Synchronous nasal rhinosporidiosis and inverted papilloma in a paediatric patient in Dodoma, Tanzania: Case report

INTRODUCTION

Nasal rhinosporidiosis refers to a rare chronic granulomatous disease caused by Rhinosporidium seeberi. It affects the mucous membrane of sites such as nasopharynx, conjunctiva and palate. Inverted papillomas are relatively rare and are benign epithelial tumors of the nasal cavity that are locally aggressive, exhibit recurrence tendency and malignant transformation. Both entities are very rare in our setting and this is perhaps the first documented case in Tanzania.

CASE PRESENTATION

The patient was a 7-year old boy with a 1-year history of left-sided nasal obstruction and intermittent epistaxis for 6 months. He had no history of cheek swelling, pain or numbness, loss or loosening of teeth or alveolar ridge fullness. There were no ophthalmological, otological or neurological complaints reported. Endoscopic excision of the nasal mass was done and histopathological analysis confirmed co-existence of rhinosporidiosis and inverted papilloma. Postoperatively, the patient was kept on oral dapsone at a dose of 50 mg/day for 6-months and with no residual disease recurrence noted after 6-months follow up.

CLINICAL DISCUSSION

The patient underwent endoscopic excision of the nasal mass and histopathological analysis confirmed co-existence of rhinosporidiosis and inverted papilloma. Postoperatively, the patient was kept on oral dapsone at a dose of 50 mg/day for 6-months and with no residual disease recurrence noted after 6-months of follow up.

CONCLUSION

Nasal rhinosporidiosis and inverted papilloma lesions may resemble the routinely encountered nasal polyps thus important for both clinicians and pathologists to have a high index of suspicion when managing patients with nasal masses even from non-endemic areas.

Pulmonary manifestations masquerading a longstanding neglected metallic foreign body in the esophagus of a paediatric patient from Tanzania: Rare case report

INTRODUCTION

Paediatric foreign body (FB) ingestion remains to be a common encounter in otorhinolaryngology and may manifest with pulmonary manifestations. Pulmonary manifestations masquerading chronic esophageal FBs in children is rare in clinical practice. This is perhaps the first documented case in Tanzania.

CASE PRESENTATION

The patient was a 6-year old boy with a 6-month history of ingesting a metallic object. The child was reported to have presented with sudden onset of drooling of saliva and difficulty in swallowing that lasted for several hours. While preparing to visit a hospital, no more drooling of saliva was noted thus the visit was cancelled. A month later the patient presented with recurrent episodes of dry cough associated with wheezing and unresponsive to medical treatment. Upon attending other health facilities no chest X-ray was ordered but rather prescribed antibiotics, mucolytics, antihistamines and antileukotrienes without relief. Chest x-ray was indicated and revealed an esophageal metallic object. Rigid esophagoscopy under general anaesthesia yielded the rusted metallic object in piece meals. Postoperative antibiotic, analgesic and an oral corticosteroid were prescribed. Postoperative visits were uneventful.

CLINICAL DISCUSSION

The patient underwent esophagoscopy and the rusted` metallic object was extracted in piece meals. Postoperative antibiotic, analgesic and oral corticosteroid were prescribed. Postoperative visits were uneventful.

CONCLUSION

It is always important to suspect FB ingestion in a child with a history of sudden onset of drooling of saliva and difficulty in swallowing. Imaging should be advocated to avoid delayed diagnosis otherwise pulmonary manifestations can masquerade the diagnosis of chronic esophageal FBs.

Awareness of head and neck cancer among patients attended at a regional referral hospital in Tanzania

BACKGROUND

Head and neck cancers (HNCs) are considered to be lethal and about 50% of the cases are diagnosed at advanced stages and are associated with poor prognosis. Despite the high disease burden globally, there are scarce studies on awareness of HNCs and this is the first study to explore such awareness in Tanzania. The study aimed at determining awareness of head and neck cancer among patients attended at a regional referral hospital in Tanzania.

METHODS

A hospital based cross sectional study was conducted at Geita Regional Referral Hospital from April to May 2022 where 315 respondents were recruited. Simple random sampling technique was utilized and data was collected using structured questionnaires and analyzed using Statistical Package for Social Sciences (SPSS) version 23. Chi-square test was performed to establish the relationship between the selected independent and dependent variables. P-value < 0.05 was considered to be statistically significant.

