Epiglottitis and related complications in adults. Case reports and review of the literature.

Since the introduction of Haemophilus influenza type b (Hib) vaccinations in child immunisation programmes, a significant decline in the incidence of epiglottitis has been observed among children. However, recent studies show an increase in the incidence of adult epiglottitis without any identifiable predominant causative pathogen. Adult disease is known to have a slightly more protracted course. Vigilance is nevertheless indicated due to the risk of a rapidly evolving airway obstruction. In this paper, we discuss three recent cases of adult epiglottitis in a tertiary care unit, and review of the current literature. In two of these cases frank abscess formation was already present at the initial evaluation. In spite of very close monitoring, with securing of the airway, administration of intravenous antibiotics and drainage of the abscess, the eldest patient died. The other patients recovered completely.

Metabolic tumour volume. Prognostic value in locally advanced squamous cell carcinoma of the head and neck.

PURPOSE: Evaluate the predictive and prognostic value of semi-quantitative FDG-PET variables derived from pretreatment FDG-PET images in patients suffering from locally advanced squamous cell carcinoma of the head and neck (SCCHN), treated by means of concomitant radiochemotherapy. PATIENTS, METHODS: 40 patients with newly diagnosed SCCHN that were treated with concomitant radiochemotherapy underwent FDG-PET/CT for treatment planning; 18 patients had neck dissection prior to their baseline scan and to receiving radiochemotherapy. FDG-PET images were used to calculate metabolic tumour volumes using region growing and a threshold of 50% (MTV50) of primary lesions and involved lymph nodes as well as the mean and maximum standard uptake value (SUVmean and SUVmax) of the primary tumours. RESULTS: Neither SUVmean nor SUVmax values of the primary tumour were significantly different between responders and non-responders whereas MTV50 values of the primary tumour proved significantly higher in non-responders. SUVmean, SUVmax and MTV50 of the primary tumour were not predictive for overall or disease free survival. Contrariwise, dichotomized summed MTV50 values (cut-off≥31 cm3) of the primary tumour and involved lymph nodes in patients that didn't have neck dissection prior to radiochemotherapy were predictive for disease free and overall survival in both univariate and multivariate analysis (p≤0.05). CONCLUSION: Summed MTV50 values of both the primary tumour and involved lymph nodes provided independent prognostic information on disease free and overall survival.

FDG uptake in primary squamous cell carcinoma of the head and neck. The relationship between overexpression of glucose transporters and hexokinases, tumour proliferation and apoptosis.

AIM: This study aimed at assessing the relationship between over-expression of glucose transporters and hexokinases, tumour proliferation and apoptosis corrected for cellularity and partial volume corrected (pvc) FDG SUV values in primary squamous cell carcinoma of the head and neck (pSCCHN). PATIENTS, METHODS: In 27 consecutive patients suffering from pSCCHN, FDG SUVmax and mean pvc values of the primary tumour were derived from a pre-surgical routine staging FDG PET/CT examination. GLUT-1, GLUT-3, HK-1, HK-3 expression, tumour proliferation (Ki-67 staining) and the number of apoptotic cells (cleaved caspase-3 staining), corrected for tumour cellularity, were subsequently assessed on the corresponding post-surgically obtained biopsies and tumour specimens. FDG SUVmax and mean pvc values of pSCCHN were correlated with the corresponding histological findings. RESULTS: FDG SUV max and mean pvc values correlated significantly: with GLUT-1 scores r = 0.408 (p = 0.04) and r = 0.439 (p = 0.03) as well as with the number of apoptotic cells r = 0.529 (p = 0.008) and r = 0.484 (p = 0.017). The number of apoptotic cells also correlated to GLUT-3 scores: r = 0.62 (p = 0.001) and GLUT-1 scores r = 0.528 (p = 0.008). CONCLUSION: FDG SUV pvc proved significantly related to GLUT-1 expression by tumour cells and to the absolute number of apoptotic cells. The latter finding warrants further exploration and confirmation by additional studies.

