Polypoid Mucosa Research Articles

Radiofrequency Ablation Eustachian Tuboplasty for the Treatment of Chronic Otitis Media with Effusion and Premature Extrusion of the Tympanostomy Tube.

Objective: This study evaluated the effects of radiofrequency ablation (RFA) eustachian tuboplasty on the treatment of chronic otitis media with effusion (COME), and associated complications, in patients with premature extrusion of the tympanostomy tube (TT). Materials and Methods: Tuboplasty and T-tube reinsertion were performed in 23 ears with COME, a history of premature TT extrusion, and thickened mucus. Tube retention, perforation closure, hearing improvement, and complications were evaluated. Results: All 23 patients with COME and previous premature TT extrusion had remarkable mucosal hypertrophic disease or mucosal polypoid changes in the posterior cushion or posterior wall in the nasopharyngeal eustachian tube (ET) orifice. All surgeries were completed within 20 minutes after general anesthesia and were performed in the operating room. Pre-and post-air-bone gap gain was 18.3 ± 2.5 dB. The TT was retained for at least 12 months in 19 patients, whereas intentional premature removal at postoperative 8 to 9 months was required in 2 patients and premature extrusion occurred in 2 patients. Thus, the tube retention success rate was 91.3% (21/23). Of the 21 ears with intentional removal, the perforation closure rate was 81.0% (17/21). None of the patients reported RFA-related serious adverse events or a patulous ET. However, a scar synechia of the anterior-posterior wall was seen in 1 ET orifice, and stenosis of the ET orifice in 4 patients. Conclusions: RFA eustachian tuboplasty combined with TT insertion is a simple and minimally invasive technique for the treatment of intractable COME in patients with a thickened mucosa of the nasopharyngeal ET orifice. This technique may prevent premature TT extrusion.

STIMA: Submucosal Temporary Inferior Maxillary Antrostomy: A Modification of Conventional Antrostomy, A Retrospective Review.

Introduction: Maxillary sinus pathology is commonly approached through endoscopic middle meatal antrostomy (MMA). However, MMA does not provide full exposure to certain aspects of the maxillary sinus, such as alveolar, zygomatic, and prelacrimal recesses. In these hidden maxillary sinus niches, a combination approach with MMA is required for better exposure and access. In this article, we present a modification of inferior maxillary antrostomy (IMA) to allow for a temporary intraoperative window with no significant postoperative consequences. Objectives: (1) To describe our modification of IMA. (2) To report the outcome of maxillary sinus disease, postoperative complications, and flap condition. Methods: This is a retrospective chart review study. It was performed on 20 patients where submucosal temporary inferior maxillary antrostomy (STIMA) was indicated in the period from January 1, 2020, and July 1, 2023. All patients were assessed for their demographics, diagnosis, indication for STIMA, maxillary disease outcome, presence of postoperative complications, and flap condition. Result: Total of 18 patients fulfilled our inclusion/exclusion criteria; of them, 13 were males while the remaining were females. Mean age of patients was 33 years; most common diagnosis was chronic sinusitis. Status of maxillary sinus mucosa was healthy in all except 4 patients having polypoidal mucosa while flap condition was intact in all patients except 2 patients with pinpoint defects. Postoperative complications assessment demonstrated no neural, orbital, lacrimal, or dental complications in all patients. Conclusion: This retrospective chart review showed promising technique to address challenging maxillary lesions in difficult-to-access locations where combined approaches are necessary.

Efficacy of endoscopic sinus surgery in management of odontogenic maxillary sinusitis after control of dental pathology

BackgroundOdontogenic sinusitis (ODS) has clinical features like rhinogenic sinusitis. Although it is usually unilateral, diagnostic overlap could happen. However, ODS necessitates different management which includes dental intervention to eliminate the dental infection source. In some patients, ODS may persist even after management of dental pathology. The aim of this study was to assess the clinical features, and diagnostic criteria of ODS that is persistent after management of dental pathology, and to evaluate the efficacy of endoscopic sinus surgery (ESS) as a therapeutic option of the disease.MethodsTwenty patients were included in this study. All patients were presented with ODS refractory to medical treatment after management of their dental problems. Clinical features of the patients were analyzed. Also, endoscopic nasal examination and computed tomography of paranasal sinuses (CT) were performed for all patients. ESS were used, with widening of the maxillary ostium for drainage. Follow-up was carried out for at least 6 months.ResultsAll patients had unilateral disease, with 3 main complaints: malodourous nasal discharge (90%), facial pain (75%), and nasal obstruction (45%). Endoscopic nasal examination showed either middle meatal purulence (70%) or polypoid mucosa (30%). CT showed either thickened maxillary sinus mucosa (50%), or complete maxillary opacity (50%) with retained foreign body in 2 patients (10%). After ESS, all patients reported relieve of their sinonasal symptoms, and nasal endoscopy showed patent middle meatus, with one patient demonstrated adhesions between the middle turbinate and lateral nasal wall which was asymptomatic.ConclusionPrior dental intervention is a suspicious diagnostic landmark for ODS, and unilateral foul nasal discharge is the main prevalent complaint. Nasal endoscopy usually shows purulence or polypoid mucosa in the middle meatus, and CT is a good diagnostic tool for ODS. ESS with good widening of the maxillary ostium is an effective therapeutic option for those patients.