RESULTS

More than half (54.9%) of the respondents considered themselves to be somewhat knowledgeable on head neck cancer. In the same study, 56.2% of the respondents didn't know anatomical sites of head and neck cancer and over half (65.9%) of the respondents didn't know signs and symptoms of head and neck cancer. Cigarette smoking (73.7%) and alcohol consumption (65.1%) were the most correctly identified risk factors for HNCs. Regarding treatment options and preventive measures, 75.2% of the respondents knew cessation of cigarette smoking as a preventive measure for HNCs and surgery (91.7%) was the most known treatment option for head and neck. Similarly, a significant association was found between awareness on HNCs and some of the socio-demographic characteristics of the respondents.

CONCLUSIONS

Although majority of respondents considered themselves to be somewhat knowledgeable on HNCs, awareness by patients on anatomical sites, clinical features, risk factors, preventive measures and curability of head and neck cancer at the Regional Referral Hospital was minimal.

The Time Preferred by Patients to Undergo Surgery: What Proportion Would Accept Day-Case Versus Overnight Tonsillectomy/Adenotonsillectomy?

Background

Day-case tonsillectomy is becoming popular with varying patients' satisfaction. Whether day-case or overnight tonsillectomy is safe and preferred by patients has been debatable among otorhinolaryngologists. To date, majority of otorhinolaryngologists in Tanzania are practicing overnight tonsillectomy unlike what is being practiced in other parts of the world. There is scarce literature regarding whether day-case or overnight surgical option is preferred by patients.

Objective

To assess the time preferred by patients to undergo surgery by ascertaining the proportion of patients who would prefer day-case to overnight tonsillectomy or adenotonsillectomy.

Methods

We conducted a hospital based cross sectional study at Ekenywa Specialised Hospital from January to December 2021. The study recruited 200 patients who underwent elective tonsillectomy or adenotonsillectomy. A structured questionnaire adopted from previously published studies and thereafter modified accordingly to fit the current study was used to collect relevant data. Data were analysed using Statistical Package for Social Sciences (SPSS) version 21.

Results

The study had more male participants 104(52%) than females, 96 (48%) with a male to female ratio of 1.1:1. Majority of the study participants were aged below 5 years. Male participants aged below 5 years accounted for 50% while females aged <5 years accounted for 65.6%. Of the 200 (100%) patients who returned the questionnaires, 135(67.5%) preferred discharge on the 1^st day post surgery while 65 (32.5%) preferred discharge on the 2^nd postoperative day or later. Similarly, five (2.5%) would have wished day-case tonsillectomy/adenotonsillectomy while 195(97.5%) preferred an overnight surgery. Patients with postoperative pyrexia, older patients and those discharged on the 2^nd day post surgery or later were more likely to prefer a longer postoperative hospital stay.

Conclusion

Day-case surgery seems feasible due to less risk of postoperative complications such as haemorrhage and fever. Majority of the participants in this study preferred overnight tonsillectomy/adenotonsillectomy.

Unsolicited ejection of an aspirated metallic foreign body in an adult male: Rare case report

INTRODUCTION AND IMPORTANCE

Being an otorhinolaryngological emergency foreign body aspiration (FBA) has continued to be a great challenge to Otorhinolaryngologists. Foreign body inhalation poses life threatening challenges and its uncommon in adult unlike paediatric population. The recommended treatment for the aspirated foreign bodies is bronchoscopy. Unsolicited ejection of an aspirated foreign body is an uncommon encounter in clinical practice and few cases have been reported in the available literatures.

CASE PRESENTATION

A man aged 38-years was attended at the clinic with a history of inhaling a metallic foreign body a day prior visiting our hospital underwent unsolicited ejection following several bouts of dry irritating cough while preparations were in progress to send the patient to an operating theatre for emergency bronchoscopy coupled with removal of the foreign body.

CLINICAL DISCUSSION

The patient underwent unsolicited ejection of the metallic object following several episodes of dry cough and was then counseled to attend the scheduled follow up after 7-days and it was uneventful.

CONCLUSION

Despite being unsafe and not recommended to wait for unsolicited ejection of an aspirated foreign body, meticulous attention should be kept to patients while waiting for bronchoscopy since there are rare chances for unsolicited ejection of such aspirated foreign bodies.

