279
Letters to the Editor UNUSUAL PRESENTATION OF BONY METASTASIS OF THYROID Dear Editor,
T
his refers to the article 'Unusual presentation of bony metastasis of thyroid (Case Report)' by Lt Col KlIilash Chand and Lt Col NK Paniker, MJAFl1999;55:75-6. The legends pertaining Fig I and 2 in this article states 'Destruction of right iliac bone', the sections being well inferior to iliac bones hence they are not secn in this sections. The Fig 1 also suggests involvement of right pubic bone, CT picture shows the age of the
patient printed as 62 years whereas the authors state the age as 70 years. In view of this it is suggested that a radiologist may please be associated with articles where his comments may be useful.
Lt Col HARIQBAL SINGH Classified Specialist. (Radiology), Command Hospital (SC), Pune 411040.
REPLY
T
he observations are well taken. The age of the patient was 70 years. It is regretted that it was printed 62 years on the CT film since the same was written on the requisition form provided to the radiologist by the ward. The opinion of Lt Col L Satija, Classified Specialist,Radiodiagnosis, Command Hospital (SC) Pune. on the CT scan depicted in the figures. is endol'!;ed. "The lesion shows involvement of pard-acetabular region (which
consists of ileum, ischium and pubic-all the three bones) on the right side with erosion of right ischium. Extension of the lesion anteriorly up to the pubic ramus is also visible".
Lt Col KAILASH CHAND·, Lt Col L SATUA +, • Classified Specialist (Pathology), Military Hospital (CTC), Pune, + Classified Specialist (Radiodiagnosis). Command Hospital (SC).
Pune40.
Otitic h)'drocephalus-A rare complication of CSOM Dear Editor,
T
his is with reference to the article 'Otitic hydrocephalus-A rare complication ofCSOM (Case report)' by Lt Col AK Mehta and Surg Capt YK Singh MJAFI 1999; 55: 63-4. The legend pertaining to Fig 2 in this article state thrombosis of sigmoid sinus, the sections ofCT Scan shown (Fig 2) are not at the level of sigmoid sinus hence does not show sigmoid sinus. The arrows depicted point to straight sinus and posterior part of falx cerebri and not sigmoid sinus. It will be appreciated if a CT section
showing sigmoid sinus throbosis is printed along with the reply to this letter being an uncommon identity.In view ofthis it is suggested that a radiologist may please be associated with articles where his comments may be useful.
Lt Col HARlQBAL SINGH Classified Specialist, (Radiology). Command Hospital(SC), Pune 411 040.
REPLY
T
he legend pertaining to Fig 2 of article entitled "Otitic Hydrocephalus-A rare complication of CSOM" should have read as focal sagittal sinus thrombosis which is consistent with otitic Hydrocephalus and not sigmoid sinus thrombosis. The error is regretted. Sigmoid sinus thrombosis was also reponed in this case as revealed by absence of enhancement of sigmoid sinus Oil contrast
studies. A radiologist was associated with this case and the CT scan findings were reported by radiologist of the Centre, where CT scan was carried out
Lt Col AK MEHTA ENT Specialist. Military Hospital. Bhopal.
SILENT GALLSTONES: TO DO OR NOT TO DO? Dear Editor.
T
he editorial on the treatment of gallstones was very informative [1]. but it has glossed over a major area by saying that managemellt of asymptomatic gallstone is controversial'. Armed Forces are famous for having standing operative procedures' for almost every situation. What is our policy for management of asymptomatic gallstone? NIH consensus development conference on gallstone had earlier suggested that the silent gallstones should be left alone as a rule[2]. This recommendation is primarily based on a study that followed 123 persons with asymptomatic gallstone overtime. At5,10. and 15 years of follow up 10 percent. 15 percent and 18 percent persons MJAF/. I'Ol. 55. NO.3. /999
became symptomatic and none developed complications of gall stones [3]. It was suggested that 90% patients with gallstone will present biliary pain and not compl ications in the first instance. Hence prophylactic removal of gallbladder is not a necessity. Subsequent information adds a new twist to this story. A few studies have suggested that the incidence of biliary pain and complications may be much ~ than this [4.5]. A retrospective analysis of our own patients with biliary pancreatitis shows that one of us (ACA) has seen 43 such patients over last decade (1989-99). As per available records 17 of these did not remember having had biliary pain in the past, whereas 14 gave history ofprevious episodes of biliary pain. In the remaining documents such history was not
Letters to the Editor
280 documented. Ifbiliary pancreatitis can be a presenting complication in a sizable proportion of patients, the recommendations of NIH consensus will need rethinking. One should remember that for an individual patient, a 2-3% annual risk becomes 20-40% within 10 years. For the Armed Forces personnel, where such a complication may develop in remote areas, will it not be prudent [0 offer cholecystectomy even when gallstones are silent?
