A case report: Giant cystic parathyroid adenoma presenting with parathyroid crisis after Vitamin D replacement

Background: Parathyroid adenoma with cystic degeneration is a rare cause of primary hyperparathyroidism. The clinical and biochemical presentation may mimic parathyroid carcinoma. Case presentation: We report the case of a 55 year old lady, who had longstanding history of depression and acid peptic disease. Serum calcium eight months prior to presentation was slightly high, but she was never worked up. She was found to be Vitamin D deficient while being investigated for generalized body aches. A month after she was replaced with Vitamin D, she presented to us with parathyroid crisis. Her corrected serum calcium was 23.0 mg/dL. She had severe gastrointestinal symptoms and acute kidney injury. She had unexplained consistent hypokalemia until surgery. Neck ultrasound and CT scan revealed giant parathyroid cyst extending into the mediastinum. After initial medical management for parathyroid crisis, parathyroid cystic adenoma was surgically excised. Her serum calcium, intact parathyroid hormone, creatinine and potassium levels normalized after surgery. Conclusion: This case of parathyroid crisis, with very high serum calcium and parathyroid hormone levels, is a rare presentation of parathyroid adenoma with cystic degeneration. This case also highlights that Vitamin D replacement may unmask subclinical hyperparathyroidism. Consistent hypokalemia until surgery merits research into its association with hypercalcemia

Aspergillosis of the Sphenoid Sinus with the Involvement of the Clivus

Introduction: Fungal infections of the nose and paranasal sinuses are frequent in this part of the world. One aspect of the increased frequency is the improved clinical, radiological and pathological diagnostic methods that are now available. Aspergillus is the commonest infecting fungus of the nose and the paranasal sinus1 . It is mainly a saprophytic spore producing fungus and can cause invasive and non-invasive infections. The initial report of fungal paranasal infection largely dealt with immunocompromised individuals as distinct from the allergic fungal infection. Aspergillosis confined to the sphenoid sinus is uncommon with only 34 cases having been reported in the literature2,3. These were mostly seen in immunosuppressed patients. Isolated sphenoid sinusitis is uncommon and that due to fungal infection is rare4 . We report the case of aspergillosis of the sphenoid siiius where disease had extended into the upper part of the clivus bone

Factors associated with recurrent nasal polyps: a tertiary care experience

OBJECTIVE: To assess the factors associated with recurrence of nasal polyps in operated patients by endoscopic surgery. METHODS: A retrospective study was conducted on 192 patients operated for nasal polyps in a hospital set-up between 2001 and 2007. The median follow-up period was 24 months (range 12 months to 60 months). Ten variables were analyzed to study their association with polyp recurrence namely; age, gender, history of purulent nasal discharge, facial pain, anosmia, post nasal dripping (PND), headache, nasal allergy, asthma and computed tomography (C.T) staging. Analysis of recurrences was accomplished using independent sample t-test, chi-square and Fishers exact test. A probability value of p \u3c 0.05 was selected as the level of significance. RESULTS: During the study period, recurrences developed in 36 patients, with a rate of 19%. No association of recurrence with age, gender, purulent nasal discharge, facial pain, anosmia, post nasal dripping, headache, nasal allergy, and asthma were observed. The C.T staging was significantly higher among the group with recurrence as compared to the group without recurrence (p \u3c 0.001). CONCLUSION: Patients presenting with extensive disease suggested by C.T scan staging are at higher risk for the development of recurrences after endonasal surgery for nasal polyps

