Primary cervical tuberculosis is uncommon, although its incidence has risen somewhat over the past few years. In this article, we describe a rare case in which the patient developed a dual pathology-cervical tuberculosis and a malignant squamous cell carcinoma-in a group of lymph nodes on one side of the neck. Initially, tuberculosis was diagnosed on the basis of histology and culture. However, when the patient did not respond to antituberculous drug therapy, a repeat biopsy detected the second pathology: squamous cell carcinoma. To the best of our knowledge, no such presentation has been previously reported in the world literature. We conclude that repeat biopsy might be required in cases of tuberculous cervical lymphadenopathy that do not respond to conventional antituberculous therapy.
Mehmet Ada, MD; M. Güven Güvenç, MD; Süleyman Yilmaz, MD
Abstract
Hemangiomas of the airway are benign vascular lesions that can involve any site from the nares to the tracheobronchial tree. Most of these lesions are seen in the subglottic area in infants. Supraglottic infantile hemangiomas are very rare. We report a case of supraglottic hemangioma in a 2-month-old boy who had been admitted to our hospital with inspiratory stridor and dyspnea. The hemangioma involved the left arytenoid and aryepiglottic fold. A tracheostomy was performed, and the patient was followed up endoscopically every 6 months thereafter. The hemangioma disappeared when the child was 30 months old. Subsequently, a Montgomery T-tube was placed for 6 months to assist in maintaining normal breathing. The patient remains disease-free during ongoing follow-up. We also discuss the management strategies for infantile laryngeal hemangiomas.
Riad Khnifies, MD; Milo Fradis, MD; Alexander Brodsky, MD; Jacob Bajar, MD; Michal Luntz, MD
Abstract
Schwannomas of the nasal cavity are extremely rare. We evaluated a 42-year-old woman who presented with a 4-year history of slowly progressive nasal obstruction. The cause of the obstruction was identified as a schwannoma in the left inferior turbinate. The tumor was completely excised, and no sign of recurrence was evident at the 1-year follow-up. To the best of our knowledge, this is only the third case of a schwannoma originating in the inferior nasal turbinate that has been reported in the English-language literature. We review the clinical and pathologic features of this case.
Pablo Martinez Devesa, FRCS (Edin); Timothy E. Mitchell, MA, FRCS (ORL-HNS); Ian Scott, FRCPath; David A. Moffat, BSc, FRCS
Abstract
Malignant peripheral nerve sheath tumors are uncommon lesions that occasionally affect the head and neck. We describe 2 new cases of head and neck pathology. One tumor involved the parotid gland and resulted in erosion of the temporal bone, and the other affected the lower lip. A rapid diagnosis has significant implications for management because of the tumor's potential for aggressive behavior and its high rate of recurrence. To the best of our knowledge, lip involvement is rare and temporal bone involvement has not been previously described.
Harold F. Keyserling, MD; John D. Grimme, MD; Daniel L.A. Camacho, MD; Mauricio Castillo, MD
Abstract
Nasal septal perforation is a rarely reported complication of rhinitis medicamentosa. We describe such a complication in a 54-year-old man, and we discuss the clinical, pathologic, and imaging aspects of this case.
Partial middle turbinate avulsion is a rare complication of nasotracheal intubation. Patients usually experience a brisk hemorrhage at the time of injury. Postoperatively, some patients develop a unilateral nasal obstruction, while others are asymptomatic. We present an unusual case in which a patient became symptomatic many years after the incident. We hope to raise awareness that a traumatic disruption of the turbinates secondary to nasotracheal intubation might lead to the development of an abnormal nasopharyngeal mass.
Acquired tracheoceles are rare clinical entities that can cause a variety of chronic and recurrent aerodigestive tract symptoms. The management of acquired tracheoceles is primarily conservative, but surgical intervention may be indicated for patients with refractory symptoms. We present a case of acquired tracheocele and describe a method of successful surgical management.
Satya Shreenivas, BA; J. Scott Magnuson, MD; Eben L. Rosenthal, MD
Abstract
We used negative-pressure dressings to treat a poorly healing cervical rotation flap following radical neck dissection in an elderly man. The wound had failed to heal properly after 2 weeks of conservative management. Following application of the negative-pressure dressings, the wound granulated quickly and healed well by secondary intention.