REFERENCES I. Pruthi HS, Varadarajulu R. Treatment of gallstones-What is the right choice MJAFI 1999;55:1-2. 2. Proceedings'of NIH consensus development conference on gallstones and 1aparoscopic cholecystectomy, Bethesda. Maryland, September 14·16. 1993. Am J surg 1993;165:387-91.
3. Gracie Wa, Ransohoff DE The natural history of silent gallstones. The innocent gallstone is not a myth. N Engl J Med 1982:307:798-801. 4. Anili AF. DeSantis A. Capri R. et al. The natural history ofgallstones: The GREPCO experience. The GREPCO group. Hepatology 1995;21 :655-62.
5. Bilhanz LE. Honon JD. Gallstone disease and its complications. In: Feldman M, Sliesenger MH. Scharschmidt SF, eds. Gastrointestinal disell5c, PathophysiologylDiagnosislManagment. 6th edition, Philadelphia. WB Saunders Company 1998;1:948-72.
Lt Col AC ANAND VSM
"
Lt Col A SAHA +
• Classified Specialist (Medicine and Gastroenterology), + Classified Specialis.t (Surgery and Gastroenterointestinal Surgeon), Command Hospital (WC), Chandimandir 134107.
MJAFJ. VOL 55. NO.3. 1999
Letters to the Editor UNUSUAL PRESENTATION OF BONY METASTASIS OF THYROID Dear Editor,
T
his refers to the article 'Unusual presentation of bony metastasis of thyroid (Case Report)' by Lt Col KlIilash Chand and Lt Col NK Paniker, MJAFl1999;55:75-6. The legends pertaining Fig I and 2 in this article states 'Destruction of right iliac bone', the sections being well inferior to iliac bones hence they are not secn in this sections. The Fig 1 also suggests involvement of right pubic bone, CT picture shows the age of the
patient printed as 62 years whereas the authors state the age as 70 years. In view of this it is suggested that a radiologist may please be associated with articles where his comments may be useful.
Lt Col HARIQBAL SINGH Classified Specialist. (Radiology), Command Hospital (SC), Pune 411040.
REPLY
T
he observations are well taken. The age of the patient was 70 years. It is regretted that it was printed 62 years on the CT film since the same was written on the requisition form provided to the radiologist by the ward. The opinion of Lt Col L Satija, Classified Specialist,Radiodiagnosis, Command Hospital (SC) Pune. on the CT scan depicted in the figures. is endol'!;ed. "The lesion shows involvement of pard-acetabular region (which
consists of ileum, ischium and pubic-all the three bones) on the right side with erosion of right ischium. Extension of the lesion anteriorly up to the pubic ramus is also visible".
Lt Col KAILASH CHAND·, Lt Col L SATUA +, • Classified Specialist (Pathology), Military Hospital (CTC), Pune, + Classified Specialist (Radiodiagnosis). Command Hospital (SC).
Pune40.
Otitic h)'drocephalus-A rare complication of CSOM Dear Editor,
T
his is with reference to the article 'Otitic hydrocephalus-A rare complication ofCSOM (Case report)' by Lt Col AK Mehta and Surg Capt YK Singh MJAFI 1999; 55: 63-4. The legend pertaining to Fig 2 in this article state thrombosis of sigmoid sinus, the sections ofCT Scan shown (Fig 2) are not at the level of sigmoid sinus hence does not show sigmoid sinus. The arrows depicted point to straight sinus and posterior part of falx cerebri and not sigmoid sinus. It will be appreciated if a CT section
showing sigmoid sinus throbosis is printed along with the reply to this letter being an uncommon identity.In view ofthis it is suggested that a radiologist may please be associated with articles where his comments may be useful.
