Heterotopic salivary duct inclusions in Warthin tumor - A cryptic histological finding involved in its pathogenesis.

Warthin tumor (WT) is the second most common benign parotid gland tumor after pleomorphic adenoma. WT is characterized by cystic and papillary proliferation of a two-layered oncocytic epithelium supported by lymphoid tissue. Heterotopic salivary duct inclusions (SDIs) are frequently observed in lymph nodes (LNs) of WT (SDI/LNs), and are thought to be the origin of WT. If this is true, SDIs should also persist in the lymphoid tissue of WT itself (SDI/WT), as a missing link between SDIs and WTs, but studies of this issue are limited. From 2008-2023, 138 WT cases were surgically excised at our hospital. SDI/LNs and SDI/WTs were histologically examined. Of 100 WT cases with LNs, SDI/LNs were observed in 67 cases (67 %). SDI/WTs were detected in 114 of 138 cases (82.6 %), including 107 of 127 smokers (84.3 %) and 7 of 11 never-smokers (63.6 %). SDI/WTs were located mainly in the subcapsular lymphoid tissue and often surrounded by a fibrous coat resembling salivary excretory ducts. This study revealed a high incidence of SDIs in WT itself, strongly supporting the theory that WT develops from heterotopic salivary ducts.

Respiratory epithelial adenomatoid hamartomas of the sinonasal tract: A histopathological analysis of 50 patients.

Respiratory epithelial adenomatoid hamartoma (REAH) is a benign lesion of the nasal cavity and paranasal sinuses. Here, we report the clinicopathological characteristics of REAH identified in 2065 cases with nasal/paranasal polypoid lesions treated with endoscopic sinus surgery (ESS) at our hospital from 2008 to 2021. Cases including the olfactory area were reviewed and 50 patients of REAH were identified pathologically (50/2065, 2.4%). The average age was 58.9 years old and the male/female ratio was 45/5. Grossly, REAH showed a whitish surface and elastic firm consistency. The histopathological characteristics included proliferation of small to medium-sized glands composed of ciliated respiratory epithelium containing goblet cells; thickening of the basement membrane compared to that for inverted papilloma (9.6 ± 2.4 vs. 1.3 ± 1.6 µm, p < 0.001); and no intra-epithelial neutrophilic infiltration. Among the REAH cases, 81% were associated with sinonasal inflammatory polyps. Many olfactory cleft polyps were REAH (38/98, 39%). The rate of REAH found in ESS in the last 7 years was higher than that in the first 7 years (3.17% vs. 1.62%, p = 0.032). Our results in Japanese patients are similar to those found in other countries, including male predominance. REAH is relatively common and that 39% of polyps taken from olfactory clefts are REAH.

A Case of Immunogloblin A Vasculitis Caused by Infection in Tracheotomy Wound.

Immunogloblin A (IgA) vasculitis is the most common systematic vasculitis disorder characterized by leykocytoclastic vasculitis , for example, purpura with white blood cell destruction vasculitis caused by allergic mechanisms. The main symptoms of this disease are purpura, arthritis, abdominal pain, gastrointestinal bleeding, and nephritis. 　We report the case of a 66-year-old man with IgA vasculitis. He was diagnosed with hypopharyngeal cancer and underwent radio-chemotherapy at our department. On the following day, he underwent tracheotomy because of recurrent laryngeal nerve paralysis associated with cancer treatment. 　His wound infection remained after the tracheostomy, and he complained of purpura on both legs. On the basis of these clinical courses we diagnosed IgA vasculatis caused by wound infection. This case illustrates that it is important to consider the possibility of IgA vasculatis if skin eruption is observed concurrent with wound infection.

[A Case of Neurally Mediated Syncope Caused by Cervical Malignant Lymphoma].

We report herein on a case of a 74 year old male with neurally mediated syncope caused by cervical malignant lymphoma. He visited our hospital complaining of a rapidly-growing left cervical mass. Local findings showed an elastic soft mass with tenderness in his cervical region. We performed an open biopsy and pathological diagnosis was diffuse large B-cell lymphoma, so we planned to treat him with CHOP therapy. But before chemotherapy, loss of consciousness occurred. This syncope was considered to be neurally mediated syncope caused by the compression of the carotid sinus by the cervical malignant lymphoma. His cervical malignant lymphoma rapidly shrank after CHOP therapy, and general fatigue and bradycardia decreased day by day. If cardiac pacemaker insertion is not enforced for a case of neurally mediated syncope, the frequency of the syncope increases. In this case the cervical tumor was reduced by CHOP therapy and the syncope and bradycardia disappeared. The patient was able to avoid cardiac pacemaker insertion.

