Trans-nasal endoscopic repair is an effective treatment for cerebrospinal fluid leaks, with a success rate of 92.2% after the first attempt and 98% after the second attempt. The cribriform plate was the most common site of leak. Recurrences were more likely in female patients with higher BMI. The study concludes that endoscopic endonasal repair is the preferred treatment approach due to its high success rate and low morbidity.
In this presentation, a clinical application of isotope cisternography is explained in detail. Several examples are provided.
The slides are based on UPTODATE.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
In this presentation, a clinical application of isotope cisternography is explained in detail. Several examples are provided.
The slides are based on UPTODATE.
The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and
offering a wide range of dental certified courses in different formats.
Brain abscess is a common neurosurgical emergencies, of which periventricular warrants urgent attention either medically or surgically. This algorithmic approach may help understand the very essentials of Brain abscess.
Endoscopic techniques have been widely adopted in sinus and skull base surgery replacing the traditional intracranial/extracranial approaches. However, one of the most common complication is an iatrogenic Cerebrospinal Fluid (CSF) leak, which places the patient at risk for meningitis, pneumocephalus and brain herniation. The instant intraoperative CSF leak diagnosis and consequent repair is crucial to avoid these complications. Traditionally, intrathecal fl uorescein injection was utilized to aid in the diagnosis. However, this technique is not FDA approved and encompasses major drawbacks (seizure, lower extremity paresis, cranial nerve palsies and patient discomfort).The purpose of this case series is to introduce a new diagnostic paradigm using topical fl uorescein strips “FLUORETS”. It has shown promising prospects due to its safety, accuracy and sensitivity in identifying CSF leaks.
Thyroid swelling and management. In detail case discussion of thyroid swelling and its management. Details of examination as well included in the slide.
Foramen magnum meningiomas are challenging tumors, requiring special considerations because of the vicinity of the medulla oblongata, the lower cranial nerves, and the vertebral artery. It accounts for 1-3% of all intracranial Meningioma.
Details of Cerebrospinal Fluid special reference to cell count and alteration of CSF Hydrodynamics explained in brief and Different Diagnostic parameters to Hydrocephalus
A Sinister Cause for Recurrent Syncope: Metastatic Parapharyngeal Space Tumorasclepiuspdfs
Introduction: Metastasis from oropharyngeal squamous cell carcinoma can occur in the parapharyngeal space (PPS). Syncope is an uncommon presentation of parapharyngeal space tumors. This can occur because of the extrinsic compression or infiltration of the carotid sinus or glossopharyngeal nerve. Aim: This study aims to raise awareness about this rare condition of recurrent syncope secondary to PPS tumor. We aim to share our knowledge of dealing with such a case focusing on clinical presentation, investigations, and multidisciplinary approach to management. Case Presentation: We present a case of a 68-year-old Caucasian male who was admitted to a medical ward with recurrent episodes of syncope. The underlying cause was found to be the extrinsic compression of the left carotid artery from a PPS tumor. The CT scan of the neck raised a suspicion of the left PPS malignancy. It was confirmed on fine-needle aspiration cytology to be a metastatic poorly differentiated squamous cell carcinoma. The patient was managed with best supportive care. Conclusion: In a patient presenting with recurrent syncope, PPS tumor-related carotid sinus or glossopharyngeal nerve involvement should be considered. In our patient, the best supportive care was chosen. However, in select patients, cardiac pacing may be required to prevent recurrent syncope so that curative intent treatment can be started.
Brain abscess is a common neurosurgical emergencies, of which periventricular warrants urgent attention either medically or surgically. This algorithmic approach may help understand the very essentials of Brain abscess.
