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   Table of Contents - Current issue
July-December 2020
Volume 10 | Issue 2
Page Nos. 45-138

Online since Thursday, January 21, 2021

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Endoscopic-assisted rigid internal fixation of anterior wall frontal sinus fractures Highly accessed article p. 45
Tarek A Emara, Ashraf E OdaBasha, Tharwat A Omara, Mohamad S Abdelazem, Ahmed M Anany
Objectives Isolated anterior wall frontal sinus fractures are usually managed through a coronal approach, with its potential complications such as big scar, alopecia, and paresthesia. This study evaluates the endoscopic repair of isolated anterior wall frontal sinus fractures with rigid internal fixation. Study design This was a prospective clinical trial. Setting This study was conducted at a tertiary care academic medical center. Patients and methods A total of 24 patients with isolated anterior wall frontal sinus fractures, documented with computed tomographic (CT) scans, were treated from 2010 to 2013. All were men with a mean age of 31 years (range, 21–43 years). Via a 10-mm skin incision placed in a skin crease, an endoscopic reduction by microplate fixation of the displaced bony segments was achieved. Results Three patients were excluded from the study owing to incomplete follow-up. Follow-up ranged from 13 to 29 months, with an average of 17 months. Contour deformities were perfectly restored, and cosmetic results were acceptable in all patients. Postoperative CT scans showed an excellent anatomic restoration of the frontal sinus contour in 17 patients. In four patients who had the anterior frontal sinus fractures affecting the superior orbital rime, the postoperative CT scans showed a suboptimal reduction of the bony fragments; however, they were satisfying with the forehead aesthetic contour. None of the patients complained of sinusitis or other related complications. Conclusion Isolated anterior wall frontal sinus fractures can be successfully treated endoscopically by microplate fixation. This method is a safe procedure that can be done with ease and minimal morbidity to avoid the comorbidities associated with the coronal approach. Level of evidence: The level of evidence is IIb.
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Supraorbital ethmoid cell: geographical and racial variations p. 50
Reda Kamel, Kareem Moussa, Dalia El Mesidy, Adel El-Antably
Background Supraorbital ethmoid cell (SOEC) is one of the most difficult frontoethmoid cells addressed during frontal sinus surgery. It has never been studied in Middle Eastern countries. The aim of work is to study the incidence of SOEC in Egyptians and its effect on frontal and/or ethmoid sinuses affection. Patients and methods Computed tomographic scans of 47 patients of chronic rhinosinusitis were studied for supraorbital pneumatization; presence of the SOEC; its size, side, number, and relation to the anterior ethmoid artery; size of the frontal sinus; and opacity of the frontal and/or ethmoid sinuses. Results The SOEC was encountered in 41 sides (43.6). The incidence of SOEC was least in Far Eastern countries (2.6–7.7%), followed by Europe (10.2–22%), and most prevalent in hot climate countries (35–45%). Conclusion It seems that the incidence of the SOEC has geographical and racial variations. Moreover, there is no association between the opacity of the SOEC and the incidence of frontal and/or ethmoid sinuses affection in chronic rhinosinusitis.
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Epidemiology and risk factors of methicillin-resistant Staphylococcus aureus complicated otorhinolaryngological cases at Khartoum ENT Hospitals in Khartoum State, Sudan in 2017 p. 54
Ayman Y A. Abdalhay, Sharfi A O. Ahmed, Mohamed T Musa
Background Methicillin-resistant Staphylococcus aureus (MRSA) is a current health concern, although patients undergoing elective, routine ENT surgery are excluded from this concern. Staphylococcus aureus is a common cause of ENT bacterial infections. Objectives To know the epidemiology and risk factors of MRSA complicated otorhinolaryngological cases at Khartoum ENT hospitals in 2017. Patients and methods This is a prospective, cross-sectional, descriptive, analytical hospital-based study conducted on 155 patients in the period from December 2016 to December 2017. Of the patients, 50% were from Omdurman Hospital, 30% from Ibn Sina Hospital and 20% from Africa hospital. Patients' data were collected through a data collection sheet. Different ENT swabs were taken from the patients and were sent to the microbiology laboratory in the University of Khartoum for culture and sensitivity. Data were analyzed using SPSS, version 22 and Excel 2010. Results Most patients of MRSA were from the age group of 21–30 years (33.3%). Males with MRSA were more (61.9%) with a male to female ratio of 1.63:1.00. Most of MRSA swabs were taken from the ear (57.1%). Ciprofloxacin (55%) was the most common previous antibiotic used in MRSA patients. Meropenem (52.4%) was the most sensitive antibiotics in MRSA patients. Diabetic, hypertensive, steroid use, chronic obstructive pulmonary disease, asthmatic, and admitted patients constitute 6.3, 8.3, 20.8, 41.6, and 47.9% of total patient percentage, respectively. Conclusion MRSA is highly prevalent among the populations of S. aureus isolated from different ENT clinical specimens in different hospitals in Khartoum State, with most of the MRSA isolates being from ear infections. The highest antibiotic sensitivity to MRSA was meropenem. Risk factors such as hypertension, diabetes, steroid use, chronic obstructive pulmonary disease, asthma, and previous admission have contributed to MRSA.
