Recurrent Sore Throat Research Articles

Gastroesophageal reflux disease: prevalence and Extraesophageal manifestations among undergraduate students in South West Nigeria

BackgroundThe reflux of noxious contents of the stomach may cause oesophageal and extra-oesophageal complications either by direct contact of aspirated gastric refluxate with the upper airway or by a vago-vagal reflex. This study aimed to determine the prevalence of gastroesophageal disease (GERD) and extraesophageal manifestations among undergraduate students in a tertiary institution in Nigeria.MethodsThis is a cross-sectional study involving undergraduate students in a private University in Nigeria. Study proforma had three parts. Part A consisted of self-administered questionnaire designed to obtain students biodata. Part B consisted of standard Carlsson-Dent questionnaire. A score of 4 and above on Carlsson- Dent questionnaire was considered diagnostic of gastroesophageal reflux symptoms (GERD). Thereafter those who had GERD were further questioned and examined for extra-oesophageal symptoms of GERD.ResultsThe total number of the study participants was 647, out of which 212 (32.8%) had GERD. One hundred and forty-four (67.9%) and 86 (32.1%) females and male had GERD respectively (p = 0.13).The extraesophageal symptoms found in those with GERD were, dysphagia, coated tongue, nocturnal cough, xerostomia, lump in the throat, asthma-like symptoms, recurrent sore throat, frequent throat clearing, halithosis and dental erosion among others.ConclusionGERD is common among this study population, with a prevalence rate of 32.8%. Only age showed significant predictor for GERD. Varying extra-oesophageal manifestations were found in those with GERD.

WITHDRAWN: Antistreptococcal interventions for guttate and chronic plaque psoriasis.

Guttate psoriasis is a distinctive acute form of psoriasis which characteristically occurs in children and young adults. It is closely associated with preceding streptococcal sore throat or tonsillitis. Some authorities have claimed that ordinary (chronic plaque) psoriasis may also be made worse by infection at distant sites. Although many dermatologists have recommended using antibiotics for guttate psoriasis in particular, it is not clear whether they influence the course of either form of psoriasis. Some dermatologists have also recommended tonsillectomy for psoriasis in patients with recurrent streptococcal sore throat. To assess the evidence for effectiveness of antistreptococcal interventions including antibiotics and tonsillectomy in the management of acute guttate and chronic plaque psoriasis. We searched the Cochrane Clinical Trials Register (Cochrane Library, Issue 3, 1999), Medline (1966- September 1999), Embase (1988-September 1999), the Salford Database of Psoriasis Trials (to November 1999) and the European Dermato-Epidemiology Network (EDEN) Psoriasis Trials Database (to November 1999) for terms [STREPTOCOCC* or ANTIBIOTIC* or TONSIL*] and PSORIASIS using the Cochrane Skin Group search strategy. Randomised trials of one or more antistreptococcal interventions in patients with guttate or chronic plaque psoriasis. Two reviewers independently examined each retrieved trial for eligibility and quality. The one eligible trial we identified compared the use of two oral antibiotic schedules in 20 psoriasis patients, predominantly of guttate type, who had evidence of beta-haemolytic streptococcal colonisation. Either rifampicin or placebo was added to the end of a standard course of antistreptococcal antibiotic (phenoxymethylpenicillin or erythromycin). No patient in either arm of the study improved during the observation period.No randomised trials of tonsillectomy for psoriasis were identified. Although it is well known that guttate psoriasis may be precipitated by streptococcal infection, there is no firm evidence to support the use of antibiotics either in the management of established guttate psoriasis or in preventing the development of guttate psoriasis following streptococcal sore throat.Although both antibiotics and tonsillectomy have frequently been advocated for patients with recurrent guttate psoriasis or chronic plaque psoriasis, there is to date no good evidence that either intervention is beneficial.

Chronic tonsillitis and biofilms: a brief overview of treatment modalities.

