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For poorly differentiated rhinopharyngeal carcinomas, the clinical presentation (association with the Epstein-Barr virus, paraneoplastic syndromes, onset of lymphoma) and the histopathological features can be polymorphous and they can confound or delay diagnosis and preparation of an adequate treatment plan (radio-chemotherapy). Often these neoplasms arise as clinically primitive laterocervical metastases, masked by clinical findings and a history that can lead to the mistaken diagnosis of systemic lymphoproliferative processes such as Hodgkin's disease. Here an observation of this type is presented in a young patient (19 years old) who came under observation for a laterocervical tumefaction recurrent from a previous exeresis performed at another hospital and symptoms of serotine febricula, dysphagia and serology positive for the Epstein-Barr virus (EBV). The patient underwent surgery and then radiotherapy and has been under close post-operative follow-up for two years. To date the patient's condition--both local and general--is good. The particular histology of the neoformation lies in the abundant infiltration of plasma cell and lymphocyte eosinophils, at times in blastic form. Moreover, elements with a large clear nucleus and evident nucleolus (Hodgkin-like) and scattered multinucleate Langhans-type giant cells can be seen. Immunohistologically the tumor cells markedly express for cytokeratin and the latent membrane protein (LMP1) of the Epstein-Barr virus (EBV) and show a high growth fraction. Under the electron microscope, the plurinucleate giant cells present large nuclei with morphology similar to that of tumor cells. The clear cytokeratin-positivity of the tumor elements and the histological and ultrastructural features mentioned led to the diagnosis of a massive metastasis from lymphoepithelial carcinoma, the Schmincke variant, plus EBV infection of the neoplastic cells. The authors conclude assuming that the particular granulomatous reaction is due to the host's reaction to the tumor cells, but also to the reaction to the viral antigens. In the former case we find an attempt to limit the carcinomatous process; in the latter it is a response caused by the EBV and is not, apparently, aimed at protecting against the neoplasm rather it facilitates the neoplastic process.

Synovial sarcomas account for 7-10% of all soft tissue malignancies and the rare head and neck region location accounts for an average 5% of them. A brief review of the data in the Literature has shown that not more than one hundred cases of cervical-facial synovial sarcoma have been reported. In the head and neck locations this form of tumor is significantly less aggressive, with a higher survival rate and a recurrence rate much lower than the 60-70% shown for other locations in the limbs. After a brief review of the Literature, Authors present a rare clinical case of hypopharyngeal synovial sarcoma which recently came under observation. Despite the accurate diagnostic procedure, after surgical removal of the tumor by CO2 laser microlaryngoscopy, diagnosis required the use of histological and ultrastructural techniques. CT and NMR of the neck using contrast medium showed that the structure of the neoformation was similar to that of the soft tissues, it was 3-4 cm in diameter, located in the hypopharynx and had an extensive surface in contact with the left glossoepiglottic groove. The lesion appeared to involve the free edge of the aryepiglottic fold, coming into contact with the free edge of the epiglottis; it could not be dissociated form the epiglottis and obliterated both the homolateral glossoepiglottic vallecula and the pyriform sinus. Structural analysis after radiography with a contrast medium showed a marked impregnation of the lesion, indicative of high degree of vascolarization. Ultrastructural, cytofluormetric and immunohistochemical analyses were performed on the neoplasm in order to process all these data together with the clinical parameters; in other words a multi-parameter evaluation was performed, as suggested by other Authors, to determine the therapy and arrange more accurate monitoring of this patient, victim of a neoplasm with a high potential for metastases.

Upper maxillary cysts are a chapter in otorhinolaryngological pathology which have been relatively neglected by the Literature. The reason for this most likely lies in the difficulty in producing a nosographic picture of these pathologies which border on other surgical fields (dentistry, maxillofacial surgery), and because they show significant clinical and etiopathogenic polymorphism. The elements that characterize upper maxillary cysts as a separate clinical entity are basically their cystic nature and origin within the upper maxillary bone, although they can expand widely within the medio-facial region (nasal vestibule, oral vestibule, nasolabial region, palate, maxillary sinus). After having reviewed the various classification schemes proposed over the years, and briefly examining the main clinical and etiopathogenic characteristics and principles for surgical treatment, the present work offers a surgical case study, together with the related iconography. Moreover this work does not neglect embryogenic considerations which are indispensable for the study of some of these pathologies. In this manner the results for 35 surgical procedures on upper maxillary cysts performed from 1989 to 1996 are presented and classified following the Cudennec classification module (1991). This study shows the variety of possible clinical manifestations for these pathologies. Such a variety makes correct diagnosis imperative--today facilitated by modern imaging techniques--and requires diversifying the surgical approach, conditioned not only by the site, extension and nature of the specific lesion, but also by the related symptoms. The significant progress in surgical techniques has made increasingly functional surgery possible and led to the abandonment of such conventional radical techniques as the Caldwell-Luc procedure. Moreover, CT and NMR have provided good image definition, specifying precisely the limits and extensions and, in most cases, facilitating diagnosis of the nature of the disorder with direct and indirect signs of the cystic nature of the lesions whenever the clinical data proves inadequate.

