Discovery of a rare aberrant artery overlying trachea during open tracheostomy

Tracheostomy is a common surgical procedure for securing a patent airway. Anatomical variations of major vessels overlying the trachea may pose significant bleeding risk during the procedure. Hence, thorough preoperative assessment of the neck and surgeon's intraoperative vigilance are essential. Open tracheostomy is a safer option than percutaneous dilatational tracheostomy. Extra caution with stoma wound care and change of tracheostomy tube are necessary postoperatively if any major vessel is detected in close proximity with the tracheal stoma.

Child requiring tracheostomy for removal of an airway foreign body at the tracheal bifurcation

Airway foreign bodies are typically removed orally using a rigid bronchoscope. We present a rare case of a foreign body at the tracheal bifurcation that required removal via tracheostomy. A child turned pale while eating nuts and was suspected to have choked on a foreign body. CT revealed a foreign body at the tracheal bifurcation. As his respiratory condition was unstable, tracheal intubation and removal were attempted using a rigid bronchoscope. Tracheal obstruction during oral removal resulted in respiratory failure and bradycardia. Following emergency tracheostomy, the foreign body was removed via the tracheal stoma after his respiratory condition stabilised. The patient was discharged 21 days later without neurological sequelae. To avoid hypoxaemia during airway foreign body removal, as in this case, assessing the size of the upper airway and foreign body is necessary. Tracheostomy and foreign body removal through the tracheal opening should be considered proactively.

Rare case of sudden onset sensorineural hearing loss in a patient diagnosed with sarcoidosis

We report the case of a woman in her 30s who was referred to the ear, nose and throat department with sudden onset left-sided sensorineural hearing loss (SNHL), left anterior uveitis and erythematous lower limb lesions with bilateral pitting oedema. Based on her symptoms, an underlying inflammatory systemic disease was suspected. Autoantibodies were negative but an X-ray and high-resolution CT scan of the chest were suggestive of sarcoidosis, which was confirmed on endoscopic bronchial biopsy. Following treatment with a course of oral steroids, the patient's hearing has improved but she still suffers from episodes of uveitis. While immune-mediated inner ear disorders are a recognised cause of SNHL, sarcoidosis is a very rare cause. This case demonstrates the importance of screening for systemic autoimmune aetiology in SNHL and highlights the importance of an effective multidisciplinary team in the diagnosis and management of these patients.

Paediatric submental epidermoid cyst

A young girl presented with an insidious onset, gradually increasing midline submental swelling of 1-year duration and pain on swallowing for 6 months. Ultrasonography of the neck suggested a hypoechoic cystic swelling of the submental region between the muscles of the floor of the mouth, with no increased vascularity. An extraoral surgical enucleation was done and a postoperative biopsy suggested an epidermoid cyst. Epidermoid cysts of the submental region are extremely rare and any midline head and neck lesion in children requires critical examination and evaluation to avoid complications. Here, we present a rare case of a paediatric submental epidermoid cyst and its clinical features and management.

Laryngeal histoplasmosis: masquerading malignancy

Laryngeal histoplasmosis is a very rare cause of laryngitis which is encountered usually in the immunosuppressed states but can also occur in immunologically intact status. We report a rare case of laryngeal histoplasmosis in a man in his 60s, a chronic smoker who presented with a history of progressive hoarseness for 3 months. The glottic growth was biopsied. The rarity of diagnosis was aided by histopathological examination of the tissue, which revealed histoplasmosis. Management was done with intravenous liposomal amphotericin B and oral itraconazole with complete resolution of symptoms.

IgG4-positive Hashimoto thyroiditis and its association with IgG4-related sclerosing disease

A woman in her 50s was referred with suspected thyroid malignancy and underwent total thyroidectomy. Immunohistochemical analysis revealed IgG4-positive Hashimoto's thyroiditis. IgG4-related thyroid disease is poorly understood, and thought to encompass various entities including IgG4-positive Hashimoto's thyroiditis, Fibrosing Variant of Hashimoto's thyroiditis, Reidel's thyroiditis and Graves' disease with elevated IgG4 levels. Furthermore, it may be associated with a systemic fibrosing condition called 'IgG4-related sclerosing disease'. The clinical significance of IgG4-positive thyroid disease, however, remains unclear.