Recurrent tonsillitis is described as when an individual suffers from several attacks of tonsillitis per year. Chronic and recurrent tonsillitis both cause repeated occurrences of inflamed tonsils which have a significant impact on a patient’s quality of life. Numerous children suffer from recurrent tonsillitis and sore throats, and these illnesses become part of their life. Antimicrobials can provide temporary relief, but in many cases, tonsillitis recurs. The cause of such recurrent infections have been identified as microorganisms which often create biofilms and a repository of infection in the wet and warm folds of the tonsils. This review discusses different treatment modalities, their advantages and disadvantages, and new treatment options focusing on biofilms. All treatment options should be selected based on evidence and individual need.

A 2-year follow-up study of patients with pharyngotonsillitis

BackgroundLongtime follow-up studies on patients with pharyngotonsillitis are rare. We aimed to describe the patterns of new visits for a sore throat, complications and tonsillectomy during 2 years in a cohort of patients with pharyngotonsillitis and non-infected controls.MethodsA retrospective chart review was performed on a cohort of patients with acute sore throat (n = 207), and non-infected controls (n = 108). New visits, complications and tonsillectomy within 2 years was recorded and analyzed in relation to microbiological findings at inclusion.ResultsPatients with Group A streptococci (GAS) (12/66) reconsulted more often within 30 days than patients with no GAS (9/141) (p = 0.009) and patients with F. necrophorum (2/29). After 2 years, we observed no significant differences in reconsultations with regard to aetiology at inclusion. A single complication was recorded and 5 patients were planned for tonsillectomy.ConclusionsGroup A streptococci were the sole aetiological agent associated with recurrent sore throat while F. necrophorum did not distinguish itself as a major cause of either recurrent infection or complications in this cohort. More studies, preferably with the focus on adolescents, are needed before F. necrophorum can be considered an important cause of pharyngotonsillitis.

Otorhinolaryngological manifestations of pediatric patients with sickle cell disease in Nguru, Nigeria

Background: Virtually no organ of the body is exempted from the effects of sickle cell disease (SCD) following repeated episodes of vaso-occlusion, infarction, and hemolysis leading to organ dysfunction. However, there is a dearth of data on the anatomic and functional changes of the ears, nose, and throat (ENT) in patients with SCD. Therefore, monitoring and evaluation of the effects of this disease on these organs will be defective due to the absence of baseline data necessary for institution of intervention programs and policy formulation. Aim: To review and determine the prevalence of the general anatomic changes and functional effects of SCD on the ENT in the pediatric age group. Materials and Methods: A cross-sectional prospective study of 52 children with SCD was carried out in 2018. Hematological parameters were determined while otolaryngoscopic examination and audiometric tests were conducted. Data were analyzed using SPSS version 19 software, and Pearson's linear correlation statistical method was also employed and level of significance was set at P ≤ 0.05. Results: The mean age of the children was 8.81 ± 4.58 years. Excessive snoring was present in 28.8% (15) of the participants, of which 60% (9) had >75% occlusion of the nasopharynx. Recurrent ear discharge was seen in 21.2% of the participants. Conductive hearing loss (HL) was 9.6% and 7.7% for the right and left ears, respectively, while sensorineural HL was 13.5% and 3.8% for the right and left ears, respectively. Recurrent sore throat was recorded in 17.3% of the participants, while 73.1% had Brodsky Grade 1 tonsillar enlargement. Conclusion: Ear infections, HL, and tonsillar enlargement are common among pediatric patients with SCD. This may not be unconnected to inadequate clinical care due to lack of good health education, ignorance, poverty, and prophylaxis from infections.

