Critical Cases

March 2021

  1. Major Surgery in Sickle and HIV +ve patient:  A middle aged male patient had to undergo Mandibullectomy, Neck Dissection and Reconstruction for Oral Cancer. The patient being sickle and HIV positive was additional risk. The risk for sickle is that major surgeries last for long duration and during this time there is cooling of patient and stasis of blood circulation in limbs. Both these factors predispose to sickling so extra precautions were taken to keep  the patient warm, use of stockings to prevent pooling of blood in lower limbs, maintaining oxygen saturation avoiding hypercarbia and to keep the blood pH alkaline. The problem with HIV was that these patients are already immune compromised and may not withstand a major surgery. For the staff the risk of HIV infection is higher in major surgeries because there is more bleeding, soakage of drapes and surgical grown, more surgeons involved so more chance of accidental transmission through sharp instruments. Use of drains is a potential threat due to chance of piercing by trocar. Our patient had a CD count so he was deemed fit for surgery with all universal precautions and PPE surgery was conducted smoothly without any problem.
  2. Parathyroid Adenoma : A middle aged lady presented with history of renal stones, investigations revealed elevated calcium ( ionic calcium- 1.41) and PTH- 287. Imaging revealed a left enlarged parathyroid adenoma. A small cervical incision open surgery was undertaken to remove the 3.5x3 cm adenoma. Pre- excision PTH -298, PTH from adenoma washing was 2500, and PTH 20 minutes after excision 26.8.
  3. Infrastructure Maxillectomy with laparoscopic excision of supearenal mass: A 65 yrs old lady had undergone excision of Ca palate at Neeti Clinics in 2013.Now in 2021 she had a recurrence. PET scan was done which showed a suprareval mass about 2x2cm in size.Suprarenal tumours if they secrete adrenocortical hormones they are known as pheochromocytoma and it can be an grave risk during surgery. As such patient gives history of sudden palpitation, tachycandia, rise in blood pressure, headache,sweating. During surgery and specially during handling of  the tumor there can be sudden release of adrenaline in the blood circulation leading to life threatening rise in blood pressure and arrhythmias. On investigation hormonal levels in our patient were normal so the mass not likely to be pheochromocytoma. However the patient gave history that in 2013 her surgery was postponed because on operation table she was found to have severe tachycardia. At that time on consultation with physician , we had given her Pre op B blockers and anxiolytics and operated success fully.But with this history and presence of the suprarenal mass, we were more cautious this time.Pre-op patients heart rate was around 120/min and BP 150/90.We gave ber B blocker and anxiolytic and on morning of surgery heart ratewas 69/min and BP 130/80.We gave her GA and lumbar epidural . In the same sitting general surgeon performed laparascopic excision of the suprarenal mass and then our surgeons performed infrastructure maxillectomy.
  4. Post operative chest infection after major Surgery : Recently almost all patients operated for major surgery found to develop post-operative chest infection most likely due to aspiration surgeons and anesthesiologists discussed the matter and have issued a set of guidelined to be followed during surgery and post operative period.
  5. Sinonasal Mucormycosis after covid infection- With second wave of covid 19 pandemic, sinonasal Mucormycosis secondary to the suppression of immunity caused by the virus is becoming a menace problem. We adopt a combined endoscopic and external approach for complete clearance of disease. To ensure safety  of medical and paramedical staff during this high risk procedure and patient safety, neeti clinics team has formulated a Comprehensive protocol giving weightage to severity of the mucor infection,covid affliction, general medical status of the patient. We have done 12 successful cases so far with no mortality/ morbidity at all.
  6. Retrosternal papillary carcinoma- 25yr/ female presented with an insconspicius thyroid swelling. Further investigations revealed papillary thyroid carcinoma with significant retrosternal component extending bilaterally upto the arch of aorta. Surgery was planned in collaboration with cardiothoracic surgeon for an SOS sternotomy standby. However after adequate mobilization the entire thyroid mass could be delivered transcervically. Patient also underwent bilateral central compartment and selective neck dissection. Post op vocal cord status was normal. Patient is now due on adjuvant RIA Dose.

February 2021

  1. Chondrometaplastic Nodule in Subglottic Region: This was a very unusual case of airway obstruction. Ours being recognised as a tertiary centre for airway management, a patient of failed intubation was referred to us by colleague ENT surgeon. This middle aged lady had been taken up for excision of thyroglossal cyst. She gave history of change in voice and off and on respiratory distress which was being treated as asthma. After induction of anaesthesia it was not possible to intubate the patient, so surgery was abandoned and patient was referred to Neeti clinics.We first did nasopharyngo laryngoscopy on the patient in OPD. It revealed a mass at the level of cricoids causing 80-90 % obstruction of tracheal findings. An elective Tracheostomy was performed under local anaesthesia and in the same sitting, direct laryngoscopy was done to assess the obstruction and obtain a biopsy. The histopathology report was “Chondrometaplastic Nodule”Later laryngofissure surgery was performed and mass removed in toto subsequently the patient will be decannulated.Literature search revealed that it is a very uncommon condition with only 250 cases reported worldwide.
  2. Injection Thyroplasty - A young female who had right vocal cord paralysis following a neck tumour surgery underwent thyroplasty. This surgery is done for voice restoration and swallowing rehabilitation by inserting a silicone implant in the paraglottic space to help approximation of the vocal cords
  3. Post operative allergic reaction: On first postoperative day a patient operated for Total Thyroidectomy and Neck Dissection suddenly complained of uneasiness and heaviness in chest .On Examination patients face was flushed  she had tachycardia and was complaining of chest pain and back pain and Sp02 94%. Immediate 12 lead ECG was done which was normal. However the patient’s clinical condition prompted us to take cardiologist opinion.2 DEcho and cardiac enzymes were all normal. Vigilant monitoring and timely alert by ward staff is to be appreciated. There was no cardiac event. Patient settled with IV steroids so it could be some severe allergic reaction.
  4. Squamous Cell Carcinoma in Nasal Cavity: A young lady had come to us 5 months back with loss of vision of short duration.Nasal endoscopy revealed inverted papilloma causing compression of optic nerve. Endoscopic surgery was performed and post operatively patient gained near normal vision. As inverted papillomas are known to turn malignant, patient later developed nasal mass which on biopsy showed small focus of squamous cell carcinoma.Neck dissection was carried out and the mass removed completely endoscopically.

January 2021

  1. Free Fibula Reconstruction -

A middle aged diabetes, hypertensive patient underwent Segmental mandibulectomy with bilateral neck dissection with free fibula reconstruction. Patient wound healed well and patient discharge day 6th.

  1. Parathyroid Adenoma -

A 39 yrs old female presented with Left Neck Swelling and elevated PTH levels. Investigation revealed Left Parathyroid Adenoma. The nodule was excised in TOTO with satisfactory stabilization of calcium metabolism in the post-op period.

  1. Maxillectomy -

An orbital plate preserving total maxillectomy was performed for Ca Maxilla. Dental prosthesis/ obturator were modeled and fitted on day 5. Patient was taking oral without regurgitation at the time of discharge.

4. Tracheo Esophageal Prosthesis presenting as Foregin body Esophagus - 

Misplaced TEP presenting as foreign body in esophagus was removed under anesthesia and a fresh well fitting TEP was successfully reintroduced for a long term Laryngectomy survival

DECEMBER 2020

1. PROVOX Insertion - A patient operated for laryngectomy 11years ago reported back in OPD with leakage and excessive granulation tissue around the long standing PROVOX (7yrs).The old indwelling PROVOX was removed in three bits as it was totally disintegrated. Granulation tissue around the TE fistula was fulgurated with laser and the fistula was allowed to shrink over 1 week. A new PROVOX 2 prosthesis was successfully inserted by anti grading method.

