Otorhinolaryngology

Swati Nair is a Junior Resident, in the Department of Otorhinolaryngology at the Dr. B R Ambedkar Medical College, Bangalore, India. She has published papers in acclaimed international and Indian journals. She is particularly passionate about Head and Neck surgery and actively contributes to the research in the field.

Pleomorphic Adenoma or benign mixed tumor is the most common salivary tumor, accounting for up to two-thirds of all salivary gland neoplasms. These are benign tumors. If the minor salivary glands are involved, the most common site is palate. The first site of origin in nasopharynx is very rare. A 21-year-old female was referred to us with complaints of gradually progressive, left sided nasal obstruction since three years. Plain and contrast-enhanced MDCT scan of the nasopharynx and the parapharyngeal space showed a fairly large ill-defined heterogeneously enhancing soft tissue lesion with internal nodular calcifications involving pharyngeal mucosal space and parapharyngeal space on the left side at the nasopharyngeal level extending onto the oropharynx. The lesion measured about 5.8 X 5.1 X 3.9 cm in size and caused gross narrowing of the nasopharyngeal airway. There was obliteration of the fossa of rosenmuller on the left side. The infratemporal fossa was normal and the right side appeared to be free of disease. A lateral rhinotomy and lip split was performed and the maxilla was split in the midline and the tumor was exposed. On digital palpation, the tumor was noted to be extending deep into the left parapharyngeal space and was delivered by blunt dissection as it was a well-encapsulated tumor. Complete surgical removal of the tumor followed by intermaxillary wiring was done. The wire was removed after 3 months. The patient reported an improvement in symptoms and the nasopharynx was disease-free even at 6 months. On histopathological examination, the tumor was composed of epithelial and stromal elements. The epithelial elements were oriented in cords, tubules and nests, consisting of cells with uniform round nuclei and moderate cytoplasm. The stroma is a mixture of fibrous, myxomatous and focally chondromyxomatous elements. A mild diffuse mononuclear cell infiltration was noted. No evidence of malignancy was seen. The features were suggestive of benign mixed tumor or pleomorphic adenoma of the minor salivary gland.

Mahmoud Ebrahim is a young doctor who just finished his internship year and has passion for otolaryngology and head and neck surgery. He is a hard working doctor at work who gives his maximum to the care of the patient’s and there well-being. Outside of work he devotes his time in research and publications and attending courses. He is currently working as an assistant registrar in general surgery and attending ENT electives, as he is building up and strengthening his CV to apply for residency outside his home country.

Malignant peripheral nerve sheath tumor (MPNST) is defined as spindle cell sarcomas arising from or differentiating towards the cells of the peripheral nerve sheath. MPNST is extremely rare in the parotid gland and, in most cases, the prognosis is grim. It usually develops in the setting of Neurofibromatosis type-1 (NF1), but can also develop sporadically. Herein, we report a rare case of MPNST of the parotid gland, in a patient with no previous history of NF1. A 45 years old patient presented with a non-tender right parotid swelling of one-year duration. A sudden increase in the size of the parotid mass over the past two months alerted the surgeon to proceed to investigate the nature of the mass and the etiology of the sudden change in size. The patient’s initial investigations, which included ultrasound imaging of the swelling, fine needle aspiration (FNA), Computed Tomography (CT) scan, and Magnetic Resonance Imaging (MRI) of the neck and swelling were consistent with a benign pleomorphic adenoma of the parotid gland. However, during the surgery the dissection was difficult and the tumor appeared adherent to the surrounding tissue, which lead to a total parotidectomy, in piecemeal! The histopathology revealed a low-grade spindle cell neoplasm exhibiting a diffuse, infiltrative growth pattern, invading into and around salivary lobules, adipose tissue, skeletal muscle bundles and fascia. The morphology and positive s100 & CD34 stains suggested diffuse neurofibroma. Scattered foci of epithelioid cells with increased pleomorphism and mitotic activity were also evident. The diagnosis rendered was thus MPNST of the parotid gland arising from a diffuse neurofibroma. The patient was also diagnosed with NF1 based on clinicopathologic correlation with a referral for confirmatory genetic testing. The patient underwent radiotherapy to continue his treatment following the resection of the tumor.

Henrique F Pauna, MD has completed his ENT training in 2015. He has his expertise in Otopathology and Middle Ear Diseases. He underwent a Re¬search Fellowship at the University of Minnesota, under the supervision of Dr. Michael M Paparella and Dr. Sebahattin Cureoglu, from 2015 to 2016. Currently he is pursuing his PhD in University of São Paulo – Ribeirão Preto, focusing his research in meningitis and hearing loss. Additionally, he is a volunteer at the University of Campinas, teaching 4th year students about ear anatomy and pathologies of the ear.

Recent advances in optics have provided greater evolution with the concept of minimally invasive surgical procedures, and endoscopic approach allows higher magnification, permitting correct identification of the diseases. Endoscopic surgeries have provided the field of Otology with many endoscopes with varying diameters and acceptable resolution. This technique is suitable for chronic otitis media, malformation of ossicles, traumatic damage, cholesteatoma, otosclerosis, and others. Endoscopic stapes surgery can be attempted in all suspected cases of ossicular malformation, whereas permits a better identification of middle ear structures, facial nerve and stapes area, since traditional techniques may not always be sufficient for diagnostic and surgical management. Additionally, preliminary studies showed a decreased postoperative pain in endoscopic approach when compared with traditional technique. Tympanic membrane tears, temporary facial nerve palsy, perilymphatic gusher, altered taste, dysgeusia and accidental complete cut of the chorda tympani nerve are the possible intraoperative complications. In conclusion, the few available studies have demonstrated that endoscopic stapes surgery is safe and provides similar audio logical results when compared to the microscopic procedures.

Henrique F Pauna has completed his ENT training in 2015. He has his ex¬pertise in Otopathology and Middle Ear Diseases. He underwent a Research Fellowship at the University of Minnesota, under the supervision of Dr. Mi¬chael M Paparella and Dr. Sebahattin Cureoglu, from 2015 to 2016. Currently he is pursuing his PhD in University of São Paulo – Ribeirão Preto, focusing his research in meningitis and hearing loss. Additionally, he is a volunteer at the University of Campinas, teaching 4th year students about ear anatomy and pathologies of the ear.

Surgical management of otosclerosis is one of the therapeutic options, and differential diagnosis includes ossicular malformations, oval or round window atresia, congenital cholesteatoma, middle ear tumors, or ossicular trauma. Recent advances in endoscopic surgery have provided greater evolution within the concept of minimally invasive procedures. Endoscopic stapes surgery is becoming one important option to treat otosclerosis, however, only few studies have described their techniques and results. Here we describe our experience using endoscopic approach on stapes surgery. Eight patients underwent to complete endoscopic stapes surgery. Three of the patients were submitted to conventional stapes surgery with surgical microscope helped with an endoscope. All of the 8 patients were submitted to stapes surgery with local anesthesia. Six patients had their complete audiological evaluation with a closing gap after the surgery. Only one patient had no audiometry after the procedure because of the short period of time after his surgery. The duration of the surgery endoscopic or conventional was a longer in endoscopic approach, however it was not significant. Endoscopic stapes surgery is an option available for training and also an option to treat otosclerosis. Our results may help to improve data regarding this subject.