CONCURRENT TONSILLECTOMY AND ADENOIDECTOMY IN THE CHILDREN

Objective: To evaluate results of concurrent tonsillectomy and adenoidectomy in the children. Materials and Methods: 82 patients were given concurrent tonsillectomy and adenoidectomy in the children from 4/2016 to 5/2017, and the results were studied by descriptive, prospective and clinical methods. Results: Average of operating time were 19.2 ± 4.2 minutes. Blood loss during the operations averaged 38.2 ± 4.1ml. Percent rate reduction of recurrent sore throat 96.3%, recurrent fever 89.0%, rhinorrhea 69.5%, nasal obstruction 88.9%, snoring sleep 63.4%, swallowing 30.5%. After surgery, 73.2% of the family members were very satisfied, 26.8% were satisfied with the results. Conclusion: Concurrent tonsillectomy and adenoidectomy, this saves on surgery costs, saves time, improves clinical symptoms, and pain levels are comparable to simple tonsillectomy. Key words: tonsillectomy, adenoidectomy

Current perspectives on the role of tonsillectomy.

Tonsillectomy is one of the most common paediatric surgical procedures performed in Australasia. The aim of this paper is to provide an up-to-date review of the indications for the procedure (and the evidence base for each of these indications), as well as describe the surgical technique and perioperative management and risks for a non-surgical audience. The primary indications for tonsillectomy are obstructive sleep apnoea (OSA) (where it is most commonly performed in association with adenoidectomy) and recurrent pharyngotonsillitis. There is now high-quality evidence that tonsillectomy improves objective measures of OSA on sleep studies, as well as quality of life and child behaviour. The impact of surgery on cognitive function is less well delineated. For recurrent pharyngotonsillitis, tonsillectomy has a modest impact on recurrent sore throat symptoms - clinicians should ensure an appropriate pre-operative observation period and adequately discuss the potential benefits with parents prior to surgery. Traditional approaches to tonsillectomy involve surgically dissecting the entire tonsil from the underlying pharyngeal muscle. Subtotal tonsillectomy (intracapsular tonsillectomy or tonsillotomy) is described for OSA and may reduce perioperative morbidity. Children younger than 3 years and those with moderate to severe OSA or significant comorbidities should be admitted for overnight observation. Simple analgesia is adequate for most patients postoperatively. Codeine is contraindicated due to reports of postoperative death due to respiratory suppression. Overall, tonsillectomy is a well-tolerated procedure, with pain and postoperative haemorrhage (2-4%) being the most common complications. Haemorrhage can be life threatening; however, the mortality rate remains very small at approximately 1:30 000.

Endoscopic Management of Maxillary Antral Diseases

Background : To see effectiveness of Endoscopies sinus surgery and it’s complication for the management of maxillary antral diseases. Materials and methods : A cross sectional observational study conducted from August’2014 to February’2016 in Otolaryngology Department, Chittagong Medical College Hospital, Chittagong. Results : The age of majority of the patients range from 21-30 years. Male and female patients were equal in number (M.F=1.1). The presenting symptoms of the patients were nasal obstruction, nasal discharge, headache, post nasal space drip, smell disturbance, recurrent sore throat and epistaxis. Major indications were chronic maxillary sinusitis 14 (46.67%), antrochoanal polyp 9(30%). Minor complication occurred in 9(30%) cases which included synechiae 3(10%) epistaxis 3(10%) and periorbital echymosis 3 (10%). Conclusion : No serious complications like CSF leak, retro orbital hemorrhage, blindness were noted.
 JCMCTA 2017 ; 28 (1) : 27 - 31

Tonsillar tuberculosis : A case report

Tuberculosis of the oral cavity which is an uncommon occurrence can be primary or secondary. In the absence of active pulmonary tuberculosis, isolated tonsillar tuberculosis is rare. Herein, we report two cases of bilateral tonsillar tuberculosis who presented as recurrent sore throat for which tonsillectomy was done. No active primary pulmonary lesion was found in these cases. Histopathological examination revealed caseating epithelioid granulomas with Langhans giant cells. Ziehl Neelson stain for acid fast bacilli was positive in one case. Tonsillar tuberculosis, though a rare entity, should be considered in the clinical differential diagnosis of tonsillar lesions. Histopathological examination with Ziehl Neelson stain should be performed for definite diagnosis.

