these two cases which had unusual presentation in King Abdul Aziz Hospital E.N.T. dept. Makkah Saudi Arabia

1. CASE PRESENTATION
Dr. Mohammad Naim Manhas

2. Lymphomas of Head & Neck arise from
Nodal or Extranodal sites or both
Hodgkins and Non-Hodgkins Lymphoma
commonly present as lymphnode
enlargement in the neck
Hodgkins disease is rare in oropharynx but
NHL account 15-20%
1/21/2017 2NAIM MANHAS

3. 20 -30%
15-20%
70-80%
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4. i
0
10
20
30
40
50
60
70
80
90
100
non-hodgkins hodgkins
lymphoma
Incidence of
Hodgkins and
Non-Hodgkins
lymphoma in
head and neck
Common sites in
oropharynx are
tonsillis ,
nasopharynx
Very rare in soft
palate
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5. Needle aspiration :- not recommended
Incisional or excisional biopsies are preferred
Immunohistochemistry
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6. C. T. Scan of Head & Neck, Chest, Abdomen,
Pelvis
Staging of disease is based on C.T.Scan
findings
Performed at primary evaluation in all patients
with NHL
Nodal and extra nodal sites
1/21/2017 6NAIM MANHAS

7. MRI
Role is limited
Infiltration to Bone marrow or involvement of
meninges
Positron Emission Tomography (PET Scan )
imaging is modality of choice for diagnosis, staging
and survillance.
1/21/2017 7NAIM MANHAS

8. Stage I
Single Extra Nodal
StageII
Nodal Invovement
Stage III
Both sides of Diaphragm
Stage IV
metastases
staging
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9. Chemotherapy
Curative ,pallative
Immunotherapy
With monoclonial
antibiodies alone
or in combination
with CHT
Radiotherapy
Limited role
Early stage
1/21/2017 9NAIM MANHAS

10. CASE REPORT
41 Years lady presented
to E.N.T.clinic with pain in
oral cavity since two
months which was not
relieved by medication.
Patient was reffered
from facio-maxillary
dept.
Patient did not have any
medical illness .
1/21/2017 10NAIM MANHAS

11. On examination :-
Left Palatal swelling was
noticed on examination which
was firm in consistency on
palpation .
Associated inflammatory
response to surrounding tissue
Neck :- No cervical
lymphadenopathy.
1/21/2017 11NAIM MANHAS

12. RADIO-IMAGING
C.t. Scan of
Neck revealed
soft tissue
mass in left
Soft Palate.
No associated
lymphnode
enlargement
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13. RADIO-IMAGING
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14. EXCISIONAL BIOPSY
PLAN :-
Excisional
Biopsy was
done under
General
Anesthesia.
Mass was
excised in
toto.
1/21/2017 14NAIM MANHAS

15. HISTOPATHOLOGY
B-cell
lymphoma
Confirmed by
immunohisto-
chemistry
method
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16. 1/21/2017 16NAIM MANHAS

17. HISTOPATHOLOGY – B CELL LYMPHOMA
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18. STAGING OF B-CELL LYMPHOMA
Depends upon
the
involvement
of nodal and
extra nodal
sites on
either side of
diaphargm
1/21/2017 18NAIM MANHAS

19. C.T. ABDOMEN C.T. PELVIS
1/21/2017 19NAIM MANHAS

20. Patient was referred to oncology department.
Patent received Radiotherapy ( 30 doses )
Recently have completed chemotherapy (8)
1/21/2017 20NAIM MANHAS

21. AFTER BEFORE
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22. The oral cavity is an anatomically complex region
and lesions can prove exceptionally challanging to
diagnosis.
Isolated extranodal B-cell lymphoma of the palate
is extremely rare. It usually present as an
inflammatory lesion. Early diagnosis are
important as the disease is confined to palate
only,therefore respond well to irriadiation.
PET is the imaging modality of choice for diagnosis,
staging and survillance
1/21/2017 22NAIM MANHAS