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Intercarotid distance variations in pituitary adenomas: a cone-beam computed tomographic study p. 58
Omar Abd El-Moneam El-Banhawya, Ayman El-Sayed Abd El-Aziza, Ahmed N M. Taha, Wael M Safwat, Magdi El-Sayed Abd El-Ghafar
Introduction Transnasal trans-sphenoidal surgery has become the most popular procedure to approach different sellar lesions. Internal carotid artery injury during this approach could be minimized by accurate preoperative assessment of its course and detection of anatomical variations. Patients and methods This study was conducted on 24 cases with pituitary adenomas. The intercarotid distance (ICD) was measured by cone-beam computed tomography, and defined as the minimal distance between the inner walls of the carotid sulcus of the horizontal parasellar internal carotid artery. Comparison of measurements in the study group with that of healthy individuals of the control group was done. Aim The aim of this study was to detect variations in ICD with pituitary adenomas. Results This study showed that ICD was statistically significantly higher in the study than control groups (P=0.01). A statistically significant correlation between lesion size and ICD was found (P=0.04). A statistically significant difference between the ICD with the type of sellar pathology was found. The widest distance was found with suprasellar lesions (mean = 8.93 ± 2.09, P1 = 0.009) and the least in sellar lesions (mean = 16.58 ± 1.94). Conclusion Preoperative measurement of ICD is applicable and helpful in operative planning for the trans-sphenoid approach to pituitary lesions. The size of the adenomas directly affects the ICD with larger adenomas showing wider distance.
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Management and outcome of treatment modalities of cerebrospinal fluid rhinorrhea p. 63
Mustafa Tajelsir, Nazik Elfadil, Mohamed Elawad
Background Management of cerebrospinal fluid (CSF) rhinorrhea includes either conservative or surgical treatment. The aim of this study is to evaluate the results of management of CSF rhinorrhea in three tertiary care centers in Khartoum state. Patients and methods This was a prospective analysis of 40 consecutive patients who underwent management of CSF rhinorrhea between April 2016 and April 2019. Conservative management consists of a 7–30-day trial of bed rest, head elevation 15–30°, stool softeners, avoidance of straining, and diuretics. All patients were offered conservative treatment except those with meningitis and iatrogenic leak, and patients with tension pneumocephalus were managed surgically from the start. Results A total of 40 patients were included. Spontaneous CSF leak cases were 19 (47.5%), with female to male ratio of 3.75: 1. Posttraumatic CSF leak cases were 16 (40%), with male to female ratio of 2.2: 1. Five (12.5%) patients were iatrogenic, with female to male ratio of 4.0: 1; they were managed? surgically only as well as one patient with history of meningitis. Conservative treatment was successful in 11 (32%) of 34 patients. Surgical treatment was performed for 29 patients, mainly by endoscopic approach in 26 (89.7%) patients, with success rate of 96.1%; osteoplastic flap for two (6.9%) patients, with a success rate of 100%; and intracranial (frontal craniotomy) for one (3.4%) patient, with a success rate of 100%. The success rates following first surgery for patients with posttraumatic, postprocedural, and spontaneous CSF leaks were 100, 100, and 93.3%, respectively. Four patients required second surgery, which was successful in three and failed in one with persistent leak. Conclusion Patients with CSF rhinorrhea were offered conservative treatment initially, except for iatrogenic leaks and past history of meningitis. Failure of conservative management warrants surgical treatment, which has high success rates. Head trauma, technical failures, lack of CSF divergence, and poor management of spontaneous leaks were responsible for recurrence of leak. Decision for surgical repair is appropriate in a teamwork between otorhinolaryngologists and neurosurgeons with attention to surgical approach, operative details, and postoperative care.