Stakeholders’ views of recurrent sore throat, tonsillitis and their management: a qualitative interview study for the NAtional Trial of Tonsillectomy IN Adults (NATTINA Part 1)

To determine the impact of recurrent sore throats and tonsillitis in adults and stakeholder views of treatment pathways. Qualitative semistructured interview design reporting novel data from a feasibility study for a UK national trial of tonsillectomy in adults. Nine study sites linked to ear, nose and throat departments in National Health Service hospitals located across the United Kingdom. Fifteen patients, 11 general practitioners and 22 ear, nose and throat staff consented to in-depth interviews, which were analysed using a framework analysis approach. Views of stakeholder groups. Recurrent sore throats were reported to severely impact patients' family, work and social life. Ear, nose and throat staff stated that patients faced increasing barriers to secondary care service access. General practitioners were under pressure to reduce 'limited clinical value' surgical procedures. The findings from this study suggest that there is a disconnect between the attitudes of the stakeholders and the reality of recurrent sore throat, tonsillectomy procedures and service provision. More evidence for the role of tonsillectomy is needed from randomised controlled trials to determine whether it should continue to be ranked as a procedure of limited clinical effectiveness.

Prevalence of rheumatic heart disease in Senegalese school children: a clinical and echocardiographic screening

ObjectiveTo study the prevalence of rheumatic heart disease (RHD) in schools (locally referred to as ‘daaras’) located in the city of Dakar and its suburbs using both clinical examination and...

Antibiotics for preventing recurrent sore throat.

Antibiotics are sometimes used to prevent recurrent sore throat, despite concern about resistance. However, there is conflicting primary evidence regarding their effectiveness. To assess the effects of antibiotics in patients with recurrent sore throat. The Cochrane Ear, Nose and Throat Disorders Group (CENTDG) Trials Search Co-ordinator searched the CENTDG Trials Register; Central Register of Controlled Trials (CENTRAL 2015, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; Clinicaltrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 25 June 2015. Randomised controlled trials (RCTs) of antibiotics in adults and children suffering from pre-existing recurrent sore throat, defined as three or more sore throats in a year, examining the incidence of sore throat recurrence, with follow-up of at least 12 months post-antibiotic therapy. Two authors independently assessed trial quality and extracted data. Multiple attempts to contact the authors of one study yielded no response. We identified no trials that met the inclusion criteria for the review. We discarded the majority of the references retrieved from our search following screening of the title and abstract. We formally excluded four studies following review of the full-text report. There is insufficient evidence to determine the effectiveness of antibiotics for preventing recurrent sore throat. This finding must be balanced against the known adverse effects and cost of antibiotic therapy, when considering antibiotics for this purpose. There is a need for high quality RCTs that compare the effects of antibiotics versus placebo in adults and children with pre-existing recurrent sore throat on the following outcomes: incidence of sore throat recurrence, adverse effects, days off work and absence from school, and the incidence of complications. Future studies should be conducted and reported according to the CONSORT statement.

The role of tonsillectomy for recurrent sore throats in children: A qualitative study

IntroductionDecisions regarding tonsillectomy for children with recurrent sore throats are mainly based on guidelines that take the number of sore throat episodes into consideration. Anecdotally, parents report a number of additional factors that change after the operation. With this in mind, the first follow up tonsillectomy qualitative study was undertaken to identify what the operation truly offers this group of children. Materials and methodsTen families were interviewed between 3 and 14 months after their child's operation. A narrative method was utilised. Interviews with families were transcribed and analysed to identify key themes that had changed due to the operation. ResultsThemes identified included an improvement in general and specific symptoms. Psychosocial aspects such as education, socialising, family consequences and psychological consequences were also important factors that families noticed. ConclusionTonsillectomy has much more to offer families and children than an improvement in the numbers of episodes of sore throats and this study could form the basis of a specific quality of life assessment tool.