Automastoidectomy — a case report

BackgroundAutomastoidectomy denotes extensive destruction of the middle ear cavity and the mastoid air cells, mimicking the appearance of a reminiscent image of the post-mastoidectomy cavity. This condition, although rare, might occur as a unique complication of chronic otitis media with cholesteatoma with subsequent destruction of the posterior wall of the external auditory canal and spontaneous partial or complete evacuation of the cholesteatoma through the canal.Case presentationSeventy-year-old gentleman, a retired soldier, presented to us in the ENT OPD with right ear pain for more than a year, right ear discharge for 9 months, and a decrease in the hearing of the right ear for 6 months. The condition started 18 months ago with intermittent right otalgia; Dull aching in nature. Ten months later, the patient started to experience right-sided otorrhoea which was profuse, offensive, mucopurulent, and yellowish in color. Later on, he noticed a gradually deteriorating hearing.On examination of the right ear, there is a fleshy mass obstructing the EAC, no auricular deformity tenderness, no preauricular swelling, sinus, or deformity, and there is thinning of the skin in the right postauricular region with mild tenderness but no swelling or sinus and preserved sulcus. Otoscopic examination shows a mass obstructing the EAC found to be an everted skin tag from the posteroinferior wall of the canal. There was a widening of the canal with the destruction of the walls and the absence of the TM, the annulus tympanicum, and the ossicles with polypoidal mucosa all over the middle ear cavity.InvestigationHRCT scan of the temporal bone shows destruction of the air cells of the right mastoid cavity with the absence of the ossicles and destruction of the posterior EAC walls.ConclusionAlthough uncommon it is considered to be a known complication of Cholesteatomatous otitis media and sometime keratosis obturates with the main feature of osteogenic destruction of the posterior wall of the EAC.

Varied Clinical Presentations of Allergic Fungal Rhinosinusitis-A Case Series.

Fungal sinusitis is broadly classified into invasive and non invasive types. Invasive type presents with fungal hyphae within the mucosa, submucosa, bone, or blood vessels of the paranasal sinuses and includes Acute Invasive Fungal Sinusitis, Acute Fulminant, Chronic Invasive Fungal Sinusitis, Chronic Granulomatous Fungal Sinusitis. Invasive forms of fungal rhinosinusitis are rare and confined to groups of patients who are immunocompromised (Key in Fungal rhinosinusitis). Noninvasive type shows absence of fungal hyphae within the mucosa paranasal sinuses. It includes Allergic Fungal rhinosinusitis, Fungus Ball (fungus mycetoma). The study was performed on a total of 30 patients, in Department of Otorhinolaryngology, at our hospital after getting approved by theInstituitional Human Ethical Committee. We selected 30 patients diagnosed with allergic fungal sinusitis and studied their varied clinical presentations and treatment for a period of 1year. It was a prospective case series type of study. Patients who presented with symptoms of allergic fungal rhinosinusitis were included. Patients who were referred with complaints of proptosis, diplopia were also included to rule out allergic fungal rhinosinusitis and its complications. Patients diagnosed with chronic granulomatous infection of nose and invasive fungal sinusitis were excluded. Evaluation of patients involved a detailed case history followed by clinical examination and radiologic investigation. After getting proper consent, we did a study of 30 patients who presented to our outpatient department with complaints of sinusitis. Our study included 12 male and 18 female patients. Among these patients, all of them had complaints of frequent allergic rhinosinusitis, nose block, facial heaviness. 12 among them had olfactory disturbances, reduced perception of smell. 4 patients presented with visual disturbances and proptosis which subsided after endoscopic sinus surgery was done.24 among these patients had presence of allergic fungal mucin in their nasal secretions and 10 patients had history of associated atopy and asthma and elevated Ig E levels. And 20 of these patients showed high eosinophil counts. All these patients in our case series were under the age group 22-70years. These patients were treated with a course of nasal sprays and preoperative steroids in case of extensive polyposis and were taken up for functional endoscopic sinus surgery. Polypoidal mucosa was removed, diseased tissue was cleared, sinus blockage was released and fungal mucin/tissue bits were sent for histopathological analysis, KOH mount and fungal culture. This study included a series of cases which showed a wide range of the various clinical presentations that occur in cases of allergic fungal rhinosinusitis, its diagnosis and treatment. The advantage of this study was we had analyzed a good number of cases with varied presentations. Since AFRS is closely related with EMRS, CRS a proper clinical, radiological and immunological evaluation of the cases help in knowing the correct diagnosis and treatment.

