Severe throat pain in patients with negative oropharyngeal examination: four case reports and overview of the literature.

Throat pain is one of the most frequent complaints prompting patient visits to healthcare professionals. Primary care physicians being the first contact point are frequently encountered with symptoms such as sore throat and odynophagia. However, high level of diagnostic uncertainty exists when the oropharyngeal examination is normal despite patients' complaints of severe pain. We present four Caucasian Greek patients, two males aged 47 and 57 years and two females aged 32 and 47 years respectively admitted to an Ear Nose and Throat department of a general hospital, with severe throat pain and initially normal oropharyngeal examination. This case series highlights the necessity for a high level of suspicion on the part of the primary care physicians when facing patients complaining of severe throat pain since their symptoms may indicate conditions such as supraglottitis, lingual tonsillitis or pemphigus vulgaris. A careful clinical examination, including an indirect laryngoscopy, is required especially when the initial oropharyngeal examination is normal.

Angiotensin-converting enzyme inhibitor (ACE-I)- and angiotensin receptor blocker (ARB)-related angioedema: a neglected issue in daily practice in Greece.

Several reports on angioedema (AE) related to the use of angiotensin-converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB) have been published recently. This study reports on the experience gained at the Ear, Nose, and Throat (ENT) Clinic of the University Hospital of Heraklion, Crete. A retrospective chart review of the patients admitted to this clinic, in a 42-month period (1999-2003), and discharged with a diagnosis ENT code for AE was performed (14 eligible patients). A complementary telephone survey was conducted during January 2005. Ten patients responded to our invitation. Of those patients, five were under ACE-I and one was under ARB treatment during the AE episode. The mean length of time between the onset of symptoms and presentation to the hospital was 4.5 hours (range 0.5-12 hours). The mean duration between the initiation of antihypertensive treatment and AE episode was 26.2 months (range 1-60 months). Patients reported that no information was provided about the possible adverse effects of these drugs. Although AE introduced by ACE-I and ARBs is an uncommon side effect, this case series conveys a key message to primary care physicians.

Epidemiologic profile of otorhinolaryngological, head and neck disorders in a tertiary hospital unit in Greece: a challenge for general practitioners?

BACKGROUND: In Greece, primary care is still developing. The aim of this study was to define the epidemiologic profile of common otorhinolaryngological, head and neck disorders in order to help general practitioners to deal with them in a primary care future. METHODS: A total of 6771 patients attended the Otorhinolaryngology emergency department of the University General Hospital of Heraklion (Crete), between January and December 2004. All cases were included in this retrospective study. The registry of the Otorhinolaryngology emergency department was analysed and age, sex, seasonality and clinical diagnosis were tabulated. All patients were evaluated by Otorhinolaryngologists. The classification of the cases was based on the main symptom or clinical sign that conditioned the reason for seeking care. Diagnoses were also coded according to the International Classification of Diseases (ICD-10). RESULTS: The male to female ratio was 1:1. The mean age for females was 36.3 years standard deviation (SD): 21.1 and for males was 36.8 years (SD = 22.0). Eight hundred eighty six patients (13.1%) formed the paediatric sub-group. Over 60% of the cases were classified in ten major groups of diagnosis. Acute tonsillitis (12.3%) and acute pharyngitis (9.0%) were the most common causes of all medical visits, followed by otitis media (7.6%) and external ear canal obstruction by ear wax (6.2%). Oedema of the larynx was detected in 0.4%. A negative diagnosis of otorhinolaryngological, head and neck disorder was formulated in 553 patients (8.2%). Hospitalization rate was 5.2%. The highest rate of visits was registered in March. CONCLUSION: Most patients used the facility as a primary care service. Real emergencies were a minority. Recovering data about which areas of Otorhinolaryngology deserve more emphasis might help primary health care providers to diagnose and manage the common otorhinolaryngological, head and neck disorders properly.

Symptomatic epilepsy due to a huge frontal sinus mucocele. A case report.

We report the case of a 57-year-old man complaining of headaches and adult onset seizures. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a process which proved to be a huge frontal sinus mucocele, eroding the posterior wall of the frontal sinus and compressing the left frontal lobe. An osteoplastic flap procedure with cranialization and obliteration of the frontal sinus was performed. The seizures and headache disappeared postoperatively. Clinical manifestations, diagnosis and surgical approaches for grand frontal sinus mucoceles are briefly discussed.