Clinical spectrum of ear, nose and throat foreign bodies at a tertiary hospital: a cross-sectional study

Presence of foreign bodies (FBs) in the ears and upper aerodigestive tract is a common encounter in children unlike adults in otorhinolaryngology practice. FBs form a major part of emergencies in otorhinolaryngology. Studies on ear, nose and throat FBs in Tanzania are scarce.

Objective

To determine the clinical spectrum of ear, nose and throat FBs at the largest tertiary hospital.

Methods

A descriptive hospital based cross-sectional study was conducted where 95 patients were recruited at the Hospital from December 2019 to May 2020. Data were collected using semi-structured questionnaires and analyzed using Statistical Package for the Social Sciences (SPSSs) version 24.

Results

In this study, there were more females, 56 (58.9%) than males, 39 (41.1%) with female to male ratio being 1.4:1. Children aged younger than 10 years predominated in this study, 69 (72.6%). The nose, 36 (37.9%) and ear, 29 (30.5%) were the commonest sites where FBs lodged followed by the pharynx, 22 (23.2%) and oesophagus, 10 (8.4%). Regarding types of FBs, inorganic types, 49 (51.6%) predominated and were mostly coins, 17 (17.9%). Majority of FBs were removed in less than 24 h (53.7%) and complications were found in 29 (30.5%) patients and being more pronounced with nasal FBs. Majority of those with complications presented to the hospital 24-72 h post lodging of FBs.

Conclusion

FBs were encountered more commonly in children aged younger than 10 years. The nose was the commonly affected anatomical site followed by the ear, pharynx and oesophagus. The commonest FB was a coin. The inorganic FB type predominated and the most common inorganic type was a coin while the commonest organic type was a seed. Complications were encountered in those who presented between 24 and 72 h post FB lodgment.

Unilateral choanal atresia and a co-existent long-standing medium-sized ipsilateral rhinolith in a 15-year old boy: Case report and literature review

INTRODUCTION AND IMPORTANCE

Unilateral choanal atresia is a congenital anomaly where a newborn baby is born with a unilateral imperforate posterior nare. In most of the time the diagnosis may be missed for years after birth. A rhinolith is an entity formed by gradual deposition and coating of different salts of calcium and magnesium over an endogenous or exogenous nidus in the nasal cavity. Coexistence of a rhinolith and choanal atresia is a very rare encounter in clinical practice and to the best of our knowledge this is perhaps the first documented case in Tanzania.

CASE PRESENTATION

We present a 15-year old boy who was attended at our department with a longstanding history of left sided non-foul smelling nasal discharge which was noticed first when he was 5 years old but at the age of 13 years, he presented with ipsilateral nose bleeding and episodic foul smelling nasal discharge. He was attended at various peripheral health facilities without relief.

CLINICAL DISCUSSION

The patient underwent left sided nasal endoscopy where unilateral choanal atresia and a rhinolith were found. Transnasal endoscopic choanal atresia release and rhinolith removal were done under general anaesthesia in operating room. Postoperatively, he was kept on a nasal decongestant, a broad-spectrum antibiotic, intranasal corticosteroid and an analgesic.

CONCLUSION

Clinicians must have a high index of suspicion so as to establish the diagnosis of unilateral choanal atresia in patients with persistent unilateral non-foul smelling discharge and also nasal foreign bodies in those with foul smelling nasal discharge.

Role of Perioperative Intravenous Dexamethasone in Management of Post Adenotonsillectomy Morbidity: A Single Blinded Randomised Controlled Study

Objective:

To determine the role of perioperative intravenous dexamethasone in reducing post adenotonsillectomy morbidity in Dar es Salaam, Tanzania.

Methods:

A Prospective, randomised, placebo-controlled study was conducted at Ekenywa Specialized Hospital. Fifty patients were randomised to receive three doses of intravenous dexamethasone (13 males and 12 females) or placebo (13 males and 12 females) administered eight hourly for the first 24hours after surgery (1mg/kg). Data were analysed using statistical package for social sciences version 21 and P-value<.05 was considered to be statistically significant.

