Thyroid function status evaluation in patient post-radiotherapy for nasopharyngeal carcinoma: A retrospective study

INTRODUCTION

Nasopharyngeal carcinoma (NPC) is among the most common malignancy in Malaysia. Radiationinduced hypothyroidism has been reported in other countries. However, in Malaysia, no studies were ever done to determine the effect of radiation on hypothyroidism. The objective of this study is to evaluate the practice of taking thyroid function test (TFT) and determine hypothyroidism post-radiation in patients with NPC.

MATERIALS AND METHODS

A retrospective study on the symptoms and results of TFT according to the dosage of intensity-modulated radiotherapy (IMRT) given to patients with NPC. Data were traced and analysed.

RESULTS

A total of 78 patients were identified. All patients received IMRT with 33-35 fractions of radiotherapy (RT) with total dosage of 66-70 Gray given. Not all patients had their thyroid function status measured routinely. Twelve patients did have symptoms of hypothyroidism. TFT were obtained in this group but the results were normal. No correlation was found between RT and hypothyroidism.

CONCLUSION

There was no correlation between IMRT and the development of hypothyroidism. A prospective study with better control of inclusion and exclusion criteria, and longer follow-up period with TFT, is needed to demonstrate the consistency of these findings.

Propolis mouthwash for preventing radiotherapy-induced mucositis in patients with nasopharyngeal carcinoma

BACKGROUND

Nasopharyngeal carcinoma (NPC) is the most common head and neck cancer in Malaysia. The gold standard treatment of NPC is radiotherapy (RT), as NPC is a radiosensitive tumour. Although RT is successful in treating NPC, patients cannot avoid the resulting RT complications. Oral mucositis is the most frequently encountered debilitating complication of RT and has no specific preventive treatment. The aim of this study was to evaluate the efficacy and safety of a 2.5% propolis mouthwash for preventing RT-induced mucositis in patients with NPC.

MATERIALS AND METHODS

The study was a prospective, double-arm, randomised control trial with intervention. The patients were randomly divided into an experimental group receiving propolis mouthwash and a placebo group receiving normal saline mouthwash. All patients were instructed to rinse their mouths with 7mL mouthwash three times daily for six weeks. The severity of oral mucositis was then evaluated by the World Health Organization Oral Toxicity Scale at the second, fourth, and sixth weeks of the study.

RESULTS

In total, 17 patients completed the study: 10 patients used the propolis mouthwash and seven used the placebo mouthwash. The mean mucositis scores for the propolis mouthwash compared to the placebo at the second, fourth, and sixth weeks were 0.10 vs. 1.14, 0.50 vs. 2.00, and 1.20 vs. 2.86, respectively, and the differences between the two groups were statistically significant (p<0.001).

CONCLUSION

A 2.5% propolis mouthwash was both safe and effective for reducing the severity of oral mucositis following RT for NPC.

Lichenoid uvula mass as a rare cause of hot potato voice and progressive dysphagia

Lichenoid uvula mass is an unusual entity and the clinicopathologic entities are important for the diagnosis. In this case report, we report an elderly lady presented with dysphagia and "hot potato voice" due to a lichenoid uvula mass. Apart from muffled voice, the other associated symptoms are dysphagia, sore throat, globus pharyngeus and snoring. She was a non-smoker, and not on any medications except for hypertension and dyslipidaemia. Apart from the enlarged uvula, other parts of the oral cavity, oropharynx and larynx were normal. She has no other signs such as cutaneous lesions. The mass was excised under general anaesthesia followed by resolution of symptoms. Awareness of this entity, the clinical and histopathological features should be highlighted to differentiate it from other diagnosis.

The louder the bigger: A case of jugular phlebectasia in a child

Jugular phlebectasia has been increasingly recognised with the advent of non-invasive diagnostic methods. Phlebectasia differs from varix, as it is an abnormal outward dilatation of a vein without tortuosity. It presents as a soft, compressible mass, apparent upon straining or execution of the Valsalva maneuver. The differentials for neck masses are broad, but if the swelling appears on the Valsalva maneuver, the type of mass narrows down to a laryngocele, superior mediastinal mass or phlebectasia. A simple non-invasive investigation, such as ultrasonography, is used as a diagnostic tool. We report a case of jugular phlebectasia that was suspected clinically and confirmed via ultrasound to be a vascular lesion which changed its size upon straining.