Intratympanic steroid treatments rescued recurrent hearing loss following COVID-19 vaccination and detection of an intralabyrinthine schwannoma

It remains unclear how to effectively treat rare cases of sudden and recurrent hearing losses which might coincidently follow vaccination. We report the first case, to our knowledge, of systemic and local steroid administration to successfully treat sudden and recurrent left-ear hearing loss, respectively, following a second dose of the BNT162b2 COVID-19 mRNA vaccination which inflammatory response potentially affected an existing left intralabyrinthine schwannoma in a young male patient. This case highlights the importance and timing of intratympanic steroid treatment strategies to suppress the progressive symptoms and restore hearing to a stable condition, and therefore avoid permanent hearing loss which would otherwise demand a surgical removal of the schwannoma to improve vertigo and reconstitute artificial hearing.

Use of circulating tumour DNA in nasopharyngeal carcinoma to detect minimal residual disease

Circulating tumour DNA (ctDNA) is defined as short DNA sequences shed by tumour cells into the systemic circulation. A promising use of ctDNA includes the detection of minimal residual disease (MRD) and is currently being studied in multiple types of solid tumours. Literature for the use of individualised ctDNA in nasopharyngeal carcinoma (NPC) is not available, although circulating Epstein-Barr virus DNA level is validated as a prognostic factor. We present a man in his 40s diagnosed with stage IV NPC who was started on chemotherapy with cis-platinum and gemcitabine. Serial monitoring of ctDNA completed to aid in detecting MRD after treatment demonstrated initial up-trending values correlating with subsequent imaging findings showing progression. Reinitiation of a different chemotherapy regimen significantly improved the ctDNA level, with corresponding imaging exhibiting a similar response. This case provides insight into the potential use of ctDNA in NPC and the benefit of serial ctDNA monitoring during treatment.

Phantosmia and psychogenic non-epileptic seizures in a patient with burning mouth syndrome suffering from severe depression

Burning mouth syndrome (BMS) is a rare but serious medical condition with important psychiatric comorbidity and specific psychological correlates. Psychopathology related with BMS represents a real challenge for clinical decision-making. In this case, depression is the leading psychiatric diagnosis associated with patient's BMS somatic pain and is driven by anxiety and a dissociative functioning. Facing a complex psychosomatic symptomatology, we offer new clinical perspectives for the screening of psychological traits of BMS. Moreover, we highlight the need to foster interdisciplinarity to improve differential diagnosis and defining an optimal care path. This case report stimulates a reflection on management challenges for the consultation-liaison psychiatry and shows the importance of a person-centred approach when communicating the diagnosis.

Primary Burkitt lymphoma of the thyroid associated with Hashimoto's thyroiditis

Primary Burkitt lymphoma of the thyroid is an extremely rare entity with only a few reported cases. A female patient in her 70s with Hashimoto's thyroiditis presented with a 2-month history of progressive left-sided neck swelling. Ultrasound examination revealed a multinodular goitre and fine needle aspiration (FNA) showed no signs of malignancy. The rapid growth of the thyroid mass raised the concern of a lymphoproliferative process. After left thyroid lobectomy and histopathological examination, the diagnosis of Burkitt lymphoma was made and the patient was included in a randomised study providing chemotherapy following a dose adjusted EPOCH-R regimen. Clinical remission was reached after 6 cycles of chemotherapy. There were no signs of relapse on follow-up, 1.5 years after the end of the treatment. Fast growing thyroid nodules in HT warrant a high index of suspicion. Despite no signs of malignancy after FNA cytology, these nodules may need further investigations.

Peritonsillar abscess due to temporomandibular joint septic arthritis: an uncommon cause of a common disease

Peritonsillar abscess is a common presentation of complicated acute tonsillitis. The temporomandibular joint septic arthritis is an uncommon clinical entity while its complications are further rare. We present a case of a man in his late 30s who presented with a painful swelling in the left preauricular region along with increasing trismus. A diagnosis of peritonsillar abscess due to septic arthritis was made based on clinical history and examination. Patient recovered fully after antibiotic and abscess drainage. This is the first case report of temporomandibular septic arthritis leading to peritonsillar abscess.

Synchronous Hürthle cell and medullary thyroid carcinomas

Hürthle cell carcinoma (HCC) and medullary thyroid carcinomas (MTC) are uncommon histological subtypes of thyroid cancers, each accounting for around 3% of all thyroid cancers. A septuagenarian woman with a history of multiple primary cancer diagnoses presented with a growing left-sided neck lump. A diagnostic left thyroid lobectomy was performed, and pathological examination found two separate malignant foci: one HCC and an MTC. The patient developed left-sided HCC nodal metastasis, and following several multidisciplinary team discussions, a right completion lobectomy with left lateral neck dissection was performed, revealing further intrathyroidal MTC and extranodal extension of HCC. We present this as the first reported case of a collision tumour of HCC and MTC, and review the available literature regarding collision tumours and their management.