Clinical and endoscopic characteristics of gastrointestinal mantle cell lymphoma

Objective: To study the clinical and endoscopic features of mantle cell lymphoma (MCL). Methods: The clinical data and endoscopic characteristics of 20 patients with gastrointestinal MCL treated in the Affiliated Hospital of Zunyi Medical University and the Digestive Endoscopy Center of Guizhou Medical University from January 2011 to January 2021 were collected, and the histological and immunohistochemical characteristics of the tumor were observed. Meanwhile, 44 cases of non-gastrointestinal MCL in the above two hospitals in the same period were also enrolled. The clinical and endoscopic differences between the two groups were compared. Results: Among the 20 patients with gastrointestinal MCL, the male to female ratio was 4∶1 (16/4), the average age was (60.3±9.7) years, and 11 patients (55.0%, 11/20) were over 60 years old. The main clinical manifestations of 20 patients at the onset of the disease were bloody stool or black stool in 9 cases (45.0%), abdominal pain in 8 cases (40.0%). Moreover, 5.0% (1/20) had B symptoms (fever, night sweat and weight loss). The most frequently involved site was colorectum (50.0%). Endoscopic findings showed mucosal polypoid lesions in 13 cases (65.0%, 13/20), involving multiple intestinal segments, with polyp diameter of 0.2-3.5 cm. Two cases (10%) were in stage Ⅲ and 18 cases (90%) were in stage Ⅳ according to Ann Arbor staging. Seven cases (35.0%, 7/20) had the involvement of the peritoneal and retroperitoneal lymph nodes, 9 cases (45.0%, 9/20) had the involvement of the superficial lymph nodes in 45.0% (9/20), and 4 cases (20%, 4/20) had other extranodal invasion. Splenomegaly accounted for 35.0% (7/20). CD20, Bcl-2 and CD5 were positive or strongly positive in all gastrointestinal MCL tumor cells in 20 cases. Cyclin D1 was positive or strongly positive, accounting for 90.0% (18/20). The sex-determining region of Y chromosome-related high-mobility-group box 11 (SOX11) was positive or strongly positive, accounting for 65.0% (13/20). The positive index of Ki-67 was 5%-80%. Twenty cases (100%, 20/20) were followed up. The median follow-up was 41.2 months (1-74 months). There was no significant difference in the 3-year overall survival rate between the gastrointestinal MCL patients (70.0%) and non-gastrointestinal MCL patients (72.7%) (χ2=0.051, P=0.822). Conclusions: Abdominal discomfort is the main symptom of gastrointestinal MCL, which often occurs in the colorectum and often presents with multiple polypoid lesions. There are relatively few cases with B symptoms and extranodal invasion, and the prognosis is not different from that of patients with non-gastrointestinal MCL.

S1971 Waldenstrom Macroglobulinemia: A Malignant Mimicker of IBD

Introduction: Waldenstrom macroglobulinemia (WM) is a lymphoplasmacytic lymphoma in the bone marrow with IgM gammopathy in the blood. Annually ∼1400 cases are diagnosed in the US, with typical presentation of B symptoms, fatigue, neuropathy, and mucosal bleeding. Only 3% of patients present with colonic symptoms. We describe a case of WM with rectal involvement presenting as bloody diarrhea, mimicking inflammatory bowel disease (IBD). Case Description/Methods: A 56-year-old man with depression, anxiety, and fibromyalgia presented with 6 months of diarrhea with mucous and rectal bleeding. He underwent upper endoscopy and colonoscopy with Helicobacter pylori gastritis, proctitis, and inflammatory polyps. He symptoms worsened despite rectal mesalamine, including weight loss and night sweats. Budesonide oral and foam resolved the bleeding but diarrhea continued despite rifaximin. Around this time, he was thought to have irritable bowel syndrome. Two years later, he had recurrence of daily bowel movements with mucous and rectal bleeding, plus fecal incontinence, tenesmus, and rectal and abdominal pain. He also noticed myalgias, arthralgias, parasthesias, fatigue, and chills. Rheumatology suggested fibromyalgia as the culprit, in part due to elevated ESR. After his GI symptoms renewed suspicion for IBD, repeat colonoscopy showed a 3 cm rectal mass with ulcer and stenosis at the recto-sigmoid colon. Biopsies showed eosinophilic proteinaceous material positive for PAS-D, negative for fibrosis and amyloid and concerning for malignancy. EUS confirmed inflammatory polyps and rectal thickness ( Figure 1). Hematology performed immunofixation with faint monoclonal IgM-lambda, and bone marrow biopsy confirmed lymphoplasmacytic lymphoma concerning for WM. Discussion: WM rarely involves the GI tract, with fewer colonic and rectal presentations than small bowel. The IgM deposition can cause severe malabsorption, steatorrhea, obstructive symptoms, or GI bleeding. Especially in cases of bloody stools and localized colonic thickening, WM can be mistaken for IBD. In our case, factors more suggestive of WM included degree of colonic thickening and pathologic PAS-D positivity. Particularly, raised lesions should prompt investigation for malignant processes, despite surrounding inflammatory changes. Diagnosis of WM usually involves multiple specialists and procedures such as bone marrow biopsy. WM treatment includes bruton tyrosine kinase inhibitors or bendamustine with rituximab, the latter of which improved our patient’s GI symptoms.Figure 1.: Image 1. Colonoscopy and lower endoscopic ultrasound (EUS) visualized circumferential wall thickening and stenosis in rectum, with polyps and stenosis in sigmoid colon. a. During colonoscopy, a benign-appearing, intrinsic moderate stenosis measuring 4 cm in length was found in the recto-sigmoid colon, due to circumferentially congested edematous polypoid mucosa with overlying exudate. b. Several 10 to 16 mm sessile polyps were seen with inflammatory appearance in the sigmoid colon. c-d. During EUS, circumferential wall thickening was found in the rectum at the superficial and deep mucosa. There was no evidence of an infiltrative subepithelial mass. The muscularis propria layer was normal throughout.

Is Posterior Nasal Nerve Neurectomy Really a Ray of Hope for the Patients of Allergic Rhinitis.

