1. NON HODGKINS LYMPHOMA

year 2016

2. NECROTIZING RETROPHARYNGEAL ABSCESS

CASE PRESENTATION

Dr. Mohammad Naim Manhas

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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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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W.H.O. guidelinesDiagnostic evaluation for NHL in 2008

Needle aspiration :- not recommended

Incisional or excisional biopsies are preferred

Immunohistochemistry

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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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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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Staging

Stage ISingle Extra Nodal StageIINodal Invovement

Stage IIIBoth sides of Diaphragm

Stage IVmetastases

staging

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Therapeutic modalities

Chemotherapy

Curative ,pallative

ImmunotherapyWith monoclonial antibiodies alone

or in combination with

CHT

Radiotherapy Limited role Early stage

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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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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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RADIO-IMAGING

C.t. Scan of Neck revealed soft tissue mass in left Soft Palate.

No associated lymphnode enlargement

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RADIO-IMAGING

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EXCISIONAL BIOPSY

PLAN :-Excisional Biopsy was done under General Anesthesia.

Mass was excised in toto.

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HISTOPATHOLOGY

B-cell lymphomaConfirmed by immunohisto-chemistry method

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Histopathological slides

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HISTOPATHOLOGY – B CELL LYMPHOMA

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STAGING OF B-CELL LYMPHOMA

Depends upon the involvement of nodal and extra nodal sites on either side of diaphargm

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RADIO-IMAGING

C.T. ABDOMEN C.T. PELVIS

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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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Post Radio and Chemotherapy

AFTER BEFORE

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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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RETROPHARYNGEAL SPACE

DIAGRAMMATIC PLAIN RADIOGRAPH

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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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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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Necrotizing Retropharyngeal Abscess

immunocompromised

Impacted foreign body

Odontogenic infectionTuberculosis of

cervical spine

trauma

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AIMEarly

diagnosis and prompt manageme

nt

Aggressive surgical

drainage and medical treatment

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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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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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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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RADIO - IMAGING

Coronal Plane C.T. scan NeckShowing Collection .

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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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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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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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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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Day XI to Day XIV Decannulation

Decannulation PlannedTracheotomy tube repalced by fenestrated one and closed.

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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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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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DAY OF ADMISSION AFTER DRAINAGE

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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

YOUR PRESENCE IS

HIGHLY APPRECIATED----THANK

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