2. Pituitary Macro Adenoma –A middle age gentle man with history of cardiac diseases suddenly complained of vision loss and difficulty in moving eyes since one month. Imaging revealed a Pituitary Macro Adenoma. The tumor was dissected by endoscopic endonasal approach jointly with the help of a neuro surgeon. Immediately after surgery patient reported significant improvement in vision and good eye movement

3. Septorhinoplasty – An open approach augmentation septorhinoplasty was performed in a 17 yrs old female to augment the depressed dorsum of nose a rib cartilage graft was harvested and implant by open rhinoplasty technique.

4. Cochlear Implant- 3 prelingual children underwent CI surgery on 31.12.20.Neeti Clinics team along with visiting mentor surgeon from Mumbai successfully completed the procedure with good intraop neural response measurable in all

November 2020

1. Parapharyngeal mass- A middle aged lady presented with swallowing difficulty due to a right paratonsillar bulge. MRI revealed a parapharyngeal tumour probably arising from the deep lobe of the parotid. A paramedian mandibulotomy approach was used to access the tumour. Medial pterygoid muscle and tonsillar bed were dissected to resect the mass in toto. Final HP was pleomorphic adenoma

2. Retrosternal goitres- 3 retrosternal goitres grade 1/2 were operated upon in november . Two of them had superior mediastinal extensions and one had a tracheo-oesophageal groove extension. The recurrent laryngeal nerve was ventral to the thyroid mass. Neuro-monitoring technique was employed in these patients to confirm anatomical integrity and robust functioning of the nerve. 

3.Pituitary adenoma- A pituitary macroadenoma pressing on the optic chiasma and eroding the floor of sphenoid sinus was resected by an endoscopic trans nasal approach. This was a combined ENT and neurosurgical team surgery. The resection was satisfactory and there were no post procedure complications 


4.Sudden vision loss- A young male patient presented with sudden vision loss since two days. Per-op vision was hand movement at 3feet (1/60). His CT scan PNS revealed a soft tissue thickening in the maxillary and ethmoid sinuses. He was taken up for an emergency sinonasal endoscopic surgery. During the surgery we found a polypoidal proliferative mass lesion extending into right maxilla, ethmoid, sphenoid going suspiciously into orbital apex region. Piecemeal macroscopic R0 resection was achieved. There was a dramatic improvement in vision with complete recovery 6/6. Final HP was inverted papilloma without any signs of dysplasia or invasion. 3.Pituitary adenoma- A pituitary macroadenoma pressing on the optic chiasma and eroding the floor of sphenoid sinus was resected by an endoscopic trans nasal approach. This was a combined ENT and neurosurgical team surgery. The resection was satisfactory and there were no post procedure complications 

 

 

 

October 2020

1. Maxillary Aspergillosis- A diabetic middle aged gentleman underwent radical clearance of the maxillary sinus for suspected fungal pathology. We also marsupalised the lower end of the nasolacrimal duct. Lateral rhinotomy sublabial approach was used.

2.Laryngectomy- The most dreaded and risky operation in COVID era is a laryngectomy. A tracheostomised patient with transglottic malignancy underwent total laryngectomy with partial pharyngectomy and B/L selective neck dissection. He healed well and starting oral feeding on day 14.

Oral cancer surgery in COVID- 19 survivors- 3 patients who had contracted COVID-19 during their work up for oral cancer were operated 4 weeks after their COVID affliction. Patients underwent RTPCR, CT chest, D dimer and CBC, CRP tests to ascertain full recovery from novel Corona virus infection before they were taken up for oral cancer surgery. For all patients, the surgery and peri-operative period went smoothly and they recovered well.

3.Locally advanced oral cancer - A T4b buccaneers cancer with high infra- temporal fossa (ITF) involvement underwent compartment resection of the buccal mucosa, upper and lower alveolus and the ITF tissue. There was 200 ml blood loss. Wounds healed well and patient started oral feeding on day 4 of surgery.

 

September 2020

Locally Advanced Thyroid Cancer: - A young female presented with a unilateral papillary thyroid cancer. There was infiltration into the strap muscles and recurrent laryngeal nerve was completely encased and invaded by tumor for a 2cm long segment at the crossing of the inferior thyroid artery. Total thyroidectomy with    RLN sacrifice with immediate neurorrhaphy was done along with extensive central compartment and superior mediastinal nodal clearance and modified lateral neck dissection.

Buccal Composite reaction with High ITF clearance: - A T4a  buccal cancer with extension into the ITF with erosion reaching the pterygoid plates received a composite resection with posterior segmental mandibulectomy with maxillectomy with pterygoid plate removal ensuring a RO resection.

Major Head and Neck Onco surgery in a CORONA recovered patient: - 6 months into the Covid pandemic we are now seeing patients who had been covid infected.

There are multiple challenges in conducted major Head and Neck surgery on a patient who had been affected by Covid.

  1. The infection might have caused lung fibrosis in the patient
  2. Since the immunity of the patient is affected, he has higher chance of catching any infection and his body may not be able to cope with the stress of surgery and anesthesia.
  3. Covid increases thrombogenicity of the patient and as such malignancy has a thrombotic effect so these patient have higher chance of having thromboembolic  episodes
  4. Patients requiring Tracheostomy have high aerosol generation which may infect surgeons, anesthesiologists or nursing staff attending on such patients if they continue to shed virus
  5. Tracheostomy also makes the patient himself highly susceptible to infection If there is covid re-infection in such patients it carries a very high mortality.

Our patient was 62 yrs old known hypertensive who had been covid positive. He had to undergo wide excision of Ca Buccal mucosa, tonsillolingual sulcus, retro molor trigone, segmental mandibulectomy neck dissection and PMMC. We took the following precautions for his surgery.

  1. We waited for 6 weeks since his was Covid infection.
  2. CT chest was checked to rule out pulmonary fibrosis
  3. Inflammatory markers were checked to rule out any active inflammatory process and increased thrombogenecity.
  4. RTPCR was checked for patient and relative and isolated 5 days before surgery as is our current protocol.
  5. During isolation SPO2 was checked 3 times a day after 7 min walk
  6.  We used our special chamber for nursing care and monitoring of the patient post operatively while he had Tracheostomy.
  7. On first post op day, on checking patient’s mouth opening and tongue movement, tracheotomy tube was removed and patient was observed for one day in recovery room before shifting to ward.

With all these precaution patient has made uneventful recovery.

 

July 2020

           1.Sinonasal undifferentiated carcinoma-

           A young gentleman with stage 2 sinonasal undifferentiated carcinoma underwent endoscopic medial maxillectomy with skull base clearance. This obviated the           

          morbidities of open surgery. We also did lacrimal duct marsupalisation to prevent epiphora post op.

 

         2.Complicated sinusitis-

        A young 10 year old boy had sudden onset fever rhinitis and swelling of the eye. CT scan revealed complicated sinusitis. He was operated by endoscopic surgery under 

        the cover of antibiotics.

 

        3.Carotid body tumour- A young female diagnosed with right parapharyngeal schwanomma underwent excision by combined trans- cervical and mandibular split 

        approach. It was a vagal schwanomma extending up to the skull base, approximately 10cm in largest dimension. Patient experienced temporary vocal paresis but no 

         aspiration or difficulty in breathing, swallow functions were normal at the time of discharge and voice showed an improving trend by post op day 5.

 

June 2020

  1. Elderly patient for Left Maxillectomy :

An elderly patient underwent Maxillectomy with Neck Dissection. The surgery lasted 5 hrs but the patient took 1 ½ hrs to recover from anesthesia. All the vital parameters were normal but patient took very long time to regain consciousness. Eventually made completely normal recovery. The only possible reason could have been Hypothermia in the patient specially because of the excessive cooling required in OT due to everyone wearing COVID PPE. Since then we have made it a practice to regularly monitor temperature of patients undergoing prolonged surgery and we also take all measures to keep the patient warm.