Bilateral nasolabial cysts associated with recurrent dacryocystitis.

OBJECTIVE: Nasolabial cysts are rare, nonodontogenic, soft-tissue, developmental cysts occurring inferior to the nasal alar region. They are thought to arise from remnants of the nasolacrimal ducts and they are frequently asymptomatic. We report a rare case of bilateral nasolabial cysts accompanied by bilateral chronic dacryocystitis. CASE REPORT: A 48-year-old woman suffering from bilateral chronic dacryocystitis was referred to our department for endonasal dacryocystorhinostomy. She had undergone external dacryocystorhinostomy on the left side a few years earlier. Physical examination and computed tomography scan revealed nasolabial cysts bilaterally inferior to the nasal alar region. The cysts were removed via a sublabial approach and endoscopic dacryocystorhinostomy was performed on the right side. Ten months after surgery, the patient was asymptomatic. CONCLUSION: There may be a correlation, due to embryological reasons, between the presence of nasolabial cysts and the presence of chronic dacryocystitis. Both can be corrected surgically, under the same anaesthesia, without visible scar formation.

Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists.

The use of angiotensin-converting enzyme inhibitors (ACEIs) has been implicated in many cases of angioedema, but, given the potential mechanism of this complication, it was not expected to be caused by angiotensin II receptor blockers (ARBs). However, in the past few years, scattered reports of angioedema associated with ARBs have appeared in the medical literature. We performed a retrospective chart review from January 1, 1998, through June 30, 2003, and a review of the literature. During this time, we managed head and neck angioedema induced by ACEIs (n = 27) and ARBs (n = 4) in 31 patients. All of them had significant mucosal swelling, and in some of them dyspnea and dysphagia coexisted. The most frequently involved areas were the oral tongue (13 cases), uvula and soft palate (5 cases), and larynx, mouth floor, and lips (3 cases each). Angioedema may be a more common complication of ACEI and/or ARB use than originally thought. This complication may occur after long-term use of these drugs. We advise that ARBs not be prescribed to patients with a history of angioedema, particularly that due to the use of ACEIs.

Critical care of the head and neck patient.

The patient with head and neck disease has several peculiarities that need to be recognized for the treating team to offer optimal care. These arise from the primary disorders (eg, head and neck cancer or injuries) and the morbidity they might cause, the associated comorbidities, and the possible complications of treatment. A team approach involving the surgeon, the intensivist, and other caretaking personnel is essential to achieve high-quality care and ensure the best results possible.

Cocaine flakes versus tetracaine/adrenaline solution for local anaesthesia in septoplasty.

The aim of this prospective study was to evaluate the efficacy of cocaine flakes compared to tetracaine with adrenaline solution, as a local anaesthetic for patients undergoing septoplasty. From January 2001 to December 2002, 220 patients underwent septoplasty under local anaesthesia. Patients were randomly classified in group A and group B, where cocaine and the solution of tetracaine/adrenaline were used respectively. A visual analogue scale was used to evaluate the severity of the patients'pain during the procedure. The patients of group B showed a statistically significant lower pain score than patients of group A. We believe that the solution of tetracaine/adrenaline is an effective and safe anaesthetic for patients undergoing septoplasty under local anaesthesia.

Excision of rhinophyma with a laser scanner handpiece--a modified technique.

Rhinophyma is a slowly progressive, benign dermatological disorder of the tip of the nose. The most widely accepted theory is that rhinophyma is the end stage result of chronic acne rosacea. The primary reason for excision of rhinophyma is cosmetic deformity. However, nasal obstruction may present, as rhinophyma may obstruct nasal vestibules. Surgery is the treatment of choice for rhinophyma. Medical therapy has not given satisfactory results. The surgical treatment modalities are divided into two main groups. The first is complete excision, with primary closure for small lesions, or skin grafting for large lesions. The second group includes incomplete excision followed by re-epithelialization from the remaining glandular epithelium. The carbon dioxide (CO2) laser has been advocated for excision of rhinophyma. Newer instrumentation, such as Swiftlase and SurgiTouch (ESC Sharplan) or Ultrapulse (Coherent) is more effective in vaporization and carbonization resulting in better hemostasis (Ries and Speyer, 1996). In this report, 7 patients with rhinophyma treated with the Swiftlase are reviewed. The surgical technique, the complications and the follow-up are discussed.

