Multiple Sclerosis Masquerading as Post Septorhinoplasty Complication: A Case Report

This is a case report of a young woman, who after a successful septorhinoplasty procedure, sustained repeated nasal trauma with a subsequent diagnosis of multiple sclerosis (MS) at a large tertiary hospital in Riyadh, Saudi Arabia. A 24-year-old woman with a history of childhood trauma presented with difficulty in breathing and dissatisfaction with her nasal appearance. After a successful and uneventful septorhinoplasty, she required numerous hospital admissions due to multiple episodes of blunt nasal trauma, culminating in clear nasal discharge and neurological symptoms, including dizziness, right-sided paresthesia and difficulty walking. Cerebrospinal fluid (CSF) leak was ruled out by CT brain; however, magnetic resonance imaging (MRI) of the brain and spinal cord showed demyelinating areas in the brain and cervical region of the spinal cord. CSF examination revealed the presence of oligoclonal bands. A neurologist confirmed the diagnosis of MS and initiated treatment, which was well tolerated. The patient is in remission with mild paresthesia in the right hand. Despite the repeated nasal trauma, the septorhinoplasty procedure had an excellent outcome. In conclusion, repeated nasal trauma, especially in the early postoperative period, in addition to procedure failure, may also point to the presence of an uncommon underlying neurological disorder, hitherto undiagnosed. It is therefore important to have an open mind when it comes to the differential diagnosis in such unusual scenarios. In addition, while investigating recurrent nasal trauma, it is extremely important to keep in mind rare neurological conditions, especially in younger patients.

Hypopharyngeal Perforation Following Foreign Body Ingestion: A Case Report

Foreign body ingestion is a common complaint frequently seen in otolaryngology. Some sharp foreign bodies may get impacted in the aerodigestive tract causing a perforation. However, hypopharyngeal perforation is a rare injury that needs early recognition due to its significant morbidity. In this case report, we report a case of hypopharyngeal perforation caused by foreign body ingestion in an adult patient. A 60-year-old female presented with a foreign body sensation in the throat, dysphagia, and odynophagia. A neck CT scan showed a foreign body in the hypopharynx with a collection of free air along the posterior pharyngeal wall. She underwent laryngoscopy and esophagoscopy for examination and foreign body removal. Following the procedure, the patient was treated conservatively for a week and then discharged home in a stable condition. Hypopharyngeal perforation following foreign body ingestion is uncommon. A high index of suspicion is required to reach an early diagnosis and treatment.

Effectiveness of Mavrilimumab in Viral Infections Including SARS-CoV-2 Infection - A Brief Review

Hyperinflammation and cytokine storm has been noted as a poor prognostic factor in patients with severe pneumonia related to coronavirus disease 2019 (COVID-19). In COVID-19, pathogenic myeloid cell overactivation is found to be a vital mediator of damage to tissues, hypercoagulability, and the cytokine storm. These cytokines unselectively infiltrate various tissues, such as the lungs and heart, and nervous system. This cytokine storm can hence cause multi-organ dysfunction and life-threatening complications. Mavrilimumab is a monoclonal antibody (mAb) that may be helpful in some cases with COVID-19. During an inflammation, Granulocyte-macrophage colony-stimulating factor (GM-CSF) release is crucial to driving both innate and adaptive immune responses. The GM-CSF immune response is triggered when an antigen attaches to the host cell and induces the signaling pathway. Mavrilimumab antagonizes the action of GM-CSF and decreases the hyperinflammation associated with pneumonia in COVID-19, therefore strengthening the rationale that mavrilimumab when added to the standard protocol of treatment could improve the clinical outcomes in COVID-19 patients, specifically those patients with pneumonia. With this review paper, we aim to demonstrate the inhibitory effect of mavrilimumab on cytokine storms in patients with COVID-19 by reviewing published clinical trials and emphasize the importance of extensive future trials.

Lingual granuloma of pregnancy

Pyogenic granuloma gravidarum is a rare condition. There have been very few reports in the literature of these tumours affecting the tongue. We describe a case of pyogenic granuloma occurring on the tongue of a female who was 32 weeks pregnant. We present the clinical and histopathological features of this rare condition, discuss treatment options and review current literature.

Complete branchial cleft fistula: diagnosis and surgical management

Branchial cleft fistulae are rare congenital abnormalities that arise from the abnormal persistence of branchial apparatus remnants. A complete fistula is a tract that has an internal opening and an external opening. Second branchial cleft fistulae pass deep to second arch structures and over third arch structures, in a direction extending from the anterior border of sternocleidomastoid (SCM) muscle to the upper pole of the ipsilateral tonsil fossa. Because of this anatomical route, these long tubular structures are intimately associated with major neuro-vascular structures in the neck. Fistulae are usually clinically apparent after birth with up to 80% being diagnosed before age 5 years. There may be an obvious opening in the anterior neck between the hyoid bone and suprasternal notch. Recurrent mucoid discharge becoming purulent during acute infection or associated with upper respiratory tract infection is the usual course. Treatment is complete surgical excision of all abnormally placed epithelium, while preserving surrounding neurovascular structures, and using cosmetically acceptable incisions. Complete fistulae in adults are rare and diagnosis can be difficult. We present the clinical presentation and surgical management of a long (14 cm) second branchial cleft fistula, in a 25-year-old female. Preoperative CT and MRI scans of the neck clearly demonstrated the fistula. We recommend a "stepladder" or Mc Fee incision and intra-oral pull-through fistulectomy to allow safe and complete excision.

The usefulness of computed tomography following open reduction and internal fixation of acetabular fractures

PURPOSE

To investigate the role of a supplemental imaging modality in postoperative assessment of acetabular fractures following open reduction and internal fixation.

