Search

A 65-year-old man admitted for a left parotid tumor and high fever unresponsive to peroral antibiotics was found in gallium scintigraphy to have “hot” spots in the left parotid gland and left maxillary sinus. The ineffectiveness of intravenous antibiotics necessitated open biopsy to histologically diagnose the man’s condition. Surgical parotid gland and maxillary sinus specimens showed necrotizing granulomas with giant cells. Elevated proteinase-3 antineutrophil cytoplasmic antibody (PR3-ANCA) comfirmed a clinical diagnosis of Wegener’s granulomatosis. Treatment with prednisolone and cyclophosphamide led to clinical improvement. Major salivary gland involvement is rarely a presenting symptom in Wegener’s granulomatosis and correctly diagnosing this condition may increase morbidity due to disease progression.

Multiple endocrine neoplasia type 2B (MEN 2B), an autosomal dominant syndrome, involves endocrine tumors caused by RET protooncogene germ-line mutations in chromosome 10. The case we report, initially suspected in jaw deformity surgery, was a 19-year-old man whose malocclusion was found in a school health checkup. In surgery, his somewhat abnormal buccal mucosa and mandible were biopsied and pathological findings indicated multiple mandibular and buccal mucosal neuromas suggesting de novo MEN 2B. Whole-body examination confirmed diagnosis, showing medullary thyroid carcinoma, megacolon, prominent corneal nerves, and mucosal tongue and lips neuromas. Gene examination showed germ-line mutations of the RET protooncogene affecting codon 918 in exon 16. Medullary thyroid carcinoma was treated by total thyroidectomy with central compartment and bilateral neck dissection. Pathological analysis revealed multiple bilateral lobe cancer foci and one central-compartment lymph-node metastasis were detected pathologically. Normal calcitonin and CEA serum levels proved the biochemical cure for medullary thyroid carcinoma 7 months postoperatively. MEN 2B-associated medullary thyroid carcinoma is more aggressive than that without known gene mutations, necessitating early diagnosis and close follow-up. Findings of multiple oral-cavity neuromas thus mandate examination for MEN 2B.

We report two cases of cochlear reimplantation due to electrode problems. Case 1: A 76-year-old woman, complaining right-ear tinnitus in the 8 years following CI22 cochlear implantation in the right ear, was found in an X-ray examination to have the electrode array bending near the cochlear stoma. In cochlear reimplantation using a CI22 device upgraded to CI24RCS, fibrous tissue around the stoma and in the cochlear basal turn was removed and the electrode was replaced. Her speech perception score improved thereafter and tinnitus was reduced. Case 2: A 6-year-old boy with bilateral inner ear malformation presented with right facial spasm and decreased speech recognition 2 years and 4 months after right-ear cochlear implantation. An X-ray examination showed slight electrode slipout, so we inserted a CI24M device upgraded to CI24RCS, after which his speech perception score improved. Cochlear reimplantation was thus proved to be safe and effective in cases of electrode problems.

Acute suppurative thyroiditis is an infection originating from the piriform sinus via a congenital fistula. Between April 1987 and April 2002, we treated five patients with piriform sinus fistula with acute suppurative thyroiditis, three boys and two girls with ages ranging from 4 to 16 years. The diagnosis of piriform sinus fistula was made by hypopharyngeal enhancement radiography in all five patients preoperatively. Surgical treatment was performed after reduction of inflammation. Total fistulectomy including partial thyroidectomy was performed in three patients, and partial fistulectomy via piriform sinus to thyroid was performed in the other two patients. Administration of 1% methylrosarilinium chloride orally before the operation clearly distinguished the fistula from the surrounding tissue without any difficulty in the operative field. No inflammatory recurrence was observed in any patient during the follow-up period.

Between January 1992 and January 2002, we treated 12 patients with metastatic carcinoma in cervical lymph nodes from an unknown primary tumor. Of 12 patients, the histological diagnosis was squamous cell carcinoma in 10 and adenocarcinoma in 2. Three patients were in clinical stage N3, 8 patients were in N2 and 1 patient was in N1. Among them, 6 patients with resectable lymph nodes were treated mainly with surgery, and 6 patients with unresectable lymph nodes or distant metastasis were treated with radiotherapy and/or chemotherapy. After these treatments, a primary lesion appeared in only one patient, who was diagnosed as having nasopharyngeal carcinoma. The loco-regional control rate in all patients was 75%. The control rate in the patients treated with surgery was 100%, and that in patients treated with radiotherapy and/or chemotherapy was 50%. Distant metastasis after treatment appeared more often in open-biopsy cases than in those receiving fine-needle aspiration (FNA) or open-biopsy with simultaneous radical neck dissection.According to these results, radical neck dissection appeared to be effective in controlling neck disease. For initial pathological diagnosis, FNA is recommended, while open biopsy should be avoided, if possible.

A case is presented of an infant who presented with foreign bodies in bilateral external auditory canals. Battered child syndrome was defined in 1962 by Kempe et al. as nonaccidental attack or injury repeatedly inflicted upon children by persons caring for them. Otolaryngologists are rarely in a position to diagnose and initiate management of child abuse presenting as injury to the head and neck area. The number of reported cases of child abuse has increased dramatically over the past several years and it is likely that physicians will examine such cases and be unaware of the fact that the child is being abused.