An Incidental Nasopharyngeal Carcinoma Coexistent with Primary Nasopharyngeal Tuberculosis

Objective: To describe a case of nasopharyngeal carcinoma coexistent with primary nasopharyngeal tuberculosis and review the literature.
 Methods:
 Design: Case Report
 Setting: Tertiary Public University Hospital
 Patient: One
 Results: A 28-year-old man presented with recurrent sore throat and neck pain with clinically enlarged tonsils. He underwent a routine adenotonsilectomy. Histopathologic examination revealed non-keratinizing squamous cell carcinoma with caseating granulomatous inflammation typical for tuberculosis in the same adenoid specimen. Nasopharyngeal carcinoma was staged T2bN2M0. He was treated with concurrent chemoradiotherapy and a 9-month course of anti tuberculosis treatment. He recovered and remained symptom free 1 year after treatment.
 Conclusion: Nasopharyngeal carcinoma (NPC) and tuberculosis (TB) are both very common diseases in Sabah, East Malaysia. However, it is very rare that both diseases present at the same time and same anatomical area in a patient. Diagnosis can be very challenging and confusing. Multidisciplinary consultations are warranted for appropriate treatment. Combined anti-tuberculosis treatment and concurrent chemoradiotherapy may be appropriate and effective.
 
 Keywords: Nasopharyngeal carcinoma, Primary Nasopharyngeal Tuberculosis, adenotonsillectomy 

Tonsillectomy for Recurrent Sore Throats in Children: Indications, Outcomes, and Efficacy

To perform a comprehensive narrative review of the literature to provide a better understanding of the indications, outcomes, and efficacy of tonsillectomy for recurrent sore throats in children. This article explores the reasons why there is a lack of robust clinical evidence for its efficacy despite good evidence of positive reported outcomes from parents of children who undergo the procedure. Articles published between 1960 and July 2013 were searched in PubMed and Cochrane databases. A narrative review method was adopted to provide a comprehensive overview of articles. Only individual, interventional studies on children (0-16 years old) undergoing tonsillectomy or adenotonsillectomy for recurrent sore throats with greater than 1 month of follow-up were included. The inclusion criteria and outcome measures in the studies were varied, but most investigated changes in symptoms related to sore throats or illness episodes. Quality-of-life tools validated for measuring pediatric outcomes were used in a number of more recent studies. None of the outcome measures were specific for recurrent sore throats in children. No qualitative method designed studies were identified. The disparity between parental satisfaction rates and published clinical efficacy can be explained by a lack of parent/child outcome measures specific to tonsillectomy for recurrent sore throats. A more parent/child-centered approach may establish what tonsillectomy could offer this group of children.