METHODS

Postoperative axial computed tomographic (CT) scans were compared with plain radiographs of 20 patients with regard to their sensitivity for detecting articular fracture reduction in terms of gap displacement and step deformity or offset. Three observers independently reviewed the plain radiographs and CT scans at 2 separate time points and categorised the outcome as either anatomical or non-anatomical. The inter-observer reliability and intra-observer reproducibility of these measurements was expressed as a kappa statistic. The radiological result was correlated with the clinical outcome measures using the Merle D'Aubigne scale, the Harris Hip Score, and the SF-36 score.

RESULTS

Plain radiography was less effective in the detection of postoperative articular displacement (mean, 75.1% sensitive). The inter-observer and intra-observer agreement between reviewers was good to excellent in detecting reduction quality between the 2 modalities. Patient management was not altered by the findings of the CT scans.

CONCLUSIONS

Although postoperative CT scanning of acetabular fractures in selective cases may be useful, issues such as higher cost, less effective allocation of resources, and excessive radiation doses do not support its routine use.

A retrospective review of stapes surgery following introduction of 'reversal of the steps' technique

A retrospective study of 73 consecutive stapedotomies is reported. The technique of reversal of steps was achieved in 59% of cases. Closure of the air-bone gap to within 10 dB was achieved in 84% of the reversal group, and 81% of the standard technique group, with no statistically significant difference between the two groups.

Wegener's granulomatosis masquerading as unilateral sinusitis

Wegener's Granulomatosis (WG) is a rare, multi-system disease of unknown aetiology. The disease is characterised by necrotizing granulomas and vasculitis of the upper and lower respiratory tracts and kidneys. The sinonasal region may be the first area to manifest this systemic condition. If the disease is diagnosed early and treated appropriately, involvement of the lungs and kidneys may be averted. Left untreated, the disease may prove rapidly fatal. A low threshold of clinical suspicion must be maintained. We report a case, of a middle aged patient who presented with unilateral sinusitis secondary to a large obstructive nasal mass. Anti neutrophil cytoplasmic antibody (ANCA) titres helped confirm the diagnosis of WG. Unilateral sinusitis with a nasal mass, is a very unusual presentation of WG, and emphasises the importance of a low threshold of suspicion for patients presenting with atypical sinonasal symptoms.

Disease laterality, eye dominance, and visual handicap in patients with unilateral full thickness macular holes

AIM

To investigate the association between visual handicap, laterality, and historical eye dominance in patients presenting with unilateral full thickness macular holes (FTMH).

METHODS

Consecutive patients presenting with unilateral FTMH and no other visually significant ocular pathology including abnormalities of binocular vision were included. A questionnaire and case note review were performed to determine the mode of presentation, presence of symptomatic binocular interference, historically dominant eye, and whether they elected to undergo surgery.

RESULTS

44 eyes of 44 patients fulfilled the inclusion criteria. 21 (48%) affected eyes were right sided and 56% of FTMH were in the historically dominant eye. 76% of FTMH in historically dominant eyes presented symptomatically compared to 36% in non-dominant eyes (p= 0.003). 72% of patients with FTMH affecting their historically dominant eye were aware of binocular interference in day to day binocular viewing compared with 21% when the FTMH was in the non-dominant eye (p= 0.001). 23 (52%) patients elected to undergo surgery, of whom 18/23(78%) had FTMH in their historically dominant eye (p= 0.0003).

CONCLUSION

This study suggests that eye dominance may be an important determinant of the visual handicap suffered by patients with unilateral FTMH.

Efficacy of incisional vs punch biopsy in the histological diagnosis of periocular skin tumours

AIMS

The aim of this study was to compare the accuracy of incisional and punch biopsy techniques in obtaining correct histological diagnosis of periorbital eyelid tumours. The technique of punch biopsy is presented and described in detail.

METHODS

A retrospective analysis was made of 20 consecutive incisional biopsies and 20 consecutive punch biopsies. In each case, the histology obtained at biopsy was compared with that identified at the time of tumour excision.

RESULTS

A total of 40 consecutive biopsies on 38 patients were analysed. The first 20 were incisional; the second 20 were punch biopsies. Of the 20 incisional biopsy specimens, 19 were confirmed accurate at the time of excision of the lesion. Of the 20 punch biopsies, 17 were confirmed accurate at the time of excision. These correspond to accuracy rates of 95 and 85%, respectively.

CONCLUSIONS

Both incisional and punch biopsy techniques have relatively high accuracy rates and there is a high concordance between tissue diagnoses made by each of these techniques. Incisional techniques should preferably be performed on any atypical lesion. Punch biopsy is a quick and simple procedure. It is easy to perform in an outpatient environment and requires a minimum of surgical equipment and no specific surgical skills. If the site of biopsy is carefully chosen, this simple technique provides tissue specimens of adequate size and quality for accurate histology and is a most useful adjunct in the management of periocular tumours.

Anterior capsular phimosis in eyes with a capsular tension ring

A 64-year-old woman with zonular weakness in the left eye and a 79-year-old man with bilateral pseudoexfoliation and intraoperative zonular dehiscence had phacoemulsification with in-the-bag implantation of a single-piece poly(methyl methacrylate) intraocular lens (IOL) and a capsular tension ring. Ten to 12 weeks postoperatively, all 3 eyes developed significant visual loss secondary to capsule shrinkage and occlusion of the capsulorhexis opening. All eyes had a neodymium:YAG laser radial anterior capsulotomy, anterior capsulectomy, or both. Visual acuity was restored in all eyes despite slight IOL decentration.