Results:

Intravenous dexamethasone was found to exert significant effects in terms of reducing the severity of some observed postoperative parameters such as pain scores, post-operative nausea and vomiting (PONV), tolerance to oral fluids, discharge from hospital, postoperative hemorrhage, postoperative pain, re-admission and wound healing between the two groups of patients. In this study, dexamethasone did not significantly exert any effect on fever in the first 24 hours after surgery.

Conclusions:

Intravenous dexamethasone is an effective and safe method for reducing post adenotonsillectomy morbidity.

A missed giant rhinolith retained for a decade in a paediatric patient at a zonal referral hospital in Central Tanzania: Case report and literature review

Introduction and importance

Rhinolith is an entity formed by gradual deposition and coating of different salts of calcium and magnesium over an endogenous or exogenous nidus in the nasal cavity. The type, size and duration of the rhinolith lead to multiple types of presentation. Giant rhinoliths are very rare in paediatric patients owing the size of their nasal cavities. To the best of our knowledge this is the first reported case of a giant paediatric rhinolith in Tanzania.

Case presentation

We present a 12-year old male who presented with a history of left sided nasal obstruction accompanied with foul smelling nasal discharge for 11 years and was marked by being followed by house flies. Had history of occasional episodes of headache but no facial pain. He was managed at various remote health facilities without specialist consultation for eleven years as case of allergic rhinitis and rhinosinusitis and finally was referred with a provisional diagnosis of chronic granulomatous disease of the nose. The patient underwent anterior rhinoscopy and a left sided stony hard mass was removed under topical local anaesthesia.

Clinical discussion

The patient underwent anterior rhinoscopy and a left sided stony hard mass was removed under topical local anaesthesia. Postoperatively he was kept on a nasal decongestant, a broad-spectrum antibiotic and an analgesic.

Conclusion

Any child with unilateral foul smelling nasal discharge should be considered to have a nasal foreign body until proven otherwise. The treatment of choice remains to be nasal foreign body removal under local or general anaesthesia.

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Giant rhinoliths are very rare in paediatric patients owing the size of their nasal cavities.

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Unilateral foul smelling nasal discharge in a child suggests a nasal foreign body.

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Type, size and duration of the rhinolith lead to multiple presentations.

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Rhinolith removal under local or general anaesthesia remains the treatment of choice.

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Clinicians must have a high index of suspicion to establish the diagnosis of a rhinolith.

Nasal rhinosporidiosis masquerading as pyogenic granuloma in a pediatric patient at a Zonal Referral Hospital in Central Tanzania: Case report

Being rare, rhinosporidiosis is a chronic granulomatous disease that is characterized by polypoidal lesions of the mucous membrane and is caused by Rhinosporidium seeberi. The disease commonly affects the mucous membrane of the nasopharynx, conjunctiva, and palate and its very rare in our geographical location.

Nasal rhinosporidiosis lesions may greatly mimic other ordinary nasal polyps, and it is crucial for otorhinolaryngologists to consider rhinosporidiosis as a differential diagnosis whenever encountering patients with nasal masses during routine clinical practice.

Utility of reflux finding score and reflux symptom index in diagnosis of laryngopharyngeal reflux disease

Objective

Methods

Results

Conclusion

Level of Evidence

Histocytopathological diagnosis of Rosai–Dorfman disease: Case report

Sinus histiocytosis with massive lymphadenopathy (Rosai–Dorfman disease) being a rare benign proliferative self‐limiting disease of the cells of macrophage‐histiocyte family is of unknown etiology and presents with massive lymphadenopathy. We are hereby reporting a case of RDD presenting with massive bilateral cervical and submandibular lymphadenopathy, diagnosed by histocytopathology.

Jael's syndrome: Case report and literature review

Introduction and importance

Jael's syndrome, an intentional injury caused by a knife in the face or skull is a rare encounter in clinical and forensic practice, rarely involving an impacted knife. Clinical and radiographic diagnosis is essential to identify severity of injury and location of the retained knife. To the best of our knowledge, this is the first reported novel case of Jael's syndrome in Tanzania.

Case presentation

We present the case of a 31-year old man admitted at Muhimbili National Hospital following an impacted knife. The stab wound extended to the medial wall of left orbit and ended just before the optic foramen associated with vitreous hemorrhage and the retained knife caused superoposterior displacement of the globe. Multidisciplinary management was instituted including prompt evaluation, imaging and surgical removal of the knife under general anesthesia.

