of heparin irrigation in the management of superficial first and second degree burns with special reference to pain relief and wound healing.

Materials and methods

This pilot study was carried out over a period of 12 months in a tertiary care centre in South India. The study patients were divided into two groups: the heparin group and the saline control group. In the control group, the burn wound was irrigated with 100 mL of normal saline before the conventional dressing with silver sulfadiazine. In the heparin irrigation group, the wound was irrigated with heparin solution before the conventional dressing. Wound healing was assessed in terms of necrotic tissue score and granulation tissue score. Patient satisfaction in terms of patient satisfaction score, visual analogue scale (VAS) score, and length of hospitalization were compared between the two groups.

Results

A total of 40 patients were analysed in the study, 20 patients in each group. Both the groups were comparable with respect to age, gender, co-morbidities, body mass index (BMI), and degree of burns. Wound healing parameters like necrotic tissue score of six [40% vs. 50%; p = 0.024] and granulation tissue score of four [85% vs. 65%; p= 0.06] were significant in the heparin group compared to the control group. However, the difference was not statistically significant. The mean length of hospitalization between the two groups [10.5 days vs. 12.6 days; p = 0.74] were not statistically significant. Similarly, there was no statistically significant difference between the two groups with respect to the VAS pain score on the seventh dressing day [6.9 vs. 7.3; p= 0.321].

Conclusion

In comparison to saline irrigation, heparin irrigation would result in better wound healing in superficial first and second-degree burns. The length of hospital stay in days and VAS pain score on the seventh dressing day were not statistically significant between the two groups.

Anatomical Features of Intratemporal Course of Facial Nerve and its Variations

Introduction

Facial nerve has the longest and complex course in its bony canal. The anatomical variations make the nerve prone to injury during mastoid surgeries. Having a thorough anatomical knowledge and its variations is must for the surgeons to avoid injury to this vital structure and for the safe surgery. The objective of the study was to describe the anatomical variations of intratemporal portion of facial nerve.

Materials and methods

The study was conducted in the department of otorhinolaryngology in the temporal bone dissection laboratory of a tertiary health care centre. Fifty wet temporal bones were dissected by the same team of surgeons for the duration of one year to study the various anomalies of the intratemporal course of the facial nerve and its relations with the other important middle ear structures.

Results

The mean length of the labyrinth, tympanic and mastoid segment of the facial nerve was 4.1 mm (±0.6 mm), 9.34 mm (±1.12 mm) and 12.8 mm (±1.8 mm), respectively. The mean distance between the horizontal segment and posterior edge of the oval window was 3.1 mm (±1.03 mm). Dehiscence in the tympanic segment was observed in three temporal bones (6%). Two (4%) specimens had bifurcation of the mastoid segment of the facial nerve. In all dissected temporal bones, the chorda tympani travelled in an ascending path.

Conclusion

The most common site for facial nerve anomaly is the tympanic portion. Anomalous conditions that can place the nerve at risk of being injured by the surgeons are highlighted here.

Anatomical Variations of the Middle Turbinate Concha Bullosa and its Relationship with Chronic Sinusitis: A Prospective Radiologic Study

Introduction  A pneumatized turbinate, also called concha bullosa, is a normal anatomical variant of the paranasal sinus region. Depending on the site of pneumatization, the concha is classified into extensive, bulbous or lamellar type. The middle turbinate concha bullosa has been implicated as a possible etiological factor in chronic sinusitis. Objectives  The aim of this study was to investigate the anatomical variations of the concha bullosa, based on paranasal sinus imaging, and its possible association with sinusitis. Methods  This prospective descriptive study was performed at the Department of ENT and Head Neck Surgery over a period of one year, from 2016 to 2017. We studied the computed tomography scans of the nose and paranasal sinuses- in axial, coronal and sagittal planes-of patients who had symptoms of nasal obstruction, or headache and features of chronic sinusitis. Results  Out of the 202 scans studied, the prevalence of concha bullosa was 31.7%. The concha was bilateral in 35 (54.7%) patients and unilateral in 29 (45.3%) patients. Out of 99 conchae, 54 were on the right side and 45 were on left side. Ipsilateral sinusitis was found in 40.4% of the sides in the scans of subjects with concha. There was no statistically significant association between any type of middle turbinate concha with sinusitis, but sinusitis was more predominant with the extensive type of concha ( p  > 0.05). Conclusion  Multiple air cells, mucocele, pyocele and inflammatory mucosal thickenings in the concha are relatively rare. Detailed knowledge of anatomic variations of the concha bullosa is imperative for the radiologists and the operating surgeons.