[A Case of Stevens-Johnson Syndrome Developing during Chemoradiotherapy for Maxillary Sinus Cancer].

Herein, we report a case of drug-induced Stevens Johnson syndrome. (SJS). A 56-year old female visited our hospital complaining of right cheek pain. Local examination revealed that the right ostium of the maxillary sinus was open and that the maxillary sinus mucosa was invaded by tumor. Biopsy revealed a histopathological diagnosis of squamous cell carcinoma. We therefore diagnosed the patient as a case of maxillary sinus carcinoma (T3N0M0) based on the CT, MRI and FDG-PET findings. During chemoradiotherapy for maxillary sinus cancer, the patient developed oral mucosal inflammation of progressively worsening severity; we initially thought that the symptom was a side effect of the treatment; however, several days later, skin lesions appeared throughout the body. We consulted a dermatologist, who suspected SJS. The patient was initiated on high-dose steroid therapy (steroid pulse therapy), and the symptoms improved. Because of SJS is a fatal drug eruption, early diagnosis and prompt treatment are important. In patients receiving chemoradiotherapy showing severe oral mucosal inflammation outside the irradiation area or oral mucosal inflammation associated with skin lesions throughout the body, it is necessary to bear in mind the possibility of SJS.

[Operative field limited by in the case of a tonsillectomy due to temporomandibular arthrosis--a case report].

We report herein on a patient with unexpected trismus after the induction of general anesthesia due to temporomandibular arthrosis. A 30 year old man visited our hospital complaining of hematuria, and he was scheduled for bil tonsillectomy under general anesthesia. Preoperative examination revealed no evidence of difficult airway and no sign of trismus. Despite the administration of muscle relaxants, it was impossible to expand the operative field due to by trismus after the introduction of general anesthesia. Malignant hyperthermia was excluded, and the trismus was judged to be due to temporomandibular arthrosis. Manual repositioning was performed, trismus was improved and expansion of the surgical field became possible. During any head and neck surgical procedure, if an otolaryngologist should encounter trismus after the induction of general anesthesia, temporomandibular arthrosis should be borne in mind if temporomandibular arthrosis is diagnosed as the cause, manual repositioning should be employed as soon as possible.

FDG PET/CT and diffusion-weighted imaging of head and neck squamous cell carcinoma: comparison of prognostic significance between primary tumor standardized uptake value and apparent diffusion coefficient.

PURPOSE: To compare primary tumor (18)F-fluorodeoxyglucose (FDG) maximum standardized uptake value (SUV(max)) and diffusion-weighted imaging (DWI) apparent diffusion coefficient (ADC) obtained in the same patients with head and neck squamous cell carcinoma (HNSCC) to clarify the prognostic significance of both indexes. MATERIALS AND METHODS: The study population comprised 26 patients with HNSCC visible on both pretreatment FDG PET/CT and DWI. Correlation between SUV(max) and ADC (b values; 0 and 800 seconds/mm(2)) was analyzed by the Spearman's rank test. Disease-free survival (DFS) was calculated by the Kaplan-Meier method. Prognostic significance was assessed by the long-rank test and Cox proportional hazards analysis. RESULTS: SUV(max) and ADC correlated significantly and negatively (ρ = -0.566, P = 0.005). High (>12.1) SUV(max) (P < 0.001), low (≤ 0.88) ADC (P = 0.009), high (T3-4) T stage (P = 0.030), and high (N2-3) N stage (P = 0.007) were significant in predicting poor 2-year DFS. The accuracy for predicting disease events was 81% (21/26) for SUV(max) (>12.1) and 73% (19/26) for ADC(≤ 0.88) without significant difference between them (P = 0.52). Disease event hazards ratios for significant unadjusted SUV(max) (P = 0.015) and ADC (P = 0.039) remained significant when adjusted for other dichotomized clinical covariates (SUV(max); P = 0.009-0.039, ADC; P = 0.017-0.037) except SUV(max) for ADC and ADC for SUV(max) and T stage. CONCLUSION: These results suggest that pretreatment primary tumor SUV(max) and ADC correlate significantly and negatively and both may have similar potential to predict DFS or disease events of HNSCC.

Venous thrombosis after microvascular free-tissue transfer in head and neck cancer reconstruction.

