The value of bilateral simultaneous nasal spirometry in the assessment of patients undergoing septoplasty.

PROBLEM: There is no consensus regarding the best approach to select patients for septoplasty. Patient dissatisfaction after septoplasty implies that clinical examination alone is inadequate to detect a clinically relevant nasal septal deviation (NSD). Objective testing provides an in-depth analysis of nasal obstruction and its underlying anatomic causes but it is effort consuming, requires training and it is not widely available. AIM: We studied the role of bilateral simultaneous nasal spirometry (BSNS) in the preoperative selection of patients for septoplasty. PATIENTS, SUBJECTS AND METHODS: Thirty patients with nasal obstruction and NSD were assessed by subjective measures and BSNS before and after septoplasty. The decongested nasal partitioning ratio (NPR) was used as a measure of the degree of NSD. Thirty healthy controls were recruited for providing a normal range of NPR values. RESULTS: All patients were subjectively improved after septoplasty but only those with NPR out of the normal limits had a significant reduction of NPR. Patients with unilateral symptoms and NPR beyond normal limits were also able to identify the more obstructed side preoperatively. For this group of patients, physicians were able to identify the convex side of NSD preoperatively. No correlation between subjective measures of nasal obstruction or airflow asymmetry and NPR was observed. CONCLUSION: BSNS is a rapid, easily interpretable, noninvasive technique, which identifies patients with large NSDs who, irrespective of concomitant mucosal factors of nasal obstruction, warrant septoplasty. BSNS is not applicable in cases with a septal perforation or an S type septal deviation, it cannot detect an insufficient nasal valve and it does not substitute rhinomanometry or acoustic rhinometry.

Herpes zoster laryngitis and Ramsay-Hunt syndrome in a patient with chronic renal failure.

OBJECTIVE: We report on a clinical case of simultaneous and unilateral involvement of the facial and superior laryngeal nerve in a patient with chronic renal disease undergoing haemodialysis. METHOD: A 75-year-old man with chronic renal failure was referred to our department suffering from severe odynophagia. During flexible endoscopy, vesicles were found on the mucosa of his right supraglottic larynx. Two days later, peripheral facial nerve palsy with a mild auricular rash appeared in the patient. RESULTS: The clinical presentation suggested varicella-zoster virus reactivation, which was confirmed serologically, and appropriate treatment was administered. CONCLUSIONS: Involvement of more than one cranial nerve in herpes zoster infection is possible, especially in vulnerable patients such as those with chronic renal failure. It is also important to suspect involvement of the superior laryngeal nerve in cases of odynophagia and throat pain, even when hoarseness is absent.

Lidocaine spray versus tetracaine solution for monopolar submucosal diathermy for inferior turbinate hypertrophy.

OBJECTIVE: To compare the efficacy of lidocaine spray 10% to tetracaine 2% solution, as a local anaesthetic for patients undergoing monopolar submucosal diathermy of the inferior turbinate. METHODS: A prospective study was conducted on 48 patients undergoing submucosal diathermy of the inferior turbinate. Patients were randomly assigned to receive tetracaine 2% solution (24 patients) or to receive lidocaine spray 10% (24 patients). Patients were asked to evaluate the severity of pain during the procedure using a visual analogue scale. Patient data, pain scores, and potential complications were assessed statistically. RESULTS: The tetracaine group had significantly lower mean pain scores compared to the lidocaine group: 2.29 vs. 3.04 (p < 0.001). There were no complications or side effects from tetracaine. CONCLUSION: Tetracaine 2% solution applied locally is an easy, safe, inexpensive, and effective analgesia for submucosal diathermy for inferior turbinate hypertrophy.

Increased frequency of rhinitis medicamentosa due to media advertising for nasal topical decongestants.

