Nasal Ulceration Research Articles

Granulomatosis with polyangitis - a case report with unique liver function de-arrangement and treatment review

Granulomatosis with polyangiitis (GPA) is a potentially lethal systemic disorder that is characterized by necrotizing vasculitis of small arteries and veins. The respiratory system is most commonly affected in limited forms of the disease, however upper and lower respiratory system, systemic vasculitis, and necrotizing glomerulonephritis are the characteristic components of the disease triad. We present a case in a young male adult patient presenting with symptoms of sinusitis, joint pains, fever with detection of lung lesions in initial chest x ray and CT scan and liver involvement on further investigations and pathological confirmation by antineutrophil cytoplasmic antibody positivity and nasal ulcers. After treatment with corticosteroid and IV Rituximab, the lung findings were entirely resolved with improvement in liver functions.

DISSEMINATED FUSARIOSIS WITH ORAL AND NASAL FIRST MANIFESTATION: A CASE REPORT

Fusariosis is a fungal infection that affects immunocompromised hosts and is mainly fatal in its disseminated form. A 49-year-old male patient with acute myeloid leukemia, hepatic and splenic infiltration, thrombocytopenia, odynophagia, and abdominal pain was referred for evaluation. Clinical examination revealed nasal and small oral ulcers with erythematous halo on the soft palate, and diagnostic hypotheses were bacterial or viral infection. Treatment with cefepime and vancomycin, local hygiene, and low-level laser therapy were adopted, and lesions presented remission. The clinical condition improved, and chemotherapy with cytarabine was initiated; however, new lesions emerged concomitantly as well as pain in the sinuses and nasal obstruction. Biopsy and surgical debridement were performed, and the final diagnosis was fusariosis based on histopathologic and culture examination. Treatment with amphotericin B and vancomycin was performed, but there was worsening of immunosuppression with the dissemination of infection evolving to death.

Effects of "Q" nose paste on fixing nasogastric tube

Objective To investigate the effects of Q nose paste on fixing nasogastric tube. Methods Totally 167 patients with nasogastric tube were divided into the observation group(80 cases) and the control group(87 cases) by random digits table method.The observation group fixed nasogastric tube using Q nose paste,while the control group using π nose paste. The occurrence rate of pressure injury of nasal mucosa and nasogastric tube dislocation, nurses′ operation time of pasting, removing nose paste, the time intervals of exchanging nose paste were observed and compared between the two groups. Results The occurrence rate of pressure injury of nasal mucosa in the observation group was 0,and it was significantly lower than the control group 6.897% (6/87), the difference was statistic between the two groups (χ2=5.523, P 0.05). Conclusions Application of Q nose paste in fixation of nasogastric tube can decrease the incidence of nasal mucosa pressure ulcers, it is conducive to extend the interval of nasal sticker replacement and improve work efficiency, thus is worthy of clinical application. Key words: Q nose paste; Nasogastric tube; Fixation; Incidence