OBJECTIVE: Microvascular free-tissue transfer is essential for functional reconstruction in head and neck cancer surgery. The risk of free flap failure depends on venous thrombosis rather than arterial thrombosis, and any type of failure caused by venous thrombosis is often diagnosed late. In this study, we studied the flap survival rate achieved by this technique depending on the recipient vein. Further, the risk factor was analyzed for venous thrombosis with regard to preservation of recipient vein during neck dissection. METHODS: This study is a retrospective review of 102 consecutive free flaps performed by a single head and neck surgical team from 2000 to 2006 at the Department of Otolaryngology, Head and Neck Surgery at Kagoshima University Hospital. The recipient vessels such as the external jugular (EJ) vein and internal jugular (IJ) system were carefully preserved during neck dissection. All patients received 80 microg of prostaglandin E1 (Alprostadil) for 5 days after surgery. RESULTS: The overall success rate was 94.1%. All the six cases of unsuccessful free flap transfer were caused by venous thrombosis. Microvascular free flaps anastomosed to the EJ vein failed at a significantly higher rate (13.3%) than those anastomosed to the IJ system (2.8%) (p<0.05). On studying the failed cases after IJ system anastomosis, we found that all complications were caused by internal jugular vein thrombosis (IJVT) and not by microvascular anastomotic thrombosis. In all the three cases of flap failure with IJVT, the dissected IJ vein was patently ballooning because of the remaining connective tissue, including the adventitia around the IJ vein in the supraclavicular lesion. CONCLUSIONS: Although the IJ system is the ideal recipient vessel when compared with EJ vein, there is another risk of flap failure due to IJVT. To improve the survival rate, IJVT should be prevented by a careful manipulation of IJ system during neck dissection to avoid ballooning of the IJ vein in head and neck cancer surgery.

TNF-alpha upregulates VCAM-1 and NF-kappaB in fibroblasts from nasal polyps.

OBJECTIVE: Lung and synovial fibroblasts produce VCAM-1 in response to TNF-alpha. However, the massive infiltration of eosinophils, the effects of the increased amount of TNF-alpha and the production of VCAM-1 in human nasal polyp fibroblasts are not yet fully understood. The present study examines the role of VCAM-1 and the molecular mechanism of its expression in nasal fibroblasts. METHODS: Nasal fibroblasts were isolated from human nasal polyps and after four passages, the cells were stimulated with TNF-alpha and VCAM-1 expression was examined by ELISA, flow cytometry, and RT-PCR. The activation of NF-kappaB induced by TNF-alpha was determined by electrophoretic mobility shift assays and the influence on the expression of VCAM-1 was investigated. RESULTS: VCAM-1 protein and mRNA were expressed in unstimulated controls and remarkably increased by TNF-alpha stimulation. NF-kappaB activity was enhanced by TNF-alpha stimulation and remarkably suppressed by NF-kappaB proteasome inhibitor. CONCLUSIONS: The present study discovered that nasal fibroblasts produce VCAM-1 protein and mRNA and that production is increased by TNF-alpha stimulation. Furthermore, VCAM-1 expression in nasal fibroblasts is induced through an NF-kappaB-dependent pathway. These findings might provide a rationale for using NF-kappaB inhibitors as a treatment for nasal inflammatory diseases such as polyps.

Oncogenic osteomalacia in a case with a maxillary sinus mesenchymal tumor.

We herein describe the rare case of a 41-year-old woman with oncogenic osteomalacia due to a tumor in the maxillary sinus who presented with chronic general pain that had been gradually deteriorating. The patient's laboratory findings revealed hypophosphatemia due to renal phosphate wasting, an inappropriately low serum 1 alpha,25-dihydroxyvitamin D3 level for hypophosphatemia and an unusually high serum level of fibroblast growth factor 23 (FGF23). The causative tumor was surgically removed, resulting in a rapid resolution of the patient's biochemical abnormalities. An improvement of the abnormal multiple deposits on (99)Technetium-methylene diphosphonate bone scintigraphy and an increase in the bone metabolism markers suggested the development of bone remodeling within 49 days after the operation. The pathologic diagnosis of the tumor was a "phosphaturic mesenchymal tumor, mixed with a connective tissue variant." The expression of FGF23 was demonstrated in the tumor by the immunohistochemical techniques and a Western analysis.

Inhibition of vascular endothelial growth factor by macrolides in cultured fibroblasts from nasal polyps.