Papilloma in the nasal cavity is a histologically benign neoplasm. However, it exhibits frequent local recurrence and is often associated with malignancy. Therefore, it is recommended that it be treated as a malignant tumor. We report a case of inverted nasal papilloma with malignant change in a 57-year-old female. This patient had suffered from nasal obstruction on the left side since December 1997. She visited a neighboring ENT clinic and underwent an excision of nasal polyp, which was diagnosed as an inverted nasal papilloma in January 1998. She was advised to undergo extended surgical treatment, however, she left it untreated for almost four years. In February 2002, she visited us because of severe headache and underwent extended Denker's operation. Chemotherapy and radiation therapy were added because the tumor was proven to be an inverted papilloma with squamous cell carcinoma. Unexpectedly, a recurrence was found in the anterior part of the nasal cavity in August 2002, and a component of spindle cell carcinoma appeared in the recurrent tumor. She was treated again by chemotherapy followed by extended maxillectomy, however, bone metastasis was found in October 2002. Since then, her general condition showed rapid deterioration and she died in November 2002.

In the present study, we retrospectively investigated states of occult metastases and lymph nodes with recurrent mesopharyngeal squamous cell carcinoma (MPSCC) to find an appropriate mode of neck dissection for MPSCC. Thirty-one patients with MPSCC who underwent neck dissection or were diagnosed with a recurrence in the neck lymph nodes following curative therapy were available for the present study. In cases of NO MPSCC (9 cases), occult metastases and recurrent nodes were mostly limited to ipsilateral levels 1 to 3. One case with recurrence on the lower border (hypopharynx) in the primary region had a reccurred node at level 6. In cases with a single swelling node (3 cases of N1 and 8 cases of N2a), metastases or recurrence never ocurred at level 5. In cases with multiple swelling nodes or a large (>6 cm) node (8 cases of N2b, 1 case of N2c and 2 cases of N3), metastases were spread through ipsilateral levels 1 to 5 but never occurred in contralateral level 5. In cases of lateral wall type, residual lymph node metastases after curative radiation therapy were observed in 3 cases. Consequently, we conclude that ipsilateral level 1 to 4 neck dissection is appropriate for NO mesopharyngeal cancer, ipsilateral or bilateral level 1 to 4 neck dissection for Nl and N2a cases, and ipsilateral level 1 to 5 and contralateral level 1 to 4 neck dissection for more than N2a cases. We also conclude that it is necessary in some cases of lateral wall type to perform neck dissection after curative radiotherapy.

A 55-year-old male suffering from general edema with dyspnea visited our hospital. The results of cardiac catheterization and monitoring SpO2 suggested congestive heart failure occurring with sleep apnea syndrome (SAS) with pulmonary hypertension. A polysomnography confirmed severe obstructive sleep (apnea index; 37.1). Although we strongly recommended the use of nasal CPAP or a surgical treatment (uvulopalatopharyngoplasty; UPPP), the patient refused therapy. Six months later, his respiratory status had deteriorated and he was readmitted to our hospital. He had marked hypoxia (PaO2 61.7mmHg) with hypercapnia (PaCO2 101.9mmHg) on admission. Since his consciousness level deteriorated after admission, he underwent endtracheal intubation and tracheostomy. After these treatments sufficiently improved pulmonary hypertension and congestive heart failure, he underwent further UPPP to make closure of the tracheostoma possible. Even after the closure, he showed no sign of dyspnea or congestive heart failure. We discuss the clinical course in this patient with referrence to the literature.

Clinical findings in 14 cases (15 ears) of acute otitis media accompanied by inner ear damage were examined. The ages of the patients ranged from 31 to 90 years (mean 51±19). All patients complained of severe otalgia and ear fullness accompanied by mixed hearing loss. Although only 5 of 14 patients (36%) suffered from vertigo, with a CCD eye monitoring system, positional nystagmus was recorded in all patients. High resolution temporal bone CT revealed a mastoid cavity occupied by soft tissue density in only 2 ears, while the other ears had only small areas of soft tissue density in their mastoid cavities. Therefore, the degree of inner ear damage was not always correlated with expansion due to otitis media. After treatment, 11 of 15 ears (73%) showed complete recovery of hearing loss and positional nystagmus disappeared in all patients.

A 56-year-old man suffering from a sore throat on swallowing, of six months duration, attended our clinic. There was an elastic hard tumor in the left lobe of the thyroid gland and a swollen jugular chain lymph node was palpable. CT scan showed a non-enhanced mass invading the esophagus, with calcification on the dorsal side of the thyroid gland. A preoperative cytological study using fine needle aspiration diagnosed the tumor as a papillary carcinoma. The patient underwent a left lobectomy of the thyroid gland and left conservative neck dissection. The initial pathological diagnosis was anaplastic carcinoma, and postoperative radiation therapy was provided. However, the clinical course of this patient was not compatible with that of anaplastic carcinoma. The patient was ultimately diagnosed as a case of epithelioid hemangioendothelioma (EH) by immunohistochemical study. EH is a rare tumor, and EH originating from the thyroid gland has not been previously reported.