Tonsillotomy: it's time to clarify the facts

Finger nails, wires, specialized knives, slings and guillotines in the 19th and 20th century were used for subtotal tonsillectomy to reduce the risk of serious bleeding complications associated with complete removal of tonsillar tissues. Therefore, success of tonsil procedures at that time was widely based on revision surgery to cure patients suffering from diseases associated with tonsillitis. Complete, i.e., extracapsular, tonsillectomy (TE) was conceived in the first decade of the 20th century but became widespread only with safer anesthesiological techniques, particularly orotracheal intubation and introduction of halothan in the 1950s [1, 2]. In 1990, Rosenfeld registered a dramatic rise in obstructive sleep apnea (OSA) as a significant indication for TE. He assumed that this phenomenon is due to the increasing awareness of the prevalence and seriousness of adenotonsillar hypertrophy as a cause of sleep apnea, particularly in children [3]. His statement and findings were confirmed recently by Parker and Walner [4]. OSA belongs to the category of sleep-disordered breathing (SDB), characterized by abnormal respiratory patterns or the inadequate ventilation during sleep in terms of snoring, mouth breathing, or interrupted breathing. The patients may become symptomatic with excessive sleepiness, inattention, poor concentration, or hyperactivity during daytime. According to the latest statement of the American Academy of Otolaryngology-Head and Neck Surgery, TE still plays a major role to resolve SDB related to tonsillar hypertrophy in children [5]. Morbidity following TE is widely determined by pain and significant limitations in activity and diet. Return to normal diet and activity, intake of analgesics and type of consumed analgesics are therefore common endpoints of studies evaluating the benefit of newer surgical TE instruments. Complications like hemorrhage and dehydration eventually occur with the potential of a devastating outcome [6, 7]. While the best method to avoid surgical complications is not to operate, this is not an option for upper airway obstruction caused by tonsillar hypertrophy. TE, however, is acknowledged to control SDB in only 60–70 % of children with significant tonsillar hypertrophy, emphasizing the multifactorial background of this disease [5]. In the light of the limited success rate and the potential complications of TE alternative surgical procedures such as a Bochon loop have been suggested in 1993 [8], cited after [2]. In 1994, Krespi and Ling [9] recommended the CO2LASER for ‘‘serial tonsillectomy’’ to treat recurrent infection, sore throat, and halitosis in adults. In children, a considerably reduced morbidity after ‘‘tonsillotomy’’ with modern techniques was first reported in 1999 by Linder et al. [10] and Hultcrantz et al. [11], followed by Densert et al. [12], and Helling et al. [13] in 2001 and 2002, respectively. The results were confirmed with the first large retrospective study in 2003 by Koltai et al. [14] who used a microdebrider as surgical instrument. However, in a small pediatric patient population, a significant impact of ‘‘intracapsular tonsillectomy’’ on OSA—albeit not successful in all patients—was proven by means of polysomnographic J. P. Windfuhr (&) Department of Otorhinolaryngology, Plastic Head and Neck Surgery, Kliniken Maria Hilf Monchengladbach, Sandradstr 43, 41061 Monchengladbach, Germany e-mail: jochen.windfuhr@mariahilf.de

Sore throat consultations in general practice prior to tonsillectomy among eight hundred and sixty‐three children in England: is this in accordance with the SIGN guidelines?

The Scottish Intercollegiate Guidelines Network first published guidelines on the indications for tonsillectomy for sore throats in adults and children in 1999. These guidelines highlighted the importance of reserving the operation for those who are severely affected by recurrent sore throats and by applying the Paradise criteria. This study aimed to determine if the guidelines have been adopted by general practitioners.

Laser tonsil cryptolysis: In-office 500 cases review

ObjectivesTonsilloliths, proven to be tonsillar biofilms cause symptoms of halitosis, foreign body sensation and recurrent sore throats. Laser Tonsil Cryptolysis (LTC) performed in the office may represent an alternative to tonsillectomy in selected cases of persistent tonsilloliths with cryptic infections. Study DesignA retrospective chart analysis using CPT codes. SettingOffice and hospital. MethodsA retrospective complications review consisting of bleeding, the need for an additional procedure, patient satisfaction and conversion rate to complete tonsillectomy was documented. ResultsFive hundred consecutive LTCs performed in the office under local anesthesia with a CO2 or diode laser were identified. Energy delivery was in continuous mode with power settings of 18W and 10W respectively. Bleeding occurred in 6 patients requiring unscheduled return office visit for evaluation. Eighty patients required a second procedure, comprising total of 1.16 procedures per patient. Eighteen (3.6%) patients underwent complete tonsillectomy. Patient satisfaction was high with an overall incidence of 0–2 days of work absence. Follow-up was 1–8 years. ConclusionsWith a small tonsil size, controllable gag reflex and cooperative adult patient LTC allows several advantages compared to conventional tonsillectomy. Benefits of LTC include avoidance of general anesthesia and limited ablation of cryptic pockets, resulting in reduced post-operative pain, bleeding, shorter recovery time and the convenience and cost advantage of an office procedure. With 1.16 sessions required per patient, low conversion rate to standard tonsillectomy and minimal complication rate LTC can be considered an alternative option to a patient suffering from recurrent cryptic tonsillitis with or without tonsilloliths.