Neck Recurrence in Early Carcinoma Tongue

Objective: To study the efficacy of different locoregional treatment options for tongue cancer in determining the prognosis, with reference to recurrence of disease in neck. Methods: This is a retrospective analysis of 80 patients with early (T1/T2) carcinoma tongue who had hemiglossectomy with or without neck surgery and radiotherapy for 14 years. Results: Eighty patients were included in this study, 49 (61.3%) men and 31 (38.8%) women; 36 (45%) patients with T1 lesion and 44 (55%) with T2 lesion. Sixty two patients (77.5%) were staged cN0 and 18 patients had a clinically palpable neck nodes (cN+). Thirty seven patients were pathologically negative (pN0), whereas 22 were pathologically positive (pN+) and 21 were not operated so they were staged pathologically (pNx) (undissected necks). Thirty patients received postoperative adjuvant radiotherapy. The median follow-up was 16.5 months with a range of 10-120 months. The over-all rate of recurrence in neck was 32.5% (27 patients). The rate of recurrence was 23% in T1 and 45.8% in T2 lesion (P-value 0.09) without radiotherapy. The recurrence rates with T1 lesion patients who were given adjuvant radiotherapy did not change significantly whereas with T2 lesions the recurrence rate decreased from 45% to 25% in the group without radiotherapy. Recurrence rate was higher in undissected neck as compared to patients who underwent elective neck dissection having radiotherapy and staged pN0 (P-value 0.009) or pN+ (P-value 0.005). Patients having therapeutic neck dissection, on comparison of final pathological node staging (i.e. pN0 or pN+) the rate of recurrence in patients pN+ was 56% and in group with pN0 it was 11%, with (P-value 0.046). Conclusion: We did not find any effect of age, gender and surgically resected margins of primary early tongue tumor on recurrence of disease in neck. There was no significant difference between primary tumor stage T1 and T2 lesions on neck recurrence when treated with surgery alone, but adjuvant radiotherapy further reduced the neck recurrence in T2 groups. Adjuvant radiotherapy also showed a significant reduction in recurrence rates in both pN0 and pN+. Undissected necks have higher incidence of neck recurrence than dissected neck irrespective of pathological status of neck metastasi

Facial Nerve Palsy Unusual Complication of Percutaneous Angiography and Emoblization for Juvenile Angiofibroma

Juvenile angiofibrorna is a locally invasive, vascular and non-encapsulated neoplasm occurring almost exclusively in adolescent males. Although histologically benign, these tumors are highly aggressive and are associated with significant morbidity and occasional mortality. It has marked tendency to recur if not completely removed1 . As the tumor is highly vascular, surgely is frequently accompanied by significant intraoperative hemorrhage, which may contribute to incomplete removal and additional morbidity and mortality2 . Roberson (1972) was first to advocate pre-operative angiography and embolization of major feeding vessels as an adjunct therapeutic method in addition to surgery, to facilitate complete excision of the tumOr and to minimize the risk of complications due to profuse haemorrhage during surgery. Since then embolization has been recommended by a number of authors3,4 . Complications of angiography and embolization, such as accidental embolization of the brain and ophthalmic artery, facial nerve palsy and necrosis of the skin and soft tissue may occur3 . We present our experience, of a patient with Juvenile angiofibroma, who had pre-operatively percutaneous angiography and embolization of internal maxillary artery followed by facial nerve palsy of the same side

Congenital bilateral choanal atresi

Congenital choanal atresia (CCA) is the developmental failure of the nasal cavity to communicate with nasopharynx. Surgical repair is recommended in the first weeks of life in bilateral cases because this is a life-threatening situation in newborns. This is a case report of a full-term, healthy newborn baby presenting with intermittent attacks of cyanosis and respiratory distress soon after birth. On examination, alternating cyanosis and normal colour was observed in the infant. The insertion of nasal catheters in both the nares revealed the diagnosis of bilateral CCA. For this rare condition, conservative management was followed with elective transnasal endoscopic repair to relieve the life threatening nasal obstruction at the tenth day of life

Fine Needle Aspiration Cytology (FNAC) in the Management of Thyroid Pathology - The Aga Khan University Hospital Experience

Objective: To report the efficacy of FNAC in patients with thyroid disease.Methods: Between January 1990 and December 1994 the records of all patients treated surgically for thyroid disease at ENT Head and Neck Surgery of Aga Khan University were reviewed. All the patients had pre­operative FNAC as the first line of evaluation and the histopathologist examined post-operative thyroid specimen.Results: Forty-five patients (36 female and 9 male) had thyroid surgery. In 26 patients out of 45, FNAC was conclusive in diagnosing the nature of disease, while in 19 patients the FNAC was inconclusive because of the presence of follicular cell neoplasia.Conclusion: Our results indicate that the FNAC is very accurate and a reliable test in the diagnosis of thyroid pathology, however, to distinguish follicular adenoma from follicular carcinoma final histology is required. FNAC is cost effective method of evaluating thyroid pathology pre-operatively and plays a vital role in planning the surgical management of thyroid nodule OPMA 49:133, 1999)

Development of skin hypopigmentation in a patient with metastatic papillary carcinoma thyroid treated with Sorafenib.