ACUTE AIRWAY EDEMA AND RESPIRATORY FAILURE SECONDARY TO INVASIVE MUCORMYCOSIS

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Mucormycosis is known for its ability to manifest in human beings with varying presentations. Most notably this particular fungus has garnered its fierce reputation secondary to its devastating rhino-orbital-cerebral infections. The organisms responsible are abundant and easily culturable, commonly found in large numbers as the species is able to rapidly divide and spread its spores airborne. Unfortunately, there are scenarios that lead to predisposition of invasive disease including, diabetes mellitus in the setting of DKA, hematologic malignancies, AIDS, and solid organ transplant (1). A review of 208 cases published in between 1970 and 1993 quantified the frequency of initial symptoms. Fever, nasal ulceration with necrosis, and facial swelling accounted for the most common manifestations (2). CASE PRESENTATION: A 45-year-old male recently treated with induction chemotherapy and FLAG-IDA for AML developed subsequent pancytopenia and neutropenia. The Medical ICU team was called for an urgent evaluation after the patient developed acute onset left sided facial swelling, increased upper airway secretions, and voice change. Examination of his oropharynx revealed a black eschar on the hard pallet. A bedside NPL was urgently performed by ENT which revealed severe airway edema concerning for impending respiratory failure. The patient was subsequently intubated in the OR fiber optically, initial cultures and sample of the eschar were taken. The patient was empirically started on Amphotericin B liposome and remained intubated and sedated. The patient was taken to the OR urgently the next day for complete debridement of the hard palate, left maxillary sinus, and nasal turbinate. Surgical pathology confirmed the underlying suspicion for invasive Mucormycosis and culture later also grew out Rhizopus species. The patient was managed in the medical ICU with help of the infectious disease team for management of antifungal therapy. He was continued on Amphotericin B liposome throughout with the addition of Isavuconazole and Posaconazole. Unfortunately, the patient progressively deteriorated, developed septic shock and was transitioned to comfort measures by his family and expired shortly thereafter. DISCUSSION: Severe laryngeal edema causing acute respiratory failure has not been well documented. The overall mortality of Rhino-orbital-cerbral mucormycosis can be as high as 65%, thus prompt identification in the right clinical setting can be lifesaving (3). Management of the disease is based upon the cornerstone of urgent surgical debridement and immediate initiation of Amphotericin B lipid formulation. Salvage therapy can be attempted with Isavuconazole and also Posaconazole. CONCLUSIONS: We presented this case as a teaching point and also to raise awareness that acute onset airway edema in an immunocompromised patient can be the only presenting symptom of invasive Mucormycosis. Reference #1: Zygomycosis: an emerging fungal infection with new options for management. AUKauffman CA, Malani AN SO Curr Infect Dis Rep. 2007;9(6):435. Reference #2: Survival factors in rhino-orbital-cerebral mucormycosis.. AU Yohai RA, Bullock JD, Aziz AA, Markert RJ SO Surv Ophthalmol. 1994;39(1):3. Reference #3: Maureen M. Roden, Theoklis E. Zaoutis, Wendy L. Buchanan, Tena A. Knudsen, Tatyana A. Sarkisova, Robert L. Schaufele, Michael Sein, Tin Sein, Christine C. Chiou, Jaclyn H. Chu, Dimitrios P. Kontoyiannis, Thomas J. Walsh; Epidemiology and Outcome of Zygomycosis: A Review of 929 Reported Cases, Clinical Infectious Diseases, Volume 41, Issue 5, 1 September 2005, Pages 634–653 DISCLOSURES: No relevant relationships by Ediri Brume, source=Web Response No relevant relationships by Andrew Chu, source=Web Response No relevant relationships by Gustavo de la Roza, source=Web Response No relevant relationships by Bishal Gyawali, source=Web Response No relevant relationships by Dragos Manta, source=Web Response No relevant relationships by Ronald Russo, source=Web Response no disclosure on file for Dana Savici; No relevant relationships by Michael Williams, source=Web Response

Cold Weather Viruses.

1. Asif Noor, MD* 2. Theresa Fiorito, MD* 3. Leonard R. Krilov, MD*,† 1. *Department of Pediatrics, Children's Medical Center, NYU Winthrop Hospital, Mineola, NY 2. †Department of Pediatrics, State University of New York, Stony Brook School of Medicine, Stony Brook, NY * Abbreviations: AAP: : American Academy of Pediatrics Adv: : adenovirus CDC: : Centers for Disease Control and Prevention FDA: : Food and Drug Administration hMPV: : human metapneumovirus PCR: : polymerase chain reaction PIV: : parainfluenza virus RSV: : respiratory syncytial virus RV: : rhinovirus Clinicians must learn to identify viral infections in children during the winter months and must practice caution with the use of unnecessary medications in such cases. Recognition of the clinical pattern of viral infection (eg, bronchiolitis) in conjunction with judicious use of viral tests (either office-based immunoassays or newer molecular tests) may assist in epidemiological monitoring, cohorting patients in the hospital, withholding unnecessary therapies, and providing a definitive diagnosis. After completing this article, readers should be able to: 1. Review the epidemiological aspects and clinical signs and symptoms of common cold weather viruses. 2. Recognize situations in which viral testing is indicated. 3. Recognize situations in which treatment is indicated. In early November you are evaluating a 9-month-old boy born at 33 weeks of gestation. The infant presents with 2 days of fevers (101°F–102°F [38.3°C–38.8°C]), copious rhinorrhea, and 1 day of coughing with difficulty breathing. He is otherwise feeding well and has had adequate urination. His 4-year-older sister has an upper respiratory tract infection. On physical examination, the infant has a respiratory rate of 45 breaths/min without chest wall retractions. On auscultation there is good air entry with scattered rhonchi bilaterally. What is the most appropriate next step in management? 1. Obtain respiratory syncytial virus (RSV) and influenza antigen testing. 2. Obtain a chest radiograph to look for focal infiltrate. 3. Provide supportive care with nasal …

