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GOLDEN JUBILEE YEAR OF OTOLARYNGOLOGY [1970-2020]

                               

                           DR.DESARDA.K.K. MS.FACS.DLO.(LONDON)

          GOLDEN JUBILEE YEAR OF OTOLARYNGOLOGY (1970-2020)                                                                                      

                                                               (ACADEMIC ACHIEVEMENTS AT A GLANCE)

1.          Honored as a Fellow of American College of Surgeons (FACS), USA-2010

2.          Honored as a professor Emeritus in otolaryngology at B. J. Medical college & KEM hospital, Pune by Director of Medical Education & Research (DMER), Mumbai -2010.

3.          Honored  as  Lifetime Achievement Award by Federation of Maharashtra state ENT association in MENTCON,  Pune 2013

4.          Roll of honor by chief medical director Mrs. B. J. Coyaji & K. J. Coyaji KEM hospital, Pune  2002

5.          Honored as Master consultant Tele-case discussion  ENT Asso. & Health group Bangalore 2020

6.          Post graduate teacher and examiner  in MS.DLO.FCPS DORL DNB Examinations.

7.          Has 15 research papers in research society of  KEM hospital, Pune.

8.          Has co-ordinated 15 surgical workshops with national &  international faculties  for innovative  surgical  interventions in otorhinolaryngology & HNS.

9.           Invited for guest orations and surgical workshops at  various conferences.

10.       Invited by  etv-marathi to present  seven episodes of nasal disorders & their management.(1980)

11.       Teaching faculty for College of Physician & Surgeons in Otolaryngology  Mumbai from 1994 to 2010.

12.       Teaching faculty in otolaryngology of Pune university from 1994 to 2005

13.       Teaching faculty in otolaryngology of Diplomat of National Board of Examination (DNB) 1994 to  2018

14.       Presented 15 scientific papers in national & international  journals.

15.       Published Three  Books In Otolaryngology.
    A) Cryosurgical Applications In Otorhinolaryngology with foreword by Prof. Kasulskar, UK.   This   
         Monoghaph was  released in British Academy Of Otolaryngology, London (2013)
    B)  A Book on Tragal Cartilage In Middle Ear Reconstructions  With Foreword by Prof. Mirko Toss –
          Denmark.  This monograph was released in American Academy of Otolaryngology Washington DC,
          USA.(2009)

              C) Emerging trends in Cartilage Tympanoplasty With foreword by Mirko Toss Copenhagen University,
                    Denmark realesed by Prof,Sandra Dessa in Mentcon Nanded India, (2016)

15.     Released Two CDs  For Post Graduates .
                   A) Clinical Atlas Of Otorhinolaryngology.
                   B) Clinical presentations in Otorhinolaryngology covering 105 presentations.

 Social services

1   Meritorious services to Lions club of Deccan Gymkhana Pune (1880-90),

2.  Organised 50 camps both diagnostic and operative surgery for Rural health services 
     catering  50 thousand population sector.

3   Organised Deaf & Dumb schools at Lions club and KEM Hospital Pune since (1978 to 
     1988.)

    Memberships:

·   Life Member of  Indian Society of Otology (1991)

·   Life Member of Association of  Otolaryngologists of India (AOI) (1970)

·   Life Member of Cryosurgical Society, UK, (1976)

·   Life Member of Indian Red cross society (1976)

    

Address and Communications:

Dr- .Desarda.K.K . MS.FACS.DLO  (LONDON)

.Emeritus Prof.otolaryngology B.J.Medical college  & HOD KEM Hospital

    Rasta Peth   Pune 411011  Maharashtra

    India

    Email: kdesarda@gmail.com

    Mobile: +91 -9822056704

Cryosurgery Treatment for Venous Hemangioma of Tongue: A Case Report Dr.K.K. Desarda, Dr. Rohan, .Dr. Nilima, Dr.Sheetal.

Cryosurgery Treatment for Venous Hemangioma of Tongue:

A Case Report

Dr.K.K. Desarda, Dr. Rohan, .Dr. Nilima, Dr.Sheetal.

ABSTRACT

Hemangiomas are frequently seen benign tumors which based on vascular tissues. These lesions are mainly identified in to two groups which are namedas capillary and cavernous hemangiomas due to vascularization of the lesions.Capillary hemangiomas consist of small capillary vessels which show lobulesformation. Cavernous hemangiomas consist of large dilated vessels and theycan reach to large sizes. Several treatment modalities including sclerotherapy,embolisation, laser surgery and cryosurgery have been described forhemangiomas. In this significant case, the cryosurgery treatment of a 32 yearsold female patient who was suffering from the huge hemangioma in the rightside of her tongue is presented with complete regression of haemangioma without any tongue deformity or atrophy.or post op morbidity.

KEYWORDS

Hemangioma, Cryosurgery

 Contact Author

Dr. K.K.Desarda-Prof.Emeritus-& Head ORL KEM Hospital, Pune.