Management of stridor in neonates and infants.

Stridor is the sound caused by abnormal air passage into the lungs and can exist in different degrees and be caused by obstruction located anywhere in the extra-thoracic (nose, pharynx, larynx, trachea) or intra-thoracic airway (tracheobronchial tree). Stridor may be congenital or acquired, acute, intermittent or chronic. Laryngotracheal inflammation (croup) is the most common cause of acute stridor. Laryngotracheomalacia is the most common cause of congenital, chronic stridor. Stridor is a clinical sign and not a diagnosis. The golden standard in the workup of stridor is an upper and lower airway endoscopy under general anaesthesia. Endoscopic examination under general anaesthesia requires a multidisciplinary approach and close cooperation between anaesthesiologist, paediatrician, ENT surgeon and nursing staff. Following this procedure, a place in the intensive care unit should be available for those cases presenting with stridor in which a definite diagnosis could not yet be established. Although important, pre-endoscopy assessment including history, physical examination and radiological examination, is only a guide to the type and degree of pathology found during endoscopy. About 1 out of 10 infants are found to have lesions in more than one anatomical site of the upper aerodigestive tract.

Initial assessment of a neck mass in children.

OBJECTIVE: To propose national recommendations for the initial assessment of a mass in the neck in children. METHODS: Comprehensive review of the available literature and consensus discussion with national experts in the field. RESULTS: Consensus guidelines are proposed concerning the work up of children presenting with a mass in the neck.

Initial work-up in head and neck squamous cell carcinoma.

OBJECTIVE: To propose national guidelines for the initial assessment of head and neck squamous cell carcinoma. METHODS: Comprehensive review of the literature and consensus discussion with national experts in the field. RESULTS: Consensus guidelines are proposed concerning the work-up of patients with a presumed diagnosis of a squamous cell carcinoma of the upper aero-digestive tract.

Management of neck masses in adults.

Initial management of a neck mass in adults is a frequently encountered problem in ENT practice. The differential diagnosis with regards to clinical presentation, localization, imaging studies and cytology and/or histology is reviewed. An algorithm is provided to help the practioner.

Comparison of decongestive capacity of xylometazoline and pseudoephedrine with rhinomanometry and MRI.

Topical and systemic sympathicomimetics have been used for many years as a treatment of nasal congestion in diseases such as coryza and sinusitis. The aim of this study was to perform an objective measurement of the decongestive capacity of topical xylometazoline and oral pseudoephedrine in normal subjects and patients with chronic sinusitis. Ten healthy subjects and 10 patients with chronic sinusitis were included in this study. Xylometazoline (0.1%) and pseudoephedrine (120 mg) were each administered to 5 healthy subjects and to 5 patients with chronic sinusitis. Decongestion was measured with active anterior rhinomanometry before, 15 minutes, 30 minutes and 1, 2, 4, 6 and 8 hours after administration. Before and about 90 minutes after drug administration a MRI was performed to visualize the decongestive effect on the turbinates and the mucosa of the sinuses. Xylometazoline reduces the nasal airway resistance for an average 37.3% in all patients and healthy subjects during 8 hours. Pseudoephedrine does not show a clear and long lasting decongestive effect on the turbinates. Important interindividual differences are also noted. MRI clearly shows a clear cut superiority of xylometazoline over pseudoephedrine concerning decongestion of the nasal mucosa. However, there was no decongestive effect whatsoever on the mucosa of the sinuses with either sympathicomimetic.

Is ambulatory 24-h dual-probe pH monitoring useful in suspected ENT manifestations of GERD?