Granulomatosis with polyangiitis: Special focus on suggestive imaging findings in head and neck involvement

Objective: Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease with frequent upper respiratory tract involvement. Early diagnosis is crucial for early initiation of effective treatment, which improves outcome. Imaging plays an important role for confirming clinically suspected cases. The aim of our study is to reveal the frequencies of imaging findings previously defined as suggestive for GPA (i.e. osseous erosions or destructions, neoosteogenesis, subglottic stenosis) and to investigate frequency and characteristics of previously under-recognized nasopharyngeal involvement in GPA.
 Materials and Methods: We retrospectively examined paranasal, nasopharynx/neck, temporal CTs (n=51) and MRIs (n=14) of 48 patients with GPA. The evaluated imaging findings include mucosal ulcerations in nasal cavity, sinonasal and temporal opacifications/inflammatory signal changes, presence and locations of osseous erosions and neoosteogenesis, periantral soft tissue infiltration, septal perforation, presence and characteristics of nasopharyngeal involvement, and subglottic stenosis. Descriptive statistics were presented as mean ± SD; categorical variables were presented as count and percentage.
 Results: Forty patients (87%) had sinonasal and fourteen (29%) patients had tympanic cavity±mastoid opacifications. Three patients (23%) had signal and diffusion characteristics suggesting a sinonasal granulomatous inflammation. Mucosal ulcerations were detected in 32% of patients. Osseous erosions/destruction (40%) was common in disease onset and frequently affected mid-line sinonasal structures. Neoosteogenesis of paranasal sinuses (21%) was more common in follow-up studies and invariably affected maxillary sinuses. Septal perforation (6%), periantral infiltration (4%) and subglottic stenosis (10%) were relatively infrequent findings. Nasopharyngeal involvement (23%) was not infrequent; predominantly presented with wall thickening, ulcerations, low T2-weigted signal changes and restricted diffusion in MRI.
 Conclusion: Sinonasal osseous erosion/destruction is a relatively common and highly suggestive finding especially when co-existent with nasal mucosal ulcerations, neoosteogenesis and nasopharyngeal thickening in a suspected case. Nasopharyngeal involvement is not infrequent and imaging could overlap with other entities such as nasopharyngeal cancer, lymphoma or sarcoma.

Does epistaxis with an unknown bleeding site originate from the posterior part of the nasal cavity?

To review the origins of epistaxis in patients with unknown bleeding sites. This consecutive case series included 26 patients with unknown bleeding sites previously considered to have posterior epistaxis. All patients had previously been examined endoscopically at least once, and were again examined with 30°, 45° and 70° endoscopes. The bleeding site was at the: anterior end of the lateral wall of the inferior meatus in one patient (3.8 per cent); anterosuperior lateral wall of the nasal cavity in five patients (19.2 per cent); anterior nasal cavity roof in seven patients (26.9 per cent); anterosuperior part of the cartilaginous septum in nine patients (34.6 per cent); ostium pharyngeum tubae in two patients (7.7 per cent); and anterior nasal base in two patients (7.7 per cent). The morphology of the bleeding point showed: nasal mucosa ulceration in 1 patient, isolated primary telangiectasia in 3 patients, prominent vessels in 5 patients and capillary angioma in 17 patients. Epistaxis originating from the anterosuperior nasal cavity and nasopharynx can be easily misdiagnosed as posterior epistaxis or unknown bleeding sites. Areas that should be considered as possible origins of epistaxis in cases with unknown bleeding sites were identified.

