A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

JUVENILE NASOPHARYNGEALANGIOFIBROMA: OUR EXPERIENCE AND LITERATURE REVIEW

ABSTRACT Introduction: Juvenile nasopharyngeal angiofibroma is a benign vasculartumor.It is commonly found in teen age males. Its site of origin is sphenopalatine foramen. Exact pathogenesis of angiofibroma is not known. It has predictable natural history and growth pattern. This tumor most often involves nasopharynx, nasal cavity, paranasal sinuses, pterygopalatine fossa and infratemporal fossa. It can also involve orbit and can spread intracranially. Its very important to diagnose this tumor very early on the basis of clinical examination and imaging. As early tumor confined to nose and sinuses can be removed exclusively with endoscope. It is very helpful to do angiography before surgery to ascertain itsblood supply and then embolization can be done to reduce intraoperative bleeding. Objective: To describe our experience of Juvenile Nasopharyngeal Angiofibroma cases in ENT Unit-I of Lahore General Hospital. Study Design: Descriptive Study with retrospective analysis after approval from Institutional Review Board (IRB) of LGH/PGMI/AMC Lahore. Methods: We studied 20 patients who underwent surgery in our department from October 2019 to October 2020. We analyzed following factors: age, gender, symptoms, staging, mode of surgery and need for intraoperative blood transfusion, hospital stay, complications and recurrences. Results: Range of patient’s age was 12 to 25 years. Eight patients underwent surgery with endoscope. Mean blood loss was about 400 ml and mean operating time was 140 minutes. All the cases were embolized preoperatively. Conclusion: Endoscopic surgery is a safe and effective method in early stage JNA patients. While patients with advance stage tumors should be managed with combined endoscopic and conventional open approaches. KEYWORDS: juvenile nasopharyngeal angiofibroma, JNA, endoscopic surgery

326. Radiologic Findings of COVID-19 Associated Mucormycosis (CAM) from India

Background The unique feature of the second wave of the COVID -19 pandemic in India has been the alarming surge of acute invasive fungal infection among COVID -19 patients. The increased incidence of rhino-orbito-cerebral mucormycosis is a matter of concern, as this fulminant infection has high morbidity and mortality. Hence, it is imperative to understand it’s imaging features, for early diagnosis, staging and treatment. Methods We systematically reviewed 32 COVID-19 cases with imaging diagnosis of acute invasive fungal rhino-sinusitis or rhino-orbital-cerebral disease between March to May 2021. These patients underwent contrast MRI of the paranasal sinus, orbit and brain. Contrast enhanced CT chest and paranasal sinuses were done as needed. Results The age group ranged between 30 to 71 yrs with male preponderance. The most common predisposing factors were intravenous steroid therapy and supplemental oxygen. All cases were confirmed by fungal culture and most common was Mucor. The rhino-orbito-cerebral mucormycosis was staged as below In our study we found that the most common site in the nasal cavity was the middle turbinate /meatus and the earliest sign was non-enhancing / “black” turbinate. Premaxillary and retroantral fat necrosis was the earliest sign of soft tissue invasion. Spread via the sphenopalatine foramen and pterygopalatine fossa was more common than bony erosions. Orbital cellulitis and optic neuritis were the most common among stage 3 cases. Of patients with CNS involvement, the most common were cavernous sinus thrombosis and trigeminal neuritis. Two patients with pulmonary mucormycosis showed large necrotic cavitary lesions, giving the characteristic “bird’s nest” appearance. Figure 1. Black turbinate Contrast enhanced coronal T1 FS images of paranasal sinuses shows necrotic non-enhancing right superior and middle turbinates (*) Figure 2: Axial contrast enhanced T1 FS image showing necrotic non enhancing premaxillary (arrowhead) and retroantral fat (straight arrow) walled off by thin enhancing rim. Figure 3: Contrast enhanced axial T1 FS images of paranasal sinuses shows necrotic non-enhancing left middle meatus spreading along sphenopalatine foramen in to pterygopalatine fossa (arrow head) Conclusion The mortality rate was 20% in our study. In our short term follow up, 30 % of recovered patients had relapse on imaging due to incomplete clearance and partial antifungal treatment. High clinical suspicion and low imaging threshold are vital for early Mucormycosis detection in COVID-19 patients. Familiarity with early imaging signs is critical to prevent associated morbidity /mortality. Figure 4: Contrast enhanced coronal T1 FS and diffusion weighted images shows necrotic non-enhancing left middle meatus with left orbital cellulitis (*) and optic neuritis (white arrow) Figure 5. Bird’s nest Axial CT chest image in lung window shows necrotic right upper lobe cavity with internal septations and debris on a background of surrounding COVID-19 changes. Disclosures All Authors: No reported disclosures