E-mail : kdesarda@gmail.com

INTRODUCTION

The author using cryoapplicator of his own modification presents cryosurgery as a successful surgical technique in cases of haemangiomas involving , tongue and oral cavity. From 1980 to 2012 in the ENT-Clinic ,KEM Hospital,Pune. Over 60 patients were operated upon using this method. Most of the cases were treated under local anaesthesia. The results were very encouraging. Total regression of haemangiomas and regeneration of normal mucosa with no noticeable scar resulted. A method of cryosurgery especially suitable for very young patients or for those who are poor risks because of associated disease and advanced age is suggested.

Hemangiomas are benign tumors ofvascular tissue which are most likely to be seen at the head and neck region. They are the most common tumors of the childhood. They

show higher prevalence in women. Most of these lesions are described hamartomas instead of tumors. Vast majority of hemangiomas are known to be regressive(1).Hemangiomas are classified as capillary and cavernouson the basis of the vascularization system. (1). Capillary hemangiomas consist of small capillary bodies that organize lobularly. Cavernous hemangiomas consis of wide and dilated vessels and can reach to large size..Hemangiomas can be encountered intraorally; on,tongue, anterior gingival and buccal mucosa. Especially the lesions on the cheeks and tongue can be traumatized by chewing and bleeding can occur.  (1-4).It is known that deep hemangiomas could be seen as blue-purple lesions during intraoral examination. For the diagnosis of cavernous hemangiomas, bidigital palpation of the region and detection of disappearance of the blood due to finger pressure and after removal of finger pressure observation of revascularization are important signs. Furthermore, if the lesion has an arterial origin, pulse can be obtained by finger pressure(1,2).

Although most hemangiomas of the tongue are asymptomatic, they could sometimes cause significant bleeding, pain or difficulty in chewing, speaking, and  even swallowing, if they are large enough. Small lesions can be excised with impunity.  Large lesions, if excised by surgery could result in significant functional  disability.  This is why several modalities of less invasive treatment have recently been advocated (Argon laser, Nd:YAG laser,radiofrequency,scelotherapy, cryosurgery and superselective embolization to avoid functional disability caused by tissue loss).

Age and general condition of the patient has great importance as well as the size and characteristics ofthe lesion in the treatment of hemangiomas. Small lesions can be surgically excised while larger ones require specific surgical interventions. These treatment methods are sclerotherapy, embolisation, laser surgery, radiofrequency and cryosurgery (1-5)

.

Amongest all modalities Cryosurgery is a very effective method for thetreatment of intraoral cavernous hemangiomas. It can be applied under basic local anesthesia. Freezing should be repeated twice for each area for three to five minutes to ensure adequate effect. The ice ball should extend a little beyond the limits of the lesion so that about three-quarter of the diameter of the observed circumference of the frozen tissue will be at a cell lethal temperature of – 15° C of normal tissue. Sloughing of some of the central tissue usually takes places at about one week post operatively and healing may be expected with 4-6 weeks.

CASE REPORT

A 32 year old female patient presented to ENT dept KEM Hospital Pune who was suffering from progressive huge swelling  on her right lateral border of tongue,pain while swallowing,distorted speech and at time occasional bleeding for over six months.She was treated conservatively by the medical practioner. She was also seen by general surgeon who advised surgery (hemiglossectomy) which patient refused.

Clinical examination :

Revealed wide, bluish purple lesion was detected on the right lateral side of the patients tongue (Figure 1). The signs of revascularization after finger pressure was determined and no pulsations were obtained from the lesion and the lesion was diagnosed with hemangioma. Rest of the ENT examination was WNL

.A clinical diagnosis of tongue haemangioma was confirmed  and patient advised for crysurgery treatment,which she has accepted since it was less invasive procedure.Routine lab study and general fitness was taken and patient was posted for cryosurgical intervention .

...

Under local anaesthesia 10cc (xylocaine + Adr.1:200000) infiltration all around the haemangiomatous mass was done with 3mm normal tongue margin. Liquid nitrogen via large contact cryo tip was applied to the entire lesion for 3 to 5 minutes .including 3mm peripheral normal tissue margin (Fig 1 & 2) Following this process, the area was washed with NaCl 0.9% and the patient was prescribed with antibiotics, analgesic, anti-inflammatory agents and tantum mouth wash.. Necrotic and sloughing area were observed in the postoperative first week (Figure 3 & 4 )and within four to six weeks  the lesion was successfully  and completely healed (Figure 5 & 6)

Pre operative & post operative  results of cryosurgery in Tongue Venous Haemangioma shown in these pictures.