 

 

  1. Normal revival of unresponsive patient: An obese elderly gentleman, diagnosed case of Ca Larynx presented with strider. Emergency Tracheostomy was performed under LA and patient was being monitored in recovery room with oxygen support. 2 hrs after surgery patient suddenly became unresponsive. CODE BLUE was called and with immediate CPR patient was completely revived.

 

  1. Epiglottic growth in a patient with failed intubation: A male patient was taken for Direct Laryngoscopy Biopsy at another hospital but the procedure was abandoned as patient could not be intubated. We performed the procedure under bilateral superior laryngeal nerve block with sedation .We could also assess his larynx for possibility of intubation if required and it was found to be feasible.

 

May 2020 

  1. Deep Neck Space Infection with Necrotising Fasciitis: An elderly patient presented with rapidly increasing neck swelling .He was toxic and gave no history of dental infection. CT neck done elsewhere showed multiple airs filled loculations. Diagnosis of Deep Neck Space Infection was made. Patient also had uncontrolled diabetes and in this situation the infection carries 93% mortality risk. Urgent exploration with multiple incisions and Dalcim Inj patient recovered well.
  2. Mucormycosis: A diabetic lady with black discoloration of gems with history of dental extraction and severe fever pain not responding to treatment was referred to us from Amravati. Instant clinical diagnosis of Mucormycosis was made. This condition carriers mortality risk of 95 %. Patient was given IV antibiotics and antifungal treatment. She underwent emergency wide excision of lesion amounting to infrastructure maxillectomy. Patient was given Lyophilized Amphotericin IV which is very expensive. But arrangements were made for her to obtain it at 1/3 cost. This treatment has to be given for 21days.She required 2 more debridement surgeries but ultimately made good recovery. Patient was sent back to Amravati after 21 days on oral anti fungal treatment

April 2020 

  1. Neeti Clinics took up the challenge of operating during the Covid Pandemic on 9th April we conducted the first surgery on a patient with oral cancer. All the surgeons, anaesthesiologists, OT technician scrub nurse and domestic were provided full PPE kit. All the recommended donning and doffing protocols were followed

March 2020

  1. Trismus Surgery Neeti Clincs is a known centre for surgery of Trismus due to Oral Submucous Fibrosis. Dr Madan Kapre is a pioneer in this field in India. He has also authored a book on this subject. A patient came to us all the way from Assam for this surgery.
  2. Reaction to Blood Transfusion A middle aged lady underwent major surgery for oral malignancy. On 3rd post operative day she was administered blood transfusion due to low Hb. After half an hour patient complained of uneasiness and saturation dropped to 90% with O2. Patient found to have bilateral rhonchi. Transfusion was discontinued immediately and reported to the blood bank. Patient was given iv steroids and nebulisation with bronchodilators.With this patient settled but then developed tachycardia 150-160/min alongwith ST segment elevation. For further management she was shifted to cardiac care centre. There was no evidence of myocardialischemia.Vigilant monitoring and timely intervention avoided any complication.
  3. Cochlear Implant Surgery Two girls about 2-3 yrs age underwent Cochlear Implant surgery. Dr Harsh Gupta and Dr Gauri conducted the surgeries independently under the guidance of Dr Kirtane Sir.
  4. Ca Mandible with Free Fibula Flap A young patient with Ca alveolus was operated and reconstruction done with Free Fibula Microvascular Flap. Challenge was that the patient’s pre operative Hb was 23gm%. Blood letting was done 3 times at intervals in the pre operative period. There was no problem with the microvascular anastamosis.

Febuary 2020 

  1. Unknown Primary- A 62 year old male patient presented with large neck nodal mass encasing carotid and involving IJV with tumour thrombus. Radical neck dissection was done with minimal blood loss and patient was discharged on post op day 5.
  2. Tracheal Resection And End To End Anastomoses- A retro-virus positive patient well controlled on ART presented with a long standing tracheostomy. Her CD4 counts were reassuring and she had no other immuno-compromised state conditions. She had tracheal stenosis involving 5-6cm length of trachea and roughly 5cm above the carina. She underwent tracheal resection with end to end anastamosis. She is phonating well on speech valve tube inserted at the defunctioning tracheostomy and awaits check airway assessment to decide plan of decannulation..
  3. Parathyroid Adenoma- A 58 year old female known diabetic and hypertensive had history of multiple fractures. PTH was 343. Serum Calcium was 11.2. She was diagnosed with left inferior parathyroid adenoma. We performed minimally invasive parathyroidectomy with intra-operative nerve monitoring. Post excision PTH level was 16pg/ml.
  4. Haemangiopericytoma- A 68 year old gentleman presented as a diagnosed case of right parapharyngeal mass encasing carotid <1cm from the base of skull situated in the high infratemporal fossa. We approached the lesion with a mandibulotomy approach, achieved in toto resection without requirement of blood transfusion and without neural or vascular injuries. Final HPR was haemangiopericytoma.
  5. Revision Neck Dissection for Thyroid Carcinoma- A young female was operated for hemi thyroidectomy two years ago, final histopathology was papillary carcinoma thyroid. She then underwent completion thyroidectomy with bilateral neck dissection. 3 months ago she again developed right sided level II nodal mass. We performed revision right comprehensive modified radical neck dissection. Nodal mass was continuous with thyroid bed recurrence and was abutting tracheal wall, pharynx and carotid artery laterally. R0 resection was achieved.

January 2020 

1.LASER EPIGLOTTECTOMY: A middle aged gentleman presented with a supraglottic squamous cell carcinoma on the free edge of the epiglottis. After careful review of the imaging and examination under anesthesia, it was staged at crT1N0. It was amenable to LASER excision. Same was performed withadequate margins.

2.ANGIOFIBROMA: A young adult male presented with epistaxis. He was diagnosed to have a nasalmass extending into nasopharynx and sphenoid sinus, alongwith a bleeding disorder. After stabilization of the haemodynamic parameters, Endoscopic excision of the mass was achieved with coablator without embolization and with minimal intra-operative blood loss. He did not require blood transfusion and was discharged on day 3.

3. Large thyroids: This month saw a series of patients with large thyroid swellings, both benign and malignant. The average size of the nodule was 8cm. These surgeries require a perfect coordination between anaesthesia and surgical team. Awake intubation is a technique we practice for very large swellings with severe distortion of the airway. Intra-operative nerve monitoring is employed in difficult cases. Sternotomy standby preparation is done for masses reaching upto arch of aorta. However, all 8 cases this month could be safely managed by transcervical approach. None of them had neural palsy and none had clinically significant hypo-parathyroidism.

December 2019

1. Sinonasal carcinoma- A young girl was detected to have a large mass involving the ethmoid sinuses without intracranial or intra-orbital extension. She underwent open fronto-ethmoidectomy with suprastructure maxillectomy through a Weber Fergusson approach.

2. Nerve monitoring- During the thyroid master class, we demonstrated two thyroid surgeries with intra-operative nerve monitoring. Both of these were thyroid cancers with central compartment and lateral compartment neck dissections.Cochlear implant- We performed two consecutive cochlear implant surgeries under the mentor ship of Dr Kirtane. Both children healed well and are scheduled for switch on next week.

3. Thyroid surgery- We performed 20 thyroid surgeries within one month. The international norms of a high volume thyroid centre are one that performs more than 50 thyroid surgeries in a month! Fortunately, none of the patients suffered any morbidity. No neural paresis, only one patient had symptomatic hypocalcaemia (she had extensive central compartment lymph nodal burden). She was discharged on day 4 on oral calcium and vitamin D supplements.