Clinical discussion

Plain skull X-ray revealed an extensive retained blade and computerized tomography (CT) showed the tip of the blade adjacent to the right styloid process with no neurovascular compromise. Initial concern was the left eye that was reported to be viable by ophthalmologists. Incredibly, the patient had no initial sequelae from such an extensive injury and had unremarkable recovery with no complications apart from the wound to left inferior rectus muscle that was conservatively managed. Simple withdrawal of the retained knife was successful.

Conclusion

Craniofacial retained knives are rare. Thorough prompt initial evaluation and intervention is vital since improper management can be devastating.

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Impacted knife at the craniofacial region is a very rare encounter.

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Clinical and radiographic diagnosis is essential to identify extent of damage to critical structures.

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Complications such as diplopia, intracranial hemorrhage and acute cerebrospinal fluid leakage have been reported.

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Multidisciplinary management has to be instituted when retained foreign bodies are encountered.

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Simple surgical removal along the path of insertion of retained foreign body seems safe and effective.

Unusual longstanding intrabronchial foreign body masquerading as intractable bronchial asthma in an adult: Case report and literature review

Introduction and importance

Tracheo-bronchial foreign body inhalation is a very common encounter in clinical practice among pediatric patients and rarely seen among adults. When inhalation of foreign bodies occurs in adults then it tends to lodge within the right bronchial tree but in children it lodges in the central airways.

Case presentation

We present a 58 year old woman, known asthmatic for 20 years and non-smoker who presented to our clinic which history of chronic cough, wheezing and pulmonary infections that did not respond to regular antibiotics and the usual antiasthmatic medications. She reported to have inhaled a foreign body about 18 years earlier. Extraction of the foreign body was performed without complications.

Clinical discussion

A chest x-ray done was found to be normal and computerized tomography scan (CT scan) of the chest was ordered and revealed bronchial wall thickening with a calcified foreign body seen in the right intermediate bronchus.

A combined rigid and flexible endoscopic bronchoscopy was performed and a chicken bone (measuring 2 cm × 1.5 cm) was extracted from the right intermediate bronchus with very minimal bleeding being encountered during and post bronchoscopy. Extraction of the foreign body was performed without complications. Post endoscopic intrabronchial foreign body removal, the patient recovered completely.

Conclusion

An intrabronchial foreign body being masked for more than a decade by co-existent bronchial asthma is a rare encounter. Moreover, adult patients with chronic cough should be handled with caution to rule out the possibility of FB aspiration.

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FB inhalation is a very common encounter in clinical practice among pediatric patients and rarely seen among adults.

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Inhaled FBs in adults tends to lodge within the right bronchial tree and in the central airways in children.

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Adult patients with chronic cough should be handled with caution to rule out inhaled FBs.

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Co-existing bronchial asthma may mask the diagnosis of FB inhalation in unclear history of its inhalation.

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Bronchoscopy remains to be the main stay in management of inhaled FBs.

Unusual giant calculus of the submandibular duct: Case report and literature review

Introduction and importance

Majority of salivary gland stones (sialoliths) occur in the submandibular gland (Wharton's duct and parenchyma) accounting for 80% of cases. A Giant calculus of more than 3 cm is a rare encounter.

Case presentation

We present a 45-year old male patient who undergone surgical removal of a giant submandibular gland calculus which was reported by the patient as a result of a hard mass beneath the tongue with occasional pain being experienced during intake of meals.

Clinical discussion

Clinical assessment revealed a painless palpable hard mass beneath the tongue though with some dull pain being experienced during intake of meals. Local examination showed a hard mass at the sublingual region but not adhered to surrounding structures. The overlying intraoral mucosa appeared normal and not inflamed and with neither enlarged ipsilateral submandibular gland nor cervical lymph nodes. The patient was then prepared for surgical removal of the calculus under general anesthesia where a single giant calculus (measuring 4 cm) was extracted by marsupialization of Wharton's duct.

Conclusion

A giant calculus of more than 3 cm is a rare encounter and they remain to be one of the causes of submandibular gland dysfunction.

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Most of the salivary gland sialoliths (80%) involve the submandibular gland

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A Giant calculus of more than 3 cm is rare

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Flow of saliva against gravity, high calcium and mucin content and its more alkaline pH explains calculi formation.