Endoscopic techniques have been widely adopted in sinus and skull base surgery replacing the traditional intracranial/extracranial approaches. However, one of the most common complication is an iatrogenic Cerebrospinal Fluid (CSF) leak, which places the patient at risk for meningitis, pneumocephalus and brain herniation. The instant intraoperative CSF leak diagnosis and consequent repair is crucial to avoid these complications. Traditionally, intrathecal fl uorescein injection was utilized to aid in the diagnosis. However, this technique is not FDA approved and encompasses major drawbacks (seizure, lower extremity paresis, cranial nerve palsies and patient discomfort).The purpose of this case series is to introduce a new diagnostic paradigm using topical fl uorescein strips “FLUORETS”. It has shown promising prospects due to its safety, accuracy and sensitivity in identifying CSF leaks.
Thyroid swelling and management. In detail case discussion of thyroid swelling and its management. Details of examination as well included in the slide.
Foramen magnum meningiomas are challenging tumors, requiring special considerations because of the vicinity of the medulla oblongata, the lower cranial nerves, and the vertebral artery. It accounts for 1-3% of all intracranial Meningioma.
Details of Cerebrospinal Fluid special reference to cell count and alteration of CSF Hydrodynamics explained in brief and Different Diagnostic parameters to Hydrocephalus
A Sinister Cause for Recurrent Syncope: Metastatic Parapharyngeal Space Tumorasclepiuspdfs
Introduction: Metastasis from oropharyngeal squamous cell carcinoma can occur in the parapharyngeal space (PPS). Syncope is an uncommon presentation of parapharyngeal space tumors. This can occur because of the extrinsic compression or infiltration of the carotid sinus or glossopharyngeal nerve. Aim: This study aims to raise awareness about this rare condition of recurrent syncope secondary to PPS tumor. We aim to share our knowledge of dealing with such a case focusing on clinical presentation, investigations, and multidisciplinary approach to management. Case Presentation: We present a case of a 68-year-old Caucasian male who was admitted to a medical ward with recurrent episodes of syncope. The underlying cause was found to be the extrinsic compression of the left carotid artery from a PPS tumor. The CT scan of the neck raised a suspicion of the left PPS malignancy. It was confirmed on fine-needle aspiration cytology to be a metastatic poorly differentiated squamous cell carcinoma. The patient was managed with best supportive care. Conclusion: In a patient presenting with recurrent syncope, PPS tumor-related carotid sinus or glossopharyngeal nerve involvement should be considered. In our patient, the best supportive care was chosen. However, in select patients, cardiac pacing may be required to prevent recurrent syncope so that curative intent treatment can be started.
New technology called Electromagnetic Navigation Bronchoscopy® (ENB) that uses virtual bronchoscopy and real time 3-dimensional CT images that enable me to localize these peripheral lung nodules for diagnosis and treatment. This outpatient procedure is minimally invasive and therefore has a small risk of pneumothorax (2-3%) and its published diagnostic yield rates range from 67% - 86%
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
created for de-functioning of the distal anastomotic site to minimise the chances of leak. Colostomy is usually reversed at 8 to 12
weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
Frequency of Anastomotic Leak in Early Versus Dealyed Oral Feeding after Elec...semualkaira
Intestinal stoma is usually performed as component of other surgical intervention for small and large bowel
pathologies. Of these temporary colostomy are commonest stomas
created for de-functioning of the distal anastomotic site to minimise the chances of leak. Colostomy is usually reversed at 8 to 12
weeks and Ileostomy closure is often considered a minor procedure but it is associated with significant morbidity and mortality
VOCAL CORD PARALYSIS: WHAT MATTERS BETWEEN IDIOPATHIC AND NONIDIOPATHIC CASES?Dr Tarique Ahmed Maka
ABSTRACT
Objective: To evaluate the clinical and demographic characteristics of patients with idiopathic and non-idiopathic
vocal cord paralysis (VCP).
Study Design: Descriptive cross sectional study.
Place and Duration of Study: Department of ENT Combined Military Hospital Quetta and Rawalpindi, from 10
Dec 2012 to 31 Dec 2015.
Material and Methods: The study was a descriptive cross sectional study. The study was conducted after
approval by the ethical committee. Patients with fixed vocal cords due to some growth of glottic region were
enrolled. All the patients presenting with hoarseness of voice in ENT outpatient department CMH Quetta and
Rawalpindi undergoing indirect laryngoscopy and the patients with vocal cord paralysis were selected. Informed
written consent was taken and gender, age, name, hospital record number, address and phone number of each
individual was noted. Every patient was evaluated by detailed history and thorough clinical examination.
