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Previous months cases
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"Think before you Leap"
History a 4 year old child was admitted to the ward with a history of falling on a vertically placed iron rod. This iron rod has a pointed, but blunt end and is used to de-husk coconuts. The incident had occoured 4 hours earlier.
Examination The child looked distressed but not in any respiratory difficulty. There was a small abration with no penetration of the skin just above the sternum in the midline. Surgical emphysema was developing over the neck, and it extended up to the face and along the sternum downwards everytime the child cried. There were no signs to indicate any bleeding. It was a very worrying site, but not life thretening at that moment. The most distressed was the mother, who didnot understand what surgical emphysema was.
Investigations Neck and chest X rays were done and a pneumothorax was excluded. The child was kept under close observation. Intravenous antibiotics were commenced, and nothing was given by mouth. The next morning the neck swelling was not any worse, and a gastrografin swallow was done to look for the possibility of a oesophageal tear as well. This was negetive and the child was given oral fluids.
Diagnosis The most probable diagnosis of a tracheal rupture due to blunt traume was made.
Outcome Over the next few days the child recovered with absolutely no complications, and was discharged 6 days after admission. The child will undergo endoscopy a week later to look for any residual affects.
Discussion A few points are of interest.
1, A step by step methodical evaluation of the situation helped to sortout what looked like an otherwise very serious injury.
2. Endoscopy was avoided as it was felt that any forceful inflation of the lungs during anaesthesia would agrevate the surgical emphysema, and may even lead to a pneumothorax.
3. A watch and see policy can be the best for certain clinical situations.
History A 30 year old man presented with a right sided swelling over the parotid region. It was not painful and had appeared about 2 months before. There was no discomfort with meals.
Examination This showed a healthy male with no other significant clinical sign except the swelling of the right parotid gland. The facial nerve function and the ductal orifice were normal. There was no evidence of deep lobe enlargement. Mouth opening was normal.
Investigations A parotid tumor was suspected and a FNAC was performed. The result showed nothing significant. This was followed by a sialogram which was again normal but as an incidental feature the ramus of the mandible was completely eroded. This prompted for a CT scan, and it showed clearly that the bone was eroded, and that a neoplastic lesion covered the entire ramus on both sides. A malignant tumor of the bone, or the parotid was suspected.
Surgery A superficial conservative parotidectomy was commenced to safeguard the facial nerve, but it was obvious that the tumor was coming from the bone. An almost complete excision was done.
Diagnosis The histology showed an Osteosarcoma of the mandible.
Discussion The important points are
1. that the FNAC did not give a positive result, most probably due to the fact that the tumor was under an intact masseter muscle.
2. there was no facial palsy, as the tumor was not really arising from the parotid gland.
"A dangerous lump"
The history A 15 year old boy was admitted to the ENT ward for a lump situated on the left forhead. He had been treated earlier for a dental abscess on the same side which had now settled. He had no other symptoms of significance. There was no headache or any nasal or neurological symptoms.
The examination Examination showed a healthy looking boy with a circular lump of 5 cm in diameter situated just above the right eyebrow. There was no tenderness over the lump, but the lump felt soft than the surrounding bone. The nasal cavity was normal. Eye movements were also normal.
Investigations. X rays of the sinuses and lateral skull were done. The lateral view showed a fluid level in the frontal sinus, and the sinus view a slight opacity.
Initial diagnosis A diagnosis of a frontal sinusitis with abscess formation was made and the patient was prepared for drainage.
CT scan this was done prior to the surgery to confirm the diagnosis.
Final diagnosis The CT scan showed an epidural abscess protruding into the frontal lobe of the brain associated with the soft tissue lump over the frontal sinus!
Management In view of the new findings it was decided to get the neurosurgeons to give their opinion prior to any intervention.
Discussion This shows the possibility of misdiagnosis if all possible investigations are not done. Had we drained the sinus without the CT scan, nothing may have happened as the abscess was epidural. However the possibility of an intra cranial extension of the disease must be entertained, and the benefit of the doubt be given to the patient.
"The ferryman and the lightening strike "
The history The 47 year old ferryman had just finished his days work and returned after dropping the last passenger on the opposite bank. He was mooring the boat in the usual way to the tree as he had been doing for the past several years. He watched as his passenger started the on his way home across the river, and started to insert the padlock to the iron chain which secured the boat in place. The next thing he remembered was waking up in hospital with a drip running into his left arm, and feeling a lot of body aches. Two of his fingers in the left hand were bandaged, and were a bit painful. He also had an odd feeling in the left ear which was also painful.
The examination Examination showed a healthy man , a bit confused and disorientated, but otherwise in good health. The index and middle fingers of the left hand were burnt from the distal end to about the mid point. The left ear had a large central perforation occupying the anterior half of the tympanic membrane. The rest of the examination was normal.
Diagnosis This is a case of a lightening strike on a human being.
Discussion A visit to the site revealed the following.
1. The tree to which the boat was being tied was the tallest structure in that vicinity.
2. There was a hole on the bottom of the boat, which was in continuity with a line drawn from it, along the iron chain to the tree. This is most probably the path the lightening had taken. The mans fingers which were burnt were in the way of this path, causing them to get burnt.
3. What would have happened if the man had not been holding onto the iron chain, but just holding the tree? Would the lightening have gone through him with a fatal outcome?
History An X year old girl was admitted with a history of nasal obstruction, mouth breathing and a lump behind the soft palate.
Examination The main finding was a fleshy lump occupying the nasopharynx and the left nasal cavity. The lump was dropping into the oral cavity from behind the soft palate on the left side. Nasal obstruction was almost complete. She was mouth breathing all the time, and heroic snoring was seen during sleep, but no episodes of sleep apnoea were noticed during her stay in hospital.
Investigations From the investigations done the CT scan was the most informative. There was a soft tissue mass occupying the whole of the nasopharynx and extending into the nasal cavity on the left side. The right pterygoid plates were involved in the mass. there was no evidence of orbital or intracranial extension. The paranasal sinuses were clear.
Exploration The lump was explored under a general anaesthetic. Elevation of the soft palate gave adequate access to the lump avoiding the need for a transpalatal approach. The mass was dissected free from the nasopahrynx easily. It was arising from the right side of the nasopharynx, and extending into the left nasal cavity. Following excision, the mucosa looked intact, but there was a palpable mass under the mucosa on the right pterygoid area, which could not be approached without more extensive and mutilating resection.
Diagnosis The histopathological result was an Embryonic Rhabdomyosarcoma.
Further management After discussion with the oncologists it was decided to give a course of combined chemotherapy followed by radical radiotherepy.