Surgical preparation is enhanced by the availability of computer-generated three-dimensional models that allow surgeons to explore the surgical field in various projections prior to an actual operation. In fact, with adequate computed tomography images, an entire operation can be simulated beforehand so that surgeons can plan the safest and most effective approach and be prepared to avoid or overcome obstacles during the actual procedure. Also, computer technology allows surgeons to conduct remote consultations and to even perform telesurgery-that is, to operate on a patient from a great distance. In this article, we describe our experience with computer-assisted local and remote endoscopic sinus surgery in Croatia.
Ismail Yilmaz, MD; Nebil Bal, MD; Levent N. Ozluoglu, MD
Abstract
Cementoossifying fibroma is a rare nonodontogenic tumor of the periodontal membrane that arises from the mesodermal germ layer. This nonneoplastic, locally destructive tumor has occurred as an osseous lesion in the mandible, the maxilla, the zygoma, all the paranasal sinuses, and the orbital and petromastoid regions. It has occurred as an extraosseous lesion in the gingiva and the auricle. The diagnosis requires correlating a variety of clinical, radiologic, and histologic factors. The recurrence rate is high, particularly for lesions in the paranasal sinuses. Surgical management via a local excision as wide as possible is suggested. We describe the case of a 32-year-old woman with an isolated cementoossifying fibroma of the right ethmoid bulla, and we review the diagnosis, differential diagnosis, and management of this tumor.
Laryngomalacia, the most common congenital laryngeal anomaly, is not a single disease entity but rather a variety of entities along a spectrum of underlying pathophysiologies. Based on our study of 10 children who were surgically treated for laryngomalacia in an urban tertiary care center, we have developed a system of classifying laryngomalacia on the basis of its different underlying pathophysiologic processes. Type 1 laryngomalacia is characterized by a foreshortened or tight aryepiglottic fold. Type 2 disease is defined by the presence of redundant soft tissue in the supraglottis. The type 3 designation applies to cases caused by other etiologies, such as underlying neuromuscular disorders. While the three types are not mutually exclusive, each should be considered as a separate disease entity with a final common clinical presentation. Each type requires a specific approach to surgical repair.
Daniel L. Monin, MD; Anthony Sparano, MD; Leslie A. Litzky, MD; Gregory S. Weinstein, MD
Abstract
Mucoepidermoid carcinoma of the subglottis is infrequently reported in the literature. This tumor subtype is more commonly associated with the major and minor salivary glands. Mucoepidermoid carcinoma of the larynx can be difficult to diagnose, and there is no consensus as to appropriate management. We report a case of a low-grade mucoepidermoid carcinoma that was confined to the subglottis and treated with organ-preservation surgery. A conservative surgical approach was taken because of the tumor's low-grade histology and its location and in order to preserve the patient's laryngeal function. At follow-up 15 months postoperatively, the patient remained disease-free, and laryngeal function was intact.
Sinonasal lymphomas are uncommon malignancies. They are difficult to differentiate from carcinomas, and immunohistochemistry is needed to make the diagnosis. We describe an unusual case of a T cell lymphoma that involved only the paranasal sinuses in a middle-aged man. The patient presented with a complete loss of vision in one eye and lateral rectus muscle palsy, but no nasal symptoms.
Carcinosarcoma of the larynx is uncommon. When it does occur, its clinical features resemble those of sarcomatoid carcinoma, and its biologic behavior is similar to that of malignant mesenchymal neoplasms. We describe 2 cases of carcinosarcoma of the glottis. The tumors were staged as T3N0M0 and T2N0M0. Both patients were treated with supracricoid partial laryngectomy with cricohyoidoepiglottopexy. Eight months postoperatively, 1 of the 2 patients experienced a recurrence of the sarcomatous component of the tumor, and he underwent a total laryngectomy. The other patient remained free of disease at 12 months of follow-up. We conclude that supracricoid partial laryngectomy may be offered as an organ-preserving measure even in patients with sarcomatous disease; total laryngectomy can be held in reserve as a rescue measure. Patients must be closely monitored for early detection of recurrence. The role of adjuvant therapy for sarcomatous neoplasms in this area has not yet been clearly established.