An Extranasopharyngeal Angiofibroma of Mandibular Ramus in a Preschool Child - An Extremely Rare Case Report

Angiofibroma or juvenile nasopharyngeal angiofibroma (JNF) is a rare vascular benign tumour predominant in male adolescents and pre-adolescents. In spite of several origin sites reported, nasopharynx in the region of the sphenopalatine foramen and pterygopalatine fossa remains most common.1 Nevertheless, sporadic description of extra nasopharyngeal angiofibromas (ENAF) are also rarely evident.2 Literature documents maxillary sinus as the most favourable site for ENAF followed by the ethmoid sinus, nasal cavity, nasal septum, larynx, sphenoid sinus, cheek, conjunctiva, oropharynx, retromolar area and others.3 However, ENAF of mandibular ramus marks rarity and no case has been reported with respect to this anatomic location especially in preschool children yet. Hence, a rare ENAF in a 3-year-old child, principally confined to mandible, with neither sphenopalatine foramen nor nasopharynx involvement presenting with swelling is described.

Surgical field visualization in patients with polyposis rhinosinusitis

Introduction. Patients with nasal polyposis are predisposed to diffuse intraoperative bleeding, that could highly impair surgical field visualization. The absence of a universal technique of improving surgical field visualization became a reason for searching the specific hemostatic methods.Objective: to evaluate the efficiency of sphenopalatine artery and/or its branches coagulation as a method of hemostasis in endoscopic surgery for nasal polyposis and to describe the surgical anatomy of sphenopalatine artery.Materials and methods. Endoscopic coagulation of sphenopalatine artery and/or its branches was performed among 30 patients with nasal polyposis. Surgical field visualization was graded by Boezaart and Wormald scales before and after coagulation.Results and discussion. Intraoperative attempts to achieve the hemostasis using warm (490С) saline irrigation and then application of xylometazoline (0.1%-10ml) and lidocaine (10%-4ml) were ineffective among 28 patients with initial grade 8 and among 2 patients with grade 9 according to Wormald scale. Sphenopalatine artery and/or its branches coagulation was effectively performed in these patients, obtaining the hemostasis in 100% of cases (р < 0,001). The initial surgical field grade improved to grade 5 by Wormald scale in 9 patients (30%), to grade 6 in 17 patients (56,7%) and to grade 7 in 4 patients (13,3%). Only one artery (trunk of sphenopalatine artery) was observed in 18 patients (60%), crossing the sphenopalatine foramen, and 2 arteries (posterior septal artery and posterior lateral nasal artery) – in 12 patients (40%). Endoscopic examination revealed no signs of mucosal atrophy in postoperative period.Conclusion: The appropriate choice of hemostatic technique depends on grades of surgical field visualization. If there is a grade 8–9 by Wormald scale, endoscopic coagulation of sphenopalatine artery and/or its branches is an effective and safe method to improve surgical field visualization.

Locating and Preserving the Sphenopalatine Ganglion in Endoscopic Endonasal Pterygopalatine Fossa Surgery: An Anatomical Study

Background The pterygopalatine fossa (PPF) contains numerous important neurovascular structures; notably, the sphenopalatine ganglion (SPG), the maxillary branch of the trigeminal nerve (V2), and the internal maxillary artery. With the advent of extended endoscopic endonasal surgery, the surgical anatomy of the PPF warrants increased investigation. Intraoperative dissection and preservation of the SPG is essential to prevent postoperative xeropthalmia and facial hypoesthesia. Objective This study aims to (1) describe a novel dissection technique for identifying the SPG and (2) define the SPG location relative to the sphenopalatine foramen (SPF), which is a consistently identifiable landmark. Methods Eight cadaveric PPFs were dissected in step-wise fashion. An endoscopic medial maxillectomy was performed, the SPF was identified, and the posterior maxillary wall was resected. The maxillary branch of the trigeminal nerve (V2) was identified anterolaterally in its infraorbital canal and traced medially to identify the pterygopalatine nerve to the SPG. The lateral distance and superior/inferior distance from the SPG to the fixed SPF was measured. Results The surgical technique described allowed for reliable identification of the SPG. The SPG was located on average 4.5 ± 1.1 mm lateral and 1 ± 1.4 mm inferior to the SPF. Conclusion Identification and preservation of the SPG is necessary to prevent complications in endoscopic endonasal PPF surgery. The SPG can be reliably located near the SPF by following the pterygopalatine nerve branch of V2.