Lt Col HARlQBAL SINGH Classified Specialist, (Radiology). Command Hospital(SC), Pune 411 040.
REPLY
T
he legend pertaining to Fig 2 of article entitled "Otitic Hydrocephalus-A rare complication of CSOM" should have read as focal sagittal sinus thrombosis which is consistent with otitic Hydrocephalus and not sigmoid sinus thrombosis. The error is regretted. Sigmoid sinus thrombosis was also reponed in this case as revealed by absence of enhancement of sigmoid sinus Oil contrast
studies. A radiologist was associated with this case and the CT scan findings were reported by radiologist of the Centre, where CT scan was carried out
Lt Col AK MEHTA ENT Specialist. Military Hospital. Bhopal.
SILENT GALLSTONES: TO DO OR NOT TO DO? Dear Editor.
T
he editorial on the treatment of gallstones was very informative [1]. but it has glossed over a major area by saying that managemellt of asymptomatic gallstone is controversial'. Armed Forces are famous for having standing operative procedures' for almost every situation. What is our policy for management of asymptomatic gallstone? NIH consensus development conference on gallstone had earlier suggested that the silent gallstones should be left alone as a rule[2]. This recommendation is primarily based on a study that followed 123 persons with asymptomatic gallstone overtime. At5,10. and 15 years of follow up 10 percent. 15 percent and 18 percent persons MJAF/. I'Ol. 55. NO.3. /999
became symptomatic and none developed complications of gall stones [3]. It was suggested that 90% patients with gallstone will present biliary pain and not compl ications in the first instance. Hence prophylactic removal of gallbladder is not a necessity. Subsequent information adds a new twist to this story. A few studies have suggested that the incidence of biliary pain and complications may be much ~ than this [4.5]. A retrospective analysis of our own patients with biliary pancreatitis shows that one of us (ACA) has seen 43 such patients over last decade (1989-99). As per available records 17 of these did not remember having had biliary pain in the past, whereas 14 gave history ofprevious episodes of biliary pain. In the remaining documents such history was not
Letters to the Editor
280 documented. Ifbiliary pancreatitis can be a presenting complication in a sizable proportion of patients, the recommendations of NIH consensus will need rethinking. One should remember that for an individual patient, a 2-3% annual risk becomes 20-40% within 10 years. For the Armed Forces personnel, where such a complication may develop in remote areas, will it not be prudent [0 offer cholecystectomy even when gallstones are silent?
REFERENCES I. Pruthi HS, Varadarajulu R. Treatment of gallstones-What is the right choice MJAFI 1999;55:1-2. 2. Proceedings'of NIH consensus development conference on gallstones and 1aparoscopic cholecystectomy, Bethesda. Maryland, September 14·16. 1993. Am J surg 1993;165:387-91.
3. Gracie Wa, Ransohoff DE The natural history of silent gallstones. The innocent gallstone is not a myth. N Engl J Med 1982:307:798-801. 4. Anili AF. DeSantis A. Capri R. et al. The natural history ofgallstones: The GREPCO experience. The GREPCO group. Hepatology 1995;21 :655-62.
5. Bilhanz LE. Honon JD. Gallstone disease and its complications. In: Feldman M, Sliesenger MH. Scharschmidt SF, eds. Gastrointestinal disell5c, PathophysiologylDiagnosislManagment. 6th edition, Philadelphia. WB Saunders Company 1998;1:948-72.
Lt Col AC ANAND VSM
"
Lt Col A SAHA +
• Classified Specialist (Medicine and Gastroenterology), + Classified Specialis.t (Surgery and Gastroenterointestinal Surgeon), Command Hospital (WC), Chandimandir 134107.
MJAFJ. VOL 55. NO.3. 1999