Lump sensation in the throat caused by tumors in the preepiglottic space.

Lump sensation in the throat is a common symptom, which accounts for 4% of first patient visits to Otorhinolaryngologic clinics. The etiology includes abnormalities of the thyroid gland, cysts, tumors and chronic infections of the pharynx, larynx, esophagus and tongue base, gastroesophageal reflux and anxiety disorders. In this article we describe two rare cases of lump sensation caused by masses in the preepiglottic space and we stress the importance of thorough investigation to exclude any possible non functional causes.

Arteriovenous malformation of the neck presented during delivery.

Vascular anomalies in the head and neck area are not infrequent and, in most cases, are congenital in origin. We present a congenital arteriovenous malformation (AVM) of the neck that manifested in a young woman during delivery. Imaging findings on ultrasonography (US), computed tomography (CT) and angiography were inconclusive and the diagnosis was reached by magnetic resonance imaging. A total excision of the mass was performed.

Bilateral sudden sensorineural hearing loss caused by Charcot-Marie-Tooth disease.

Charcot-Marie-Tooth (CMT) disease or hereditary motor and sensory neuropathy (HMSN) is a relatively common neurological syndrome, which has seldom been associated with hearing dysfunction, particularly sudden sensorineural hearing loss (SNHL). Families with autosomal dominant, autosomal recessive and X-linked forms of inheritance have been described. Sudden sensorineural hearing loss is a frustrating and frightening condition, especially if the hearing loss is bilateral. Regarding the site of the lesion, the evidence from the literature on HMSN suggests that either the VIIIth nerve or central auditory pathways are primarily involved in patients with hearing loss. We report the first case in the English literature of a patient with Charcot-Marie-Tooth type II disease presenting bilateral SNHL in the course of his disease. The patient was hospitalized for 15 days, and undergoing treatment without any audiological improvement. Detailed clinical, audiological and laboratory examination was performed. The aetiology and prognostic indicators of bilateral SNHL are discussed, as well as, the incidence of hearing loss in CMT patients.

Palate ulcer due to mucormycosis.

Mucormycosis is caused by fungi of the order Mucorales and is one of the most rapidly fatal fungal infections known to man. Rhinocerebral mucormycosis is the most common type and its extension to the orbit and brain is quite usual. Location of mucormycosis on the palate is a rare and late occurrence. A case of deep hard palate ulcer due to sinonasal mucormycosis in a 79-year-old man is reported. He was successfully treated with a combination of surgical debridement and systemic liposomal amphotericin B administration for six weeks. By presenting this case report we would like to point out that mucormycosis should be included in the differential diagnosis of hard palate ulcers.

Seborrheic keratosis of the auricle: report of an unusual case.

Seborrheic keratoses are superficial epithelial lesions. They are usually pigmented and often warty, but sometimes they appear as smooth papules. These lesions frequently occur on the face during middle and old age. We report an unusual case of a large seborrheic keratosis of the auricle. We also emphasize the importance of the differential diagnosis, and we discuss the treatment strategy for these usually benign but disfiguring tumors.

Glomus tumor of the cheek: a case report.

Glomus tumors are benign, subcutaneous neoplasms of the perivasculature. Though facial location is rare, the diagnosis of a glomus tumor should be considered in cases of undiagnosed painful facial nodules or chronic facial pain. Imaging aids in defining the tumor and planning a complete excision in order to avoid recurrence. Histological examination is mandatory after every attempted excision. A case of glomus tumor of the cheek along with the possible pitfalls of diagnosis and treatment and a brief review of the limited associated literature are presented.

Diagnosis of tetanus by an otorhinolaryngologist and immunity against tetanus among adults on the island of Crete.

BACKGROUND: Tetanus (lockjaw) is a rare disease in developed countries. METHODS: An otorhinolaryngologist can be the first physician to see a patient with tetanus. In our department, we have seen 10 such cases presenting with head and neck symptoms. We report 2 of these cases followed by an investigation of the immune status of the adult Cretan population against tetanus using 200 random patients who visited our clinic. RESULTS: A negative history of complete childhood immunization was recorded in 37% of individuals. Of the male population, 88.5% had received active immunization during adulthood, although 47% had received all three doses. Only 12.6% of the females had received full-dose immunization during adulthood. Overall, only 8.5% of the studied population had received either complete immunization or a scheduled booster dose during the last decade. CONCLUSIONS: In many cases, an otorhinolaryngologist can be the first physician to examine a patient with tetanus. The incidence of the disease in Crete, Greece, is significantly higher than in most parts of developed countries.