Adenoid cystic carcinoma of sinonasal origin masquerading as an intraconal lesion

Adenoid cystic carcinoma is an uncommon tumour of the salivary glands, although affliction of mucin-producing glands present in the oral cavity, oropharynx and paranasal sinuses is not uncommon. Other possible sites are lacrimal, oesophagus, trachea-bronchial tree, lungs, uterus, cervix, prostate. These tumours have a tendency to be aggressive and most show invasion into the adjacent region. Adenoid cystic carcinoma contributes to about 0.3% of all sinonasal tumours.

Malignant mixed tumour of the parotid gland in a preterm neonate with cytomegalovirus infection

A young pregnant woman presented to the emergency department with acute lower abdominal pain. The ultrasound examination showed not only a viable fetus with a gestational age of 24 weeks but also a heteroechoic mass of about 7×7 cm involving parts of the face. The patient was found to be in active labour with rapid progression, and she gave birth to a dead female neonate. The autopsy showed a large malignant mixed tumour of the left parotid gland and revealed infection with cytomegalovirus. To our knowledge, this is the first reported case of a malignant mixed tumour of salivary glands in fetuses.

Teprotumumab-associated chronic hearing loss screening and proposed treatments

We report a case of a woman in her 50s with chronic teprotumumab-associated sensorineural hearing loss. The patient presented with chronic thyroid eye disease with proptosis and diplopia despite systemic thyroid control and orbital decompression. She was started on teprotumumab but developed tinnitus after the third dose, followed by frank hearing loss after the fifth dose. Her audiogram showed bilateral mild to moderate-severe hearing loss, which was significantly worse compared with her baseline audiogram obtained prior to treatment. Teprotumumab was immediately stopped, however repeat audiogram 6 weeks later showed no improvement. Given potentially irreversible sensorineural hearing loss, we recommend close monitoring with regular audiometric testing before, during and after teprotumumab therapy and propose potential treatment to reverse its effects in the ear.

Nodular fasciitis of the submandibular gland

A woman in her 20s presented with a non-tender swelling of the right submandibular gland. Ultrasound was suggestive of pleomorphic adenoma. The histology result of the excised tumour later confirmed a diagnosis of nodular fasciitis which is extremely rare in the submandibular gland. Postoperatively, she has made good recovery. Due to the similarity of the radiological image of pleomorphic adenoma and nodular fasciitis, it poses difficulty in diagnosing nodular fasciitis without cytology or histology of the salivary gland. Although being extremely rare, it would be worth to consider nodular fasciitis as one of the differential diagnosis in future cases of benign submandibular lesions.

Sinogenic polymicrobial anaerobic orbital cellulitis: the importance of source control and broad empirical antibiotics

A man in his twenties with a history of recurrent sinusitis was urgently referred to the emergency department (ED) by an out-of-hours general practitioner following a 2-day history of increasing right eye pain, redness and swelling after a week of coryzal symptoms. He denied visual impairment and any history of recent dental pain or procedures. Initial assessment in ED noted fever, tachycardia and hypotension. Video consultation with ophthalmologist in the ED identified proptosis, periorbital erythema and chemosis with full eye movement solely affecting the right eye. Visual acuity of 6/6 was confirmed in both eyes. After review by the ear, nose and throat (ENT) team, a diagnosis of sinogenic right orbital cellulitis was made, empirical antibiotics started and care transferred to the ENT team for immediate surgical intervention. 48 hours postoperatively, the patient acutely deteriorated, developing ophthalmoplegia and visual acuity of 6/95 in the right eye. Repeat imaging demonstrated a deteriorating picture and urgent surgery was organised at a neighbouring hospital's specialist ENT unit combined with a change to his antibiotics. On day 4, 1 day following transfer, an anaerobic bacterium, Eggerthia catenaformis, was isolated from blood cultures collected on admission. The patient improved clinically following the second surgery and targeted antimicrobial therapy, eventually being discharged 10 days after initial presentation. In addition to E. catenaformis, the Anaerobic Reference Unit (Cardiff) identified two further anaerobic bacteria, Parvimonas micra and Dialister pneumosintes This paper presents the first documented case of polymicrobial anaerobic orbital cellulitis secondary to acute bacterial sinusitis. Moreover, this case underpins the importance of broad empirical antibiotics coupled with surgical source control to effectively manage a rare but sight-threatening and life-threatening disease.