Background: Sorafenib can be considered as the effective option of treatment in patients with metastatic radioiodine refractory differentiated thyroid cancers. The cutaneous manifestations of Sorafenib include rash, desquamation, hand foot skin reactions, pruritus, alopecia and erythema. We report the first case of hypopigmentation related to sorafenib therapy. Case presentation: We report the case of a middle aged gentleman with metastatic papillary carcinoma of thyroid diagnosed in 2005. He was managed with total thyroidectomy, radioactive iodine and TSH suppressive therapy. Despite receiving radioactive iodine 530 mci cumulative dose, patient had persistant disease with lung metastasis. Therefore a TKI, sorafenib, was started. He developed hypopigmentation of the skin more prominent on face six weeks after starting sorafenib treatment.He also developed diarrhea, desquamation of hands and feet, hair loss over scalp, eye brows and moustache. Sorafenib treatment was discontinued. His diarrhea stopped in one week and after four weeks his skin became normalized whereas he regained his hairs in six weeks. Conclusion: To our knowledge, hypopigmentation in our patient appears to be the first reported of its kind in the literature to date. Sorafenib is used in Renal cell carcinoma, Hepatcellular carcinoma and radioactive iodine refractory thyroid carcinoma therefore it is very important to be aware of hypopigmentation as a potential side effect for both physicians and patients

Daycare adeno-tonsillectomy: is it safe in developing countries

OBJECTIVE: To determine the safety of daycare adeno-tonsillectomy in a tertiary care centre. METHOD: A retrospective chart review of 207 patients who had undergone tonsillectomy and/or adenoidectomy as daycare procedure in Aga Khan University Hospital, Karachi, between January 2008 to March 2009 was done. Demographic data as well as complications requiring unplanned admissions were recorded. Any emergency room visit in the first 24 hours was also noted. Telephonic calls were then made to collect the first 24-hour, postoperative data in order to know if there were any complications requiring visit to some nearby health facility. All data was analysed using SPS version 19, while Fisher\u27s exact test was used to compare complications with respect to age groups. RESULTS: Of the total, 132 were males and 75 females. Only one (0.48%) patient developed bleeding soon after surgery which required a revisit to the operating room. Another 13 (6.2%) patients were admitted for reasons like post-operative vomiting, desaturation and raised blood pressure. There were no hospital visits within the first 24 hours after the patient was discharged. Besides, 172 (83%) patients preferred daycare surgical procedures if given an option again. CONCLUSION: Daycare adeno-tonsillectomy is a safe practice which can help to save resources in developing countries

The rationality of prescribing antibiotics after tonsillectomy

Objective: To compare the antibiotic therapy with the absence of antibiotic therapy in reducing post-tonsillectomy morbiditiesMethods: The quasi-experimental study was conducted at the Aga Khan University Hospital, Karachi, from November 2006 to September 2007. It involved 60 patients fulfilling the criteria for recurrent tonsillitis who were divided in two groups based on the different practice of two sets of surgeons. In one group antibiotics were used, while in the other group, no antibiotic was given. Patients filled a questionnaire about pain, post-operative bleeding, day of normal diet intake, day of normal activity and any consultation received during the first post-operative week. The data collected was analyzed using SPSS version 16.Results: There were 60 patients who were divided in two groups of 30 each on the basis of purposive sampling technique. Mean age was 21.43 ± 8.3 years. Of the total, 55% were male and 45% were female. Post-operative pain was comparable between the two groups. Four patients had secondary haemorrhage - three in the antibiotic group, and one in the non-antibiotic group. Mean day of normal activities and normal diet intake was almost the same in both groups. Unscheduled hospital visits were 6.9% in the antibiotic group, and 3.3% in the non-antibiotic group.Conclusion: The study showed that antibiotics did not have any significant impact in reducing the post-tonsillectomy morbidities