Stercoral Ulcer Not Always Indolent: A Rare Complication of Fecal Impaction

Stercoral sigmoid perforation is a dangerous surgical emergency. It is also a life-threatening situation because the spillage of fecal contents into the abdominal cavity leads to sepsis with many postoperative complications. Chronic, intermittent constipation can lead to fecal impaction, especially in older patients.

An 80-year-old male patient presented with intestinal abdominal pain and distention for three days. His chest X-ray showed air under the diaphragm. On laparotomy, a small rent was discovered in the rectosigmoid junction with fecal contamination. The presence of a fecaloma is the speculated reason for the perforation. Primary closure of the defect with a diverting transverse colostomy was performed, and subsequently, the patient recovered well. A colostomy closure was performed six weeks after the primary surgery.

It is imperative to understand the incidence of stercoral perforation in a normal bowel. Early treatment and intervention are the important aspects of stercoral pathology. We report a rare case of stercoral sigmoid colonic perforation with fecal peritonitis.

Role of Thermography in the Diagnosis of Chronic Sinusitis

Introduction

Thermography is a form of radiography that images the skin surface temperature. Thermograms are pictorial representations of thermal maps of the entire body’s outer surface. Thermography was applied as an attempt to evaluate its usefulness in the diagnosis of chronic sinusitis (CS). Hence, this study was done to determine the diagnostic value of thermography for patients suffering from CS.

Methodology

Patients attending the Department of Otorhinolaryngology and Head and Neck Surgery over a two years' duration with symptoms suggestive of CS were included in this diagnostic evaluation study. X-ray paranasal sinuses (PNS) and nose, thermography of head and neck, and computed tomography (CT) of PNS and nose (axial and coronal sections) were performed on them. The thermograms and X-ray sinuses obtained were compared with the computed tomography of PNS findings.

Results

The study population consisted of 167 patients (75 males and 92 females) and the mean age of the study population was 38.6 years. The sensitivity and specificity of thermography of the head and neck in diagnosing frontal, ethmoidal, maxillary, and sphenoidal sinusitis were 92.59% and 68.58%, 100% and 66.32%, 70.06% and 85.88%, 99.18% and 0%, respectively. Whereas the sensitivity and specificity of the X-ray PNS and nose in diagnosing frontal, ethmoidal, maxillary, and sphenoidal sinusitis were 92.59% and 77.88%, 73.61% and 81.05%, 89.19% and 98.92%, 74.44% and 99.18%, respectively.

Conclusion

Thermography is better than X-rays in diagnosing frontal and ethmoidal sinusitis and as good as X-ray PNS and nose in diagnosing maxillary sinusitis. Thermography failed to pick up sphenoidal sinusitis. The advantages of thermography are that it is a radiation-free, non-invasive, and cost-effective method for diagnosing CS.

Clinical Study on Middle Ear Diseases in Children with Orofacial Clefts

Introduction

Orofacial clefts are associated with middle ear diseases, but the magnitude of this problem is not generally well appreciated. The aim of this study was to describe the middle ear findings and audiological profile in children with orofacial clefts.

Materials and methods

Children with orofacial clefts attending plastic surgery and otorhinolaryngology departments of a tertiary hospital over one-year duration were included in this study. Ninety-six children with orofacial clefts were identified. They were categorized age-wise as zero to five years, more than five years to 10 years, and more than 10 years to 15 years. They underwent a detailed ear, nose, and throat examination followed by audiological tests, including brainstem evoked response audiogram (BERA), pure tone audiogram (PTA), and tympanometry.