Allergic rhinitis significantly affects the quality of life, it contributes to missed or unproductive time at school or work, disturbed sleep pattern and day time somnolence. Rhinitis is defined clinically as having two or more symptoms of anterior or posterior rhinorrhoea, sneezing, nasal blockage and/or itching of the nose during two or more consecutive days for more than 1 h on most days (International rhinitis management working group, 1994). Allergic rhinitis is diagnosed when these symptoms are caused by allergen exposure leading to an IgE mediated reaction. Nerve irritation causes sneezing and itching, the loss of mucosal integrity causes causes rhinorrhoea and the vascular engrogment leads to nasal blockage. Medical modalities are symptomatically effective in mild cases, with temporary relief and addressable adverse effects. Prolonged treatment with allergy immunotherapy causes a sustainable financial burden while remaining inaccessible at smaller towns. Posterior nasal nerve neurectomy is short, easy and effective alternative. The basic procedure is to selectively cut nerve bundles at the level of the sphenopalatine foramen (SPF) with a trans nasal approach. By denervating the nasal mucosa one renders it unresponsive to any sorts of allergen or allergic reaction. The aim of the study was to evaluate the outcome of posterior nasal nerve neurectomy in cases of severe allergic rhinitis by assessing its impact on the total nasal symptom score. The study is a hospital based prospective study, conducted on 15 patients who presented to the ENT department of Mahatma Gandhi Hospital from march 2021 to October 2021 (6months) suffering from allergic rhinitis and did not show any satisfactory improvement even after 1year of medical treatment. Adult patients in the age group of 20-45 yrs. diagnosed with allergic rhinitis were enrolled into the study after obtaining a due written consent. These included patients having 2 or more symptoms of allergic rhinitis and refractoriness to medical therapy for > 1year along with significantly affected quality of life and elevated IgE level. Patients with drug induced & hormonal causes of rhinitis, chronic rhinosinusitis and any anatomical feature which precipitates to rhinitis such as deviated nasal septum, hypertrophied turbinates, blocked osteomeatal unit, polypoidal nasal mucosa and sinonasal polyposis were excluded from the study. During our study period from march 2021-September 2021, 15 patients were enrolled in the study. All the patients were followed up at 2nd and 6th month postoperatively. Amongst these patients, there were 11 females (73.34%) and 4 were male (26.67%)The mean age of patients was 35.2years. Subjective nasal symptoms of all 15 patients improved over the period of 6months. The mean TNSS improved from 12.067 preoperatively to 8.66 at the end of 2nd month, i.e., 23.1% improvement. By the end of the 6th postoperative month there was a consistent reduction in the tnss, which further reduced to a mean of 3.4 (70.2% reduction) indicating a further improvement in symptoms with time. With the advancement & popularity of endoscopic sinus surgery in the past decade, endoscopic resection of the posterior nasal nerve is emerging as a safe and less invasive technique with long standing results. Medical treatment usually provides mild and symptomatic relief with long duration of treatment period. Thus, PNN is safer, economical & easier alternative to current trend of treatment of allergic rhinitis, proving to be highly efficient in cases of intractable allergic rhinitis.

English

BACKGROUND We wanted to study the preoperative clinical, audiological, radiological findings & compare them with the perioperative findings of ossicular necrosis. METHODS 100 patients were clinically diagnosed as mucosal chronic otitis media (COM). They underwent a thorough clinical, audiological & radiological examination. X-ray mastoid Schuller's view on both sides was done in all patients & HRCT temporal bone was done in 51 patients. They were then posted for surgery & findings were compared with the perioperative ossicular necrosis. RESULTS 42 patients had ossicular defects perioperatively. Incus was found to be the most commonly necrosed ossicle & malleus was the most resistant ossicle. There was a positive association found between duration of disease, posterior perforations, large central & subtotal perforations, polypoidal middle ear mucosa, granulations over margins of perforations & audiological findings with the perioperative ossicular defects. HRCT was the most reliable investigation to predict ossicular necrosis. CONCLUSIONS From the study, it was concluded that all patients with mucosal COM can be assessed preoperatively for ossicular erosion. HRCT gives us a preoperative picture of the extent of ossicular necrosis & helps the surgeon in planning the surgical intervention. KEY WORDS COM, HRCT, Ossicular Necrosis, Mucosal, PTA

Endocervicoscopy with Office Hysteroscope for Complete Visualization of Transformation Zone in Cases of Invisible Squamocolumnar Junction on Colposcopy.

Aim:To evaluate the role of endocervicoscopy for the visualization of the T3 transformation zone (TZ) on colposcopy.Materials and Methods:Forty patients with either abnormal Pap smear or positive VIA-VILI and T3 TZ on colposcopy were recruited from the colposcopy clinic and subjected to endocervicoscopy with a 4-mm office hysteroscope. The view of the endocervical canal was recorded before and after the application of 5% acetic acid and the squamocolumnar junction was identified in its entirety. An endocervical curettage was taken in all the cases and compared with the final histopathology report.Results:Squamocolumnar junction was visible in all the 40 cases; however, in two patients (5%), cervical dilatation had to be done. The positive predictive value (PPV) of endocervicoscopy in our study was 33.3% and negative predictive value (NPV) was 100%. Dense acetowhitening/irregular polypoidal endocervical mucosa with dilated blood vessels was significant in predicting the premalignant and malignant lesions with PPV of 67% and NPV of 100%.Conclusion:Endocervicoscopy allows a panoramic view of the endocervical canal. It is a safe, effective, and feasible technique for visualization of squamocolumnar junction with 5% acetic acid in cases of T3 TZ on colposcopy.