Patients were not investigated further if cause were revealed after some investigation. Follow-up of patients was
done regularly in ENT OPD. CT scans/US neck was done by radiologist and FNAC/biopsy was reported by
histopathologist. Data collected were recorded on proforma.
Results: In our study, out of 245 cases, 47.76% (n=117) were 16-40 years old and 52.24% (n=128) were 41-80 years,
mean ± SD was calculated as 41.23 ± 11.25 years, 45.71% (n=112) male and 54.29% (n=133) were females.
Frequency of causes of vocal cord paralysis was recorded as 15.92% (n=39) for idiopathic, 46.53% (n=114) had
iatrogenic, 33.06% (n=81) had malignant neoplasm while 4.49% (n=11) had radiation.
Conclusion: Vocal cord paralysis is a common clinical condition with substantial morbidity. Awareness on the
clinical characteristics and identification of the underlying etiology are keystones for foreseeing complications
and determining the required therapeutic modality.
Keywords: Etiology, Iatrogenic, Idiopathic, Vocal cord paralysis.
International Journal of Pharmaceutical Science Invention (IJPSI) is an international journal intended for professionals and researchers in all fields of Pahrmaceutical Science. IJPSI publishes research articles and reviews within the whole field Pharmacy and Pharmaceutical Science, new teaching methods, assessment, validation and the impact of new technologies and it will continue to provide information on the latest trends and developments in this ever-expanding subject. The publications of papers are selected through double peer reviewed to ensure originality, relevance, and readability. The articles published in our journal can be accessed online.
1. Gupta Madan ,Singh Shuchita,Verma Rohit, Thakar Alok
Department of Otorhinolaryngology and Head – Neck Surgery
All India Institute of Medical Sciences, New Delhi
Spontaneous leak
Introduction
Site of leak
Cerebrospinal fluid (CSF) rhinorrhoea results due to an aberrant communication
between subarachnoid space and nasal cavity1
Could be spontaneous, traumatic, iatrogenic or congenital
Failed medical management mandates surgery
Trans-nasal endoscopic approach (TER)to skull base revolutionized CSF
rhinorrhoea treatment making repair less invasive with more than 90% success
rates after first repair2
Key point in TER is accurate identification of leak site3
Aims & Objective
4 patients had recurrence (7.8%), out of which 2 required revision surgery while the
rest were managed conservatively
To analyze and evaluate the long-term surgical outcomes and recurrence rates of
trans-nasal endoscopic repair (TER) of CSF leak
The success rate of our study was -
To determine the prognostic factors governing treatment success
Success rate at Ist attempt – 92.2% (47/51)
To identify the high risk factors for recurrent CSF leaks
Success rate at IInd attempt – 98% (50/51)
To correlate CSF leak recurrence with various clinical parameters (etiology, sex,
BMI, leak site)
Materials and Methods
Recurrences
Pt
Retrospective study of 52 consecutive patients of CSF rhinorrhoea (52 primary
and 4 recurrent), treated at a single tertiary care centre over a period of 14 years
(1999 - 2013)
1
Epidemiological parameters and clinical presentation of all patients were noted
2
The patients were subjected to TER for CSF leak
The surgical outcomes were analyzed by serial clinical evaluation and nasal
endoscopy for a follow up period ranging from 2 to 14 years (median 7 years)
All the epidemiological and clinical parameters defining the success or failure of
treatment outcome were evaluated
3
4
Recurrence of CSF leak was correlated with various clinical parameters (etiology,
sex, BMI, leak site)
Results
Primary/Recurrent ratio – 52 : 4
Male/Female ratio – 1 : 1.08
Age Range was 3 to 63 years (median 31 years)
Invariably all patients presented with clear watery nasal discharge, followed by
headache and anosmia in 57% and 22% patients respectively
21 patients (40.38%) had previous history of meningitis
Age Distribution
Clinical Presentation (Frequency)
Age
Site Size Etiology Comorbiditie Time of BMI
(yrs)/Sex
(mm)
s
recurr.