23. CASE PRESENTATION

24. DIAGRAMMATIC PLAIN RADIOGRAPH
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25. RETROPHARYNGEAL SPACE
RPS is potential space
between middle and deep
layers of deep cervical
fascia.
Extends from base of
skull to T4 level.
At C6 level it goes more
posteriorly and forms a
danger space which
communicates with
mediastrinum.
For practical purposes:-
on imaging studies it is
indistinuishable.
1/21/2017 25NAIM MANHAS

26. Non- traumatic retropharyngeal abscess is very
rare in adults
Retropharyngeal abscess alone occur in children
from 6 months to 6 years of age.
Recent reports suggest that Necrotizing
retropharyngeal abscess (NRPA) occurs in adults
who are immunocompromised.
1/21/2017 26NAIM MANHAS

27. 1/21/2017 27NAIM MANHAS

28. Early diagnosis
and prompt
management
Aggressive
surgical
drainage and
medical
treatment
1/21/2017 28NAIM MANHAS

29. mortality remains high because of occurrence of
lethal complications :-
Acute Respiratory obstruction
Aspiration Pneumonia
Juglar Thrombophelibitis
Descending necrotizing mediastinitis
1/21/2017 29NAIM MANHAS

30. 54 years old male presented to our E.R. with h/o
difficulty in swallowing, breathing and bleeding
per mouth.
Patient known case of diabetes and had h/o sore
throat for six days for which he had taken
medication from outside.
On examination patient was ill looking with mild
dyspnea, but hemodynamically stable.
1/21/2017 30NAIM MANHAS

31. CASE REPORT
Oral and laryngeal
examination failed as
oral cavity was fullof
blood clots.
Urgent C.T. scan of
neck was done which
revealed widening of
RPS with gas shadows
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32. RADIO - IMAGING
Coronal
Plane
C.T. scan
Neck
Showing
Collection .
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33. Patient developed Respiratory Distress in E.R.
and started desaturating.
Urgent laryngeal intubation was planned but
failed due to non-visualization of larynx.
As patients condition worsened he was shifted to
O.R. on laryngeal mask.
1/21/2017 33NAIM MANHAS

34. Airway established by surgical Tracheotomy
General Anesthesia induced through
tracheotomy tube.
Retropharyngeal abscess drained along with
necrotic tissue per oral approach
Hypopharyngoscopy and laryngoscopy done using
rigid endoscope.
1/21/2017 34NAIM MANHAS

35. Necrotic tissue found upto cricopharynx, but
larynx was found normal.
Post operatively combination of
pipercillin/Tazobactam along with clindamycin
1/21/2017 35NAIM MANHAS

36. Day IV
• Follow up fiberoptic endoscopic
examination
• Pharynx and Larynx :- revealed no
residual abscess or necrotic tissue
DayV
• follow up C.T Scan neck
• Contrast study of pharynx
1/21/2017 36NAIM MANHAS

37. Day XI to Day XIV Decannulation
Decannulation
Planned
Tracheotomy
tube repalced by
fenestrated one
and closed.
1/21/2017 37NAIM MANHAS

38. Day to Day Events during Hospitalization
Day XV :- patient
developed acute Renal
failure due to
contrast induced
tubular injury.
Oliguria with rise in
cretinine levels.
Day XVI :- underwent
hemodialysis
1/21/2017 38NAIM MANHAS

39. Day to Day Events during Hospitalization
Follow up C.T.
Was not possible
because of
contrast induced
acute renal
injury.
Contrast study
by gastrograffin
of pharynx .
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40. DAY OF ADMISSION
AFTER DRAINAGE
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41. Day to Day Events during Hospitalization
Day XVII to day XX
Kidney function
improved with adequate
urine output and
gradually decrease of
cretinine levels.
Day XVIII :- oral
feeding started
Day XXV :- Discharged.
1/21/2017 41NAIM MANHAS