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Prognostic factors affecting success rate in endoscopic management of spontaneous cerebrospinal fluid rhinorrhea p. 69
Adel El-Antably, Nassim T Ghobriala, Ezzat R Aboelsaad
Objective Endoscopic sinus surgery has been established as the standard procedure for management of most cases of cerebrospinal fluid (CSF) rhinorrhea and meningoceles. Spontaneous leak represents the most common etiology, whether it is associated with idiopathic intracranial hypertension or not. Nevertheless, results of endoscopic repair of spontaneous CSF leaks represent the worst among other nonspontaneous etiologies in most literatures, with a wide range of success (25–87%). Patients and methods This is a retrospective study that included 52 cases of spontaneous CSF leak, which had been managed by endoscopic sinus surgery, in the last 8 years, in Kasr Alaini Hospital, Faculty of Medicine, Cairo University, and Shebin Alkom Teaching Hospital; and also some cases were done in New Kasr Alaini Teaching Hospital. Data collected included age, sex, manifestations of high intra cranial tension (ICT), duration of leak, site, method of repair, and whether repair was successful or not. Results In 52 cases with spontaneous CSF leak, successful repair was achieved in 73% (38 out of 52). There were 41 (78.8%) female and 11 (21.2%) male patients. Success in female patients was 70.7% (29 of 41 cases), and success in male patients was 81.8% (9 of 11 cases). Manifestations of increased ICT were found in 17 of 52 cases (32%), where nine of them failed (52%). Leaks in the ethmoidal region represented 27 (52%) cases, sphenoidal region 19 (36.5%) cases, and frontal region six (11.5%) cases. There were three methods of repair: in the first group, repair was done with fat and overlay mucosal graft in 17 (33%) cases; in the second group, repair was done with under lay epidural graft plus overlay mucosal graft in 29 (56%) cases; and in the third group, an underlay graft was used, and in addition, an overlay septal flap was put in six (11%) cases. Conclusion Spontaneous CSF leak represents a common cause of CSF rhinorrhea. Success rate is in general lower than in other etiologies of CSF leaks. The outcome of the surgical intervention could be related to variable demographic and preoperative factors.
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Could there be an association between ethmoid anatomical variations and chronic rhinosinusitis? A clinicoradiological study p. 76
Mohamed M Osman, Mohamed A Abdel-Razek, Hazem Abu-Zeid Yousef, Shimaa A M. Abdel-Ghany
Background The complicated anatomy of the ethmoid bone is associated with multiple anatomical variations. These anatomical variations may have clinical significance in pathogenesis of rhinosinusitis, which is still unclear, and in the surgical workup to avoid the risk of potential complications. Aim The aim of this study was to evaluate the rate of the different ethmoid anatomical variants in the patients with chronic rhinosinusitis (CRS) and to assess if there is any correlation between these variants and CRS. Patients and methods This case–control study included 40 patients with CRS (study group) and 20 healthy individuals with no criteria of CRS (control group). Anatomical variations of ethmoid complex were evaluated as either being present or absent in each side in both groups. In the study group, Lund-Mackay scores of the different sinuses were evaluated and compared in relation to the detected ethmoid variants. Results No statistically significant difference was found between the rate of different ethmoidal anatomical variations in the study and control groups. There was also no significant difference in the Lund-Mackay scores of the different sinuses in relation to the presence of anatomic variations. The most common ethmoidal anatomical variation in both groups was agger nasi cell. Conclusion This study showed that there is no significant association between ethmoidal anatomical variations and CRS, and so, these anatomical variations are not a potential risk factor for chronicity of sinusitis.