Use of platelet-rich plasma in irradiated patients to treat and prevent complications of head and neck surgery

Nowadays, many patients facing head and neck oncological surgery have a history of tissue irradiation. This represents an important risk factor for postsurgical complications, including dehiscences and fistulas. Platelet-rich plasma (PRP) obtained from the patient's blood represents an easy, fast and inexpensive method for the prevention and treatment of such complications. We present three cases of previously irradiated patients in which PRP was successfully used to prevent and treat postsurgical complications.

Acoustic neuroma with orofacial paresthesia: description of an atypical presentation

Acoustic neuroma (AN) usually manifests with asymmetric hearing loss, tinnitus, dizziness and sense of disequilibrium. About 10% of patients complain of atypical symptoms, which include facial numbness or pain and sudden onset of hearing loss. Patients with atypical symptoms also tend to have larger tumours due to the delay in investigation. We report a particularly interesting case of a patient presented to us with numbness over her right hemifacial region after a dental procedure without significant acoustic and vestibular symptoms. Physical examination and pure tone audiometry revealed no significant findings but further imaging revealed a cerebellopontine angle mass. The changing trends with easier access to further imaging indicate that the presentation of patients with AN are also changing. Atypical symptoms which are persistent should raise clinical suspicion of this pathology among clinicians.

Reminder of an important clinical lesson: breast cancer metastasis to the parotid gland

A 59-year-old woman presented to an otolaryngology clinic with an 8-week history of a painless lump over her left parotid gland. Her medical history included an invasive ductal carcinoma (33 mm) and a ductal carcinoma in situ (70 mm) of the right breast, for which she had a mastectomy and various adjuvant therapies. The primary tumour presented 8 years prior to the metachronous metastasis. This patient was a non-smoker and had no significant family history. Post-superficial parotidectomy pathology revealed the parotid gland tumour to be oestrogen receptor-positive and HER2 receptor-positive, thus ruling out the initial differential diagnosis of a pleomorphic adenoma. A consequential total parotidectomy with a posterolateral neck dissection was performed with sparing of the facial nerve. The patient recovered well having only encountered a self-resolving salivary fistula. She portrayed no signs of facial nerve palsy and subsequent imaging scans showed no abnormalities.

Nintedanib as a novel treatment option in hereditary haemorrhagic telangiectasia

A 70-year-old patient with known hereditary haemorrhagictelangiectasia (HHT) was seen regularly in our outpatient clinic. He underwent multiple therapeutical interventions, including both surgical and medical, for the treatment of recurrent epistaxis without sustained success. Due to a concurrent diagnosis of idiopathic pulmonary fibrosis, treatment with the tyrosine kinase inhibitor nintedanib was initiated, after which point the patient reported a dramatic and unanticipated improvement in his epistaxis and skin telangiectasia. On the basis of this case report, we propose that nintedanib may be a potential treatment option for refractory epistaxis in HHT.

Middle ear adenoma with uncommon presentation and literature review

Middle ear adenoma (MEA) is a rare benign tumour. Here we report a case of MEA in a 39-year-old man with hearing loss. Some significant histopathological features of MEA and neuroendocrine differentiation identified by immunohistochemistry are described. The tumour showed remarkable and rare degenerative histological characteristics. There were a few tumour cells which were covered by degenerated tissue. Consequently, following frozen biopsy, the tumour was misdiagnosed as chronic ear inflammation. No recurrence was seen in this patient after 45 months of follow-up; regular clinical and radiological follow-up is necessary since recurrence is possible. A literature review for MEA is presented and this type of tumour is discussed clinically, microscopically and immunohistochemically. The differential diagnosis and associated treatment are described.

Go-karting injury: a case of laryngeal trauma

We report a case of accidental strangulation and crush injury to the anterior neck resulting in laryngeal trauma. This extremely uncommon mechanism of injury provides a safety warning regarding precautions with neck wear, and the unusual resulting injury represents an opportunity to review best practice in management of laryngeal trauma.