Results

Among 96 children with orofacial clefts, only 24 children (25%) had symptomatic ear problems, whereas on ear examination, 56 children (58.3%) had abnormal ear findings. Middle ear effusion (MEE) was the most common ear condition, and it was seen in 94 ears (48.9%). Cholesteatoma was noted in six children (3.1%). Out of 73 children in the zero to five age group, 58 children (79.5%) did not have any history of ear problem but 55.5% (81 ears) had features of MEE such as a dull tympanic membrane (TM). In the age group of more than five years to 10 years, only four children (28.5%) were symptomatic. Five children (55.5%) out of nine in the age group of more than 10 years had a symptomatic ear problem of which four children (44.4%) had chronic otitis media squamosal disease. The earlier age groups showed a trend of ear disease being asymptomatic compared to older children. Normal hearing was present in only 40 children (41.7%) and various degrees of hearing loss were seen in 56 children (58.3%). The mean air conduction threshold in the age group zero to five years, more than five years to 10 years, and more than 10 years were 33±8.3 decibels (dB), 25±6.2 dB, and 31.5±14 dB, respectively. Out of 144 ears (72 children) in the asymptomatic group, 67 ears (46.5%) had normal hearing. Seventy-seven ears (53.5%) had some degree of hearing loss. Mean air conduction hearing loss in the asymptomatic group was 29.8±7.3 dB.

Conclusion

This study highlights the higher incidence of middle ear diseases compared to the presenting symptoms in children with orofacial clefts. This stresses on the need for a detailed otological evaluation to identify any middle ear pathology so that timely intervention can be taken.

Efficacy of Homologous, Platelet-rich Plasma Dressing in Chronic Non-healing Ulcers: An Observational Study

Background

Chronic non-healing ulcers are a frequent problem in developing countries and represent a heavy burden to the patients because they lack the necessary growth factors (GFs) to maintain the healing process and are frequently complicated by super, added infections. Traditional therapies, such as regular dressings and wound debridement, cannot provide satisfactory results since these treatments are not able to provide the necessary GFs. Platelet-rich plasma (PRP) helps in enhancing the wound healing by releasing various GFs. The aim was to evaluate the efficacy of PRP dressing in the treatment of chronic non-healing ulcers.

Methods

Patients attending the outpatient department on a regular basis and those admitted as inpatients for chronic wound management were included in the study. It was an observational study done in a tertiary health center for a period of one year. All patients with eligible criteria were treated with PRP at twice-weekly intervals for a maximum of 10 dressings. At the end of the five weeks period, the reduction in the size of the ulcers (area and volume) was assessed.

Results

A total of 104 cases with chronic non-healing ulcers of various causes were treated with homologous PRP twice weekly for a maximum of 10 dressings. In those 104 patients, non-healing ulcers in 85 patients (81.73%) were healed at the end of the last dressing. Non-healing ulcers in 13 patients (12.5%) were healed with skin grafting. Among those patients, the baseline mean ulcer area was 5.03 cm². For each visit, there was a reduction in the ulcer area. At the end of the last visit, the mean ulcer area was 1.69 cm², which was significant in this study.

Conclusion

Due to the lack of necessary GFs in chronic non-healing ulcers, PRP is safe and enhances the healing rates of chronic wounds, thereby reducing overall hospital stay and morbidity.

Pediatric Primary Tuberculous Osteomyelitis of the Mandible Mimicking Parotitis

Tuberculosis (TB) is a worldwide public health problem; however, primary tuberculous osteomyelitis involving the mandible is extremely rare. Here, we report a 14-year-old boy who presented with a recurrent, generalized swelling of the cheek in the right side, mimicking parotitis. Fine needle aspiration cytology (FNAC) from the swelling was inconclusive. Contrast-enhanced computed tomography (CECT) of the head and neck revealed an osteolytic lesion of the mandible with a surrounding abscess. An intraoral incisional biopsy of the tissue showed a granulomatous lesion. The patient was started on anti-tubercular therapy (ATT) for six months. Our patient's presentation underscores the clinical difficulty in establishing a diagnosis and considering tuberculous osteomyelitis in the differential diagnosis.