November 2019

1. Collision tumour-A patient with thyroid nodule and lateral nodal metastasis was diagnosed as medullary carcinoma thyroid.He underwent total thyroidectomy with bilateral central compartment and lateral compartment neck dissection. Both vocal cords were mobile and patient did not require calcium supplements. Final Histopathology was medullary carcinoma with focus of papillary carcinoma thyroid. This is a very rare entity called collision tumour.

2. Kikuchi disease- A young girl presented with cervical lymphadenopathy. The FNAC was suspicious for lympho proliferative disorder. Excision biopsy of the node revealed pathological diagnosis of Kikuchi disease. This is a rare type of histiocytic necrotising lymphadenitis. Surgical resection is curative and diagnosis is often IHC dependent.

3. Parotid with nodes- A young boy with hard parotid swelling presented with FNAC suggestive of adenoid cystic carcinoma. He underwent total conservative parotidectomy with modified neck dissection. The nerve was encased by tumor, but we were able to achieve R0 resection and patient had normal eye functions post-op.

 

Octomber 2019 

1.Cochlear implant-  Two young children who were congenitally hearing impaired underwent cochlear implant surgery on 4th October. Dr.Gauri Kapre Vaidya and Dr.Harsh Karan Gupta performed these surgeries under the mentor ship of  Dr. Milind Kirtane sir.

2.Masseteric cysticercosis- A middle aged female presented with complaints of decreased mouth opening, external cheek swelling. She had been taking antibiotics for long without relief and there was a suspicion for malignancy. However the clinical and imaging findings prompted us a diagnosis of masseteric cysticercosis. She underwent a wide local excision of the lesion; his to pathology report confirmed the same.This is the third patient to be treated for this rare condition at our hospital in the past three years. A publication towards the same has been submitted to Indian Journal of Otolaryngology and Head and neck surgery.

3.Juvenile laryngeal papillomatosis- A young boy presented as follow up case. Papillomas could be successfully removed in toto from subglottis and trachea and glottic web LASER excision and dilatation was done.

4. Migratory foreign body with neck space infection-A diabetic lady gives history of mutton bone ingestion followed by dysphagia and pain. She presented with a deep neck space infection. Exploration revealed a perforation in the pyriform fossa and a deep neck parapharyngeal abscess. After adequate surgical addressal, patient is now being managed conservatively with dressings, strict diabetic control and culture specific antibiotics.

September 2019  

Huge Goiter: - A 65 years old lady presented with a huge thyroid enlargement which had progressively increased over last 20 years. Such large goiters present risk during induction of anesthesia because of difficulty in bag mask ventilation, weight of the gland compressing the trachea and difficult intubation.

Surgically the challenges are distorted anatomy, increased vascularity and higher chances of injury to recurrent laryngeal nerve and parathyroids. There is also chance of tracheomalacia which may lead to airway compromise postoperatively. However with due planning, the induction of anaesthesia and intubation was smooth. Surgery was performed with minimal blood loss, no injury to recurrent laryngeal nerve or parathyroid. Postoperatively patient’s voice was good and she had no calcium deficiency.

 

July -August 2019 

1. Angiogibroma- A 14 year old boy presented with extensive Angiofibroma extending into the pterygopalatine and infratemporal fossa. He underwent embolization followed by resection using combined endoscopic and open approach (lateral rhinotomy). Total blood loss was 150ml and patient did not require any blood transfusions. He was discharged on post-op day 3.

2.Parapharyngeal Mass- A 31 year old female presented with right peritonsillar bulge. Imaging revealed a neurogenic tumour in right parapharyngeal space. Lateral mandibulotomy approach was employed to ensure complete in toto resection.

3.Trismus Release- A 19 year old boy presented with grade IV trismus with  absolutely nil mouth opening . Inspite of this nasal intubation was possible in this patient. He had been consuming tobacco for 10 years. Bilateral trismus release with coronoidectomy and platysma flap was performed and post-op mouth opening was 4.5 cm .

4.Parotid Cancer- Total Parotidectomy with modified radical neck dissection was performed for a high grade muco-epidermoid cancer. The superior division of the nerve was preserved, however the inferior division was engulfed by the disease so it had to be sacrificed. Greater Auricular  Nerve grafting and repair was performed for the same.

5.Osler Weber Rendau Syndrome-A severely anaemic lady presented with epistaxis. She had undergone multiple procedures including a maxillary artery embolisation for this complaint. A septodermoplasty was performed using the split thickness skin graft. Patient is doing very well post-op with no fresh episode of nasal bleed.

6. Total Thyroidectomy- A 65 year old gentleman with history of ischaemic heart disease and CABG done presented with a large multinodular goitre, FNAC- Bethesda IV follicular neoplasm. Intubation was tricky in view of gross supralaryngeal compromise and tracheal compression. Total thyroidectomy with central compartment exploration was performed. Thyroid tissue was extending into the tracheo-esophageal groove with encasement of the recurrent laryngeal nerve. Bilateral recurrent laryngeal nerves and parathyroids were preserved. He had normal voice post-op and didn’t require any calcium supplements.

7. Glomus Tympanicum- A middle aged female was operated for Malignancy of Right Ear Glomus Tympanicum. Inspite of radiology dispersing all claims of Glomus, clinical suspicioun helped to prepare and remove the lesion completely without much intra-operative blood loss or need for blood transfusion post-op. Histopathology eport confirmed our conviction .Patient is doing well and is on regular follow up.Clinical suspicioun helped to clinch the diagnosis inspite of conflicting imaging findings. The lesion was excised in toto without requirement of any post-op blood transfusion. Final histology proved our clinical diagnosis right. Patient recovered well without any  sensorineural hearing loss or vestibular dysfunction. 

May and June 2019

 

1.Triple pathology: A 42 year old gentleman presented with right lateral border tongue carcinoma. His CT scan revealed two more separate lesions- a upper alveolar cortical cyst and a false vocal cord vestibular cyst. All three lesions were addressed on their own merit each requiring a different approach. Patient recovered well. We were able to salvage his dentition with single sitting root canal treatment.

 

2.Ameloblastoma: A young severely anemic female came with a large paramandibular mass. She underwent a hemimandibulectomy with neck dissection with peri-operative blood transfusions. She was discharged on the 6th day and was comfortably swallowing by then. Her final HPR was amelobalstoma.

 

3.Revision Thyroidectomy:  

a. An elderly diabetic, hypertensive, gentleman with history of ischemic heart disease had undergone a total thyroidectomy 2 years ago at Chandigarh for papillary thyroid cancer. He had a recurrence since 6months that was not responding to radio-iodine and surgery was declared not possible at his native place in view of close proximity of disease to recurrent laryngeal nerve, trachea and carotid artery. We did a PET scan and found a large thyroid bed recurrence with central compartment nodes. He underwent revision surgery without any damage to his recurrent laryngeal nerve or parathyroid glands.

b. A young girl underwent a nodulectomy at her native place and HPR revealed papillary thyroid cancer. She was referred to us for revision/ completion thyroid surgery. Amidst the post-op fibrosis of her recent surgery we were able to do total thyroidectomy with central compartment neck dissection and ipsilateral lateral compartment node clearance. Voice was normal post-op. She had temporary hypocalcaemia which was managed conservatively and is now free of symptoms and awaiting adjuvant RAI treatment.

 

4.Cochlear implant- A 2 year old boy underwent cochlear implant surgery by Dr Harsh Karan Gupta under the guidance of Dr Milind Kirtane sir. The surgery went very well. Switch on was performed today and the response was very good. The child will now undergo auditory verbal therapy and will soon begin to hear and speak.