Nonmicrosurgical reconstruction of the auricle after traumatic amputation due to human bite.

BACKGROUND: Traumatic auricular amputation due to human bite is not a common event. Nonetheless, it constitutes a difficult challenge for the reconstructive surgeon. Microsurgery can be performed in some cases, but most microsurgical techniques are complex and their use can only be advocated in specialized centers. Replantation of a severed ear without microsurgery can be a safe alternative as long as a proper technique is selected. METHODS: We present two cases, one of a partial and one of a total traumatic auricular amputation, both caused by human bites, that were successfully managed in our Department. The technique of ear reattachment as a composite graft, with partial burial of the amputated part in the retroauricular region, as first described by Baudet, was followed in both cases. RESULTS AND DISCUSSION: The prementioned technique is described in detail, along with the postoperative management and outcome of the patients. In addition, a brief review of the international literature regarding ear replantation is performed. CONCLUSION: The Baudet technique has been used successfully in two cases of traumatic ear amputation due to human bites. It is a simple technique, without the need for microsurgery, and produces excellent aesthetic results, while preserving all neighboring tissues in case of failure with subsequent need for another operation.

Primary nasal non-Hodgkin lymphomas presented initially as benign disease.

BACKGROUND: Primary non-Hodgkin lymphomas (NHLs) of the sinonasal tract comprise a rare entity that constitutes 1.5% of all NHLs and 2.2% of extranodal lymphomas in the whites. Clinical diagnosis may be very challenging because of the variety and low specificity of the presenting symptoms and signs. METHODS-RESULTS: We present three cases of NHLs, initially diagnosed as benign diseases. All three cases have been eventually correctly diagnosed and treated in our hospital between January 2000 and December 2003. The patients have been under close follow-up from 11 to 36 months after the initial treatment. One of them remains without clinical or radiological evidence of recurrence, whereas the two others died 11 and 16 months after the initial diagnosis. CONCLUSION: It is important to underline that atypical or persistent symptoms of rhinosinusitis may represent the initial expression of a more serious condition such as deep fungal infection, vasculitis, lymphoma, or other malignancy.

Oral mucosal melanoma: a malignant trap.

Oral mucosal melanomas are highly malignant tumors. The 'chameleonic' presentation of a mainly asymptomatic condition, the rarity of these lesions, the poor prognosis and the necessity of a highly specialized treatment are factors that should be seriously considered by the involved health provider. We present the case of a 75-year-old man who was referred to the Ear, Nose and Throat department. His symptoms were voice alteration and saliva drooling, progressively worsening during the last few weeks. The absence of pain was the reason for the delay of seeking medical care. The diagnosis was an oversized oral melanoma. This is an example of how the time of diagnosis and the evolution of a disease could be seriously influenced by patient's behavior. Melanomas arising from oral mucosa have poor prognosis unless they are discovered and treated early. The vigilance of the physicians is necessary to have success in this difficult task.

The use of botulinum toxin type A in the treatment of Frey and crocodile tears syndromes.

PURPOSE: We sought to investigate the efficacy of botulinum toxin type A in the treatment of Frey and crocodile tears syndromes. Frey syndrome is a common complication after surgical intervention or injury in the region of the parotid gland. Crocodile tears syndrome is unusual and manifests after facial nerve paralysis and other causes such as head trauma. PATIENTS AND METHODS: This was a prospective nonrandomized, nonblinded study. We used botulinum toxin type A for the treatment of 11 patients with gustatory sweating and 2 patients with crocodile tears syndrome. RESULTS: The follow-up (6 to 23 months) of patients with gustatory sweating syndrome showed complete absence of sweating in the affected regions. One patient had recurrence after 16 months and was retreated successfully. At 1 and 24 weeks after treatment of the patients with the crocodile tears syndrome, the Schirmer test showed a reduction of stimulated lacrimation on the impaired side approaching the normal values of the unaffected side. CONCLUSIONS: Our study supports the widely accepted aspect that botulinum toxin type A could be the treatment of choice for gustatory sweating syndrome. We also propose the toxin as a valuable treatment for crocodile tears syndrome.