Diode Laser Stapedotomy vs Conventional Stapedotomy in Otosclerosis: A Double-Blinded Randomized Clinical Trial

OBJECTIVES

To assess and compare the efficacy of diode laser stapedotomy (DLS) and conventional manual stapedotomy (CMS) in the treatment of otosclerosis.

STUDY DESIGN

Randomized clinical trial.

SETTING

Tertiary health center.

SUBJECTS AND METHODS

We randomly assigned 60 patients with otosclerosis planned for primary stapedotomy to receive either DLS or CMS. Primary outcome measure was hearing gain measured by pure-tone audiometry (PTA) performed preoperatively and postoperatively. Hearing gain was compared within and between the groups. Secondary outcome measures were the incidence of intraoperative (bleeding and fractured footplate) and postoperative (vomiting, vertigo, sensorineural hearing loss, tinnitus, facial nerve paralysis, and hospital stay) morbidities.

RESULTS

Sixty primary stapedotomies (30 in the CMS group and 30 in the DLS group) done for 60 patients (male, n = 42; female, n = 18) were included in the analysis. Preoperative mean air-bone (AB) gap in the DLS and CMS groups was 38.51 ± 8.643 dB and 36.42 ± 8.678 dB, respectively. Mean AB gap at 6 month was 10.86 ± 5.383 dB and 11.05 ± 5.236 dB in the CMS and DLS groups, respectively. Air conduction was improved by 24.98 ± 5.348 dB in the DLS group and 24.08 ± 5.911 dB in the CMS group at 6 months. No statistically significant differences were found in hearing gain between the 2 groups at 6 months (P > .05). A decreased rate and severity of intraoperative bleeding, postoperative vertigo, and vomiting were observed with the diode laser (0%, 6.6%, and 10%) compared with the conventional technique (16.7%, 16.7%, and 16.7%), but these differences were not statistically significant (P > .05).

CONCLUSION

Hearing outcomes and complications of DLS were similar to CMS. These study findings confirm the efficacy of the diode laser in stapedotomy, but DLS offers no advantages over CMS for otosclerosis surgery.

Fractured and migrated tracheostomy tube in the tracheobronchial tree

OBJECTIVE

To study the clinical presentation and management of fractured tracheostomy tube (FTT) presenting as tracheobronchial foreign body (FB) in children.

METHODS

A retrospective chart review of children with a diagnosis of FTT, FB in tracheobronchial tree was carried out. Data regarding the patients' demographic details, diagnosis, clinical presentation and management were noted and analyzed.

RESULTS

Total 8 cases (males 3 and females 5, average age 8.8 years, range 1-15 years) wearing tracheostomy tube for an average period of 2 years (range 3 months-4 years) were found. Indications for tracheostomy were bilateral abductor palsy, subglottic stenosis and congenital subglottic hemangioma in 4 (50%), 3 (37.5%) and 1 (12.5%) cases, respectively. Classical triad of FB aspiration (coughing/choking, wheezing and reduced breath sounds) was present in 6 (75%) patients. Aspirated FTTs were Jackson's metallic inner tube, Romson's polyvinyl chloride plastic tube and Fuller's outer tube flange in 4 (50%), 3 (37.5%) and 1 (12.5%) respectively. The most common fracture site was at the junction between tube and neck plates {in 7 (87.5%) children}. Sites of lodgment of FTT were right bronchus, trachea and both trachea and left bronchus in 5 (62.5%), 2 (25%) and 1 (12.5%) cases, respectively. FTTs were retrieved by transtracheostomal rigid bronchoscopy and exploring the tracheostomal wound in 7 cases and 1 case, respectively.

CONCLUSION

Though FTT presenting as pediatric tracheobronchial FB is rare, it should be considered in differential diagnosis in a tracheostomised child with respiratory distress. When diagnosed, FTT removal is best done using a rigid bronchoscope through the tracheal stoma.

Microbiological profile with antibiotic sensitivity pattern of cholesteatomatous chronic suppurative otitis media among children

INTRODUCTION

Chronic suppurative otitis media (CSOM) is the most common cause of childhood hearing impairment in the developing countries and atticoantral type is associated with increased incidence of intracranial and extracranial complications. This study was undertaken to define the microbiology of atticoantral type of chronic otitis media and the antibiotic sensitivity pattern, thereby reducing the potential risks of complications.