Application experience of integrated nursing mode for extremely severe burn patients in August 2nd Kunshan factory aluminum dust explosion accident

Objective: To explore the application experience of integrated nursing mode in the treatment of extremely severe burn patients in August 2nd Kunshan factory aluminum dust explosion accident. Methods: On August 2nd, 2014, 35 extremely severe burn patients involved in the August 2nd Kunshan factory aluminum dust explosion accident were admitted to Wuxi Third People's Hospital, including 18 males and 17 females, aged 21-50 years. According to the characteristics of the wounded, the situation of the nursing staff, and the characteristics of the nursing work, the integrated nursing mode was constructed and implemented to improve overall nursing quality. The standardized management measures such as cluster management of facilities and equipments in wards, improving and unifying nursing system, standardized training, drawing up " Nurses Compulsory Reading" , optimizing nursing shift handover and so on were taken. Professional quality control groups such as continuous renal replacement therapy (CRRT) group, static therapy group, airway group, and burn group were established, and standardized writing nursing group, wound nursing group, psychological nursing group, and enteral nutrition nursing group were set up under burn group. The treatment outcomes of patients and effects of nursing management, nursing methods, and specialty nursing were recorded. Results: Twenty-seven patients survived the shock period, infection period, and recovery period smoothly. The success rate of rescue was 77.14%. During the treatment, the ward was in good order. The implementation rate of disinfection and isolation system, the completion rate of shift handover, the standard rate of intravenous therapy, the implementation rate of bed head elevation, the correct rate of posture placement, and the success rate of CRRT were all 100%. Successful turn over of rotating bed without interruption of CRRT for 24 hours was implemented in two patients. In many cases, the single filter for hemodialysis continuously run for more than 72 hours. The airway mucosa of patients healed around 20 days after injury. No adverse nursing events such as tracheal cannula detachment/blockage, respiratory distress, atelectasis, lung consolidation, aspiration by mistake, rotating bed rollover, ear chondritis, nasal septal pressure ulcer, vacuum sealing drainage (VSD) catheter blockage, VSD dressing leakage, severe abdominal distension/diarrhea, non-planned extubation/blockage of various intravenous treatment catheters implanted into deep veins and arteries were observed. Conclusions: The integrated nursing mode significantly optimizes the nursing work process in the treatment of extremely severe mass burns, clarifies the duties of nursing staff, and improves the quality of nursing. This mode is worthy of taking reference by other burn treatment units.

Prognostic factors for cats with squamous cell carcinoma of the nasal planum following high-dose rate brachytherapy.

The aim of the study was to investigate retrospectively the prognostic impact of variables such as sex, neuter status, breed, age, number of lesions, location and size of the tumour, tumour extension beyond the nasal planum, ulceration and lymph node status, among others, in a population of cats treated with high-dose rate brachytherapy. This study reviews the outcome of 58 cats with cytologically and/or histologically confirmed squamous cell carcinoma of the nasal planum, treated at the Clinic Alliance (Bordeaux, France) with high-dose rate brachytherapy from 2010-2016. The total radiation dose delivered was 30 Gy, administered in two different schedules: five fractions of 6 Gy for a period of 4 days (Tuesday-Friday) or four fractions of 7.5 Gy for a period of 3 days (Tuesday- Thursday). Data were collected from cats' clinical records. Complete response was achieved in 72% (n = 36) of the cats, partial response in 24% (n = 13) and 2% (n = 1) did not respond. Median progression-free survival and overall survival times were 316 and 835 days, respectively. Results indicated that sex (P = 0.045), extension of the tumour from the nasal planum to the upper lip (P = 0.015), tumour size (P = 0.015; P = 0.001), the existence of a previous treatment (P = 0.043) and the tumour response to high-dose rate brachytherapy (P = 0.038; P <0.001) are prognostic factors for cats with squamous cell carcinoma of the nasal planum following high-dose rate brachytherapy.