Rare presentation of annular and polypoid heterotopic gastric mucosa in duodenum.

In this case, Esophagogastroduodenoscopy showed an approximately 25-mm diameter annular and polypoid mucosa at the opposite side of Pylorus ring in first part of duodenum. The biopsy specimens were diagnosed with the heterotopic gastric mucosa (HGM) pathologically. This is a rare presentation of annular and polypoid HGM in duodenum. This may indicate the needs for other documents as well as analysis regarding the mechanism for the development of HGM in duodenum.

To assess the hearing improvement in patients of Chronic Otitis Media Tubotympanic type post tympanoplasty

Aim: To determine hearing improvement in type- 1 tympanoplasty by comparing mean preoperative air bone gap with mean postoperative AB gap. Material and method: Patients clinically diagnosed as 75 cases of Chronic Suppurative Otitis Media Tubotympanic Type Disease presenting to the ENT OPD of Chhatrapati Shivaji Hospital attached to Subharti Medical College, Meerut were taken up for study. Detailed clinical examination and history was taken. Pure tone audiometry was conducted, hearing loss and mean AB Gap was noted pre-operatively. X-Ray mastoid B/L Schuller’s view was done and findings were noted. Tympanoplasty type 1 with or without mastoidectomy was performed. Cortical mastoidectomy with type 1 Tympanoplasty was performed in patients having granulations & polypoidal middle ear mucosa along with sclerotic mastoid. All these patients were followed up post-operatively at 6 weeks. The status of graft uptake was noted. Pure tone audiometry was performed. Hearing loss and mean AB Gap results were compared with pre-operative findings. Results: In our study out of 75 patients, 33 (44%) patients were affected with Right ear and 42 (56%) patients were affected with Left ear. Hearing loss was the chief complaint in all 75 patients (100%) followed by blocking sensation. Post operatively 58 (77.33%) patients had normal hearing followed by 16 (21.33) patients who had mild hearing loss. Only 1 (1.33%) patient had moderately severe hearing loss. Pre-operatively, mean AB Gap was 46.62+/-7.89dB while post-operatively mean AB Gap was 23.43+/-5.52dB with statistically significant difference as p<0.05. Conclusion: In our study, the post-operative Mean AB Gap was improved significantly as compared to preoperative mean AB Gap.

S2307 COVID-19 in a Patient on Dual Biologic Therapy for Inflammatory Bowel Disease

INTRODUCTION: Preliminary data suggest that dual biologic therapy might be effective and safe in a subgroup of inflammatory bowel disease (IBD) patients. However, the safety and outcomes of dual biologic therapy in IBD with Coronavirus Disease 19 (COVID-19) is unknown. Here, we present a case of a Crohn’s disease (CD) patient on adalimumab (ADA) and ustekinumab (UST) combination therapy who developed COVID-19. CASE DESCRIPTION/METHODS: This is a 24-year-old man with fibrostenotic Crohn’s ileocolitis diagnosed at age 9. He had a secondary loss of response to infliximab despite dose escalation to 10 mg/kg in combination with methotrexate (MTX). He was then transitioned to ADA and dose was escalated to 40 mg weekly with MTX (subsequently self-discontinued MTX). He achieved clinical response but not remission with ADA. Magnetic resonance enterography showed active inflammation in the terminal ileum, distal sigmoid colon, and rectum (Image 1). A colonoscopy showed ulcerated and polypoid mucosa in the terminal ileum and at the ileocecal valve with narrowing and patchy, mild pan-colonic inflammation (Image 2A/B). ADA level was 17 mcg/mL without antibodies. Switching to a different biologic was recommended. The patient was hesitant about discontinuing ADA due to symptomatic improvement. After discussion of risks and benefits, it was decided to bridge with UST and continue ADA with a plan to eventually discontinue ADA if remission was achieved. He received standard intravenous UST loading followed by 90 mg subcutaneously every 8 weeks. Five months later, he tested positive for COVID-19 due to exposure to an infected individual. He was asymptomatic from a respiratory standpoint and his gastrointestinal (GI) symptoms were at baseline. He received a dose of UST 1 day prior to COVID-19 testing and last ADA was 1 week prior to testing. ADA was held and resumed 2 weeks after as he remained without fever, respiratory symptoms or new onset GI symptoms at 2 and 6 weeks after testing positive for COVID-19. DISCUSSION: This case describes a favorable outcome of a CD patient who tested positive for COVID-19 while on ADA and UST. Multiple series have demonstrated that biologic monotherapy is not associated with poor outcomes in COVID-19 infected IBD patients. Instead, corticosteroids, advanced age and co-morbidities are predictors of adverse outcomes. However, more data is needed on the safety of combination biologic therapy in the COVID-19 era.Image 1.: Magnetic resonance enterography (coronal T1 weighted image) showing wall thickening, edema and hyperenhancement involving the terminal ileum over a length of approximately 20 cm with associated vascular engorgement is present.Image 2.: Colonoscopy images showing polypoid stenotic ileoceal valve (A) and the terminal ileum showing ulcerations (B).