This study examined 71 pediatric tonsillectomy patients through accurate case history and clinical examination, placing particular emphasis on pathologies concomitant to tonsillopathy. In an attempt to find anatomo-clinical correlations, these data were processed together with the results of a histomorphological study of thetonsil epithelium, performed on all tonsillectomy samples. The majority of these patients were females and none more than 13 years of age. Numerous pathologies were found associated with the tonsillopathy and in varying combinations, first and foremost of which was adenoid hypertrophy. Only approximately one fifth of the patients did not show any concomitant pathology of note. All patients presented a history of recurrent pharyngotonsillitis (at least 4 episodes a year) with symptoms arising from 1 to 10 years prior to surgery. The concomitant pathologies included: respiratory, cutaneous and food allergies, asthma, obstructive sleep apnea, rheumatic diseases, etc. From the histomorphological point of view, particular modifications were found in the follicle epithelium and interstitial cells of the palatine tonsil. An exasperated fibrotic interstitial reaction and chronic duration of the disease appeared to prevent tonsil filter function, facilitating chronicization of the tonsillopathy or onset of recurrent infections and concomitant allergies. In the allergic patients the tonsil epithelium was thickened and compact and showed various degrees of chorion edema, in agreement with what is found in the literature. On the contrary, few morphostructural palatine tonsil mutations were found in those subjects which did not present any concomitant pathology or were affected by tonsillopathy of brief duration. All the histomorphological modifications encountered appear related to the individual patient history, confirming the hypothesis that tonsil epithelium can not only condition the evolution of tonsillopathy--reflecting the effect of various factors--but, above all, it directs the immune response, thus playing a role in the development of various concomitant pathologies.

Schwannoma is a rare neoplasm in the E.N.T. areas although it is characteristic of this discipline. Indeed, examination of the most recent data in the literature shows that approximately 45% of all neoplasms of the peripheral nerve linings occur in the head and neck district, the most common neurogenic tumors are schwannomas and these constitute 35% of all head and neck tumors. In reviewing the literature attention was focused on schwannomas originating in unusual sites, neglecting the most common sites originating in the eighth and seventh pair of cranial nerves. It was seen that the site of origin and clinical manifestation of these lesions varies widely and the four cases presented here are no exception. These are four schwannomas which came under observation between 1994 and 1997. The sites of origin were, respectively: the floor of the mouth, the submandibular region (corresponding to the Warthon duct), the anterior wall of the external auditory canal and the hypopharynx (corresponding to the pyriform sinus). All of these cases proved quite rare in the literature. All the cases underwent accurate anatomopathological examination and the paper discusses the particular histological and immunohistochemical features encountered. Reference is also made to the problems of differential diagnosis vs. other types of soft tissue tumors. Emphasis is placed on the demonstrated difficulty in recognizing schwannomas from the macroscopic and surgical points of view. The absence of mitoses, necroses, invasiveness and specific features--i.e. hyperchromia and pleomorphism of the nuclei or the presence of large atypical cells--are all parameters confirming that the lesions observed in the present study were benign. No anatompathological features were observed that could justify any particular expression of the schwannoma in the specific sites involved. Nevertheless, the authors present these case because a review of the literature indicated that they are extremely rare and because differential diagnosis of these unusual manifestations is so complex.

Using the most recent TNM revision as a basic framework to build upon, the Authors set up a graphic representation of the larynx on the basis of data gathered using clinical-instrumental examination. This graph, which allows automatic extrapolation of the degree of T, represents various sites and subsites of the larynx (including the pre-epiglottic area, the retro-cricoid area and the piriform sinus) which are divided by different coloured lines. This simple graphic representation of cancerous tumours, whose various colours indicate tumor extension in depth (data had with CT and RM), allows for automatic T classification of larynx cancer on the basis of T extension as well as on that of the degree of vocal cord impairment. Particularly useful for students in memorizing TNM classification, this graph, furthermore, groves to be a means of facilitating under standing the disease as well as opinion exchange among members of the medical staff. As furthermore proves of utmost value in patient management in that it may be fed into computerized management programmes containing individual patient's records thereby permitting a more rapid classification of the tumor. Moreover, the data easily stored in the programme are readily accessible for eventual statistical elaboration. The Authors conclude with a proposal of the eventual use of a similar graph of other sites in the body which may be adapted in the event of future TNM revisions.