BACKGROUND AND AIMS: The present study is aimed at assessing the relationship between ear, nose and throat manifestations and proximal reflux in gastro-oesophageal reflux disease by using 24-h dual-probe pH monitoring. PATIENTS AND METHODS: Fifty-eight patients were included: (;) 28 patients with suspected ear, nose and throat manifestations of gastrooesophageal reflux disease: (ii) 18 patients with typical symptoms of gastro-oesophageal reflux disease without extraoesophageal manifestations of gastro-oesophageal reflux disease; (iii) 12 healthy volunteers. Ambulatory 24-h dual-probe pH monitoring was performed in all patients. Oesophagogastroscopy was performed in all patients of groups I and II. Ear, nose and throat examination was performed in all patients with ear, nose and throat complaints. RESULTS: At the upper oesophageal sphincter, results of pH monitoring were significantly different between groups I and III (0.009 < P < 0.02) and between groups I and II (0.008 < P < 0.03). When comparing data at the lower oesophageal sphincter, we found a significant difference between groups II and III (0.002 < P < 0.009) and between groups I and III (0.001 < P < 0.002). Endoscopic examination of the oesophagus did not show any significant difference between groups I and II. Laryngoscopy was abnormal in 86% of the patients with ear, nose and throat symptoms. CONCLUSIONS: Ambulatory 24-h dual-probe pH monitoring is useful in the assessment of patients with suspected ear, nose and throat manifestations of gastro-oesophageal reflux disease, especially in the case of abnormal laryngoscopy.

Evaluation of the response to therapy of head and neck squamous cell carcinoma by using 3-[123I]iodo-L-alpha-methyl tyrosine and single photon emission tomography.

Early detection of residual tumour tissue offers the possibility for rapid administration of adjuvant treatment. Single photon emission tomography (SPET) with 3-[123I]iodo-L-alpha-methyl tyrosine (IMT) offers the ability to detect recurrence. The aim of this study was to carry out a prospective evaluation of sequential IMT SPET before and after primary therapy and to determine the best timing for scanning in order to establish the response to treatment. Sixteen consecutive patients with histologically proven head and neck cancer (HNC), who underwent IMT SPET before therapy, within 1 week of therapy, and 1 and 3 months after completion of primary therapy were included. Images were classified, according to clinical evaluation, as indicating a high likelihood (HL), intermediate likelihood (IL) and low likelihood (LL) that residual tumoural tissue was present. The definitive clinicopathological diagnosis and follow-up was considered as the 'gold standard'. Based on the definitive clinicopathological outcome, 10 of 16 patients were diagnosed with evidence of local tumour and six without. Nine of 10 patients with evidence of local tumour presented with an HL IMT SPET image after 3 months, seven of whom were from within the first week. In this group, 1/10 patients was considered clinically HS the first week and eventually 4/10 patients became HL, of which there were three at 3 months. Of the six patients diagnosed without local evidence of tumour, with an average follow-up of 15 months, 6/6 were clinically LL in the first week. Three of six had a consistently LL IMT SPET from within the first week. The three other patients had an HL scan the first week, of which one became IL. It is concluded that IMT SPET assessed the response to primary therapy most accurately 3 months after completion of therapy. An IMT SPET image that indicates a high likelihood of residual tumoural tissue may allow earlier stratification of the patients for secondary treatment. If negative, an IMT SPET can exclude residual tumoural tissue from within the first week after completion of therapy.

Nasal patency and sleep-related breathing disorders.

This article reviews the current insights in the contribution of nasal physiology, resistance and pathophysiology in relation to sleep-related breathing disorders. Different possible pathways have been followed to prove a clear role for the nose in this matter; they are reviewed and discussed. From all this it should be concluded that today there is only evidence for abnormal nasal resistance to be a possible cofactor in the disease. A short reminder about the currently available diagnostic tools for assessing nasal patency and resistance is given next. Finally the relation between the nose and treatment of sleep-related breathing disorders with nocturnal continuous positive airway pressure is discussed.

Diagnosis of recurrent head and neck squamous cell carcinoma with 3-[123I]iodo-L-alpha-methyltyrosine SPET.