AIM: The aim of this study was to investigate the frequency of rhinitis medicamentosa (RM) in patients attending the ENT outpatient clinic of the General Hospital of Rethymnon (Crete, Greece) before and after the launch of an intensive nasal decongestant advertising campaign in Greece. METHODS: We reviewed the medical records of the patients with RM seen at the ENT outpatient clinic in May, June and July of 2003 and 2006. We analyzed and recorded the gender, age, and related clinical information of the patients with RM. RESULTS: In May, June and July of 2003, 41 patients out of a total of 1780 patients attending the ENT outpatient clinic were diagnosed with RM (2.3%). In the same months in 2006, 161 patients out a total of 1898 patients were diagnosed with RM (8.5%). The frequency of RM in these groups was therefore found to have increased significantly between 2003 and 2006. In 2006, 8 out of 10 patients with RM reported that they had made their purchasing decision solely on the basis of the information supplied by the drug advertisement without consulting their doctor or pharmacist. CONCLUSION: We suggest that the intensive media advertising campaign for nasal topical decongestants (particularly on TV) which started in 2004 is probably the main reason for this "endemic" RM.

Intraparotid lymph node tuberculosis.

PROBLEM: Parotid gland Mycobacterial infection is a rare disease that causes parotid swelling without disease-specific manifestations. CASE REPORT: We present a case of intraparotid lymph node tuberculosis that mimicked a tumour. Computed tomography of the head and neck indicated a left parotid enlargement involving two intraparotid lymph nodes. The cervical lymph nodes of the ipsilateral posterior triangle and the submandibular and jugulodigastric areas were also enlarged. Contrast enhancement indicated homogenous tissue with no necrotic areas. A biopsy revealed a caseating granuloma most likely due to tuberculosis. A purified protein derivative test gave strong positive results (35 mm). After one month of antituberculous treatment, the cervical lymphadenopathy and left parotid lumpiness disappeared. CONCLUSIONS: Tuberculous parotitis and neoplasms have similar clinical manifestations. In patients with a mass in the parotid gland, a high clinical suspicion of underlying tuberculosis is crucial for establishing an accurate diagnosis and the proper management.

Cavernous haemangioma of the left nasal cavity.

Cavernous haemangioma of the nose is a rare lesion but it has to be added to the differential diagnosis of an intra-nasal bleeding mass. A high index of suspicion, upon computed tomography delineation of the extent of the mass, including the presence of bone remodelling plus histological evaluation can be usefully employed to define an accurate diagnosis. In the present case of an adult female with a huge cavernous haemangioma arising from the mucosa of the left middle nasal meatus, the two most interesting points were the rarity as a site of occurrence of this tumour and the successful extirpation of this lesion with the minimally invasive trans-nasal endoscopic technique. We recommend the minimal invasive trans-nasal endoscopic technique for adequate exposure, sufficient control of bleeding and for complete removal of a nasal haemangioma reaching the nasopharynx and paranasal sinuses.

The risk of foreign body aspiration in children can be reduced with proper education of the general population.

OBJECTIVE: To evaluate the effect of a campaign for proper education of the public on the risk of foreign body aspiration in children. METHODS: A retrospective analysis of 87 endoscopic foreign body removals in children was performed at the Department of Otorhinolaryngology, Head and Neck Surgery of the University Hospital of Crete, during the period between January 2000 and December 2004. Results were compared with those of a previous study conducted by the same Department during the period between 1991 and 1999. RESULTS: A foreign body was discovered in 44 cases, while in 43 cases there were no findings. Twenty-one foreign bodies (47.73%) were found in the right main bronchus, 20 foreign bodies (45.45%) were found in the left main bronchus and 3 (6.82%) in the trachea. Both crude and age-standardized bronchoscopy rates appear to be lower in the time period 2000-2004, as compared to the time period prior to the educational program. CONCLUSIONS: The decline in the total number of bronchoscopies during recent years has been a result of a campaign for proper education of the public and especially parents, caretakers and families. All aspects of the educational campaign are described in detail. The risk of high morbidity and mortality from foreign body aspiration makes it mandatory to increase even more the awareness of the general population.

Subcutaneous benign fibrous histiocytoma of the cheek. Case report and review of the literature.

Fibrous histiocytoma is a benign tumour composed of a mixture of fibroblastic and histiocytic cells. Based on the location of this tumour, fibrous histiocytoma are usually divided into cutaneous types and those involving deep tissues. These lesions most often arise on the skin, but may rarely occur in soft deep tissues. The diagnosis of fibrous histiocytoma may be clinically difficult when the lesion is located in the deep tissues, and is frequently confirmed after local excision. The most important diagnostic distinction is the separation of this tumour from aggressive forms of fibrohistiocytic neoplasms, including dermatofibrosarcoma protuberans and malignant fibrous histiocytoma. A 19-year-old male presented with a painless swelling on the right cheek. Detailed clinical and laboratory examinations were performed. The lesion had been totally excised under local anaesthesia, and histopathology revealed a benign fibrous histiocytoma. The diagnosis, location, treatment and prognosis of fibrous histiocytoma are also discussed.