                                          Pre op Venous Haemangioma of Tongue              

  
                                    Cryofreezing of tongue venous Haemangioma

                                          Fig.3.   Intra op cryosurgery lesion

                                             Fig.4.    Intra op cryosurgery lesion

                                          Fig.5   Post cryosurgery result 4 wks

                                            Fig.   Post cryosurgery result 6 wks

                                              

                                                                     

 DISCUSSION

The diagnosis and the classification of the vascularmalformations have a great importance on the treatment plan of the lesions. Mulliken and Glowackiproposed a terminology for classifying these lesionsthat is based on clinical and microscopic features(6) .This system broadly classifies vascular lesions into hemangiomas and vascular malformations. The hemangioma is the true vascular tumor that results from a neoplastic overgrowth of normal vascular tissue.The hemangioma grows by endothelial proliferation.In distinction to hemangiomas, vascular malformation results from abnormal vascular or lymphatic vesselmorphogenesis, not as the result of abnormal endothelial growth. Hemangiomas are usually present at birth and can be diagnosed by 1 year, where asvascular malformations are present at birth but often not diagnosed until second decade of life.Hemangiomas show rapid growth until 6-8 monthsand involute by 5-9 year

 Vascular malformations show slow growth throughout life with increase in response to infection, trauma, or hormonal fluctuation and they do not involute. Osseous involvement of the hemangiomas is rare but 35% of the vascular malformations show osseous involvement .A wide variety of methods are utilized for the treatment of intraoral hemangiomas.

Embolisation technique which is one of them has been utilized since early nineties. However, embolisation technique has two major disadvantages. One of these disadvantages is the risk of embolisation material reaching cranial cavity via external and internal carotid arteries and the need for an experienced radiologist in order to perform this procedure. The other disadvantage is the temporary blockage of flow . It would be proper to utilize this method prior to the surgical excision of large hemangiomas in order to reduce to risk of bleeding

Another method for the treatment of hemangiomas is sclerotherapy. In this method, a sclerotic agent is injected into or peripheral to the vein that the hemangioma originates from. This method is successfully utilized in the treatment of extra oral lesions. However, pressured bandage can not be applied to the region after the injection of sclerotic agent inintraoral lesions. Thus, sclerotherapy is recommended to be applied together with other treatment methods Subzero temperatures can cause so-called ‘frosbite’whilst temperatures above the coagulation point of proteins results in ‘burns’. Thermal surgery employs these effects in carefully controlled manner: the use of temperatures below freezing point constituting cryosurgery while heating effects are obtained by theuse of lasers normally functioning in the infrared range of wavelengths.

The results of the cryosurgery can be explained as acold-induced coagulative necrosis.

 Cryodestruction of a normal or benign neoplastic tissue normally requiresthe attainment of a temperature of at least -15°C (thetemperature at which intracellular ice forms) while total ablation of malignant tumor tissue calls for somedegree of overkill at level of -50°C .For the management of oral benign, premalignant and malignant lesions liquid nitrogen is used as a freezing agent and delivered by either probes or sprays  Inthis case, probes are preferred in order to have limited effect on the lesion.In cryosurgery tissue regeneration is remarkably betterthan the other surgical techniques. When the body spontaneously separates the coagulated slough there is a powerful stimulus to cellular division, hyperplasia and apparent hypertrophy; this may be associated with concomitant cytokine release .Laser surgery is another effective method used for the treatment of intraoral hemangiomas  But, it has several disadvantages when compared with cryosurgery. Laser surgery is a much more complex process compared with cryosurgery

Laser surgery is a much more complex process compared to cryosurgery and requires general anesthesia.(5) Nerve damage is less in cryosurgery and regeneration is quicker.Postoperative scar formation is less in cryosurgery.Laser surgery application can be hazardous around salivary gland ducts, which should be taken into consideration. Laser surgery costs much more expensive compared to cryosurgery. However in laser surgery, postoperative edema is less and the procedure does not require to be repeated. Additionally, laser surgery is a faster and more dramatic technique

CONCLUSION

A variety of methods of treatment are thus available for intraoral hemangiomas. The majority of theselesions can be regarded as capillary-cavernous hemangiomas. In this case, cryosurgery was preferred for the treatment of the cavernous hemangioma since it has multiple advantages like being an easy, cheap,successful method which can be done under local anesthesia and can be repeated if required for residual lesion.

REFERENCES

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Chapman&Hall Medical, 1998.

2. Tal H. Cryosurgical treatment of hemangiomas of the lip. Oral Surg Oral

Med Oral Pathol 1992;73:650-54.

3. Hartmann PK, Verne D, Davis RG.Cryosurgical removal of a large oral

hemangioma. Oral Surg 1984;58:280-82.

4. Reischle S, Schuller-PetrovicS.Treatment of capillary hemangiomas of

early childhood with a new method ofDept. of Oral and Maxillofacial Surgery

Faculty of Dentistry, Ankara UniversityAnkara, Turkey.

5.Mulliken JB, Glowacki J. Hemangiomasand vascular malformations in infants andchildren: A classification based on

endothelial characteri

Bidaye R, Desarda K, Thakkar J, William CS (2018) Adenoid Hypertrophy in Adults. JSM Head Face Med 3(1): 1007