 

5.Tracheo-tracheal resection and anastomosis- A patient of oral cancer underwent a peri-operative tracheostomy. However, he could not be decanulated after completion of his oral cancer treatment. Fifteen years later, he remained completely disease free however had developed tracheal stenosis due to long standing tracheostomy. We performed tracheal resection with end to end anastomsis two months ago, and last week airway assessment revealed normal airway. Therefore he was decannulated after two days of hospitalization and observation.

 

6.Tracheo-esophageal fistula: A 20 year old boy developed a tracheo-oesophageal fistula during tracheostomy performed elsewhere. After thorough work up and assessment, he underwent fistula repair by primary closure and vascularised sternohyoidmuscle flap. He is recovering well. He is eating solids orally. He is phonating well and is now under intermittent trial of tube blockage. Decanulation will be planned after 2 months.

 

7.Neuro-endocrine carcinoma: A young man was diagnosed with stage 3 high grade neuro endocrine carcinoma involving ethmoid sinuses. He underwent 2 cycles of neo-adjuvant chemotherapy followed by open fronto-ethmoidectomy. He is recovering well.

April 2019:

Medullary Carcinoma Thyroid: A large Multinodular Thyroid swelling approximately 12 cm in largest dimension with lateral nodal metastasis underwent total Thyroidectomy with bilateral central compartment and lateral neck dissection.There was good nodal yield on the central compartment nodes and patient was normocalcemic without requirement of calcium supplements.


Parotid Malignancies: 1.An adult female underwent Total Parotidectomy and neck dissection for adenoid cystic carcinoma.
2.A young boy underwent Total Parotidectomy with neck dissection for Mucoepidermoid Carcinoma.Both these patients required sacrifice of  lower division of facial nerve.However immediate intraoperative neurorhaphy was performed with cable grafting.Both patients had normal facial function post operatively.


Large multinodular goitre:-A middle aged lady presented with a large Multinodular Goitre largest dimension 16 cms.Intubation although challenging ,could be successfully performed in single attempt with bougle guidance.Intra-operative nerve monitoring was used.Post-op patient had normal vocal cord function and no hypocalcaemia.


Free Fibula reconstruction:-An obese middle- aged gentleman underwent free fibula reconstruction for a lower alveolus malignancy.Strict ambulation protocols and anti-DVT protocols were followed.Patient was discharged on post op day.At the time of discharge he was phonating and swallowing well.

February and March  2019

Glomus Tympanum: A young female presented with a large vascular mass in the tympanic cavity behind the ear drum. Imaging clinched the diagnosis, In toto surgical excision could be accomplished.

Cordectomy : A 72 yr old gentleman presented with T2 vocal cord carcinoma. He underwent LASER type IV cordectomy with clear resection margins. He had no aspiration and voice is recovering satisfactorily.


Injection Laryngoplasty: A middle aged male with spasmodic dysphoma underwent office based procedure of BOTOX injection laryngoplasty. This was his second injection & he is very satisfied with the voice quality.


Angiofibroma: Grade III was excised by endoscopic approach. He has received pre – operative embolization. There was only 150 cc blood loss. He did not require any post op blood transfusions.


Nasal Mass: A 68 yr old gentleman presented with a right sided nasal mass extending into maxilla with erosion of floor of the orbit. Mass was excised via lateral rhinotomy approach & was successfully excised in toto. Floor of orbit was reconstructed with nasal septal cartilage and fascia lata mesh composite graft.


Intra operative Nerve Monitoring : Neeti Clinics has acquired NIIM Machine for Intra Operative NerveMonitoring during Thyroid Surgeries. In the past 2 months, we have performed 12 Thyroid and 2 parotid surgeries using the IONM techniques. This method allows us to precisely map the anatomical location & monitor functioning of the nerve during surgery.

 

Jannuary 2019

Vallecular cyst: A 60 year old gentleman who was a known case of liver cirrhosis and thrombocytopenia presented to the OPD with complaints of dysphagia and foreign body sensation in the throat. He was diagnosed to have a large vallecular cyst. He required multidisciplinary care. Platelet transfusions were administered peri-operatively according to guidelines. An elective tracheostomy was performed. Cyst was excised by LASER. At the time of discharge patient was decanulated with excellent speech swallow outcomes.

Multinodular goitre: A middle aged female underwent total thyroidectomy for a large multinodular goitre, largest dimension 12 cm. She had comorbidities of obesity poorly controlled diabetes and hypertension. She recovered well with no requirement of calcium supplements and good voice.

Oral cancer: A 42 year old gentleman was diagnosed with T4bN1M0 buccal mucosa cancer. There was disease extension into the masticator space. A thorough infra-temporal fossa clearance along with bite composite resection was performed.

Angiofibromas: Two very challenging and extensive stage III angiofibromas were performed endoscopically. One of them underwent ore-operative embolisation and the other underwent an elective intra-operative external carotid ligation. None of them required conversion to open approach. Both patients were discharged on the third post-operative day.

 

 

 

December 2018

Schwanomma : A young male presented with a left cervical schwanomma abutting great vessels with approximately 180 degree encasement. The surgery was successfully performed without any major blood loss or vessel or nerve damage. Patient has slight hoarseness of voice but is recovering well.

Carotid body tumour: A middle aged female presented with Right carotid body tumour extending superiorly up to the jugular foremen encasing the carotid -270 degree and engulfing all major nerves. Mass was excised uneventfully without any great vessel compromise. Patient is recovering well.

Parotid cancer- Adenoid cystic carcinoma parotid was operated for total parotidectomy with modified radical neck dissection. Patient did not suffer any facial weakness. He is now awaiting adjuvant treatment and healing well.

Thoracic mass- A large retrosternal goitre was operated at PK Deshpande hospital. The swelling was reaching up to the arch of aorta and brachiocephalic vein causally. We could approach the entire swelling trans cervical without need for sternotomy. Patient has both vocal cords functioning and no hypocalcemia post-op.

November 2018

 

Cochlear Implant: In a first ever in Neeti Clinics, 3 Cochlear Implant surgeries were done back to back. Dr Harsh Gupta and Dr Gauri Kapre Vaidya were the operating surgeons under the mentor ship of Dr Kirtane. One of these patients was a post-lingual hearing challenged adult. Switch ons were performed for all three patients with satisfactory results.

Unknown primary: An elderly female presented with large lateral nodal mass. It was diagnosed unknown primary. Modified radical neck dissection was performed preserving all important structures and no functional morbidity. It was a poorly differentiated/ anaplastic tumour. IHC is being processed for same.

 

Trismus surgery: A young adult male underwent Trismus Release Surgery. He had travelled all the way from Gujarat to undergo surgery here. Two surgeons had also specially traveled from Gujarat to witness the surgery and learn the technique.

 

October 2018

Total Thyroidectomy with central compartment clearance:-A young unmarried female underwent total Thyroidectomy with central compartment clearance for proven papillary carcinoma thyroid.She had good voice and serum calcium postoperatively.

 

Total Type 3 Cordectomy: Trans muscular cordectomy was performed by laser for a mid vocal cord mass.Patient had satisfactory voice post op.

 

Botox injection for spasmodic Dysphonia: A case of Adduction spasmodic dysphonia ,ADSD,underwent Botox injection in B/L vocal folds under flexible laryngoscopic  vision.By doing Botox under FOI guidance we have tried to eliminate the need of an EMG which causes extra cost to the patient.Neeti Clinics is the only centre in Central India offering this treatment for SD patients

September 2018

Carotid body tumour  - A Type III Shamblin’s paraganglioma was operated. Both the external and internal carotid artery was more than 1800 encased by the tumour. The patient had negligible blood loss and no neurological-deficit

                

Kartagener’s Syndrome with Sickle Cell Trait – A young lady with Kartagener’s syndrome was operated for Functional Endoscopic Sinus Surgery (FESS). In Kartagener’s Syndrome patients have Dextrocardia, Situs Inversus and Mucociliary dysfunction. Patients suffer from Bronchieactasis, repeated chest infections. In this case additional challenge was the patient being sickle cell positive. Pre operatively patient was prepared with antibiotics, decongestants and chest physiotherapy for the Kartagener’s syndrome. She was given Folic acid, Steroids and Sodamint tablets for her sickle cell trait. During surgery due care was taken to maintain oxygenation, good hydration and to avoid hypothermia. With all the necessary precautions the surgery and post of recovery of the patient was uneventful. 