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The optimum duration of anterior nasal packing after common nasal surgeries p. 84
Ahmed M Abdelghany, Ashraf S Elhamshary, Elsayed A Hegazy, Abd E F. Ghallab
Background Anterior nasal packing (ANP) after nasal surgeries usually causes significant pain and discomfort. Up to the best of our knowledge, there is no evidence accepted for the optimum duration of postoperative ANP. Objective Th aim was to determine the optimum duration for ANP in patients undergoing common nasal surgeries associated with the least discomfort and complications. Patients and methods A prospective randomized clinical study was carried out in Benha University Hospital from November 2018 to August 2019. It included 150 patients who underwent common nasal surgeries: submucosal resection of the nasal septum and/or inferior turbinoplasty or functional endoscopic sinus surgery. Patients were allocated into four groups (A, B, C, and D) according to the duration of ANP (6, 12, 24, and 48 h, respectively). The groups were compared regarding pain during removal of the pack, epiphora, dysphagia, sleep disturbances, bleeding, infection, septal hematoma, septal perforation, crustations, and adhesions. Results Mean pain score was significantly lower in group A and higher in group D. Incidence of epiphora and sleep disturbances before pack removal was significantly lower in group A and higher in group D regardless of the type of surgery, whereas it was not significant regarding dysphagia. Bleeding, infections, crustations, hematoma, adhesions, and septal perforations showed nonsignificant statistical difference among the four groups. Conclusion Early removal of ANP is significantly associated with better patient comfort and less pain and does not increase the incidence of other complications.
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Frontal sinus fracture classifications: a review of literature and presenting a new classification p. 89
Mohammad W El-Anwar, Ahmed S Elaaser
Introduction Several classifications have been published for the frontal sinus (FS) fractures. Objectives To review the literature regarding different classifications of the FS fractures to collect and analyze the most commonly used classification and to present a new easily applicable and therapeutically helpful classification that avoids the disadvantages of the previous classifications. Data synthesis Repeated searches were performed in the PubMed, LILACS, MEDLINE, SciELO, databases, and Cochrane Library, and the key words used in the search were FS fractures, FS outflow tract, classification, and frontal bone. Collected studies were read and analyzed, and different FS fractures classifications were described and assessed for advantages, disadvantages, missed data, and pitfalls. Conclusion This review would be helpful for surgeons to be familiar with different classifications of the FS fractures. A new classification for the FS fractures was presented and described here to overcome the pitfalls of the already described classification and to update the categorization data to the currently used treatment philosophy and tools to be more applicable and treatment based. Moreover, we precisely provide the supposed appropriate treatment for each FS type.
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Platelet-rich plasma nasal packing in endoscopic sinus surgery p. 94
Osama Hassan, Mohamed Ibrahim, Ahmed ElFarouka, Aly El Garem
Introduction Synech ia and scarring are the most common complications encountered after endoscopic sinus surgery that may result in occlusion of sinus drainage pathway, leading to recurrent symptoms and subsequent surgical failure. Platelet-rich plasma (PRP) has been used in many aspects of medicine to accelerate healing, avoid bleeding, and prevent synechia. Patients and methods A total of 40 patients with bilateral sinusitis candidate for endoscopic sinus surgery were encountered in the study. The middle meatus and ethmoidal cavity at one side of the nose was irrigated using PRP, whereas the other side was irrigated with normal saline. Postoperative assessment was done by subjective (questionnaire) and objective (endoscope) methods. Results This study showed that PRP side was more comfortable, giving less pain, bleeding, nasal crustations, and synechiae compared with the other side of the nose irrigated with saline (control) and that was statically significant. Conclusion PRP is a safe and simple procedure that can improve mucosal healing and decrease postoperative synechiae, crust, and edema. It also provides better quality of life for patient by decreasing postoperative pain and bleeding.