Ear-nose-throat manifestations of autoimmune rheumatic diseases.

Ear-nose-throat (ENT) manifestations of connective tissue disorders represent a diagnostic challenge for clinicians as they often constitute the initial sign of an otherwise asymptomatic autoimmune disease. Moreover, in patients with known autoimmune rheumatic diseases, ENT manifestations can be overlooked. Hearing disturbances may be seen in patients with systemic lupus erythematosus, Wegener's granulomatosis, relapsing polychondritis, polyarteritis nodosa, Cogan's syndrome, Sjögren's syndrome, and less frequently in Churg-Strauss syndrome and Adamantiades-Behçet's disease. Nose and paranasal sinuses are variably affected during the course of Wegener's granulomatosis, Churg-Strauss syndrome, relapsing polychondritis and sarcoidosis. Recurrent mucosal ulcerations are common in systemic lupus erythematosus and Adamantiades-Behçet's disease. Xerostomia is a common feature of primary and secondary Sjögren's syndrome; salivary gland enlargement may be also seen in these patients, as well as in patients with sarcoidosis. The cricoarytenoid joint can be involved during the course of rheumatoid arthritis, ankylosing spondylitis and gout; osteoarthritic changes have also been described. Motility disorders of the upper and/or the lower portions of the esophagus have been reported in patients with dermatomyositis/polymyositis, systemic sclerosis and systemic lupus erythematosus. Trigeminal nerve dysfunction may occur in patients with Sjögren's syndrome, systemic sclerosis, systemic lupus erythematosus and mixed connective tissue disease. Peripheral facial nerve palsy has been described to complicate the course of Sjögren's syndrome and sarcoidosis.

Combined irinotecan, docetaxel and conventionally fractionated radiotherapy in locally advanced head and neck cancer. A phase I dose escalation study.

Both docetaxel and irinotecan have shown strong radiosensitizing properties in vitro. Encouraging results have been reported by phase I/II studies on combined docetaxel or irinotecan with radiotherapy. In the present study we investigated the feasibility of double radiosensitization with weekly docetaxel and irinotecan in head and neck cancer. Twelve patients with locally advanced squamous cell head and neck cancer were recruited in a phase I/II dose escalation protocol. Radiotherapy was given as a standard fractionation regimen (2 Gy/day, 5 fractions/week) to a total dose of 66-70 Gy. Three Docetaxel/Irinotecan dose levels were examined thus, 20/25 mg/m2 (level 1), 20/40 mg/m2 (level 2) and, 25/55 mg/m2 (level 3). Severe asthenia was observed in 1/4 patients treated in the 2nd dose level and in all 4 patients treated in the 3rd. The onset of severe asthenia was associated with the onset of severe grade 3/4 mucositis during the 4th week of treatment. Radiation induced mucositis was accompanied by fungal infection in all 5 patients. The symptomatology persisted for 10-14 days. Mild grade 2 mucositis was observed in 7/8 patients treated at the 1st and 2nd dose level, which enforced treatment delay for 3-5 days. Neutrophil toxicity was minimal. There was only one patient treated at the 3rd dose level that presented with grade 2 neutropenia. Hemoglobin toxicity was also minimal, showing a median drop of 1.2 gr/dL. There was no platelet toxicity observed. Complete response was observed in 9/12 (75%) patients and partial response was observed in 3/12 patients. Of interest, the lowest CR rate was observed in the 3rd dose level (2/4; 50%), which may be a consequence of overall treatment time prolongation. It is concluded that docetaxel and irinotecan combination with radiotherapy is feasible and, a high CR rate can be expected. Combination of the regimen with cytoprotective agents warrant further investigation.

Successful treatment of rhinocerebral mucormycosis with liposomal amphotericin B and surgery in two diabetic patients with renal dysfunction.