August 2018

1.Cochlear Implant: A 7 year old child who was already an implantee on one side underwent cochlear implant surgery for the opposite ear. Surgery was performed very smoothly by Dr Harsh Karan Gupta under the guidance of Dr Kirtane sir.

2.Tracheal Resection and end-to-end Anastomoses: Two patients of tracheal Resection with end to end Anastomoses were assessed by follow up endoscopic assessment. A young 28year old boy could be successfully decannulated. A middle aged lady with multiple comorbidities was shifted to T-tube. She was breathing and phonating well on discharge.

3.Substernal goitre: A Large Mutlinodular 14 x10cm in dimensions with retrosternal extension was operated by cervical approach. He had normal vocal cord functioning and was normocalcaemic in post-op period.

4.Nasopharyngeal Carcinoma: An OPD patient came with complaints of diminished hearing since 1 month. He had consulted many ENT surgeons and was managed conservatively. A Puretone Audiogram revealed unilateral moderately severe mixed hearing loss. An astute decision by the audiologist to do impedance audiometry for a meagre 15db conductive component revealed Ctype curve. On this suspicion we did a Nasopharyngoscopy that revealed a Nasopharyngeal Carcinoma

June & July  2018

  1. Cricotracheal Resection + Thyrotracheal AnastomosisFollowing organophosphorous poisoning a 26 yr male patient had post intubation tracheal stenosis. The stenotic segment was 3 cm in length extending from C5-C7  level causing near complete luminal narrowing. The stenotic segment was excised and anastomosis achieved between lower end of thyroid cartilage and 4th tracheal ring.
  2. Sub glottis Foreign Body A 4 yr old girl presented with 6 months history of sudden onset hoarseness of voice and difficulty in breathing. Hopkins rod examination in OPD revealed papillomatous growth in Larynx and provisional diagnosis of juvenile recurrent Laryngeal papillomatosis was made. She was posted for Co2 LASER vapourisation of the papillomas. However CT scan revealed a foreign body vertically placed in the tracheal in subglottic region. The child was referred to pediatric surgeon Dr. Rajendra Saoji. Following morning the patient developed respiratory arrest and emergency tracheostomy had to be performed. Dr. Saoji did direct laryngoscopy under general Anaesthesia and attempted to remove the foreign body endoscopically but could not dislodge it .Open surgery was planned for a later date. On that day under anesthesia, direct laryngoscopy was done to begin with. Surprisingly no foreign body was seen. The only explanation possible was that during attempt at endoscopic removal the foreign body might have been slightly dislodged and later coughed out by the child. She was later decannulated uneventfully.
  3. Endoscopic CSF leak repair: A 42 yrs old female patient presented with CSF leak leading to watery discharge from the nose. The leak was from right cribriform plate. Endoscopic repair was done with fascia lata and medical glue.
  4. Glomus Tympanicum A 45 yrs old female patient was operated for right ear by Dr. R. B. Deshmukh , Dr. Abhishek Vaidya and Dr. Prashant Naik by post aural approach. Near complete excision was achieved with minimal blood loss.The patient was morbidly obese with diabetes and hypertens which posed anaesthesia related high risk issues. The surgery lasted 6 hours and the patient was discharged the next day.

May  2018

  1. Tracheal Granulations- A middle aged female had post extubation breathing difficulty. She had granulations polypoidal lesions in her trachea above the level of carina. These were successfully removed by joint team work of Dr. Rajendra Saoji, Dr. Vikrant Deshmukh. Anaesthesia management was very critical in this case where intubating bronchoscope along with intermittent apnea technique was used. Dr. Vidula Kapre & Dr. Latika Panpaliya approved anaesthesia team.
  2. Base of Tongue- A 74 year old gentleman had base of tongue cancer with bilateral cervical nodal metastases. The base of tongue lesion was removed with safe margins using LASER. He also underwent bilateral modified radical neck dissections. His wound healing is now satisfactory.
  3. Carotid Body - A young gentleman had right sided carotid body tumor Shamblin’s type II with >1800 encasement & indentation of internal carotid artery. The entire tumor was excised with minimal bleeding. His post operative recovery was satisfactory.

  

4.CSF leak- A middle aged lady suffering from diabetes & hypertension had CSF rhinorrhoea on the right side. She had flown down from Pakistan for her surgery- endoscopic repair of CSF Leak.

5.Choanal Atresia - A young 16 year old girl was suffering from recurrent mucoperulent discharge from right nostril. Nasal endoscopy revealed & complete blockage of post nasal passage on that side. Endoscopic removal of body & mucosal blockage was performed.

6.Thyroid – We had 19 thyroid surgeries within a single month at Neeti Clinics.

April 2018

  1. Angiofibroma-A stage III Angiofibroma was operated via endoscopic approach. Patient was non-affording for embolization so the external carotid artery was ligated before the start of excision. Patient was consented for sos conversion to open approach. However, it was successfully completed in toto through endoscopic approach. Patient recovered well and went home after pack removal on the fifth day.
  2. Laryngectomy- Three total laryngectomies were performed within a month. All three patients healed well and were able to take fluids orally by their first follow-up visit. They are receiving voice rehabilitation through electrolarynx (Two were non-affording, one was not a good candidate in view of his coexisting COPD)
  3. Juvenile laryngeal papillomatosis- A young child has been under our treatment in the past 1 year for papillomatosis. He has undergone 22 surgical procedures so far. He unfortunately has tracheobronchial type of papillomas which is the most difficult to cure completely and takes the longest to decannulate.
  4. Spectrum of cases- We operated 9 thyroids, 3 parotids and 1 parathyroid.The thyroids were ranging from a large multinodular goiter with retrosternal extensionto a hemithyroidectomy for a small 2cm unilateral solitary thyroid nodule.All three parotid surgeries were superficial parotidectomies, one of which was a revision surgery for three times recurrent pleomorphic adenoma. None of the patients had a facial nerve injury.Parathyroid adenoma was operated at Trinity hospital with the aid of intra-operative PTH monitoring. The 20 minutes post excision reading was nearly less than 1/10th pre-operative values.

 

March 2018

  1. Awake oral intubation- A young adult patient had been operated for ca buccal mucosa elsewhere and had already received Radiotherapy. He was posted for excision of recurrence in parotid lymph nodes Apart from difficulties posed by previous surgery and RT, patient had an anatomically difficult airway.Awake intubation was planned for this patient since the surgery involved maxilla, nasal intubation was not possible.The airway was anaesthetized and decongested with xylocaine adrenaline nasal pack, alongwith 4% xylocaine nebulization and superior laryngeal nerve blocks. In addition, spray as you go technique was employed to anaesthetize the larynx. Laryngoscopy provided minimal view of larynx. FROVA was introduced, its position in trachea confirmed by ETC02 and oral endotracheal intubation performed over the FROVA.
  2. Non-recurrent laryngeal nerve: This is a condition that is extremely rare 0.2% of all thyroid surgeries. We saw two back to back cases of this condition during total thyroidectomies. The surgical skill lies in identifying and preserving these atypical nerves to avoid post-operative nerve weakness and voice changes.

