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July 1989, Volume 39, Issue 7

Minor Surgical Procedures In Clinical Practice


Fatema Jawad  ( 7/6, Rimpa Plaza, M. A. Jinnah Road, Karachi. )

ANKYLOSIS OF TEMPOROMANDIBULAR JOINT. Beg, M.H.A. Pak. J. Otolaryngol., 1987; 3:71-73.
The case of a 12 year old boy who developed ankylosis of both temporomandibular joints fol­lowing trauma is presented. The complaints were of inability to open the mouth since 3 years follow­ing a fall from the rooftop and landing on the chin. The pain following the injury was relieved by anal­gesics but the inability to open the mouth persisted and the child could take liquids and semisolids only. On exaniinatiofl the patient was unable to move his lower jaw. He could not open his mouth and could only move his lips. On palpation of the temporomandibular joints solid bone was felt in place of the joints bilaterally. After performing a tracheostomy the right temporomandibular joint was exposed. The solid bone replacing the joint was divided and excised giving a gap of about 1/2 inch between the zygo­matic arch and mandible. The same procedure was repeated on the left side after one week. The day following surgery, the patient could open his mouth and chew solid food. Intensivejaw exercises were given and the child made satisfactory progress Ankylosis of the temporomandibular joint occurs after a fall on the chin causing intracapsular fracture of both necks of mandibles. Surgery is a successful treatment which cràates a gap between the two bony surfaces.
Two cases of different ethnic origin, diag­nosed as submucous fibrosis are presented. The first case was a 38 year old Pathan woman who migrated to Karachi 20 years ago. She started using chilies one year after migration and chalia (areca nut) two years later. She developed symp­toms of inabilityto open her mouth and eat chillies, 16 years after use of chalia. Examination showed classical bands on anterior pillars and palate ex­tending to the cheek mucosa. The second case was a 13 year old girl whose parents had migrated to Karachi from Baluchistan 25 years ago. She had started using chalia since the age of 3 years and developed symptoms of inability to eat chillies since 6 years and inability to open the mouth since 4 years. Examination showed ex­tensive submucous fibrosis extending upto the la­bial commisures. Sub-mucous fibrosis has not been reported in Pathans and Baluchis as these races are not exposed to chillies and chalia. After migration the eating habits change and the pathology develops though the Pathtn woman took 16 years whereas the Baluchi girl only 4 years after exposure to start the symptoms.
KAPOSI\'s SARCOMA OF THE PALATE. Younus, M. Pak. J. Otolaryngol., 1987; 3:65-68.
The case of Kaposi’s sarcoma of the palate in an immunosuppressed patient, following a renal transplant is presented. A 52 year old male deve­loped two painless swellings on the palate since 15 days. There was no ulceration or bleeding. No other such swellings were noted elsewhere. The patient had had two renal transplants and was on immunosuppressive drugs. Gastroscopy revealed similar lesions in the stomach and duodenum. A biopsy taken from the palate reported mild acanthosis, intracellular oe­dema and karyorrheatic debris. The sub-mucosa showed proliferative vascular spaces with promi­nent endothelial cells lining the small capillaries and surrounded by neoplastic spindle cells with frequent mitosis. Globular hyaline bodies were scattered in the tumor. The appearance was of kaposi’s sarcoma. Attempts to culture Human T­cell lymphotrophic virus type III proved unsuc­cessful. Kaposi’s sarcoma was described 114 years ago. The nodules appear on the feet and hands and gradually on the arms, legs, trunk and face. Later similar nodules are found on the mucous mem­brane of the larynx, trachea, gastro-intestinal tract and liver. The nodules appear pigmented due to the large amount of blood and hemorrhage within. This disease was originally seen in the Ashkenazy Jews and later reported from Africa. In the last five years it has been noted in American homosexuals associated with AIDS. The lesion is similar his­tologically but it may be localized or fulminating type. it is classified as the classical European type which is slow progressing and macules form on the legs. The African type seen in Negroes, is a ful­minating type associated with cell mediated im­mune deficiency. The post immunosuppressant type is seen in immunosuppressed patients and is usually localised to the skin but may involve the mucous membranes. The epidemic or Aids related type, discovered in 1981 is found in homosexual males, heterosexual males with multiple partners and females. Hemophiliacs, intravenous drug ad­dicts and blood transfused patients also have a high incidence. Generailsed lymphadenopathy, fever, weight loss, malaise are the symptoms and the mortality is high usually within a year.
The role of anaerobes in chronic suppura­tive otitis media has been studied. In Nigeria SCOM is the most common condition seen in the ENT Clinic. The ear discharge fails to dry up inspite of intensive conservative treatment. This gave a suspicion of anaerobes being the causative organisms. 35 children between the ages of 5 and 12 years suffering from CSOM with perforated ear­drums, over a period ranging from nine months to seven years were subjected to mastoid exploration. They had all received antibiotics earlier but were off drugs for at least one month before the study. Under general anaesthesia and operating microscope, the external ear canal was cleaned with chlorhexidine and packed with cotton wool soaked in 70% alcohol for 3 miflutes. A culture swab was then taken to ensure sterility. Middle ear exudate was collected from the tympanic mem­brane, diluted with 0.5ml thioglycolatà broth and inoculated on anaerobic and aerobic media. The mastoid was exposed and chips of its cells were removed, washed in 0.5ml thioglycolate and this was inoculated on the two media. The external canal proved to be sterile in 33 of 35 cases. The cultures of the mastoid air cells showed 10 anae­robes and 23 a mixture of aerobes and anaerobes. The middle ear cavity swabs revealed 15 aerobes, 3 anaerobes and 17 mixed growths. The most com­mon bacteria found was pseudomonas aeroginosa followed by bacteroides, anaerobic gram positive cocci, staphylococcus aureus, anaerobic gram po­sitive bacilli and kiebsiella pneumonia. The bacteroides are known pathogens of the mucous membrane and cause granulation and cholesteatoma. To achieve eradication of these organisms, mechanical cleaning of the middle ear cavity along with systemic appropriate antibiotics are necessary. Cindamycin and Carbenicillin give favourable results; Metronidazole with Ampicillin has also proved effective. Ear drops localiy are of no value.

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