Nasal septum ulcer as an isolated manifestation of histoplasmosis

Histoplasmosis is an infection caused by the dimorphic fungus Histoplasma capsulatum, which is saprophyte of contaminated soil. In the immunocompetent host, the symptoms of histoplasmosis tend to be mild or even non-existent. In immunocompromised patients, the manifestations may be more severe and the disease manifests itself in a disseminated form, with high mortality rates. Isolated mucosal lesions are infrequent and the purpose of this report is to describe an unusual case of nasal septum ulcer as an isolated clinical manifestation of the disease.

Carbamazepine-induced systemic lupus erythematosus: A case-based review.

A case of carbamazepine-induced systemic lupus erythematosus (CBZ-DILE) is presented, along with a literature review, with the aim to define the clinical and serological characteristics of this group, and compare them with systemic lupus erythematosus (SLE) triggered by other drugs (DILE). A 31-year-old woman presented with a 6-month history of hand arthritis and nasal ulcers. She had been diagnosed with epilepsy at 12 years of age and had continued treatment with carbamazepine (CBZ) for the past 18 years with excellent clinical control. Laboratory data revealed antinuclear antibodies (ANA) positive to a titer of 1/1280, and positive anti-nucleosome antibodies. The patients’ clinical symptoms disappeared after the CBZ discontinuation and did not reappear during the 1-year follow-up period. A search was made in the PubMed/Medline database of the (CBZ-DILE) published cases. A total of 26 cases of CBZ-DILE were found in the search. CBZ-DILE cases are characterized by variable latency periods that often last for years and are not related to the dose of CBZ. Most frequent clinical findings of CBZ-DILE in patients are arthralgia/arthritis, mucocutaneous manifestations, constitutional symptoms, and pleuritis or pericarditis. The renal involvement has not been reported in CBZ-DILE. Antihistone antibodies were observed less frequently, and anti-dsDNA antibodies were observed more frequently than in the “classic” DILE. The ANA remained positive in over 60% of cases during the follow-up after withdrawal. The CBZ-DILE has significant clinical and laboratory manifestations that distinguish it from classic DILE or idiopathic SLE.

Cavernous hemangioma of the nasal bones: a case report

Cavernous hemangiomas represent less than 1% of all bone tumours, with the vertebrae and the skull being the most common locations. These tumours are extremely rare in the bones of the nose, with very few cases published in the medical literature, where they have been reported in turbinates, vomer, nasal bones or perpendicular lamina of the ethmoid. They usually present as a tumour lesion that grows over time, involving the bone and even the soft tissues, which can cause complications such as nasal obstruction, bleeding, ulcerations and infection. We present the case of a 37 year-old patient with a cavernous hemangioma located in the bones of the nose, reviewing the most notable aspects of this rare tumour. Keywords. Cavernous Hemangioma. Bone hemangioma. Nasal tumor. Nasal bones. Surgical treatment.

Classification of primary antiphospholipid syndrome as systemic lupus erythematosus: Analysis of a cohort of 214 patients.

To assess the limitations of the SLICC (Systemic Lupus International Collaborating Clinics) classification criteria for systemic lupus erythematosus (SLE), in patients with primary antiphospholipid syndrome (PAPS). Retrospective study of a cohort of APS patients (Sydney criteria). We successively excluded patients with (1) at least one "SLE-specific" manifestation (biopsy-proven SLE nephropathy, arthritis, cutaneous, or neurologic SLE manifestations, pericarditis, autoimmune haemolytic anaemia, oral and nasal ulcers, non-scarring alopecia, anti-dsDNA, and anti-Sm antibodies), (2) any other autoimmune connective tissue disease, and/or (3) antinuclear antibodies >1/320. Careful file review confirmed PAPS among the remaining patients. We then assessed the number of SLICC criteria each patient met. Among these 214 APS patients, we excluded 85 with at least one SLE-specific manifestation, 8 with another connective tissue disease, and 21 with antinuclear antibodies >1/320, leaving 100 patients with primary APS. Among them, 28% met at least 4 SLICC classification criteria including one clinical and one immunological criterion (antiphospholipid antibodies, aPL, by definition) and could thus theoretically be classified with SLE. Fourteen had an arterial phenotype (50%), 9 a history of catastrophic APS (32%), and 18 a triple-positive profile for aPL (64%). None had developed SLE during a median follow-up of 12 [6.5-17] years. Because 28% of our patients with longstanding and strictly defined PAPS could be mistakenly classified as SLE, they were at risk of deleterious therapeutic management. We therefore suggest that any future classification for SLE should specifically require at least one SLE-specific criterion for patients with aPL.

