--(1918), Revue Neurol., 11-12, 117.

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1 1 BRT. J. SURG., 1969, Vol. 56, No., FEBRUARY may be initiated by exceptionally strong inhibitory stimuli being conveyed by the surviving glossopharyngeal and vagus nerves, a concept supported by the findings of Kitaiev (1908), who reported that in the dog weak stimulation of the glossopharyngeal nerves inhibited swallowing while stronger stimulation evoked it. n our case simultaneous withdrawal of the nasogastric tube and injection of the contrast medium should be regarded as a strong stimulus, and possibly more effective after a period of sensory deprivation. n cases where central re-education for one reason or another fails, the partly denervated sphincter will in time become fibrous and it is in those cases that myotomy is of most use (Kaplan, 1951). Although in civilian surgical practice this syndrome is very rare, this example is instructive in indicating that if nutrition can be maintained by tube-feeding then gastrotomy, pharyngeal myotomy, or digastric transposition should be deferred for a significant interval. t also suggests that there may be some therapeutic value in artificial stimulation of the hypopharynx. SUlMlMARY A case of Vernet s syndrome, following division of the last four cranial nerves, is described. Complete failure of deglutition lasted from the time of injury for a period of 8 weeks. Recovery was relatively sudden, although there is a persisting mild dysphagia. The mechanisms of this lesion and its recovery are discussed. REFERENCES AVELLS, G. (1891), Bed. Klin., 40,. BOSMA, J. F. (1957), Physiol. Rev., 7, 75. CARLSON, A. J., and LUCKHARDT, A. B. (191), Am. J. Physiol., 57, 99. CHAWLA, J. C., and FALCONER, M. A. (1967), Br. med.j.,, 59. JACKSON, H. (1864), London Hospital Reports,, 88. KAPLAN, S. (~s), Ann. Surg., 1, 57. KTAEV, T. J. (1908), Jber. Fortsclzr. Physiol., 17, 151. KNGHT, G. C. (194), Br. J. Surg.,, 155. LAST, R. J. (196), Anatomy, Regional and Applied, rd ed. London: Churchill. LUND, W. S. (1969, Ann. R. Coll. Surg., 7, 5. NAFFZGER, M. D., DAVS, C., and BELL, H. G. (1948), Ann. Surg., 18, 7. NEGUS, V. E. (~gzg), The Mechanism of the Larynx, p London: Heinemann. --(1956), Lectures on Scientific Basis of Medicine V, p.. London: Athlone Press. PRCE, F. W. (1966), Textbook of the Practice of Medicine, 10th ed., p London: Oxford University Press. VERNET, M. (1916), Bull. Mim. SOC. mid H8p. Paris, 40, (1918), Revue Neurol., 11-1, 117. PRMARY ASPERGLLOMA OF PARANASAL SNUSES N THE SUDAN A REVEW OF SEVENTEEN CASES BY B. MLOSEV, EL s. MAHGOUB, 0. ABDEL AAL, AND A. M. EL HASSAN UNVERSTY OF KHARTOUM ASPERGLLOMA is a fungal granuloma which can primarily affect the paranasal sinuses and later involve the orbit. The sole causative organism in the Sudan is Aspergillus flavus. Preliminary reports of the condition in the Sudan were published by MiloSev, Davidson, Gentles, and Sandison (1966) and by Sandison, Gentles, Davidson, and MiloSev (1967). This paper describes the clinical,,pathological, and mycological findings in 17 patients treated in Khartoum Hospital since 196. The histological diagnosis was first suspected by Professor Lynch* when he saw a granuloma, resembling that caused by Aspergillus species, in biopsy material from patients with proptosis. However, the organism was not cultured at that time. CLNCAL FEATURES The clinical details of each patient are described in Table. Most patients presented with unilateral proptosis of varying severity (Fig. ). Sometimes this was associated with a swelling on the medial * Professor of Pathology, Faculty of Medicine, University of Khartoum, canthal region corresponding to the ethmoid (Fig. z), or a swelling of the maxilla (Fig. ), or both (Fig. 4). The swelling is usually very firm and hard. The surface is irregular. Thus it simulates malignancy from which it could be differentiated by the slow rate of growth, lack of metastases, and absence of nasal bleeding. Nasal obstruction, diplopia, and loss of vision were uncommon symptoms (Fig. 5). A striking feature of the lesion is its painless nature and therefore patients do not seek early medical advice. The duration of symptoms and visible signs varies from 4 months to 10 years. RADOLOGY Radiographs show opacities of paranasal sinuses involved, usually, with bone destruction (Figs. 6, 7, 8, 9), thus resembling a malignant neoplasm. n no case did radiography of the chest give any suspicion of Aspergillus infection of the lung. Radiologically, the cases could be divided into three forms :-. Ethmoidal.. Antral.. Ethmoido-antral. Secondary orbital involvement was of varying degree.

