presentation 2017
TRANSCRIPT
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1. NON HODGKINS LYMPHOMA
year 2016
2. NECROTIZING RETROPHARYNGEAL ABSCESS
CASE PRESENTATION
Dr. Mohammad Naim Manhas
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NAIM MANHAS 2
lymphomaLymphomas of Head & Neck arise from Nodal or Extranodal sites or both
Hodgkins and Non-Hodgkins Lymphoma commonly present as lymphnode enlargement in the neckHodgkins disease is rare in oropharynx but NHL account 15-20%
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NAIM MANHAS 3
20 -30%
15-20%
70-80%
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4i
non-h
odgk
ins
hodg
kins ly
mphom
a0
102030405060708090
100Incidence of Hodgkins and Non-Hodgkins lymphoma in head and neck
Common sites in oropharynx are tonsillis , nasopharynx
Very rare in soft palate
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NAIM MANHAS 5
W.H.O. guidelinesDiagnostic evaluation for NHL in 2008
Needle aspiration :- not recommended
Incisional or excisional biopsies are preferred
Immunohistochemistry
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NAIM MANHAS 6
Imaging
C. T. Scan of Head & Neck, Chest, Abdomen, PelvisStaging of disease is based on C.T.Scan findingsPerformed at primary evaluation in all patients with NHLNodal and extra nodal sites
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NAIM MANHAS 7
Imaging
MRI
Role is limited Infiltration to Bone marrow or involvement of meninges
Positron Emission Tomography (PET Scan ) imaging is modality of choice for diagnosis, staging and survillance.
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NAIM MANHAS 8
Staging
Stage ISingle Extra Nodal StageIINodal Invovement
Stage IIIBoth sides of Diaphragm
Stage IVmetastases
staging
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NAIM MANHAS 9
Therapeutic modalities
Chemotherapy
Curative ,pallative
ImmunotherapyWith monoclonial antibiodies alone
or in combination with
CHT
Radiotherapy Limited role Early stage
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NAIM MANHAS 10
CASE REPORT
41 Years lady presented to E.N.T.clinic with pain in oral cavity since two months which was not relieved by medication.
Patient was reffered from facio-maxillary dept.
Patient did not have any medical illness .
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NAIM MANHAS 11
On examination :-
Left Palatal swelling was noticed on examination which was firm in consistency on palpation .
Associated inflammatory response to surrounding tissue
Neck :- No cervical lymphadenopathy.
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NAIM MANHAS 12
RADIO-IMAGING
C.t. Scan of Neck revealed soft tissue mass in left Soft Palate.
No associated lymphnode enlargement
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NAIM MANHAS 13
RADIO-IMAGING
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NAIM MANHAS 14
EXCISIONAL BIOPSY
PLAN :-Excisional Biopsy was done under General Anesthesia.
Mass was excised in toto.
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NAIM MANHAS 15
HISTOPATHOLOGY
B-cell lymphomaConfirmed by immunohisto-chemistry method
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NAIM MANHAS 16
Histopathological slides
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NAIM MANHAS 17
HISTOPATHOLOGY – B CELL LYMPHOMA
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NAIM MANHAS 18
STAGING OF B-CELL LYMPHOMA
Depends upon the involvement of nodal and extra nodal sites on either side of diaphargm
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NAIM MANHAS 19
RADIO-IMAGING
C.T. ABDOMEN C.T. PELVIS
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NAIM MANHAS 20
stage I B-Cell Lymphoma
Patient was referred to oncology department.
Patent received Radiotherapy ( 30 doses )
Recently have completed chemotherapy (8)
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NAIM MANHAS 21
Post Radio and Chemotherapy
AFTER BEFORE
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NAIM MANHAS 22
LEARNING POINTS
The oral cavity is an anatomically complex region and lesions can prove exceptionally challanging to diagnosis.
Isolated extranodal B-cell lymphoma of the palate is extremely rare. It usually present as an inflammatory lesion. Early diagnosis are important as the disease is confined to palate only,therefore respond well to irriadiation.
