Itchy Ears

Introduction Though itchy ears cause significant discomfort, patients generally do not consult a doctor till it becomes chronic. Moreover, itching as a symptom hardly receives any attention in non-dermatological clinics and is generally not considered as a condition worth evaluating. Thus, this study was performed to examine the predisposing factors of itchy ears and the outcomes of corresponding treatment. Materials and Methods This was a prospective observational study carried out over a period of 12 months (July 2019 to June 2020). The study included 200 patients belonging to the age group ranging from toddler to elderly (≤70 years) and presenting at the ENT OPD of a Tertiary Care Teaching Institute with the complaints of itching in one or both the ears. Following the diagnosis, appropriate treatment was started. The patients were then followed-up after 10 days, to note if symptom of itchiness in the ear(s) had relieved. Results Out of 200 patients, 89 presented with itchy ears due to various etiology, of which most common were otomycosis (N=30), allergic rhinitis (N=15), and keratosis obturans (N=10). However, majority of the patients (N=111) had impacted wax as the predisposing factor (trauma (N=27), abnormal anatomy (N=65), or hereditary (N=19)), resulting in itchy ears. On the 10th day, complaint of itchy ears was relieved in majority of the patients. However, amongst 30 patients, 3 patients with fungal infection of the external auditory canal still complained of itchy ears and thus, were referred to dermatologist. Conclusion Impacted wax was the most frequently observed predisposing factor and was commonly observed across all the age groups. Majority of the patients responded well to the treatment and were relieved of itchy ears.

The Pulmonary Venous Return from Normal to Pathological—Clinical Correlations and Review of Literature

Pulmonary veins carry oxygenated blood from lungs to the left atrium of the heart. The anatomy of the pulmonary veins is variable with some anatomic variants. In clinical practice the difference between the normal anatomy of pulmonary veins with its variants and abnormal anatomy is very important for clinicians. Variants of pulmonary veins may occur in number, diameter and normal venous return. We present a case report and a review of the literature with the pulmonary venous return that deviates from the usual anatomical configuration and ranges from normal variant drainage to anomalous pulmonary—systemic communication. Initially, it was considered as an anatomical variant of the pulmonary venous return associated with the persistence of the left superior vena cava. Upon detailed exploration it was established that it was an anomaly of the pulmonary venous return which led in time to the installation of its complications. Diagnosis can be difficult, sometimes missed, or only made late in adulthood when complications were installed. Knowledge of variant anatomy and anomalous pulmonary venous return play a crucial role in the diagnostically challenging patient.

A rare presentation of midgut malrotation as an acute intestinal obstruction and perforation in an adult

Midgut malrotation is a congenital anomaly seen usually in childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually identified intra operatively. A high index of suspicion is always required when dealing with any case of acute intestinal obstruction. We report a case of young adult who presented with symptoms of acute intestinal obstruction and was diagnosed intra-operatively as cecal volvulus with impending perforation caused by midgut malrotation. Malrotation of the intestinal tract is seen due to aberrant embryology. The presentation of intestinal malrotation in adults is very rare. Contrast enhanced Computed tomography (CT) can show the abnormal anatomy clearly. Anomalies like midgut malrotation can present as an operative dilemma and awareness regarding these conditions can help surgeons deal with these conditions.

Dysplasia of Ovary Without Abnormal Development of Uterus and Urinary System: A Report of Four Cases

Background Congenital anatomic abnormalities of fallopian tubes and ovaries are rarely reported. Herein, we describe four cases of abnormal ovarian descent during laparoscopic surgery with abnormal anatomy of fallopian tube, without abnormal uterine development and urinary system abnormalities. These cases are analyzed by their clinical features and their effects on reproductive function. Case presentation For patients with undescended ovary, the upper part of the unilateral/bilateral ovary decline was much higher than that of the common iliac vessel bifurcation, and the fallopian tube on the same side opened in the para-colonic sulcus. Among four patients, two cases had primary infertility, one case had tubal pregnancy rupture and bleeding, and one case had uterine leiomyoma. The development of uterus was normal in all the four patients, and there was no abnormal development of urinary system. During the infertility examination, hysterosalpingography (HSG) suggestion of oviduct lift was a sign for possible undescended ovarian. The pelvic B-ultrasound examination was limited to discover ovarian maldescent. Conclusion Laparoscopy was the gold standard for the diagnosis of poor ovarian decline. When B-ultrasound prompts one-sided or double-sided "ovary display is unclear" or detects "shrinking small ovaries", it might be ovarian maldescent. When there is periodic post-sacral spinal pain, MRI positioning or HSG can be used for diagnosis.