The distribution of 3-[123I]iodo-L-alpha-methyltyrosine (123I-3-IMT) in the tumour region of 21 patients with clinically suspected recurrent squamous cell head and neck carcinoma was studied. Single-photon emission tomography (SPET) imaging of the head and neck region was performed 10 min after the injection of 130-170 MBq 123I-3-IMT using a dual-detector gamma camera. Images were interpreted visually and classified as positive or negative for recurrent disease. In addition, target to background ratios (T/B) were measured using semi-automated region of interest analysis. IMT-SPET results were compared with the data derived from clinicopathological follow-up. IMT-SPET detected recurrent disease in 14 of 15 patients (sensitivity 93%). T/B ratios ranged between 1.5 and 2.4 (mean 1.88). One patient with a small tumour (1.2 cm) had a false-negative result. This is attributed to the limited spatial resolution of the SPET system. Five of six patients were correctly diagnosed to be negative for tumour recurrence. T/B ratios ranged between 1.2 and 1.4 (mean 1.30). In one patient IMT-SPET was positive without evidence of recurrence based on clinicopathological follow up. This finding was probably due to uptake into inflammatory tissue. IMT-SPET appears to be a sensitive tool (93%) for the detection of recurrent head and neck squamous cell carcinoma. Further studies with 123I-3-IMT as a metabolic tracer for the detection of head and neck cancer recurrence using SPET are recommended.

Metastasis of a renal cell carcinoma to the nose and paranasal sinuses.

We present a case of a metastasis of a renal cell carcinoma to the nose and paranasal sinuses. A 66 year old male patient developed a mass in his left nasal cavity and paranasal sinuses, five years after he underwent a left sided nefrectomy for a renal cell carcinoma. The histopathologic examination of the nasal mass showed metastasis of a renal cell carcinoma. A craniofacial resection was performed followed by radiotherapy.

Otodental syndrome. A case report.

A 12-year-old boy with characteristic findings of otodental syndrome is presented. Abnormalities of deciduous and permanent dentition included bulbous canines, globe-shaped posterior teeth and agenesis of maxillary premolars. High-frequency sensorineural hearing loss was demonstrated, and results of genetic studies indicated an autosomal dominant trait. This patient presented previously unreported findings, including generalized macrodontia, delayed mineralization of the mandibular premolars, and supplementary permanent maxillary canines.

Iodine-123 alpha-methyl-l-tyrosine single-photon emission tomography for the visualization of head and neck squamous cell carcinomas.

The uptake of iodine-123 alpha-methyl-l-tyrosine (IMT) in the primary tumours and metastatic lymph nodes of squamous cell carcinoma of the head and neck was examined with single-photon emission tomography (SPET). Eleven patients with biopsy-proven carcinomas were studied prior to any therapeutic action. The evaluation of cervical lymph node involvement was based on the findings of physical examination, computed tomography and magnetic resonance imaging, and in six patients on the histological data relating to tissue samples obtained by fine-needle lymph node aspiration or surgical intervention. SPET imaging was performed 10 min after the injection of 130-170 MBq IMT using a triple-head gamma camera equipped with medium-energy collimators. High-quality IMT SPET depicted the primary tumour in 10 of 11 patients (sensitivity: 91%). Tumours located in the larynx were visualized more clearly than those located in the mouth or oropharynx. The mean tumour-to-background ratio was 2.35 (range: 1.6-3.1) for laryngeal tumours and 1.67 (range: 1.2-2.2) for mouth and oropharyngeal tumours. Metastatic cervical lymph nodes were involved to various degrees in 8 of the 11 patients. Among these eight patients there were 16 sites, nine of which were detected by IMT SPET (sensitivity: 56%). If the IMT SPET findings were recorded per side of the neck, the sensitivity was 64%. Five of the seven missed metastatic lymph nodes were smaller than 15 mm. The mean tumour-to-background ratio of the scintigraphically visualized lymph nodes was 1.81+/-0.51 (range: 1.39-2.77). Asymmetric physiological submandibular salivary gland IMT uptake led to false-positive lymph node assessment in three patients. This study indicates the potential use of IMT SPET as a metabolic imaging modality in patients with head and neck squamous cell carcinoma.