Dilip D. Madnani, MD; Natalie P. Steele, MD; Egbert de Vries, MD
Abstract
Early identification of smoke inhalation patients who will require intubation is crucial. We conducted a retrospective chart review to identify predictors of respiratory distress in patients who present with smoke inhalation injury. Our study involved 41 patients who had been treated in the emergency room at a regional burn center. Eight of these patients required intubation. Intubation was positively correlated with physical examination findings of soot in the oral cavity (p < 0.001), facial burns (p = 0.025), and body burns (p = 0.025). The need for intubation was also predicted by fiberoptic laryngoscopic findings of edema of either the true vocal folds (p < 0.001) or the false vocal folds (p < 0.01). No statistically significant correlation was found between intubation and any of the classic symptoms of smoke inhalation: stridor, hoarseness, drooling, and dysphagia (all p = 1.0). Also, multivariate analysis revealed that facial burns correlated significantly with edema of the true vocal folds (p = 0.01) and body burns correlated significantly with edema of both the true (p = 0.047) and false (p = 0.003) vocal folds. We conclude that patients with soot in the oral cavity, facial burns, and/or body burns should be monitored closely because these findings indicate a higher likelihood of laryngeal edema and the need for intubation.
Primary malignant melanoma of the oronasal region is rare. When it does occur, it is difficult to manage, and the prognosis is not good. Early diagnosis and radical surgical management appear to offer the best hope of curing the disease. We report 3 new cases of malignant melanoma of the mucous membranes of the head and neck. Despite the generally poor outlook, 2 of these patients underwent excision of the tumor and remained disease-free 2 years later; the other patient refused surgery and was lost to follow-up.
Sandra Koterski, MD; Norman Snow, MD; Mike Yao, MD
Abstract
Laceration of the posterior tracheal wall is one of the risks of transhiatal esophagectomy. Various methods of repairing such lacerations have been described; many of these methods involve a thoracotomy, but some do not. We describe a case of a posterior tracheal wall tear that occurred during a laryngopharyngectomy with a gastric pull-up. The tear was repaired with the transposed stomach and did not require a thoracotomy. The transposed stomach was used to patch the tear and block communication between the environment and the mediastinum. Bedside endoscopic examination on postoperative day 5 revealed that the tear had healed. Key management considerations in such a circumstance include having the patient breathe without positive pressure ventilation postoperatively and keeping the tracheal lumen and stoma clear during the healing process in order to prevent the development of positive tracheal pressure. With these safeguards in place, the transposed stomach approach is a safe method of repairing posterior tracheal wall tears.
Perilymph fistulae are difficult to diagnose because they present with a wide variety of signs and symptoms, they are associated with many etiologies, and they often mimic other conditions. In this article, we describe a case of perilymph fistula that featured one of its more rare causes: acoustic trauma-specifically, damage from a loud blast from the siren of a fire engine. We also review the literature and discuss the difficulties of diagnosis and treatment and the possible mechanisms by which acoustic trauma and other etiologies cause perilymph fistulae.
Elaine Cheng, MD; Margie Ho, MA; Cindy Ganz, MS; Ashok Shaha, MD; Jay O. Boyle, MD; Bhuvanesh Singh, MD; Richrd J. Wong, MD; Snehal Patel, MD; Jatin Shah, MD; Ryan C. Branski, PhD; Dennis H. Kraus, MD
Abstract
The current study retrospectively reviewed the cases of 68 patients who had undergone total laryngectomy and tracheoesophageal puncture (TEP) over a 16-year period. Fifty-one patients underwent primary TEP and 17 underwent secondary TEP. Nearly 80% of patients who received TEP at the time of laryngectomy achieved excellent voice quality perceptually. In contrast, only 50% of secondary TEP patients achieved excellent voice ratings. This difference was statistically robust (p = 0.03). Although both surgical and prosthesis-related complications occurred more frequently following primary TEP, statistically significant differences were not achieved. Neither pre- nor postoperative radiotherapy had any effect on voice restoration or complication rates. Based on these data, primary TEP may be preferable for several reasons, including a greater likelihood of successful voice restoration, a shorter duration of postoperative aphonia, and the elimination of the need for a second operation and interim tube feedings.
Thrombosis of the internal jugular vein (IJV) is uncommon. It usually responds to conservative medical treatment. We describe a case of IJV thrombosis in a 31-year-old man. The patient was successfully treated with IJV ligation after conservative therapy had failed.
Primary malignant melanoma of the epiglottis is extremely rare. Until now, only 4 cases have been reported in the world literature. We describe a new case of epiglottic primary malignant melanoma in a 74-year-old man who presented with hoarseness and a foreign-body sensation. Clinical examination revealed the presence of a small, whitish, polypoid tumor on the laryngeal surface of the epiglottis; no other primary melanoma was detected. Wide excision of the lesion was performed, and microscopy revealed that it contained melanin-pigmented tumor cells in both the mucosa and submucosa. Immunostaining was positive for S-100 protein. The patient was treated with radiotherapy, and he remained well 1 year after the diagnosis with no evidence of recurrence.
