TRANSPOSITION OF LACRIMAL SYSTEM AND INFERIOR TURBINATE PRESERVATION TO AVOID POST OPERATIVE EPIPHORA , SECONDARY ATROPHIC RHINITIS AND EMPTY NOSE SYNDROME IN ENDOSCOPIC MEDIAL MAXILLECTOMY FOR BENIGN SINONASAL DISEASES
37 year old engineer presented with left sided nasal obstruction, recurrent left sided headache and facial pain since 3 months.Nasal endoscopy finding-Biopsy revealed Inverted papilloma. NECT scan findings-Homogenous opacification in the left maxillary sinus and nasal cavity. Intraoperatively it was identified that the sinus opacity was mainly constituted by retained secretions behind the tumour. Hence a CT with contrast or an MRI is recommended to differentiate tumour from secretions. Thick secretions were suctioned from sinus cavity. Nasolacrimal duct was exposed by drilling the bone anterior to it dividing the inferiormost attachment of duct to inferior meatus.In cases of malignant tumours the lacrimal duct will have to be sacrificed
Posterior part of inferior turbinte was pushed to the nasopharynx for visualisation of mass.after complete removal of mass inferior turbinate was brought forward and attached at medial maxillectomy using vascular clips. Nasal packing was not done post operatively. A cotton ball was placed in the anterior nare to prevent forceful blowing and to avoid injury to the delicate post op nasal cavity .Inferior turbinate was preserved using clips to avoid post op secondary atophic rhinitis and empty nose syndrome
ROLE OF FACIAL NERVE MONITORING IN REVISION EAR SURGERIES
- Reexploration surgery in a patient with h/o epidural absess as a complication of unsafe ear.
- Monopolar probe for facial nerve identification-initially at 2.00 milliAmp ,reduced to 1.00 milliAmp
- Evidence of biphasic curve on oscilloscope and dual tone sound suggest facial nerve/close proximity to it.
- Always use facial nerve monitor when anatomical landmarks are not present.
- Always maintain dry field to avoid false positive results and maintain a low current.
- Pseudo facial nerve like structures in the field may have other nerve fibres in it eg;chorda tympani which may confuse experienced surgeons and affect good clearance of the disease.
- For residents performing mastoidotympanoplasty the monitor gives an early indication of proximity and damage to facial nerve
In these days of medicolegal problems such monitors will be of great help to doctors.
DESTRUCTIVE MAXILLARY FOREIGN BODY GRANULOMA PRESENTING AS INVASIVE FUNGUS-A CASE REPORT
A 42 year old recently detected diabetic lady advised dental extraction for left upper molar was found to have mobile alveolus with multiple tooth with extensive destruction of maxilla.The patient had Root canal therapy on same side 4 years ago.
On examination In the hard palate the pathology stopped at the midline and infraorbital nerve was anesthetized. CT findings showed extensive bony destruction upto zygoma and ipsilateral hard palate.
Provisional diagnosis of invasive fungus was made.
Open surgery and maxillectomy preserving soft tissue of hard palate was done with primary suturing of cheek to alveolar margin . All infected bones were cleared. The bones had a moth eaten, friable , yellowish, non viable state and fungal culture sensitivity and biopsy were sent for a provisional diagnosis of invasive mycosis. Fearing the acute mucor we started on Amphotericin.
The biopsy revealed foreign body granuloma. Hence antifungal therapy was withdrawn , and patient was discharged and was advised strict diabetic control.
- Since soft tissue of hard palate was preserved there was no immediate fistula and the need of dental obturator was avoided.
- In these days of Invasive dental treatment with multiple materials, foreign body reaction and bacterial infections should also kept in mind till invasive fungus is proven by histopathology.
22 year old female patient presented with right sided facial swelling and fever since 1 month.history of similar episodes since 10 years on and off.treated conservatively at local hospital with poor response.
O/E-3 X 2 cm firm,tender,indurated swelling R parotid area
R stensons duct orifice indurated,no mucopus expressed from gland
- The parotid duct is easy to access with a sialendoscope but difficult to work with.
- Before introducing the scope the duct is treated with sensorcaine and adrenaline.
- throughout the procedure saline irrigation is done
The calculus was a linear one so a blunt ended basket was used
POST STAPEDOTOMY SN LOSS MANAGEMENT
50 year old female post Right Stapedotomy with hearing improvement after surgery, developed sudden onset of hearing impairment 1 month following surgery. Managed with IV steroids (Inj Solumedrol 500 mg slow IV ) followed by grommet insertion and steroid (Dexona) instillation . Following this hearing improvement occurred within 24 hours. Further improvement awaited.