46/F
43/F
9/F
57/F
CP
SPH
CP
SPH
20
35
30
50
Spon.
Spon.
Traum.
Spon.
DNS
HT+DNS
HT+DM
Placemen
t
Spinal
drain
(days)
29
Abd.
Fascia+ fat
Overlay
Yes (3)
10-20
33
Abd.
Fascia+ fat
Overlay
Yes (3)
90-120
Fascia lata +
11
fat
Overlay
No
30-40
Fascia lata +
35
fat
Overlay
Yes (4)
180-220
Graft
Discussion
Dandy (1926) – First intracranial CSF leak repair –high morbidity and complication
risks with 60% success rate4
Dohlman (1948) – First extracranial CSF leak repair – less complications with a
success rate of 60 – 80%5
Wigand (1981) – First endo-nasal endoscopic CSF repair- low morbidity and high
success rates of 90% after the Ist attempt and 95-98% after IInd repair6
Advantages of TER - excellent field of vision, exact localization of leak, better
evaluation and quantification of bony defect, better chances of placing the most
suitable graft for leak repair, reduced invasiveness and hospitalization time.
Presence of I/C haematoma, fractures of ethmoid, orbital roof or posterior wall of
frontal sinus limits endoscopic repair
In accordance with previous studies7, our study also shows success rate of 92.2%
after Ist repair (4 recurrences), which increases to 98% after IInd surgery (1
recurrence)
As reported by various authors8, cribriform plate was the commonest site of leak in
this study as well
In present study recurrences were seen in female patients with a higher value of BMI
BMI ranged from 11 to 38, with a mean of 25
A higher BMI was noted in female population (mean 26.5) as compared to males
(mean 23.5)
Conclusion
Majority of patients belonged to post traumatic and spontaneous group with 42%
patients in each
In recent advancement technology, the preferred modality of CSF
rhinorrhea should be endoscopic endonasal with high success rate and
lower morbidity.
Spontaneous CSF rhinorrhoea was commoner in females (90%)
Majority of patients with spontaneous leak had higher BMI (mean 30)
Right sided CSF leak was commoner than left (70% vs 30%)
Lateral lamella of cribriform plate (58.8%) was the commonest leak site, followed
by fovea ethmoidalis (23.5%) and sphenoid leak (11.7%)
Traumatic leaks predominantly had fossa ethmoidalis defect, however, defect in
cribriform plate was equally distributed in spontaneous and traumatic groups
No significant complication
BMI distribution
Etiology
References
1.
Ahmed Soliman Ismail et al : Transnasal Transsphenoidal Endoscopic Repair of CSF Leakage
Using Multilayer Acellular Dermis : Skull Base / Volume 17, Number 2 2007; 125-132.
2.
Michele Cassano et al: Endoscopic treatment of cerebrospinal fluid leaks with the use of lower
turbinate grafts: a retrospective review of 125 cases : Rhinology, 47, 362-368, 2009
3.
L. Presutti et al : Transnasal endoscopic treatment of cerebrospinal fluid leak: 17 years’
experience : Actarhinolaryngologica ITALICA: 2009;29:191-196
4.
Castelnuovo P et al: Endoscopic repair of cerebrospinal fluid rhinorrhea: learning from our
failures.Am J Rhinol 2001;15:333-42.
5.
Dohlman G: Spontaneous cerebrospinal rhinorrhea. Acta Otolaryngol Suppl 1948;67:20-3.
6.
Wigand ME: Transnasal ethmoidectomy under endoscopical control. Rhinology 1981;19:7-15.
7.
Achkar Jet al: Endoscopic endonasal repair of csf rhionorrhea.2009;10.
8.
Schlosser R et al : Endoscopic management of csf rhionorrhea. Otolaryngol clin north
Am.2006;39:523-38.
Skull base conference 2013, PGI, Chandigarh