MLOSEV ET AL.: ASPERGLLOMA OF PARANASAL SNUSES n very advanced cases the sphenoidal sinus was material surrounded by fungus containing giant cells also involved as well as the base of the skull (Fin.

- The histological picture is essentially of a granuloma composed of multinucleated giant cells scattered in a fibrous connective-tissue stroma (Fig. 10). The FG.

2 MLOSEV ET AL.: ASPERGLLOMA OF PARANASAL SNUSES n very advanced cases the sphenoidal sinus was material surrounded by fungus containing giant cells also involved as well as the base of the skull (Fin.. - 9). _. and palisading histiocytes. n- healed lesions fibrous connective tissue without HSTOPATHOLOGY - eranuloma elements is seen (Fip..- 1). - The histological picture is essentially of a granuloma composed of multinucleated giant cells scattered in a fibrous connective-tissue stroma (Fig. 10). The FG..-Left proptosis due to a very advanced antral aspergilloma. FG..-Right ethmoidal aspergilloma with proptosis Table.-CASES OF PARANASAL ASPERGLLOMA 60 M. 5 M. 4 M. 18 M. 5 M. 0 M. 40 M. 5 M. 1 M. 8 M. 0 F. 6 F. 17 F. 40 M. F. F. 1 F. Policeman Student Policeman Soldier Soldier Official s wife Housewife Student Official* Official s wife s wife 0 4 * Died 6 months after operation. DURATON OF SYMPTOMS N PROPTOSS YEARS i : 4 mth. giant cells contain the septate hyphae of a fungus which sometimes show branching. The hyphae are occasionally seen in the ordinary H. and E. section when the light is reduced, but they are best visualized with PAS stain when they appear red (Fig. 11). A variable number of lymphocytes and plasma cells is often seen in the connective tissue. n some sections the blood-vessels show endarteritis obliterans. n the centre of some of the granulomas microabscesses (Fig. 1) are seen and in these free fungal hyphae are found. n some cases the centre of the granuloma is composed of eosinophilic necrotic + - T ENDONASAL FNDNGS MYCOLOGY Biopsy and operation specimens were sent immediately to the laboratory in sterile containers. The tissue was either cut down in small pieces by scissors or ground up in a small volume of normal saline in a Ten Broeck tube. The suspension produced by the latter method can be examined directly under reduced light for bits of fungal mycelia and so will give an immediate diagnosis. Cultures were made either on malt-extract agar containing chloramphenicol or Sabouraud s agar plus chloramphenicol.

4 BRT. J. SURG., 1969, Vol. 56, No., FEBRUARY White growth could be seen after 48 hours. n all strains the colour of the colony gradually changed to yellowish-green or green.

-left antral aspergilloma with proptosis. who were submitted for the study. The Ouchterlony (1949) method of immunodiffusion in gel was used. MANAGEMENT Treatment is essentially surgical.

The operative approach is varied according to the main site and extent of lesion.