Cancer Risks of Hexavalent Chromium in the Respiratory Tract.

Hexavalent chromium (Cr(VI)) compounds are recognized as carcinogens in the respiratory tract, giving rise to cancers of the lung, nose and nasal sinuses, especially in certain occupational environments. Inhalation exposure of Cr(VI)-containing particles, dusts and fumes commonly occurs in chromium-related occupational environments, such as chromium production, plating, welding of chromium-containing metals and alloys, electroplating, chromium-containing pigments and paints. Epidemiological surveys of chromium compounds have shown strong associations between exposure to Cr(VI) and mortality due to lung cancer, as well as positive associations with cancers of the nose and nasal cavity. Nasal symptoms, such as nasal irritation, ulceration and perforation of the nasal septum, nasal turbinate engorgement and hypertrophy, are important signs for the early diagnosis of lung cancer and cancers of the nose and nasal cavity in those with an occupational history of Cr(VI) exposure. Cr(VI) exposure in the workplace remains a serious problem as a cause of lung cancer and cancers of nose and nasal cavity, especially in relatively small enterprises that use chromium compounds. Appropriate protection for workers should be considered in occupations that involve exposure to chromium compounds.

Pyoderma gangrenosum on the nose

Pyoderma gangrenosum is a rare ulcerative condition associated with various systemic diseases. Lesions on the lower extremities and the trunk are common, but lesions on the nose are rare. Here we report a case of pyoderma gangrenosum on the nose. A 33-year-old woman presented with fever, nasal obstruction, and painful swelling on the nasal bridge. Physical examination revealed swellings on the nasal septal mucosa bilaterally. Computed tomography showed a septal abscess and a subcutaneous abscess on the nasal bridge. The lesions worsened despite treatment with intravenous antibiotics and abscess drainage. Meanwhile, the patient also complained of bloody stools and was diagnosed with ulcerative colitis. Therefore, pyoderma gangrenosum on the nose was suspected, and was diagnosed by exclusion of other diseases. Treatment with systemic corticosteroids was started and the nasal lesions improved rapidly. However, saddle nose deformity occurred. A review of the literature reveals that pyoderma gangrenosum on the nose can cause ulcerations, septal abscess, and sinusitis. Further, there is a high likelihood of nasal complications, including saddle nose deformity, septal perforation, and skin defects. Pyoderma gangrenosum should be included in the differential diagnosis when nasal ulceration, abscesses, and sinusitis do not improve with antibiotics and drainage.

Maxillary Ameloblastoma-Diagnostic Challenge for the Surgeons: A Case Report

Ameloblastoma previously known as adamantinoma is a histologically benign, locally invasive odontogenic neoplasm of epithelial origin which is derived from the odontogenic ectoderm. It was first described by Cusack in 1827. However, the first detailed description of this lesion was given by Falkson in 1879. The term ‘ameloblastoma’ was coined by Churchill in 1933. Ameloblastoma is an odontogenic tumor representing 1% of all tumors of the jaw, with 80% to 85% occurring in the mandible and 15% to 20% in the maxilla. In the maxilla, 47% of ameloblastomas have been reported in the molar region, 15% in the maxillary antrum and floor of the nose, 9% in the premolar region, 9% in the canine and incisor region and 2% in the palate. Maxillary ameloblastoma is most commonly associated with painless swelling, loosening of teeth, nasal airway obstruction, malocclusion, periodontal diseases and ulceration. The proximity of maxilla to the orbit, skull base and intracranial contents contributes to the high morbidity and mortality rate associated with them.