S1704 Mantle Cell Lymphoma Presenting as Colonic Polypoid Nodules in a Crohn’s Disease Patient With History of Azathioprine Use

INTRODUCTION: The gastrointestinal (GI) tract is the most common extra nodal site affected by lymphoma, accounting for 5–20% of all cases. Of all GI lymphoma subtypes, mantle cell lymphoma (MCL) is more frequently noted in the ileum and colon. We present a case of MCL presenting as mucosal polypoid nodules in a Crohn's disease patient with history of azathioprine use. CASE DESCRIPTION/METHODS: A 71-year- old male presented to the clinic for management of Crohn’s disease (CD). He was diagnosed at the age of 25 when he developed acute small bowel obstruction secondary to a terminal ileum (TI) stricture and required resection and ileo-colonic anastomosis. He had treatment failure with infliximab due to antibody formation and was managed with azathioprine for over 30 years. Surveillance colonoscopy a year ago showed active ileo-colonic disease and ustekinumab was initiated. Past medical history was remarkable for generalized lymphadenopathy involving the supraclavicular, mediastinal and mesenteric regions. Previously, patient had undergone an excisional lymph node biopsy that was negative for lymphoma. Laboratory testing showed leukocyte count of 5.5 × 109/L with normal differential, hemoglobin of 14.1 g/dL, and a platelet count of 106 L K/uL. Colonoscopy showed scattered erosions and friable mucosa in the entire examined colon and TI. Interestingly, a 2 cm submucosal nodule was noted in the proximal colon that appeared to be a lipoma with mucosal inflammation. Similar small submucosal nodules were noted in the rectum and biopsies were obtained. Pathology of the biopsied nodules revealed atypical lymphoid proliferation. On immunohistochemical staining, B cells were identified, positive for CD 20, CD5, BCL-1, BCL-2, CD43 but negative for CD10 and CD23. The findings were consistent with mantle cell lymphoma. PET scan and bone marrow biopsy revealed disseminated disease with bone marrow involvement. The patient’s immunosuppression was discontinued, and he was referred to oncology for chemotherapy. DISCUSSION: MCL is an aggressive subtypes of B-cell non-Hodgkin lymphoma and most patients have advanced-stage disease at diagnosis. Patients with MCL and GI involvement could be asymptomatic or may present with abdominal pain, obstruction, diarrhea, or overt bleeding. Endoscopic findings may include normal mucosa, nodules, polyps, ulcers, and masses. It is important to biopsy seemingly benign lesions as in our case, if index of suspicion is high. Further history of azathioprine is known to increase lymphoma risk.Figure 1.: A 2 cm smooth submucosal nodule with erythematous mucosal changes noted in the proximal colon.

S2766 Sunburn of the Upper GI Tract: A Case of Metastatic Melanoma of the Stomach and Duodenum

INTRODUCTION: Malignant Melanoma is the fifth most common cancer among the population, and it is known to spread to most organs in the body. Severity of this dastardly disease is predicated based on the stage of the cancer. It is one of the most common cancers that can disseminate to the gastrointestinal tract (GIT). To the best of our knowledge as per literary review, there are fewer than 10 reported case reports discussing cutaneous melanoma with metastasis to both stomach and duodenum simultaneously. This case report aims to add yet another example of this phenomenon to the literature. Here, we present a 49-year old female with biopsy proven melanoma of the back, who presented three years later with nausea and vomiting, and was found to have metastasis to the stomach and duodenum. CASE DESCRIPTION/METHODS: Our patient is a 49-year-old female who presented with chief complaints of intractable nausea and vomiting for eight weeks. She was diagnosed with benign superficial spreading melanoma of the back three years prior. Two years later she had a CT chest suggestive of metastatic disease (stage IV), and she was subsequently started on immunotherapy with nivolumab. Given her persistent nausea and vomiting, an EGD was performed which showed three mucosal polypoid nodules, approximately 5–10 mm with tip ulcerations, in the gastric body and multiple mucosal nodules, approximately 5–10 mm, in the duodenum (Figure 1). Biopsies of these nodules showed S-100 and MART-1 positive metastatic melanoma (Figure 2). Genetic sequencing revealed mutations in the following genes: BRAF V600E, PTEN, PD-L1 28-8. DISCUSSION: This case highlights the severity of melanoma and its negative impact on the GIT. Metastatic melanoma of the GIT is a common postmortem finding, however antemortem diagnosis of this lethal disease is quite rare. The most widely used “melanoma markers” are: S-100, HMB-45, and MART-1/Melan-A [6]. It is also important to appreciate that due to their wide differences in sensitivity and specificity, these markers are often tested together to optimize statistical yield. It has been shown that the incidence of metastatic melanoma of the GIT is as follows: Jejunum and ileum 58%, stomach 26%, colon 22%, duodenum 12%, and the least common being to the rectum and anus. GI symptoms in a melanoma patient should always prompt one to explore further endoscopic investigation. In the event of a negative endoscopy in a melanoma patient, one should consider a capsule endoscopy to ensure complete examination of the GIT.Figure 1a.: Mucosal nodules seen in duodenum.Figure 1b.: Mucosal nodule seen in gastric body.Figure 2.: Gastric nodule seen at 100x, stained MART-1 positive (brown). Metastatic infiltration of glands seen (yellow arrows).