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Patients normally present with pain either before or during intake of meals and may have a history of recurrent swelling of the involved gland

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Intraoral extraction of a calculus should be advocated aiming at gland preservation

Unilateral Pyoderma gangrenosum of the external ear in a resource-limited setting: Case report and literature review

Involvement of the external ear by PG is a rare encounter, and steroids remain to be the main stay in its treatment.

Clinical effect of an active transcutaneous bone-conduction implant on tinnitus in patients with ipsilateral sensorineural hearing loss

OBJECTIVES

This study investigated the effect of an active transcutaneous bone conduction implant (BoneBridge^Ⓡ) in the management of tinnitus in patients with unilateral sensorineural hearing loss.

METHODS

From October 2016 to July 2018, 15 patients with unilateral tinnitus accompanied by ipsilateral sensorineural hearing loss received BoneBridge^Ⓡ implants. Pure-tone average, tinnitus handicap inventory (THI), and a visual analogue scale (VAS) for awareness, loudness, and annoyance were measured before and 6 months after surgery. We defined improvement as a reduction of more than 20% between preoperative and postoperative VAS and THI scores, and changes in the THI of over 7 points were also assessed.

RESULTS

Mean THI scores before surgery (72.8 ± 16.1) had significantly improved by 6 months postoperatively (50.9 ± 18.9) (p = 0.003). VAS scores for loudness and annoyance also statistically significantly improved (p = 0.011 and 0.002). The amount of functional hearing gain correlated with changes in VAS scores for annoyance. This correlation was stronger with the improvement of high frequency hearing.

CONCLUSION

BoneBridge^Ⓡ is beneficial in patients with tinnitus accompanied by sensorineural hearing loss. This finding can help select patients who will benefit most from bone conduction implants.

Spontaneous expulsion of an intrabronchial sharp metallic foreign body and migration to the gastrointestinal tract at Muhimbili National Hospital: Case report and literature review

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Early intervention of inhaled foreign bodies should be advocated.

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Spontaneous migration of foreign bodies may be hazardous to both respiratory and digestive tracts.

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Children with a history of sudden onset of difficulty in breathing must be considered to have aspirated foreign body(ies) until proven otherwise.

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Imaging remains to be of paramount importance when investigating children suspected to have inhaled foreign body(ies).

Introduction

Aspirated foreign bodies continue to pose challenges to Otorhinolaryngologists and are potentially life threatening thus an otorhinolaryngological emergency. The main stay of treatment of foreign bodies (FBs) in the tracheobronchial tree remains to be bronchoscopy while bearing in mind earlier and safer removal of such foreign bodies. Spontaneous expulsion of an Intrabronchial foreign body is a rare entity with few cases reported in the available literatures.

Presentation of case

We are reporting a rare case of a 3-year old male child who presented to otorhinolaryngology department with a 2-days history of foreign body inhalation (sharp metallic pin) prior admission which undergone spontaneous migration and went to be excreted in feaces after passing through the gastrointestinal tract.

Discussion

It is unwise, dangerous and inadvisable to wait for spontaneous expulsion in cases of intrabronchial foreign body but while preparing for endoscopy, a constant watch should be kept over the patient and every forceful bout of cough should be looked with suspicion of spontaneous expulsion and a danger of foreign body lodgment into subglottis during such rare but possible occurrence should be kept in mind.

Conclusion

It’s always worth to rule out the possibility of foreign body inhalation in children with sudden onset of difficulty in breathing to avoid diagnostic delays.

Total Transcanal Endoscopic Facial Nerve Decompression for Traumatic Facial Nerve Palsy

A few approaches can be used to decompress traumatic facial nerve paralysis including the middle cranial fossa approach or transmastoid approach depending on the site of injury. In some specific situation of treating traumatic facial nerve palsy whose injured site was confined from the geniculate ganglion to the second genu, transcanal endoscopic approach for facial nerve decompression can be used. We performed two cases of total endoscopic transcanal facial nerve decompression in patients with traumatic facial nerve palsy. After a six month follow-up, both patients showed improvement in facial function by 2 grades according to House-Brackmann grade system. In terms of treatment outcomes, total transcanal endoscopic facial nerve decompression for traumatic facial nerve palsy is an alternative for lesions limited to the tympanic segment I, and has an advantages of being minimally invasive and is cosmetically acceptable without an external scar or bony depression due to drilling.