Primary sinonasal tuberculosis: Our experiences in a tertiary care hospital of eastern India

BackgroundPrimary sinonasal tuberculosis is an extremely rare clinical entity. Often the clinician fail to diagnose the primary sinonasal tuberculosis, so treatment is frequently delayed and leading to complications. ObjectiveTo evaluate the clinical profile, diagnostic tools, treatment and outcome of primary sinonasal tuberculosis. Materials and MethodsRetrospective studies of six cases of primary sinonasal tuberculosis were done over period of five years. The detail clinical profile, diagnosis, treatment and outcome were studied in these patients. ResultsOut of the six cases of primary sinonasal tuberculosis, four cases were female and two were male. The mean age during the time of diagnosis was 35 years (16–67 years). The most common clinical presentations were chronic nasal obstruction, epistaxis and ulcerations at the nasal vestibule and nasal cavity. Diagnosis was confirmed by Histopathological diagnosis in all six cases. All cases received antitubercular therapy for 6–9 months. All six patients successfully responded to antitubercular therapy. Two year follow up showed no relapse, dissemination and death. ConclusionPrimary sinonasal tuberculosis is a rare clinical entity. It is always suspected among the patients with nasal obstruction, epistaxis and ulcerations at nasal vestibule and nasal cavity in the region with high prevalence of Tuberculosis.

Respiratory Failure From Enlarging Diaphragmatic Hernia: A Rare Complication of Noninvasive Positive Pressure Ventilation

SESSION TITLE: Obstructive Lung Diseases SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Non-invasive positive pressure ventilation (NIPV) is useful for management of hypercapnic respiratory failure. Use of NIPV can have devastating complications.We report a rare case of diaphragmatic herniation that worsened due to gastric insufflation. CASE PRESENTATION: An 87-year-old man with history of COPD and left-sided diaphragmatic hernia presented with cough, worsening shortness of breath and wheezing. Vitals were significant for heart rate of 98 bpm, BP 140/90 mmHg, respiratory rate 28/min, and oxygen saturation 78% on room air. Physical examination demonstrated diffuse wheezing in the both lungs and tympanic percussion in the left hemi-thorax. The initial chest X-ray showed left hemi-diaphragm elevation (Figure 1). Patient was placed on bilevel NIPV (10/5 cm H2O and FIO2:60%) for hypercapnia due to COPD exacerbation. Patient’s respiratory distress worsened while on bilevel NIPV. Repeat CXR showed bowel loops compressing the whole left lung (Figure 2). NIPV was discontinued and patient was made NPO. CT thorax showed a large left diaphragmatic hernia containing most of the stomach, distal transverse colon, and proximal descending colon within the hernia. After discontinuing NIPV, patient’s respiratory status improved with O2 saturation of 95% on 2 L/min NC. Patient underwent surgical repair for bowel strangulation. Post-operative imaging confirmed re-expansion of the left lung with minimal basilar atelectasis and normal vasculature. Patient’s symptoms significantly improved after surgery. DISCUSSION: NIPV reduces the need for intubation, mortality, complications, and length of stay in COPD exacerbation. Some of the NIPV complications are mask intolerance, nasal bridge ulceration, inadequate gas exchange, sinus pain, aspiration and mucus plugging. Pneumothorax and pneumocephalus have been reported as the most serious complications of NIPV. Gastric insufflation is usually a minor adverse effect; however, our patient had significant worsening of diaphragmatic herniation and dyspnea due to to gastric insufflation with NIPV. CONCLUSIONS: There is no ideal target pressure when choosing NIPV settings. There should be a balance between inspiratory pressure supporting gas exchange and patient’s tolerance and comfort. When choosing NIPV physicians should watch for pre-existing diaphragmatic hernia and be aware that applying NIPV could potentially worsen herniation and gas exchange. Reference #1: Gay PC1.Complications of noninvasive ventilation in acute care.Respir Care. 2009 Feb;54(2):246-57. DISCLOSURE: The following authors have nothing to disclose: Mahsan Farokhi, Viren Kaul, Assad Oskuei, Michael Megally, Daniel Nicastri, Martin Warshawsky No Product/Research Disclosure Information