Paediatric burkitt lymphoma presenting as a mandible swelling and intussusception

Burkitt lymphoma is a rare entity especially in this part of the world. We had an 11-year-old patient presented with swelling of the mandible for a short one-month duration. He was planned for excision biopsy. However developed severe abdominal pain while in the hospital and was diagnosed as intussusception after ultrasound was done. We proceeded with right hemicolectomy and excision of buccal mass. Early recognition and close monitoring of insidious jaw lesions is recommended even in young adults not within the modal age category of endemic Burkitt.

Coughing on palpation: A rare complication of vagal schwannoma

Cervical vagal schwannoma is an uncommon, benign neoplasm. It is usually asymptomatic and presents as a painless, palpable mass in the neck. However, large schwannomas can cause dysphagia, dysphonia or dyspnea as a result of compression. We report a case of an extremely rare complication of vagal schwannoma in which neck palpation induced the patient to cough. As the patient refused any surgical intervention, conservative management was used.

Metallic hair pin aspiration into the left tertiary bronchus

Foreign body aspiration is commonly described in infants and children. However, recently, a new high-risk group was identified among young women, especially those from the Muslim population who wear the traditional hair scarf. This is due to the habit of holding the scarf pin in between the lips to free hands to adjust the scarf more easily. Talking, laughing, or coughing while fixing the scarf may result in inadvertent inhalation of the pin into the tracheobronchial tree. We present a case of scarf pin inhalation and the challenges encountered in managing this patient during the successful removal of the pin via flexible bronchoscopy under fluoroscopy guidance. This particular case was technically challenging for us as the sharp tip of the needle was pointing upward and piercing the bronchial mucosa.

Kimura Disease: A differential diagnosis in a nephrotic child

Kimura disease presents as benign lesion and is commonly present among the Asian population. It is a disease with a favourable prognosis and a peak age of onset in the third decade. It is a chronic inflammatory disorder of unknown etiology that involves the lymph nodes and subcutaneous tissues of the head and neck region. We report a case of a 15-year-old boy with multiple Kimura lymphadenopathies involving the left posterior auricular region as well as the anterior and posterior triangles of the neck.

Bilateral peritonsillar abscess: A rare emergency

Peritonsillar abscess, or quinsy, is a rare complication of acute tonsillitis. It usually presents with odynophagia, trismus, and muffled voice, reflecting the space-occupying lesion in the oral cavity. Examination reveals a unilateral swelling on either side of the soft palate, which drains thick pus after an incision is made. It is regarded as an emergency as an upper airway obstruction can develop. Bilateral peritonsillar abscess is a rare presentation and results in catastrophic sequelae. We present a case of bilateral peritonsillar abscess that was initially referred by a primary care centre facing a dilemma in diagnosis. Prompt diagnosis and fast drainage are warranted to avoid unwanted morbidity, and, also, mortality.

A food bolus obstructing the oesophagus in a patient with infantile cerebral palsy

INTRODUCTION

A foreign body (FB) in the upper aerodigestive tract is a fairly common encounter. Fish bones are the commonest FB seen in adults. The commonest presentation is odynophagia. Usually, the patient will point at the level of FB on the neck to indicate the location.

METHODS

Clinical report.

RESULTS

This case report describes a large FB in an adult with underlying infantile cerebral palsy. Besides dysphagia, it was associated with drooling of saliva and pain in the throat region.

CONCLUSION

FB ingestion with complete obstruction of the oesophagus is an emergency. It may cause total dysphagia as the passage of food is completely blocked.

A rare case of a sharp foreign body on the vocal cord

A foreign body (FB) in the upper aerodigestive tract is a common clinical problem that presents as as acute emergency. Sharp FB, such as fish bone or chicken bone, commonly lodges in the tonsil, base of tongue, vallecula or pyriform fossa. Dislodgement of a FB into the laryngopharynx is very rare and specifically onto the vocal cord is extremely uncommon. This case report illustrates a rare case of a sharp FB that was dislodged into the airway and stuck on to the right vocal cord, which was removed under local anaesthesia.

An elderly man with an air-fluid level in the middle ear

A 68-year-old Malay man who is a rubber tapper, presented with a large painful right-sided neck swelling for 6 months, which was gradually increasing in size and associated with odynophagia, dysphagia, hoarseness and significant weight loss. He did not complain of any ear symptoms, but on further questioning, he admitted having a 3-week history of occasional tinnitus and reduced hearing on the right ear. Other ear symptoms were negative.

The effect of antenatal lifestyle advice for women who are overweight or obese on secondary measures of neonatal body composition: the LIMIT randomised trial

OBJECTIVE

To evaluate the effect of providing antenatal dietary and lifestyle advice on neonatal anthropometry, and to determine the inter-observer variability in obtaining anthropometric measurements.

DESIGN

Randomised controlled trial.