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Effect of using diluted adrenaline injection on hemodynamical parameters during septoplasty p. 100
Naif A Alfattani, Ghaydaa S Hazzazi, Bayan O Besharah, Abdullah S Assalem, Albaraa Y Alsini, Fawziah A Halawani
Context Septoplasty is a common surgical procedure performed to correct the deviated nasal septum. A clear surgical field is imperative for the success rate of the procedure. It can be achieved by improving the visualization of the sinonasal structures by optimizing good hemostasis. Adrenaline local infiltration was commonly used despite its potential risks and complications; it is still controversial and referred to as surgeon preference. We aimed to study and evaluate the effect of diluted adrenaline injection in the submucoperichondrial plane in the nasal septum during nasal surgery in relation to hemodynamic parameters of the patient during the procedure. Aims We aimed to study and evaluate the effect of diluted adrenaline injection in the submucoperichondrial plane in the nasal septum during nasal surgery in relation to hemodynamic parameters of the patients during the procedure. Patients and methods This retrospective single-?center study included patients who underwent septoplasty under general anesthesia at Al-Noor Specialist Hospital from 2014 till 2018. Statistical analysis Statistical analysis was performed using Statistical Package for Social Science software, version 21.0. Results This study included 223 patients who underwent septoplasty. Males were more prevalent than females (72.6 vs. 27.4%). The sample included 19.3% patients with diabetes, 17.5% were hypertensive, 3.6% had cardiac disease, 1.8% had hypothyroidism, and 2.2% had renal diseases. The mean ± SD of heart rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, and oxygen saturation at baseline and after injection for 12 min was recorded, reflecting no significant changes regarding increasing in all parameters. Conclusions Injection of diluted adrenaline (1: 100 000 or 1: 200 000) during septoplasty in relation to hemodynamic parameters is safe, as there is no increase in heart rate, blood pressure, or mean arterial pressure after the infiltration in the submucoperichondrial plane regardless of the patients' comorbidities.
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Comparative study between absorbable and Non-Absorbable nasal packings after nasal surgeries p. 105
Ayman Abdelaal Mohamady, Hossam Abdelhay Gad, Ashraf Salah El-Hamshary, Dalia Ragab Abd-Elmaksoud, Abd-Elhakeem Fouad Ghallab
Background Nasal packing is frequently used after nasal surgeries to control bleeding and prevent adhesions. Many absorbable packing materials have been developed to avoid the drawbacks of the traditional nonabsorbable ones and to help in wound healing. Objective This study was done to compare between absorbable and nonabsorbable nasal packings regarding patient satisfaction and clinical outcome. Patients and methods A prospective, single-blinded, randomized controlled clinical study was carried out in Benha University Hospital from May 2018 to November 2019. A total of 40 patients (80 nostrils) were enrolled in this study undergoing surgery. At the end of the procedure, the operative cavity of each patient was randomly packed with Merocel, as a nonabsorbable material on one side, and an absorbable material, which was sinufoam or gelfoam, on the other side. Patients' symptoms, including pain, nasal obstruction, and nasal discharge, were evaluated with a visual analog scale. Objective findings about bleeding, crustations, adhesions, infection, and mucosal edema were evaluated endoscopically. Each evaluation was done at third day, 2 weeks, 4 weeks, 6 weeks, and 12 weeks after surgery. Results Absorbable packings had minimal pain, less nasal obstruction scores, and lower incidence of discharge. Bleeding was significantly higher on absorbable side early postoperatively, especially with Gelfoam. Crustation and adhesion scores were significantly higher on Merocel-packed sides. Gelfoam showed crustations and adhesions more than Sinufoam. Mucosal edema score was significantly higher in Merocel group than the absorbable. However, there was no difference at 6 and 12 weeks. Gelfoam showed only significantly higher edema than Sinufoam at 6 weeks. There was a significant difference between absorbable group and Merocel regarding infection at 1 and 2 weeks. There was no difference between Gelfoam and Sinufoam regarding infection except at 6 weeks. Conclusion Absorbable packings are associated with less discomfort, more bleeding, and fewer complications.
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Prelacrimal versus canine fossa approach for anterior maxillary sinus lesions p. 118
Samer B Kamel, Hossam A Gad, Hossam M Abdelazeem, Mohammed G A. Elnems
Introduction Extensive disease in the maxillary sinus is difficult to clear with standard instrumentation during traditional endoscopic sinus surgery, so access to the anterior and anterolateral walls of the maxillary sinus is often difficult despite the creation of a large maxillary antrostomy or the use of adjuvant surgical procedures such as canine fossa puncture to gain improved access and allow for good debridement of maxillary sinus. Objective To study the outcome of prelacrimal approach compared with canine fossa approach (CFA) for surgical treatment of anterior maxillary sinus diseases. Patients and methods A randomized prospective clinical study, in which 40 patients with recurrent anterior maxillary sinus lesion were divided into two equal groups: group I included 20 patients who underwent endoscopic prelacrimal recess approach (PLRA), and group II included 20 patients who underwent endoscopic CFA. Patients were evaluated between February 2018 and October 2019. The two groups were compared regarding facial pain, facial numbness, cheek swelling, nasal obstruction, epiphora, inferior turbinate destabilization, inferior turbinate-nasolacrimal duct flap status, crustations, synechiae, bleeding, infection, and antrochoanal polyp recurrence. Results Operation time was significantly longer in CFA group II (38 min) compared with PLRA group I (27 min) (P<0.001). Cheek swelling was significantly higher in CFA group in comparison with PLRA group (P<0.001). Facial numbness and facial pain were significantly higher in CFA group compared with PLRA group at 1 week postoperatively (P=0.047 and 0.025, respectively). There were no significant differences between both groups regarding type of lesion and recurrence (P=1.0 for each). Conclusion PLRA is a safe and simple technique for manipulation of anterior maxillary sinus lesions with short operative time and minimal postoperative complications.