3 4 BRT. J. SURG., 1969, Vol. 56, No., FEBRUARY White growth could be seen after 48 hours. n all strains the colour of the colony gradually changed to yellowish-green or green. dentification was made according to the characteristics set by Raper, Fennel, and Austwick (1965). All strains were identified as Aspergillus jlavus because the colonies were yellowish FG. -j.-left antral aspergilloma with proptosis. who were submitted for the study. The Ouchterlony (1949) method of immunodiffusion in gel was used. MANAGEMENT Treatment is essentially surgical. The object of treatment is removal of as much as possible of the granuloma without damage to neighbouring structures, particularly the optic nerve and other intraorbital contents. The operative approach is varied according to the main site and extent of lesion. For ethmoidal cases a medial orbitotomy incision is used and could be extended superiorly or inferiorly according to the need. n antral forms a Caldwell-Luc approach is preferred. When both sinuses are involved, in extensive cases, a lateral rhinostomy incision and approach are used. At operation the granulomatous tissue is found to be of pale colour, hard to cut. Sometimes it contains visible small cavities with pus. The dural membrane is not usually infiltrated-only twice in this series. The sclera was never found to be involved. The operation should end in establishing adequate drainage of the involved sinuses into the nose. This is achieved by removing the whole medial wall of the antrum or by radical ethmoidectomy or both if necessary. t was found that radical removal of the granuloma is not necessary because complete regression of the growth follows a good exposure and wide drainage. The cavity left behind is packed with iodoform powdered gauze which is haemostatic and antiodorous. The pack is removed after to 4 days. Antibiotics are not used postoperatively. F,~. 4.-Right ebmoido-antral aspergilloma with proptosis. green, conidiophores rough, sterigmata occurred in one or two seiies, and heads were hemispherical to columnar (Fig. 14). MMUNOLOGY Precipitating antibodies against Aspergillus jlavus were demonstrated in the sera of 4 out of 6 patients FG. 5.-Visible granulomatous mass in the right nasal cavity of an ethmoido-antral aspergilloma. (The same patient as Fig. 4.) f vision is lost the eyeball is retained for cosmetic and social reasons in contradistinction to what was done when the first patients were treated (Sandison and others, 1967). FOLLOW-UP All patients are being followed up and assessed clinicallv and radiologically. Nasal swabs are taken periodically and cultured fdr fungi. Definite improvement was shown by regression of the lesion (Fig. S).

MLOSEV ET AL. : ASPERGLLOMA OF PARANASAL SNUSES n spite of the marked clinical improvement, AspergiZZus ftavus was isolated from the nasal cavities of patients.

The other patient in whom the dura mater was found to be involved at operation is still alive 4 years after surgery. FG. 6.

(The same patient as Fig..) and involvement of the floor of the orbit. Marked asymmetry of the orbits. (The same patient as Fig..) FG.

4 MLOSEV ET AL. : ASPERGLLOMA OF PARANASAL SNUSES n spite of the marked clinical improvement, AspergiZZus ftavus was isolated from the nasal cavities of patients. 5 One patient died 6 months after the operation because of extensive involvement of the base of the skull (Fig. 9). The other patient in whom the dura mater was found to be involved at operation is still alive 4 years after surgery. FG. 6.-Ethmoidal aspergtlloma showing opacity of the ethmoid FG. 7.-Antral aspergilloma showing opacity of the left antrum and invasion of the orbit. (The same patient as Fig..) and involvement of the floor of the orbit. Marked asymmetry of the orbits. (The same patient as Fig..) FG..-Ethmoido-antral aspergilloma showing opacity of the right antcum and right anterior ethmoidal cells. Early case of the disease. FG. 9.-Advanced case of an ethmoido-antral aspergilloma (the same patient as Figs. 4 and 5). The base of the skull is involved with destruction of the sella turcica.

( x So.) FG..-Septate fungal hyphae in a giant cell. PAS. ( x 500.) FG. 1z-A micro-abscess in the centre of a granuloma.

5 6 BRT. J. SURG., 1969, Vol. 56, No., FEBRUARY FG. 10.-Granuloma composed of multinucleated giant cells in a fibrous connective-tissue stroma. H. and E. ( x So.) FG..-Septate fungal hyphae in a giant cell. PAS. ( x 500.) FG. 1z-A micro-abscess in the centre of a granuloma. H. and E. FG. ~j.-healed aspergilloma showing dense, hyaline, fibrous ( x ZOO.) connective tissue. H. and E. ( x So.)

to cause secondary unilateral proptosis (Abdel Aal and MiloSev, 1968). The disease is more frequent in males in the second and third decades of life.