MATERIALS AND METHODS

A retrospective study was done in the Department of Otolaryngology, JIPMER, Puducherry from the year August 2003 to October 2009 using the medical record department database to retrieve the patient details. During this study period, 223 children with atticoantral type CSOM consisting of 126 males and 97 females with an age range of 1-14 years were assessed. Patients with persistent otorrhea for more than 3 months with atticoantral type of chronic otitis media were selected. The exudates were collected under sterile conditions and inoculated onto culture media; bacterial growth and antibiotic sensitivity pattern were studied.

RESULTS

Nine species of micro organisms were isolated from the middle ear aspirate, Pseudomonas aeruginosa being the most predominant isolate constituting about 32% (72 discharging ears) of the total isolates followed by Proteus mirabilis (20% of isolates) and Staphylococcus aureus (19% of isolates). Gram negative organisms accounted 58% of total isolates and gram positive organisms constituted 22% isolates. Candida albicans and methicillin resistant S. aureus were identified in 4% and 2% of isolates, respectively. 100% of Pseudomonas isolates showed susceptibility to ceftazidime and a high sensitivity (92% of isolates) to ciprofloxacin and 88% isolates were sensitive to amikacin. 100% of P. mirabilis isolated from inoculates showed sensitivity to ceftazidime and ciprofloxacin. It also showed 87-97% sensitivity to ceftriaxone, amikacin and ampicillin. All (100%) of the Staphylococcus isolates were sensitive to vancomycin and 84-86% were sensitive to ciprofloxacin and erythromycin. In general, gram negative organisms showed increased sensitivity to ceftazidime, ciprofloxacin and amikacin, while gram positive organisms to vancomycin, erythromycin and ciprofoxacin.

CONCLUSION

Continuous and periodic evaluation of microbiological pattern and antibiotic sensitivity of cholesteatomatous CSOM is necessary to decrease the potential risks of complications by early institution of appropriate systemic and topical antibiotic alongside mastoid exploration. We believe that our data may contribute to an effective medical management of chronic suppurative otitis media with cholesteatoma. Since the most common organisms in our clinical set up being P. aeruginosa, P. mirabilis and S. aureus, which showed a percentage susceptibility of 100% to ceftazidime and vancomycin, thus making it an empirical antibiotic combination therapy of choice in the recent times.

Recurrent neck infection with branchial arch fistula in children

OBJECTIVE

Acute suppurative neck infections associated with third or fourth branchial arch fistulas are frequently recurrent. Third and fourth branchial arch anomalies are much less common than those of second arch and usually present with left thyroid lobe inflammation. The authors present their experience with 15 cases of pyriform sinus fistulae (PSF) of third branchial arch origin and 3 cases of fourth arch origin, all of which presented as recurrent neck infection mainly on the left side.

METHODS

A retrospective review of 18 cases of third and fourth arch fistulae treated at JIPMER from 2005 to 2010. This study includes 18 patients with PSF diagnosed by the existence of fistulous tract radiologically and intraoperatively with pathological correlation. Neck exploration with excision of tract and left hemithyroidectomy was performed in all cases.

RESULTS

The patients consisted of 7 males and 11 females, and the ages ranged from 3 to 15 years. All of them presented with recurrent episodes of neck infection. Investigations performed include computed tomography (CT) fistulography, barium swallow and ultrasound which were useful in delineating pyriform sinus fistulous tract preoperatively. All cases were on the left side and the fistula was identified by barium swallow in 14 cases (80%), while intraoperative and pathologic confirmation of the tract was possible in all cases (100%). Neck exploration with an emphasis on complete exposure of the recurrent laryngeal nerve and exposure of the pyriform sinus opening to facilitate complete fistulous tract excision with left hemithyroidectomy was successful in all patients. A follow up period of 1-3 years showed no recurrence.

CONCLUSION

Recurrent neck infection in a child should alert the physician to the possibility of an underlying pyriform sinus fistula of branchial origin and CT fistulography should be performed after the resolution of the neck infection to delineate the tract anatomically.