PET is the imaging modality of choice for diagnosis, staging and survillance
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NECROTIZING RETROPHARYNGEAL ABSCESS ( CASE NO. 2 )
CASE PRESENTATION
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NAIM MANHAS 24
RETROPHARYNGEAL SPACE
DIAGRAMMATIC PLAIN RADIOGRAPH
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NAIM MANHAS 25
RETROPHARYNGEAL SPACE
RPS is potential space between middle and deep layers of deep cervical fascia.Extends from base of skull to T4 level.At C6 level it goes more posteriorly and forms a danger space which communicates with mediastrinum.For practical purposes:- on imaging studies it is indistinuishable.
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NAIM MANHAS 26
RETROPHARYNGEAL ABSCESSNon- traumatic retropharyngeal abscess is very rare in adults
Retropharyngeal abscess alone occur in children from 6 months to 6 years of age.
Recent reports suggest that Necrotizing retropharyngeal abscess (NRPA) occurs in adults who are immunocompromised.
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NAIM MANHAS 27
Necrotizing Retropharyngeal Abscess
immunocompromised
Impacted foreign body
Odontogenic infectionTuberculosis of
cervical spine
trauma
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NAIM MANHAS 28
AIMEarly
diagnosis and prompt manageme
nt
Aggressive surgical
drainage and medical treatment
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NAIM MANHAS 29
Complications
mortality remains high because of occurrence of lethal complications :-
Acute Respiratory obstruction
Aspiration Pneumonia
Juglar Thrombophelibitis
Descending necrotizing mediastinitis1/21/2017
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NAIM MANHAS 30
case no.2
54 years old male presented to our E.R. with h/o difficulty in swallowing, breathing and bleeding per mouth.
Patient known case of diabetes and had h/o sore throat for six days for which he had taken medication from outside.
On examination patient was ill looking with mild dyspnea, but hemodynamically stable.1/21/2017
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NAIM MANHAS 31
CASE REPORT
Oral and laryngeal examination failed as oral cavity was fullof blood clots.
Urgent C.T. scan of neck was done which revealed widening of RPS with gas shadows
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NAIM MANHAS 32
RADIO - IMAGING
Coronal Plane C.T. scan NeckShowing Collection .
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NAIM MANHAS 33
Acute Respiratory Obstruction
Patient developed Respiratory Distress in E.R. and started desaturating.
Urgent laryngeal intubation was planned but failed due to non-visualization of larynx.
As patients condition worsened he was shifted to O.R. on laryngeal mask.
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NAIM MANHAS 34
AIRWAY
Airway established by surgical Tracheotomy
General Anesthesia induced through tracheotomy tube.
Retropharyngeal abscess drained along with necrotic tissue per oral approach
Hypopharyngoscopy and laryngoscopy done using rigid endoscope. 1/21/2017
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NAIM MANHAS 35
Surgical Drainage
Necrotic tissue found upto cricopharynx, but larynx was found normal.
Post operatively combination of pipercillin/Tazobactam along with clindamycin
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NAIM MANHAS 36
Day IV
•Follow up fiberoptic endoscopic examination
•Pharynx and Larynx :- revealed no residual abscess or necrotic tissue
Day V
•follow up C.T Scan neck•Contrast study of
pharynx
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NAIM MANHAS 37
Day XI to Day XIV Decannulation
Decannulation PlannedTracheotomy tube repalced by fenestrated one and closed.
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NAIM MANHAS 38
Day to Day Events during Hospitalization
Day XV :- patient developed acute Renal failure due to contrast induced tubular injury.Oliguria with rise in cretinine levels. Day XVI :- underwent hemodialysis
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NAIM MANHAS 39
Day to Day Events during Hospitalization
Follow up C.T. Was not possible because of contrast induced acute renal injury.
Contrast study by gastrograffin of pharynx .
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NAIM MANHAS 40
DAY OF ADMISSION AFTER DRAINAGE
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NAIM MANHAS 41
Day to Day Events during Hospitalization
Day XVII to day XXKidney function improved with adequate urine output and gradually decrease of cretinine levels.
Day XVIII :- oral feeding started
Day XXV :- Discharged.1/21/2017
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YOUR PRESENCE IS
HIGHLY APPRECIATED----THANK
YOU