SETTING

Public maternity hospitals across metropolitan Adelaide, South Australia.

POPULATION

Pregnant women with a singleton gestation between 10(+0) and 20(+0) weeks, and body mass index (BMI) ≥25 kg/m(2).

METHODS

Women were randomised to either Lifestyle Advice (comprehensive dietary and lifestyle intervention over the course of pregnancy including dietary, exercise and behavioural strategies, delivered by a research dietician and research assistants) or continued Standard Care. Analyses were conducted using intention-to-treat principles.

MAIN OUTCOME MEASURES

Secondary outcome measures for the trial included assessment of infant body composition using body circumference and skinfold thickness measurements (SFTM), percentage body fat, and bio-impedance analysis of fat-free mass.

RESULTS

Anthropometric measurements were obtained from 970 neonates (488 Lifestyle Advice Group, and 482 Standard Care Group). In 394 of these neonates (215 Lifestyle Advice Group, and 179 Standard Care Group) bio-impedance analysis was also obtained. There were no statistically significant differences identified between those neonates born to women receiving Lifestyle Advice and those receiving Standard Care, in terms of body circumference measures, SFTM, percentage body fat, fat mass, or fat-free mass. The intra-class correlation coefficient for SFTM was moderate to excellent (0.55-0.88).

CONCLUSIONS

Among neonates born to women who are overweight or obese, anthropometric measures of body composition were not modified by an antenatal dietary and lifestyle intervention.

A thyroid mass that moves with tongue protrusion: An ectopic thyroid gland

Thyroglossal duct cyst (TDC) is a developmental anomaly that usually appears in early childhood. The common presentation is midline swelling of the neck, which moves with both tongue protrusion and deglutition. Diagnosis is usually clinical and radiological. Fine needle aspiration cytology (FNAC) can be used as a tool for the exclusion of malignancy in adult patients. In some cases thyroid scan is done to rule out the presence or absence of the normal thyroid gland. A complete work-up is mandatory before cyst removal given that it contains only thyroid tissue. We report the case of a 32-year-old woman with only thyroid tissue in thyroglossal duct cyst.

Hoarseness as the sole symptom of an impending thoracic aneurysm rupture?

Unilateral vocal cord palsy secondary to thoracic aortic aneurysm is a rare occurrence. Direct compression of the enlarging thoracic aneurysm on the left recurrent laryngeal nerve causes neuronal injury of the nerve, which is manifested as hoarseness. We present a rare case of unilateral vocal cord palsy in a 60-year-old healthy gentleman caused by a large thoracic aortic aneurysm. This rare presentation, with a serious underlying pathology might be misdiagnosed or delayed. Therefore, it is important for us to have high index of suspicion in cases with a rare presentation such as this.

Otitis externa complicated with chloramphenicol ear drops-induced perichondritis

Otitis externa is a common condition of the ear. It is manifested as narrowing of the lumen owing to the edematous swelling of the ear canal lining. Perichondritis may occur independently or as a complication of the otitis externa. We report a case of perichondritis after using a topical ear drop. Changing the medication provides immediate resolution of the condition.

Rhinolith: An important cause of foul-smelling nasal discharge

Rhinoliths result from neglected nasal foreign bodies that gradually increase in size. They are usually discovered incidentally during routine ENT examination or due to the associated symptoms such as nasal obstruction or persistent foul-smelling unilateral nasal discharge. A case of a 14-year-old girl was reported with a year history of the symptom. The foul-smelling nasal discharge noted by her mother was not the main concern to them. She was referred by her primary care physician as she complained of impacted ear wax. However, rhinolith was incidentally found upon routine clinical examination in the ENT clinic and was removed uneventfully.

An elderly man with acute anterior neck pain and odynophagia after a meal

The upper aerodigestive tract, specifically the cricopharyngeal area, is the most common site of foreign body impaction. Anatomically, this area is the first constriction of the oesophagus. Fish bones, one of the most common foreign bodies encountered in the throat, tend to get stuck in this area. The movement of this sharp-edged foreign body upon swallowing will induce odynophagia and an acute onset of neck pain. We report a case of a healthy elderly man who complained of sudden anterior neck pain and odynophagia after eating yellowtail scad fish.

Submandibular mass as a rare presentation of advanced nasopharyngeal carcinoma

Cervical lymphadenopathy is a common presentation of nasopharyngeal carcinoma (NPC). It can be present in the classical location of the level II or VI lymph nodes or at any other levels of the lymph nodes in the neck. NPC should be suspected when a patient presents with cervical lymphadenopathy and conductive hearing loss. A thorough endoscopic assessment of the nasopharynx should be performed to rule out this radiotherapy-curable disease at its early stage.