The dilemma of the duplicated cystic duct: a case report

We present a rare case of a duplicated cystic duct encountered during an elective laparoscopic cholecystectomy in a patient with biliary colic. Prompt recognition of an intraoperative bile leak followed by thorough examination and recognition of the source allowed for timely and appropriate management of the affected patient with a satisfactory post-operative outcome. Our case is unique by the lack of availability of intraoperative cholangiogram at the time of surgery, which posed a significant diagnostic and therapeutic challenge, and by how aberrant anatomy was confirmed intraoperatively by reviewing prior cardiac magnetic resonance imaging. Unremarkable preoperative imaging does not rule out the presence of abnormal anatomy. Early involvement of a specialist hepatobiliary surgeon is essential in an unexplained bile leak, with a low threshold in converting to an open procedure if there is difficulty in clearly deciphering anatomy.

Unusual intraoperative finding of abnormal retroperitoneal ileum: a case report

A 52-year-old female patient diagnosed with an adenocarcinoma of the sigmoid colon underwent anterior resection with direct anastomosis. Intraoperatively, we found the ileum completely retroperitonealized. Previously, the patient was asymptomatic and no congenital syndromes were diagnosed. The intraoperative finding of abnormal anatomy made the mobilization of the left hemicolon and the vessel ligation more challenging. This anatomical situation is a rare variation due to an embryonic malrotation, which occurs in about 1:500 newborns.

Traumatic Craniocervical Dissociation in Patients with Congenital Assimilation of the Atlas to the Occiput

Traumatic atlantooccipital dissociation (AOD) is a severe and usually fatal injury. Patients with assimilation of the atlas to the skull are exposed to a higher risk of injury and delay diagnosis due to the abnormal anatomy. We report two cases of acute traumatic craniocervical dislocation in patients with baseline congenital assimilation of the atlas to the skull. Computer tomography (CT) was used to identify the injury. Computer tomography angiography (CTA) showed variations of the vertebral arteries’ location on both patients. Assimilation of the atlas was complete in patient one and partial in patient two. Emergent surgical instrumentation and fusion were performed with a very careful and meticulous posterior dissection. As general rule, most of the patients with CCD will undergo occiput to C2 posterior segmental instrumentation and fusion. In the presented cases, a more extensive fusion was necessary based on the type and severity of the CCJ injury and the anatomical anomalies associated. Postoperatively, patient one remained neurologically intact and patient two died. Alternative fixation techniques should be used to minimize risk of VA injury during the surgical procedures.

Medical Imaging of the Airway

Non-invasive imaging techniques such as ultrasonography, x-ray, computerized tomography (CT) and magnetic resonance imaging (MRI) provide details about airway anatomy that complement the physical examination. They are of particular value in patients with traumatic injury, malignancy, abscess, foreign body or mass in the airway that displace, distort, disrupt, encroach or compress airway structures in ways that may not be readily apparent otherwise. Many anesthesiologists do not receive formal training in interpreting medical imaging, and a thorough discussion of this subject is beyond the scope of this review. Interpreting the subtleties of normal and abnormal anatomy require years of experience and best left to expert radiologists. The goal here is to introduce the imaging techniques available and examples of clinical applications in airway evaluation of interest to the anesthesiologist. This review contains 12 figures, 2 tables, and 37 references. Keywords: piezoelectric effect, photoelectric interaction, Faraday’s law, pneumothorax, cervical spine injury, LeFort fracture, foreign body, airway infection, mediastinal mass