     

3.Thyroid micro-carcinoma: A middle-aged gentleman was suffering from ca buccal mucosa and was operated for wide excision with neck dissection. His final histopathology revealed metastases from thyroid cancer in the cervical lymph nodes. Several months later, we could convince him for thyroid surgery and completion neck dissection. It was a difficult operation because of post-op fibrosis and chyle leak changes from previous surgery.

4.Parathyroid adenoma: A middle aged lady had complaints of bony pains was diagnosed to have parathyroid adenoma. Her pre-op PTH was 269ng/ml. Intra-op washings from excised specimen was >2000. Post-excision 20 minutes Sr. PTH was 29ng/ml. She is recovering well.

 

February 2018

  1. Endoscopic Repair of CSF Leak: A young male patient had CSF leak from his nose. Endoscopically the leak was identified in ethmoid area and repaired with fascia from thigh and medical glue.
  2. Tracheal Diverticulum : A  young male patient having tracheal diverticulum was operated successfully.
  3. Eminectomy: A patient operated for Trismus; subsequently had dislocation of temporomandibular joint, hence could not close his mouth. He had to undergo another surgery where TMJ was approached externally and condylar eminence excised on both sides. Intraoral occlusion achieved and opening and closing of jaw obtained.
  4. Free Radial Artery Fore Arm Flap: was used in a patient to reconstruct buccal mucosa defect after excision of oral cancer.
  5. Augmentation Pharyngoplasty: Post Laryngectomy, a patient developed stricture and had dysphagia. Augmentation pharyngoplasty was done using patch PMMC.
  6. Total Thyroidectomy  in a male patient with cardiac disease: A male patient with ischemic heart disease had very low ejection fraction. He was operated successfully at American Oncology Institute.

January 2018

  1. Deep Vein Thrombosis with IVC Filter: An elderly patient was to be operated for Ca Buccal Mucosa. He had history of Deep Vein Thrombosis with filter placed in Inferior Vena Cava. The patient was on warfarin which was withheld two days prior to surgery and patient put on Inj Heparin.All pharmacologic and non pharmacologic thromboprophylactic measures were taken. Patient underwent surgery and had uneventful post op recovery.
  2. Juvenile Laryngeal Papilloma: A 2 year child was referred from Govt. Medical College Nagpur for CO2 LASER excision of Juvenile Recurrent Papillomatosis. Induction of anaesthesia was challenging due to the possibility of papillomas obstructing the airway.
  3. Cervical Epidural Anaesthesia: During Annual Thyroid Surgical Workshop 6 patients were operated under cervical Epidural Anaesthesia successfully. One was for Hemithyroidectomy and 5 for Total Thyroidectomy. 3 Surgeries lasted more than 3 hrs.

 

November  & December 2017

  1. Endoscopic Repair of CSF Leak: In case of injury , the thin bone separating nasal cavity and skull, can get fractured. Cerebrospinal fluid begins to leak continuously from the nasal cavity. This defect was repaired endoscopically using tissue from the thigh and medical glue .Two such surgeries were performed during November & December .
  2. Free Radial Artery Fore arm Flap: An old operated case of Ca mandible was disease free  for several years and wanted to undergo plastic surgery to get rid of  facial scar of PMMC. Free Radial Artery Fore arm Flap was done by a surgeon who came from Bangalore for the surgery.
  3. Free Fibula Micro Vascular Flap: was performed to cover defect after excision of Carcinoma Mandibular Arch.
  4. Cochlear Implant Surgery: 7 Year girl had been operated for cochlear implant .5 year back by Dr. Gauri Kapre Vaidya . Patient has been doing very well and the family wanted implant surgery for the second ear as well . Dr. Harsh Karan Gupta  performed the surgery.
  5. Awake Blind Nasal Intubation: A young 32 year  male patient had zero mouth opening due to trismus because of oral submucous fibrosis caused by chewing tobacco .Administering anesthesia in such cases is difficult as there is no access to the airway with the help of  local anaesthesia and sedation .Awake Blind Nasal Intubation was performed and then patient was administered anaesthesia for the surgery. After the surgery the patient had wide mouth opening of 3 cm.

October 2017

  1. Free Radial Artery Forearm Flap: Free Radial Artery Forearm Flap was done to reconstruct defect after excision for Ca Alveolus.
  2. MicroLaryngeal LASER Surgery in an Obese Patient with Obstructive Sleep Apnea Syndrome : A middle aged obese patient with Obstructive Sleep Apnea Syndrome was posted for MicroLaryngeal LASER Surgery. Anesthesia in such patients is challenging. During induction patient can have airway obstruction. For LASER surgery patient is intubated with small sized Endotracheal Tube. In an obese patient, ventilation with small size tube can lead to high airway pressures, inadequate ventilation of some regions of the lung and ventilation perfusion mismatch. After reversal of anesthesia obese patients tend to hypoventilate and recovery from anesthesia may be delayed. With careful titration of anesthesia doses, patient had smooth anesthesia course and good recovery.

September 2017

  1. Cochlear  Implant Surgeries -Two Cochlear Implant Surgeries on boys age 2 yr and 5 yr were conducted by Dr. Milind Kirtane. Dr. Harsh and Dr. Gauri assisted Dr. Kirtane during the surgeries.
  2. Juvenile Recurrent Laryngeal Papillomas – Two boys age 4 yr and 7 yr are chronic patients of JRLP. They are undergoing multiple settings of CO2LASER excision of the papillomas.
  3. Endoscopic CSF Leak Repair – was done on a young lady. Free Fibula micro vascular Flap was performed after excision of cancer mandible in a young male patient.

August 2017

  1. A girl with tracheal stenosis underwent cricotracheal resection anastomosis for reconstruction of the airway, Check endoscopy 3 weeks later showed good patient airway. Repeat endoscopy 1 month later showed adequate airway patency. 1 week after endoscopy patient was decannulated successfully.
  2. End to End Tracheal Resection Anastamosis  An adult lady had undergone tracheoplasty elsewhere. Montgomery’s T tube had been inserted, but the procedure was not successful. At our clinic we attempted tracheal dilatation on 3-4 occasions but patient continued to have distress. Hence End to End Tracheal Resection Anastamosis done. Tracheostomy tube was removed on 4th day of surgery. Patient was comfortable and discharged 1 week post op.

 

July 2017

  1. A girl with tracheal stenosis underwent cricotracheal resection anastomosis for reconstruction of the airway, Check endoscopy 3 weeks later showed good patient airway.
  2. An adult lady with papillomas underwent laser excision. Due to the multiple previous surgeries (some of them with cold steel at another centre) she had developed a glottic web which was causing her respiratory distress. The web was laserized & good airway achieved.

June  2017 

An elderly lady having facial palsy due to mastoiditis was operated upon by mastoidectomy. Post surgery her facial palsy recovered completely.

Trans nasal endoscopic pituitary macroadenoma excision done at CIIMS with neurosurgeon Dr. Pankaj Sarda.

Tracheal Stenosis:  A young lady was operated elsewhere for tracheal stenosis. Montgomery T tube was inserted. 6 weeks after the surgery the T tube was removed but patient had to be tracheostomised as she had respiratory distress. She is now undergoing CO2 LASER vaporization of stricture and tracheal dilatation.

Endoscopic CSF leak repair: was done in a young female patient.

Juvenile Recurrent papillomatasis: A 3 year old girl was totally aphonic due to laryngeal papillomas. Cautious spontaneous inhalational induction was done and papillomas excised with CO2 LASER.

Free Fibula Micro Vascular Flap: was done for Mandibular defect after excision of alveolar cancer.