An unusual position of retromandibular vein: a surgical challenge in parotid surgeries

A 44-year-old man presented with swelling in the left parotid region. The swelling was firm and Fine Needle Aspiration Cytology report proved pleomorphic adenoma. In the CT scan, the tumour was confined to the superficial lobe of parotid. So, left superficial parotidectomy was planned. Modified Wilson Blair's incision was used. On course of identifying the facial nerve, a large calibre vein was identified running vertically through the parotid substance. Assuming it as retromandibular vein, further dissection was carried out more meticulously. Marginal mandibularbranch of facial nerve was identified near the angle of mandible and retrograde dissection showed the cervicofacial division running medial to retromandibular vein with the main facial nerve trunk lying unusually medial and posterior to it. Adding to it, the temporofacial division was found 'forked' between the branches of retromandibular vein. These variations in head and neck venous channels are not that rare as we believe. All these variations have an embryological basis. Therefore, knowledge and understanding of this complex anatomy will help us preventing devastating complications like bleeding and facial nerve injury in such cases.

Pathological fracture of the femoral neck following septic coxitis and chronic osteomyelitis: a potential complication of Lemierre's syndrome

We portray the case of a 16-year-old girl who was initially admitted to the paediatric emergency department with non-specific symptoms of a severe cold and was first treated symptomatically on an ambulatory basis. Within 6 days she developed the full clinical picture of Lemierre's syndrome with the extraordinary manifestation of involvement of her right hip. Despite an interdisciplinary coordinated treatment as well as surgical therapy, a full-blown sepsis evolved within a short time period and resulted in almost 2 months of intensive care. While the primary focus could be successfully controlled, a progressive avascular necrosis of the right proximal femur developed on the basis of a chronic osteomyelitis. This finally led to a pathological fracture of the femoral neck. After excluding the possibility of an enduring bacterial infection, the fracture was treated with a total hip replacement.

Angioleiomyoma of the upper lip

This report describes a case of labial angioleiomyoma in a 52-year-old woman. The patient had noticed a slow-growing painless isolated mass in her upper lip for 6 months. The mass was surgically excised, and pathological examination was consistent with angioleiomyoma. Surgical excision was curative, and there was no recurrence at 12-month follow-up.

Median philtrum sinus: a rare presentation and review of management options

Nasal dermoids are rare congenital abnormalities, and there is only one previously reported case of a philtrum sinus tract extending to the skull base. A 2-month-old boy was presented with an incidental finding of a median philtrum sinus with no infective features and no other abnormal clinical findings. MRI demonstrated a sinus tract extending from the philtrum to the crista galli. On multidisciplinary review, a conservative approach was taken due to the asymptomatic nature of the patient. Given the rarity of nasal dermoids, diagnosis requires precise clinical examination and MRI to identify the extent of the tract. Management options require a multidisciplinary case-specific approach and include non-surgical as well as surgical approaches.

A paediatric case of bilateral mandibular condyle fracture presenting with bloody otorrhoea following trauma

A 7-year-old boy presented to the emergency department with bilateral bloody otorrhoea after falling from his scooter. Skull base fracture was suspected. CT showed no evidence of skull base fracture but bilateral mandibular condyle and external acoustic canals fractures. We report this case to illustrate a rare possibility of bilateral external acoustic canal fracture associated with condylar fracture in trauma patients presented with bloody otorrhoea.

Pneumatic dental extractions: an unusual cause of extensive cervical surgical emphysema

A 50-year-old fit and well man presented to the Accident and Emergency Department in a tertiary centre following lower molar extraction, complaining of voice hoarseness with neck and facial swelling. Clinical examination along with plain film radiography revealed pneumomediastinum and extensive cervical surgical emphysema. He was subsequently admitted for observation and managed conservatively under the ENT team with input from the maxillofacial and anaesthetic teams. With supportive treatment only, the emphysema resolved and he remained well up until discharge.

Isolated unilateral upper alveolar numbness in silent sinus syndrome

We present a case of a 59-year-old man with left upper alveolar numbness of 2 years’ duration in the absence of sinonasal symptoms. On physical examination, he demonstrated mild left facial asymmetry and diminished sensation of his left upper alveolus from the left second upper incisor to first canine. CT imaging revealed chronic sinusitis changes of the left maxillary sinus, with reduced volume and depressed anterior wall. The patient underwent functional endoscopic sinus surgery to re-establish maxillary sinus ventilation. He was noted to have some improvement of his upper alveolar paraesthesia postoperatively. Silent sinus syndrome is part of the spectrum of chronic maxillary atelectasis. In the presented case, chronic osteitic bony sclerosis, as opposed to osteopenic change of the maxillary sinus, was seen. We postulate that bony encasement of the anterior superior alveolar nerve resulted in chronic nerve compression and the patient’s unusual symptom of upper alveolar paraesthesia.