Very early complication of rheumatic heart disease (valvuloplasty for severe mitral valve stenosis for 6 year old male patient)

Rheumatic heart disease continues to contribute greatly to the burden of cardiovascular disease in Yemen, It’s usual to see a lot of advance RHD cases in adult in Yemen but in pediatric it is rare to see such advance case specially under the age of eight. Case report A.M, a 6 year old Yemeni male child was seen in September 2012 with history of recurrent breathlessness which started about 4 years earlier. His symptoms worsened in the previous three weeks when he became breathless at rest, had paroxysmal nocturnal dyspnea, huge abdominal distention, bilateral leg swelling and cough productive of whitish sputum. Past history was not significant for recurrent sore throat but he was diagnosed to have RHD at age of 3 year old without any farther follow up and irregular using to long acting penicillin. He was the second child in his family; both parents are in a very low income group. There was no family history of the disease in any of his siblings. Examination revealed that the child looked marasmic, pale, was chronically ill, and had a tinge of jaundice with bilateral pitting pedal edema. A cardiovascular system examination revealed a pulse rate of 101 per minute, regular and small volume, blood pressure of 90/60 m mmHg, elevated jugular venous pressure, displaced apex beat which was located at 5th intercostal space anterior axillary line, loud first and second heart sounds opening snap and mid diastolic rumbling murmur with systolic murmur at left parasternal border. The respiratory rate was 26 cycles per minute and bilateral crepitations. Other examination findings were visible dilated abdominal vein, a tender, pulsatile hepatomegaly of 3 cm below the right coastal margin and massive ascites. An echocardiography showed densely thickened mitral valves with severe commissural fusion leading to doming of the mitral valve in diastole, markedly dilated left atrium, normal left ventricular eject ion fraction, markedly dilated right atrium and right ventricle. Colour flow showed severe tricuspid regurgitation and severe pulmonary hypertension. The calculated mitral valve area is 0.6 cm square and pressure gradient max/mean (14/6 mmHg) respectively. ECG sinus rhythm normal axis and dilated LA with RBBB Complete blood count showed low HB 9 mg/dl with normal a white cell count. The chest X-ray revealed cardiomegaly with a double cardiac shadow positive mitralization sign. He was placed on diuretics (furosemide and low-dose spironolactone) Angiotensin Converting Enzyme inhibitor (Lisinopril), intranasal oxygen, intravenous heparin and antibiotics. And was prepared for percutaneous mitral valvuloplasty On the third day of admission, The PMVP was done with good out come the mitral valve area increase from 0.6 to 1.8 cm 2 and decrease in the pressure gradient to 6/4 mmHg and the pulmonary hypertension to mild. After that patient condition get better with improving to the dyspnea, the child become more active start to eat and play more frequent than before with decrease to the abdominal distension and the patient discharge to home in good condition and advice to follow up the hospital after six month. Discussion Rheumatic heart disease, no doubt remains a disease with great morbidity and mortality in most low and middle income countries specially in Yemen despite been having almost eradicated in high income countries, it affects the young population of our community whom presented late most of the time with complication due to the shortage of the medical service in the most of the regain of Yemen specially the remote areas. The case being presented typifies the cost of late presentation in patients with rheumatic heart disease. its usual in our country to see such cases in late stage and complicated but it’s rare to see a 6 year old child presented with severe mitral stenosis and he needed PMVB even it is successful procedure that saved his live but all that could be prevented from happening in the first place by a simple preventive program which we do not have in our country.

AN UNUSUAL CASE OF HORNER'S SYNDROME

A 71-year-old man presented with headache for a month and left eyelid droop for 2 days. He complained of recurrent sore throat, weight loss and long-standing anorexia, depression, iron deficiency...