Impact of Patient Guidance Handouts on Outcomes of FESS.

Post-operative care in FESS is an important aspect. Nasal saline irrigation and Nasal steroid spray are highly recommended worldwide in post-operative protocol after endoscopic sinus surgery. Hence patients compliance for both these procedures becomes a deciding factor for outcomes following FESS and there is not much evidence in literature regarding the same. The present study was conducted to evaluate the role of giving patients pictorial handouts regarding nasal saline irrigations and various positions of using nasal steroid spray in improving outcomes of FESS. It was a randomised control study.46post operative patients of FESS were randomised into two groups. Group A patients were verbally explained and practically demonstrated the technique of nasal saline irrigation and nasal steroid spray in the language best understood and by showing them the relevant images. Group B patients were also verbally explained as well as practically demonstrated the above mentioned procedure but were also given pictorial handouts (depicting in detail the positions of nasal saline irrigation and steroid spray} which were explained and handed over to them at the time of discharge. The patients were evaluated a 1st, 2nd 3rd and 4th post-operative week for compliance of both the procedures and its effect on post-operative cavity. In the present study there were 21 females versus 25 males. The average male: female ratio in group A was 1.3 versus 1 in group B. The mean age was 35.5652 ± 4.595 in group B versus 33.1739 ± 4.438 in group A. The average compliance over three weeks was 2.5765 ± 0.207 in Group B as compared to 1.4935 ± 0.27 in Group A. The t score for the difference in compliance between two groups was 15.2691. The two-tailed P value was less than 0.0001. The average Lund and Kennedy endoscopic appearance score for crusting was 1.75 ± 0.532, 1.217 ± 0.6, 0.696 ± 0.703 for Group A in post-operative follow up during week 1, 2 and 3 respectively as compared to 1.45 ± 0.59, 0.304 ± 0.47, 0.826 ± 0.49 for Group B. The P value was < 0.05 for the difference in both groups for all three weeks. The average Lund and Kennedy score for edema and other parameters has been enumerated in Table 1. 11/23 followed correct method for nasal saline irrigation in Group A as compared to 20/23 in Group B. 18/23 used nasal steroidal spray in all positions compared to only 9/23 in Group A. 3/23 in group B had polypoidal mucosa at frontal recess area at 1month post-operative as compared to 16/23. Overall their was a negative correlation between the compliance of nasal saline irrigation with edema, crusting and discharge. The respective R score was -0.5311, -0.25296 and -0.19889 respectively. The pictorial handouts definitely improved compliance and hence outcomes in our study. We recommend this practice in routine to all our fellow rhinologists.

Meckel's diverticulum with polypoid hyperplasia of ectopic gastric mucosa diagnosed by double-balloon enteroscopy and single-photon emission computed tomography/computed tomography.

Meckel’s diverticulum (MD) is a relatively common true congenital diverticulum on the ileum. Bleeding caused by polypoid hyperplasia of ectopic gastric mucosa in MD is rare. A 14-year-old Chinese boy presented with intermittent melena and haematochezia for 1 month. Laboratory data showed normocytic anaemia. Gastroscopic findings were normal. The patient underwent exploratory laparotomy without bowel preparation on day 2 because of sudden haematochezia and decreased haemoglobin. Intraoperative colonoscopy revealed inflammatory changes in the terminal ileal mucosa with diffuse haemorrhage. Melena with decreased haemoglobin recurred 20 days after the first operation. Computed tomography (CT) and angiography revealed a tubular lesion that was localised in the right lower abdominal quadrant. Single-photon emission computed tomography/computed tomography (SPECT/CT) fusion imaging with 99m-technetium pertechnetate confirmed moderately increased uptake in the distal ileum. Retrograde double-balloon enteroscopy (DBE) showed a diverticulum with prominent mucosal polypoid hyperplasia at an insertion depth of 100 cm from the anastomotic stoma. Diverticulectomy and end-to-end anastomosis were performed, and MD was confirmed by a histopathological examination. The patient’s postoperative recovery was uneventful during the 2-month follow-up. MD with polypoid hyperplasia of ectopic gastric mucosa is rare. Complementary use of DBE and SPECT/CT can accurately diagnose MD by providing anatomical and functional information.

A Prospective Longitudinal Study to Evaluate the Patency of the Aditus ad Antrum in Chronic Otitis Media Mucosal Type.

Chronic otitis media is defined as the chronic inflammation of the mucoperiosteal lining lining of the middle ear cleft which presents with recurrent ear discharge through tympanic membrane perforation. The study was planned to evaluate the patency of the aditus ad antrum in cases of chronic otitis media mucosal type, and its correlation with various direct and indirect indicators of blocked aditus. The prospective longitudinal study was conducted on 100 patients with chronic otitis media mucosal type. The commonest complaint of patients was ear discharge (100%) followed by hearing impairment in 72% patients.Tympanoplasty with antrotomy was performed. The patency and dimensions of the aditus ad antrum were assessed by saline water test. In 41% cases saline test showed blockade, on further drilling patency achieved in 27 cases with minimal drilling and dissection of mucosa with or without fibrotic mucosal bands. In rest 14 cases widening of aditus and atticotomy was required to achieve patency. Out of these nine were having associated tympanosclerosis and five were having edematous mucosa. Ossicular necrosis was seen on 18 cases. Presence of myringosclerosis and polypoidal edematous mucosa increases the probability of an obstructed aditus ad antrum. Mastoid antrostomy and water test for patency can be performed without additional cost and risk to the patient in minimal time and can be considered as the surest indicator of patency of aditus ad antrum.