Post Tonsillectomy Secondary Hemorrhage: Post tonsillectomy a young boy had secondary hemorrhage due to infection. Coagulation profile was normal. 3rd generation IV antibiotics were given. He had two episodes of massive bleeding every 3rd day. On examination under general anaesthesia no specific bleeder was found in tonsillar bed. Angiography was also done but no specific bleeding vessel or aneurysm was located. Finally the bleeding was controlled spontaneously after 10 days.

Chronic Kidney Disease with Oral Cancer: A middle aged adult male was operated for oral cancer. He had chronic kidney disease with high levels of blood urea, serum creatinive and potassium. All precautions were taken to avoid any nephrotoxic drugs, use relaxants not dependent on kidneys clearance and to maintain renal perfusion. Patient had uneventful recovery after 7 hrs surgery.

Glomus tympanicum: A patient having a co -existing cholesteatoma along with a glomus  tympanicum  in right ear was operated .The glomus tumor was very large and had feeders from ICA which made surgical challenging.

 

April & May  2017

  1. Awake Blind Nasal Intubation- was done for a patient with zero mouth opening, posted for surgery of trismus.
  2. UvuloPalato  Pharyngo Plasty-  Adult male patient with obstructive Sleep Apnea Syndrome was posted for LASER  assisted . UvuloPalato Pharyngo Plasty. He had a difficult airway with Mallampatti Grade IV short mandible and large tongue.

              Awake nasal intubation was performed.

  1. Decanulation of tracheal stenosis: Young female patient suffering from tracheal stenosis   for more than 1 year was successfully decannulated.
  2. Subglottic Web- A 2 &frac12; year old female child was referred for CO2 LASER excision of  subglottic web . She had undergone long term intubation and ventilation leading to the formation of  web. Effective subglottic diameter was only 2.4 mm. Patient was intubated with a 2.5 mm tube and LASER vaporization of the web was done.
  3. Free Antero Lateral Thigh Flap was done for closure of defect after excision of oral malignancy.
  4. Juvenile Recurrent Laryngeal Papillomatious – 10 year old boy has been undergoing repeated CO2 LASER excision of papillomas. Now the papillomas are fairly under control.
  5. Temporal Bone Resection: We achieved a land mark by performing a Temporal Bone Resection with Pinna resection with Total Parotidectomy and PMMC Flap. This is a very rare surgery and performed in our clinic for the 1st time in Vidarbha. 

March 2017

1.    Juvenile Recurrent Laryngeal Paillomatosis- A 4 year old boy is undergoing multiple procedures for CO 2 LASER vaporization of recurrent Laryngeal Papillomas.

2.    Total Thyroidectomy in a patient with large artic Aneurysm- A middle aged lady with large thoracic aortie aneurysm was posted for Total Thyroidectomy.
She was operated at a cardiac centre due to risk of rupture of aneurysm. The surgery was conducted uneventful.

3.    Subglottic Web- A 2 &frac12; year old girl came with history of meningoencephalitis when she was intubated and ventilated for prolonged period. Subsequently she developed a web in subglottic region. She had dyspnea with slightest exertion and was admitted two weeks back in stridor at another hospital with conservative management the patient was slightly better and she was referred to Dr. Madan Kapre.
CT scan of the child showed that in subglottic region her tracheal diameter was only 2.4 mm. Anesthesing and securing airway was risky due to possibility of airway obstruction and difficulty in introducing even 2.5 endotrachal tube.
The child was gradually induced with IV glycopyrnolate, fentanyl, propofol and O2, N2O and sevoflorane.
2.5 mm red rubber uncuffed endotracheal tube with stiletto could be introduced. 
The risk during LASER vaporization of the web was that sina the tube was uncuffed, there would be free O2 enriched gases in the larynx. As the tracheal lumen was very narrow there was no space for covering the endotracheal tube to prevent LASER punction. To ivercome these difficulties, just before Laserisation the endotracheal tube was disconnected from anaesthesia circuit. During Laserisation the endotracheal tube contained only air, so the risk of tube puncture and airway fire was minimized.
The web was successfully vaporized with CO 2 LASER and adequate tracheal lumen achieved. Subsequrently 4 mm endotracheal tube could be introduced easily. The patient made good recovery.

4.    Bilateral abduction Palsy in young child – A 7 year old girl came with history of head injury followed y frontal lobe syndrome requiring long term intubation and ventilation.. The child developed bilateral abduction and palsy leading to stridor and had to be tracheostomised.

5.    Kashima procedure was done using CO2 LASER. Adequate laryngeal inlet was achieved. On subsequent visit airway assessment will be done and if the laryngeal inlet remains adequate, the tracheostomy tube can be removed.

6.    Extensive thyroid malignancy with extranodal spread & nodes stuck to common carotid RLN & esophagus – underwent successful Total Thyroidectomy & Neck Clearance with Complete Clearance.


February 

1.    Juvenile Recurrent Laryngeal Paillomatosis- A child with recurrent laryngeal papillomatosis is undergoing treatment with multiple sittings of CO2 LASER vaporization. His larynx is now clear, but there are subglottic pailloma which have to be removed with cold steel instruments through the tracheostome.
2.    Botox injection done for spasmodic Dysphonic- Injection of botulinum toxic into the vocal folds was done in two patients of spasmodic dysphonia. This procedure was done under local anaesthesia with EMG guidance and for the other patient was done under general anaesthesia.
This procedure was done for the first time in Nagpur. Previously such procedures were only being done in one centre Mumbai and one centre Pune in Maharashtra. 
3.    CSF Leak Repair- CSF leak in a middle aged lady was repaired endoscopically with fascia lata and surgical glue.
4.    Nasopharyngeal Angiofibroma – A young boy presented with Nasopharyngeal Angiofibroma. Patient was operated after embolisation and blood loss was minimal.

January

1.    CSF Leak Repair- CSF leak from cribriform plate was repaired endoscopically in a middle aged lady. The leak was sealed with fascia lata graft and medical glue.


2.    Tracheal Stenosis- A young girl had tracheal stenosis post ventilation after suicidal attempt. She had undergone tracheostomy due to the narrow airway. CO2 LASER vaporization of the stenosis was done in 2 sittings. Further endoscopy revealed normal patent airway, so the tracheostomy tube could be removed and patient decannulated successfully. 


3.    Cochlear Implant Surgery- was performed on a 2 year old child who had profound sensorineural hearing loss. Dr. Harsh performed the surgery under the guidance of Dr. M.V. Kirtane and helped by Dr. Gauri.  

 

 

December

1.    Awake Blind Nasal Intubation A adult male patient had undergone Hemimandibulectomy several year back. He came for excision of CA Buccal Mucosa. Patient has also developed Trismus. Local Anaesthesia of the airway was achieved by Bilateral Superior Laryngeal Nerve Blocks. Transtracheal local anesthetic injections and Nebulisation with local anesthetic. The mouth opening was severely restricted and would not even admit magill forceps. So awake Blind Nasal Intubation was performed

 

2.      Rare tumour in Parapharyngeal Space- A middle aged lady had a rare tumor ( lipoepithelioma) in the neck. Major arteries were passing through the tumors hence the surgery was high risk. Patient also had strongly positive stress test so she was operated at Dr. Tambe’s critical care unit.
 

3.    Supraventricular Tachycardia- A male patient with no co – morbidities was to be operated for ca Tongue. After intubation, patient had severe tachycardia in the range of 160/min which persisted even after administration of  beta blocker and IV xylocard after consultation with cardiologist, surgery was postponed, patient awakened. Later a thorough cardiac evalution was done, patient  was given Tab Diltiazem and operated after 5 days uneventfully 

 

November

  1. Free Radial Artery Forearm Flap- was done for a patient operated for Ca Buccal Mucosa.
  2. Endoscopic CSF leak repair- was done for a middle aged lady patient.
  3. Antero lateral Thigh Flap- was done in a patient after excision of Ca Alveolus.