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Revision endoscopic sinus surgery for bilateral nasal polyposis p. 127
Ashraf S Elhamshary, Alaa F Ghita, Rami A Desokey, Abd E F. Ghallab
Background Nasal polyps have an incidence of 4% in all of the population. Apart from the surgery performed, some patients will present with recurrence. Recurrence ranged from 4 to 60% in? nasal polyps (NP), with a median of 20%, across all studies reviewed over a maximum of 2 years. Objective The aim? was to review cases of recurrent bilateral nasal polyposis in terms of the incidence of local factors contributing to recurrence. Patients and methods This prospective study included 50 adult patients (males and females) experiencing recurrent BNP after previous functional endoscopic sinus surgery. The patients were recruited from the outpatient clinic, Otorhinolaryngology Department, Kobry El-Kobba Military Hospital. The mean age of primary disease was 39 years. There were significant differences between endoscopic and computed tomography (CT) findings according to the presence of different local factors contributing to recurrence of NP, in the form of lateralized middle turbinate, residual infected air cells, scarred frontal recess, middle meatal antrostomy stenosis, retained uncinate process, and retained agar nasi cells. The detection rate of endoscopy was higher than the CT scan. Results The most frequent finding was lateralized middle turbinate (74.0%) followed by residual infected air cells and scarred frontal recess (60.0% for each). Middle meatal antrostomy stenosis was found in 40.0% of cases. Retained agar nasi cells was found in 48.0% of cells, whereas retained uncinate process was found in only 36.0% of cases. Conclusion There were significant differences between endoscopic and CT findings according to the presence of different local factors contributing to recurrence of NP, in the form of lateralized middle turbinate, residual infected air cells, scarred frontal recess, middle meatal antrostomy stenosis, retained uncinate process, and retained agar nasi cells. The detection rate of endoscopy was higher than the CT scan.
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Transnasal endoscopic repair of orbital blowout fracture: case report p. 132
Nazik E Abdullah, Israa M Osman, Omer A Babikir
A blowout fracture is a fracture of the walls or floor of the orbit, due to blunt orbital trauma. Management is conservative or surgical when indicated, and classical external approaches are subciliary, transconjunctival, and subtarsal. We report a case of orbital blowout fracture, presented with vertical diplopia and managed successfully by transnasal endoscopic approach. This approach is very promising for the management of blowout fracture with ocular movement limitation owing to trapped muscles or fascia. It is minimally invasive, avoids surgical scars and eye traction, and shortens operative time. The limitation is it gives no access to lateral wall fractures.
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A rare case report of Langerhans cell histiocytosis (Hand–Schuller–Christian disease) and review of literature p. 136
Kasim S Kasim Aljanabi
Introduction Langerhans cell histiocytosis is a rare disease that can present as uniorgan or multiorgan involvement. More than 60% of cases of Langerhans cell histiocytosis can present with head and neck lesions. Tissue biopsy is mandatory for confirming the diagnosis beside clinical and radiological findings. Case Report The authors present a 9-year-old boy who initially presented with oral cavity lesion and gum swelling for 3-week period, who subsequently showed severe diffuse lung infiltration complicated with pneumothorax and pituitary stalk involvement with diabetes insipidus. Diagnosis was confirmed with oral lesion biopsy. Conclusion Oral lesions are easily approachable, and biopsy can be done under local anesthesia, with minor medical and cosmetic complication. Any initial aggressive surgical intervention should be avoided.
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