The Effectiveness of Budesonide Nasal Irrigation After Endoscopic Sinus Surgery in Chronic Allergic Rhinosinusitis with Polyps.

Nasal polyposis is one of the most common chronic upper airway diseases. Management of allergic rhinosinusitis with polyps is to control the disease process and the local immune response of the nasal mucosa. This is achieved by surgical removal of polypoid mucosa of all sinuses by functional endoscopic sinus surgery (FESS) followed by suppression of local immune response by using steroids. Budesonide nasal douching was introduced recently for postoperative management of patients with allergic rhinosinusitis. The therapeutic effectiveness and safety of this procedure are becoming accepted by many physicians. Evaluation of the efficacy of budesonide nasal irrigation in the postoperative management of chronic allergic rhinosinusitis with polyps. A total of 60 postoperative chronic allergic rhinosinusitis with polyps patients were randomly divided into two groups. Both groups received routine post-FESS medication as per the institute protocol. One group of patients received budesonide nasal douching in addition to regular care. Both groups were evaluated endoscopically at 1, 2, 6 and 10weeks after surgery. Pre and postoperative quality of life change, the patient complaints, need for revision surgery were evaluated. Endoscopic Lund-Kennedy scoring (objective measurement) and Sino-Nasal Outcome Test-22 (subjective analysis) were used to compare the two postoperative groups. The average preoperative Sino-Nasal Outcome Test 22 score was 52.2. It was reduced to an average of 29.4 in patients who used the standard postoperative regimen and to 15.8 postoperatively in patients who had budesonide added to their douching solutions. The average endoscopy score was 2.2 for patients who did receive budesonide as compared to 2.9 for patients who did not receive budesonide nasal douching. Budesonide nasal douching can offer a safe and effective tool in managing local inflammatory response in allergic rhinosinusitis. It leads to a significantly better quality of life and has an adequate response on nasal mucosa-leading to less mucosal oedema and lower incidence of polypoidal changes postoperatively.

Silymarin, boswellic acid and curcumin enriched dietetic formulation reduces the growth of inherited intestinal polyps in an animal model.

BACKGROUNDSome substances of plant origin have been reported to exert an effect in reducing intestinal neoplasm development, especially in animal models. Adenomatous polyposis coli multiple intestinal neoplasia - ApcMin/+ is the most studied murine model of genetic intestinal carcinogenesis.AIMTo assess whether an enriched nutritional formulation (silymarin, boswellic acid and curcumin) with proven “in vitro” and “in vivo” anti-carcinogenetic properties may prevent inherited intestinal cancer in animal model.METHODSForty adenomatous polyposis coli multiple intestinal neoplasia - ApcMin/+ mice were used for the study of cancer prevention. They were divided into two groups: 20 assumed standard and 20 enriched diet. At the 110th d animals were sacrificed. In each group, four subgroups received intraperitoneal bromodeoxyuridine injection at different times (24, 48, 72 and 96 h before the sacrifice) in order to assess epithelial turnover. Moreover, we evaluated the following parameters: Intestinal polypoid lesion number and size on autoptic tissue, dysplasia and neoplasia areas by histological examination of the whole small intestine, inflammation by histology and cytokine mRNA expression by real-time polymerase chain reaction, bromodeoxyuridine and TUNEL immuno-fluorescence for epithelial turnover and apoptosis, respectively. Additionally, we performed western blotting analysis for the expression of estrogen alpha and beta receptors, cyclin D1 and cleaved caspase 3 in normal and polypoid tissues.RESULTSCompared to standard, enriched diet reduced the total number (203 vs 416) and the mean ± SD/animal (12.6 ± 5.0 vs 26.0 ± 8.8; P < 0.001) of polypoid lesions. In enriched diet group a reduction in polyp size was observed (P < 0.001). Histological inflammation and pro-inflammatory cytokine expression were similar in both groups. Areas of low-grade dysplasia (P < 0.001) and intestinal carcinoma (IC; P < 0.001) were significantly decreased in enriched diet group. IC was observed in 100% in standard and 85% in enriched formulation assuming animals. Enriched diet showed a faster epithelial migration and an increased apoptosis in normal mucosa and low-grade dysplasia areas (P < 0.001). At western blotting, estrogen receptor beta protein was well expressed in normal mucosa of enriched and standard groups, with a more marked trend associated to the first one. Estrogen receptor alpha was similarly expressed in normal and polypoid mucosa of standard and enriched diet group. Cleaved caspase 3 showed in normal mucosa a stronger signal in enriched than in standard diet. Cyclin D1 was more expressed in standard than enriched diet group of both normal and polypoid tissue.CONCLUSIONOur results are suggestive of a chemo-preventive synergic effect of the components (silymarin, boswellic acid and curcumin) of an enriched formulation in inherited IC. This effect may be mediated by the reduction of epithelial proliferation, the increase of apoptosis and the acceleration of villous cell renewal due to dietary formulation intake.