Preliminary evaluation of sequential therapy by high flow nasal cannula oxygen therapy following endotracheal tube extubation in mechanically ventilated patients

To evaluate the feasibility and effect of sequential treatment by the heated humidified high flow nasal cannula oxygen therapy (HFNC) in mechanically ventilated patients following endotracheal tube extubation. A prospective randomized controlled trial was conducted. Forty-nine patients with the sequential treatment after tracheal intubation extraction admitted to Department of Critical Care Medicine of Shanghai Tenth People's Hospital from January 1st to December 31st 2016 were enrolled. The patients were randomly divided into HFNC group (n = 25) and non-invasive positive pressure ventilation (NPPV) group (n = 24) in accordance with the random number table. During the study, arterial blood gas and the sputum viscosity were assessed at 12, 24, and 48 hours after NPPV or HFNC treatment, and the nasal and facial pressure ulcers within 1 week was also recorded. Receiver operating characteristic curve (ROC) was plotted, and the effect of NPPV or HFNC on oxygenation was analyzed. Among the 25 patients in the HFNC group, 1 patient who was re-intubated and 2 patients who were changed to NPPV were excluded, and a total of 22 patients with complete data were enrolled in HFNC group. Among the 24 patients in the NPPV group, 1 patient who gave up the treatment and 1 patient who was re-intubated were excluded, and a total of 22 patients with complete data were enrolled in NPPV group. After the sequential treatment, most patients in NPPV group showed moderate viscous sputum (12, 12 and 10 cases at 12, 24 and 48 hours, respectively), whereas the patients in HFNC group showed thin sputum (15, 16 and 15 cases at 12, 24 and 48 hours, respectively). Sputum viscosity of patients in HFNC group at each time point was significantly lower than that in NPPV group (all P < 0.01). Arterial oxygen saturation (SaO2) and arterial partial pressure of oxygen (PaO2) at 12, 24 and 48 hours in the HFNC group were significantly higher than those in the NPPV group [SaO2: 0.978±0.009 vs. 0.906±0.139 at 12 hours, 0.976±0.019 vs. 0.924±0.103 at 24 hours, 0.973±0.019 vs. 0.935±0.079 at 48 hours; PaO2 (mmHg, 1 mmHg = 0.133 kPa): 97.85±22.99 vs. 79.24±25.86 at 12 hours, 108.10±43.87 vs. 84.44±29.24 at 24 hours, 102.31±39.02 vs. 79.04±27.46 at 48 hours, all P < 0.05], however, the difference in arterial partial pressure of carbon dioxide (PaCO2) at all of the time points between the two groups was not significant. In NPPV group, 4 patients with nasal and facial pressure ulcers was found, and all with I phase of pressure ulcers, and no nasal and facial pressure ulcers was found in HFNC group, which was significantly decreased as compared with NPPV group (χ 2 = 4.400, P = 0.036). A good effect of oxygen therapy was defined as PaO2 at 48 hours after the sequential treatment was increased by 20% as compared with that before the treatment. ROC curve analysis showed that the area under the ROC curve (AUC) of HFNC on improving oxygenation was higher than that of NPPV (0.917 vs. 0.830); when PaO2 at 48 hours after HFNC treatment was 76.25 mmHg, the sensitivity was 100%, and the specificity was 75.0%. Compared with NPPV, adoption of HFNC as sequential treatment is a feasible manner in dealing with the mechanically ventilated patients after endotracheal tube extubation, which can improve the oxygenation as well as reducing the degree of sputum viscosity and incidence of nasal and facial pressure ulcers. HFNC is a promising therapy, which may be worthy to recommend broadly in such a clinical situation.

Trigeminal Trophic Syndrome: An Unusual Cause of Nasal Ulceration

Trigeminal Trophic Syndrome: An Unusual Cause of Nasal Ulceration