6 MLOSEV ET AL. : ASPERGLLOMA OF PARANASAL SNUSES DSCUSSON Aspergilloma of the paranasal sinuses, a rare disease in many parts of the world, is not uncommon in the Sudan where it is found to be the commonest lesion to cause secondary unilateral proptosis (Abdel Aal and MiloSev, 1968). The disease is more frequent in males in the second and third decades of life. t is not confined to any particular occupation although 7 patients were either farmers or farmers wives. n cases of paranasal Aspergillus infection 7 could be cultured from the nasal cavities several months after operation in spite of regression of the granuloma. SUMMARY A clinical, mycological, and histopathological study of primary paranasal aspergilloma in the Sudan is given. This is characterized by unilateral proptosis in healthy adults. The causative fungus isolated is Aspergillus jfavus. FG Aspergillus pavus: needle mount from a culture in lactophenol cotton blue. ( x 400.) reviewed by Sandison and others (1967) there was no mention of occupation except in who was a farmer s wife. t is well known that human aspergillosis usually affects the lung secondary to an underlying debilitating disease or may complicate prolonged steroid or antibiotic therapy. This was not the case in any of the patients in this series who were otherwise in good general health. However, the possibility of a preceding local pathology in the paranasal sinuses could not be excluded. The causative organism of this condition in the Sudan is Aspergillus jfavus. n all the literature surveyed by Adams (19) Aspergillus fumigatus was isolated from such lesions. Bailey and Fulmer (1961) have isolated Aspergillus jfavus from their reported case. Aspergillus flavus is a saprophyte of soil in the Sudan (Tarr, 1955). Although the pathogenesis of this condition is not fully known, we believe that inhaled spores of AspergillusfEavus settle down in the sinuses, commonly the ethmoid. t seems a reasonable hypothesis to suggest that the fungus becomes pathogenic when conditions in the sinuses become relatively anaerobic. This is concluded from the favourable results of the adopted treatment which consisted of partial excision of the granuloma, if radical removal is not indicated, followed by wide drainage into the nasal cavity, thus resulting in re-aeration of the affected sinuses. This is also supported by the fact that Aspergillus flavus FG. i5.--fostoperative photograph of the same patient as Fig., 8 months after surgery. Lefr-side enophthalmos as the result of fibrosis. Acknowledgement.-We would like to express our appreciation and gratitude to Professor M. F. Nicholls for encouragement and valuable advice on this study. REFERENCES ABDEL AAL, A. O., and MLOSEV, B. (1968), Sudan med. J., Dec. ADAMS, N. F. (g), Archs Surg., Chicago, 6, 999. BALEY, J. C., and FULMER, J. M. (1961), Am.. Ophthal., 51, 670. MLOSEV, B., DAVDSON, C. M., GENTLES, J. C., and SANDSON, A. T. (r966), Lancet,, 746. OUCHTERLONY, 0. (1949), Acta path. microbiol. scand., 6J 5O7. RAPER, K. B., FENNEL, D.., and AUSTWCK, P. K. C. (1965)~ The Genus Aspergillus. Baltimore: Williams and Wilkins. SANDSON, A. T., GENTLES, J. C., DAVDSON, C. M., and MLOSEV, B. (1967), Sabouroudia, 6, 57. TARR, S. A. J. (1955), The Fungi and Plant Diseases of the Sudan. London: Commonwealth Mycological nstitute.

Actinomycosis and aspergillosis in the nose of a diabetic: A case report

Volume 2 Issue 3 2012 ISSN 2250-0359 Actinomycosis and aspergillosis in the nose of a diabetic: A case report 1 Meenu Khurana Cherian 1*, Rajarajeswari 2 1 Department of ENT, Gulf Medical College Hospital