Antrochoanal polyp mimicking juvenile nasoangiofibroma

Antrochoanal polyp is a benign lesion, usually arising from the maxillary sinus extending posteriorly into the nasopharynx. Typically it presents as a unilateral nasal obstruction with mucopus rhinorrhea, sleep disturbance, postnasal drip, and mouth breathers. Epistaxis is an extremely rare complaint. Unilateral nasal mass presenting in a teenage boy will increase the suspicion of juvenile nasoangiofibroma. We report a teenage with extensive unilateral nasal mass with such presentation, which later turned out to be antrochoanal polyp. DOI: http://dx.doi.org/10.3329/bjms.v12i4.16664 Bangladesh Journal of Medical Science Vol. 12 No. 04 October ’13 Page 432-434

Peritonsillar swelling is not always quinsy

Quinsy is a common encounter in family physician practice. It is defined as a collection of purulent material in the peritonsillar space, giving appearance of unilateral palatal bulge. Presenting symptoms include trismus, muffled voice, odynophagia, and ipsilateral otalgia. When the diagnostic needle aspiration reveals no pus, the diagnosis is changed into peritonsillar cellulitis or also known as perintonsillitis. Peritonsillitis is sufficiently treated with antibiotics unlike a quinsy which warrants surgical incision and drainage.

Masked rhinolith: The significance of unilateral symptom

This is a case report of an 11-year old child who was suffering from rhinorrhoea for five years. As there was no history of foreign body insertion into the nose, the diagnosis of a nasal problem was not suspected. Furthermore, the initial presentation of unilateral rhinorrhoea (nasal discharge) masked the suspicion of other pathologies. The child was treated for allergic rhinitis until she presented herself to our attention whereby a rhinoscopy was performed, showing a rhinolith.

Base of tongue as an unusual site for Non Hodgkin Lymphoma

Background: Non Hodgkin Lymphoma (NHL) has about 3-7% of oral manifestation. Most of the lesions are from the palate, gingival, tongue, buccal mucosa, floor of the mouth and lips. These site consist approximately 2% of all extra nodal lymphomas as primary origin. The prognosis of NHL depends to the tumour stage, tumour aggressiveness and their response to treatment. The oral lesions appear to respond quite well to irradiation or chemo radiation.Methods: We present a case of a 68 year-old Malay male presented with symptoms of voice change, poor oral intake and bleeding from oral cavity, which turns out to be NHL of the base of tongue without visceral involvement. DOI: http://dx.doi.org/10.3329/bjms.v11i3.11740 Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12

Brain Abscess Mimicking Intracranial Extension Of Nasopharyngeal Carcinoma

With the advent of more effective but aggressive cancer treatment regimens, survival in many types of cancer has improved including nasopharyngeal carcinoma (NPC). Radiotherapy (RT) is still the mainstay of treatment for patients with NPC. Unfortunately, it has led to several new complications of cancer and its therapy. One of the most important complications is central nervous system (CNS) infections. We report a case of NPC presented with signs of increased intracranial pressure making the diagnosis of intracranial extension of NPC. Imaging studies later on proved that it was an abscess which responded well with conservative medical treatment. DOI: http://dx.doi.org/10.3329/bjms.v11i3.11741 Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12  

Huge hard palate and nasal septum perforation as a presentation of syphilis: A case report

A patient presented with septal and palatal perforations imposes a diagnostic challenge because various potential causes need to be established. Therefore, elucidating the cause of the septal perforation requires obtaining a thorough history. In addition, it is very important to perform necessary investigations for the patients to determine and fix the underlying disease which cause these complaints. We report a case of patient presented with palatal and septal perforations which later was confirmed to have syphilis. DOI: http://dx.doi.org/10.3329/bjms.v11i3.11737 Bangladesh Journal of Medical Science Vol. 11 No. 03 July’12

Ludwig's Angina: The Importance of Oral Cavity Examination in Patients with a Neck Mass

Neck mass is a common condition in primary care. The most common affected area is the cervical lymph node. The neck region is also prone infection as structurally the nodes and spaces are in close contact with the upper respiratory tract and the alimentary tract. Oral cavity is one of the most common route for harbouring infection. Poor oral hygeine and periapical dental problems are the main causes. Thus, it is important to perform a complete oral cavity examination even when trismus is present. Besides dental caries, floor of the mouth should be inspected for oedema that may impose threat to the upper airway. We report a case of Ludwig's angina originating from a periapical lesion of the lower molar stressing the importance of oral examination in patient with neck mass.