Myxoma of the maxilla: a case with extremely aggressive biologic behavior.

BACKGROUND: Osseous "bone-derived" myxoma is a benign, slow-growing, locally invasive tumor that is found exclusively in the facial skeleton. Although recurrence is frequent, uncontrolled growth is not classic. METHODS AND RESULTS: We report the case of a patient with myxoma of the maxilla in which the growth of the myxoma was so invasive that it resulted in destruction and deformation of the facial skeleton even after repeated resections. Eventually, destruction and infiltration of the skull base with a fatal outcome was the result. CONCLUSIONS: This case of locally aggressive myxoma of the maxilla illustrates the need for a correct primary treatment of this benign tumor. Although complete resection may result in a significant functional and aesthetic mutilation, incomplete primary removal results in high recurrence rates. Therefore, a radical primary resection of the tumor with maximal preservation of surrounding anatomic structures is necessary. Follow-up should be meticulous and based upon regular clinical and radiographic examinations.

Tumour-associated tissue eosinophilia in head and neck squamous-cell carcinoma.

The possible role of tumour-associated tissue eosinophilia (TATE) as a prognostic factor in epithelial tumours has been investigated before. TATE is supposed to be associated with good prognosis. In this study concerning 63 patients with laryngeal and/or pharyngeal squamous-cell carcinoma, we tried to verify this hypothesis. Of the 25 patients with TATE, 17 (68%) had a good outcome opposed to 8 (32%) with a poor outcome. This numerically better chance for a good outcome in case of TATE was however not statistically significant. Uniformity of research material, staining and classification of TATE together with more representative and larger series of patients should ascertain the real value of TATE as a valid prognostic factor in head and neck squamous-cell carcinoma.

Radiation-induced fibrosarcoma of the tongue.

Three patients with a radiation-induced fibrosarcoma of the tongue are presented. All three patients had interstitial radiotherapy and tumour-induction by irradiation seems to be the most likely explanation for the tumour in these patients.

Septal surgery and tubal function: early and late results.

The influence of nasal septal deviation and its surgical correction on the opening pressure of the Eustachian tube was studied. The Tuba Compliance Manometric test by the Valsalva manoeuvre was used. On the basis of early and late post-operative measurements, it was stated that surgical correction of a nasal septal deviation in order to improve the tubal opening pressure is justified, both on the deviated side and on the non-deviated side. Late post-operative results confirmed this finding.

Nosocomial pansinusitis in orotracheally intubated critically ill patients.

Nosocomial pansinusitis (N P) is most often described in nasotracheally intubated patients with craniocerebral or facial trauma. We retrospectively reviewed its occurrence and complications in the course of prolonged mechanical ventilation in orotracheally intubated patients without maxillofacial or cranial injuries. N P was deemed to be present when (1) CT scan showed opacification and/or air-fluid levels in the maxillary, ethmoid and sphenoid sinuses and (2) aspiration of both maxillary sinuses yielded pus, cultures of which revealed a high concentration of micro organisms. Nosocomial pneumonia and bacteremia were considered related to the N P if the organisms found in the sinus were identical to those recovered from the blood and/or the bronchi. During an 18-month study period, 38 cases of sinusitis were diagnosed. N P was present in 13 patients: 18 organisms (12 Gram-negative, 5 Gram-positive and 1 Candida albicans) were isolated. Pneumonia occurred in 8 patients, 6 with multi-resistant Pseudominas aeruginosa and 2 with methicillin resistant Staphylococcus aureus. Pseudomonas aeruginosa was isolated from the blood, lung and sinus in two patients. This study demonstrates that N P is relatively frequent in patients requiring long-term mechanical ventilation, even in the absence of predisposing factors. N P in these patients is mostly monomicrobial with multi-resistant Pseudomonas aeruginosa and Staphylococcus aureus as the main causative agents.