OBJECTIVE: In order to study a new mechanism of efficacy of 14-membered ring macrolides in treating chronic rhinosinusitis, inhibitory effects of macrolides on vascular endothelial growth factor production were examined in vitro. METHODS: Vascular endothelisal growth factor production in cultured fibloblasts from human nasal polyps obtained from surgery for chronic paranasal sinusitis stimulated by hypoxia or tumor necrosis factor-alpha was assessed under the administration of Clarithromycin or Roxisthromycin by enzyme linked immunosorbent assay and reverse transcriptase polymerase chain-reaction. RESULTS: Dose-dependent inhibitory effects on vascular endothelisal growth factor production stimulated by hypoxia or tumor necrosis factor-alpha were noted in the groups treated with Clarithromycin and Roxisthromycin, including inhibition of vascular endothelisal growth factor mRNA levels. CONCLUSION: While, to date, several evidences have indicated that the mechanisms by which 14-membered ring macrolides reduce inflammation are not simply bactericidal, these results suggest another new mechanism of efficacy of macrolides in treating chronic rhinosinusitis.

Extravascular papillary endothelial hyperplasia arising from parapharyngeal space.

A 66-year-old man visited our clinic suffering from swelling of right pharyngeal space. He was not aware of other symptoms. The contrast CT showed patchy enhancement with calcification. The enhanced MRI revealed a non-homogeneous signal pattern and patchy central enhancement. During surgery, egg-shaped hard elastic tumor was observed in parapharyngeal space without any sign indicating an invasion into surrounding nerves or feeding vessels. Then the tumor was removed without significant hemorrhage or damage to the cranial nerve. Histological examination of the tumor revealed a nodular lesion with blood clot and hematoma encapsulated with fibrous tissue having vascular spaces of irregular shape and size. From those findings, the tumor was diagnosed as papillary endothelial hyperplasia (PEH). However, since the location of the tumor differed from that of PEH commonly observed in the intravascular space, the tumor was classified as extravascular PEH.

The role of nuclear factor-kappa B in interleukin-8 expression by human adenoidal fibroblasts.

OBJECTIVES/HYPOTHESIS: The production of cytokines by adenoids is known to be associated with inflammation of nasopharynx and the pathogenesis of otitis media with effusion. However, the role of adenoids in producing inflammatory cytokines such as interleukin-8 (IL-8) is not yet clear. In the present study, expression of IL-8 in adenoidal fibroblasts was investigated at the level of transcription factors. Further, the effects of clarithromycin, a 14-member ring macrolide, on IL-8 gene expression and nuclear factor-kappa B (NF-kappa B) activation in adenoidal fibroblasts were evaluated. STUDY DESIGN: In vitro study for the production of inflammatory cytokine from human adenoidal fibroblasts. METHODS: Adenoidal fibroblasts were incubated with nontypeable Haemophilus influenzae endotoxin or interleukin-1 beta. Then the expression of IL-8 and the influence of NF-kappa B inhibitor and clarithromycin were evaluated. Interleukin-8 protein production was assessed by ELISA, and IL-8 messenger RNA production was measured by Northern blot analysis and reverse transcriptase-polymerase chain reaction. Activation of NF-kappa B and inhibition of its activation were determined by electrophoretic mobility shift assay. RESULTS: The expression of both IL-8 protein and messenger RNA in adenoidal fibroblasts was enhanced by Haemophilus influenzae endotoxin and interleukin-1 beta and was positively correlated with increases in NF-kappa B activity. Treatment of cells with the NF-kappa B inhibitor N-tosyl-(L)-phenylalanine chloromethyl ketone, as well as with clarithromycin, reduced expression of IL-8 and NF-kappa B activity in a dose-dependent manner. CONCLUSIONS: Results suggest that adenoidal fibroblasts produce IL-8 in response to endotoxin through NF-kappa B activation. The inhibitory effects of clarithromycin on NF-kappa B activation and IL-8 production in adenoidal fibroblasts might explain, in part, the mechanism of this drug in improving otitis media with effusion.

[Application of prosthetic replacement for bilateral maxillectomy defect].

A 59-year-old woman with large hard palate cancer underwent surgical resection. We constructed a maxillary prosthesis to be connected to the patient's mandibular denture. Bilateral maxillectomy resulted in total loss of the hard palate and bilateral alveolar and partial loss of the soft palate. A obturator prosthesis was prepared beforehand to fit the surgical cavity. The patient recovered functional speech and swallowing at a relatively early stage, achieving satisfactory cosmetic results.