The zygomycetes are a class of fungi that can cause a variety of infections in humans. Rhinocerebral mucormycosis is a rare disease and usually affects diabetic or immunosuppressed patients. The disease progresses rapidly and is usually fatal despite aggressive surgical and medical therapy. We report the management of two cases of rhino-sinusal and orbital mucormycosis in diabetic patients on treatment with corticosteroids, and mild renal impairment, successfully treated with a combination of aggressive surgical debridement and liposomal amphotericin B.

Acute candidiasis of the oro- and hypopharynx as the result of topical intranasal steroids administration.

Topical nasal steroids have become increasingly popular for the treatment of allergic and other types of rhinitis. However, undesirable local effects of intranasal steroids, such as nasal irritation and burning, crusting and epistaxis are quite common. Candidiasis of the pharyngeal mucosa is a complication, which has not been described so far after treatment of rhinitis with intranasal topical corticosteroids. Between March 1997 and September 1998, we managed to treat successfully three patients with acute erythematous candidiasis of the pharynx, which was the result of the use of intranasal topical steroids. Mechanism, clinical features of acute pharyngeal candidiasis, differential diagnosis and treatment are discussed.

Frontal lobe abscess secondary to head trauma and nasal polyposis.

Cerebral frontal lobe abscess may be a frequent intracranial complication of paranasal sinusitis. An unusual case of cerebral abscess complicating massive polyposis is described in a patient with history of previous severe head trauma 30 years ago. Imaging evaluation using both computed tomography and magnetic resonance imaging is important to diagnose such rare entities.

Efficacy of 'two-man' FNAB technique in the assessment of patients with non-thyroid neck masses.

OBJECTIVE: To show the superiority of 'two-man' FNAB technique comparing to the standard FNAB technique, in order to identify the cause of non-thyroid neck masses. METHODS: Over an 18 months period, a consecutive paired study was conducted in the tertiary referral Venizelion General Hospital. Forty-four cytologic examinations were performed in patients with non-thyroid head and neck masses. The samples were taken from the same side using both techniques the standard FNAB technique and the 'two-man' FNAB technique (for which two persons carried out the procedure). The slides were seen by the pathologist and were defined as diagnostic, suggestive or inconclusive. The diagnosis was confirmed in any case by definite histology after surgical treatment or open biopsy. RESULTS: From 44 samples taken with the 'two-man' technique, 34 were diagnostic (all true) verified by histopathology, seven suggestive (five true and two false) and three inconclusive (6.82%). The correct diagnosis was confirmed in 39 cases (88.64%). From 44 samples of standard technique, 22 were diagnostic (all true), 12 suggestive (five true and seven false) and 10 inconclusive (22.72%). The correct diagnosis was confirmed in 27 cases (61.36%). The accuracy of diagnosis with the standard FNAB technique was 0.79 (SE=0.07), while with the 'two-man' FNAB technique was 0.95 (SE=0.03), a significant statistical difference (Fischer exact test, P=0.041). CONCLUSIONS: 'Two-man' FNAB technique proved to be as safe and patient friendly as the standard FNAB, but more accurate and may be easier to perform than this. The 'two-man' FNAB technique could become the preferred method for fine-needle cytology, particularly for difficult to reach areas of the head and neck.

Maxillary sinusitis of dental origin due to oroantral fistula, treated by endoscopic sinus surgery and primary fistula closure.

AIM: To present the current treatment approach for oroantral fistula causing maxillary sinusitis. DESIGN: Case series. Four cases of oroantral fistula (diameters: 6, 9, 11 and 13 mm) due to chronic maxillary sinusitis were treated by excision of all diseased oroantral fistula tissue, followed by endoscopic creation of a large middle antrostomy and closure of the fistula using buccal flaps. A synthetic surgical glue and local alveolar bone were used. RESULTS: Patients were followed up for six months to three years; all were considered cured. CONCLUSION: Most surgeons use buccal or palatal flaps, combined with the Caldwell-Luc procedure, to treat chronic odontogenic sinusitis and to repair fistulae more than 5 mm in diameter. This study supports the hypothesis that an endoscopic technique could be successfully used in patients with oroantral fistula causing chronic maxillary sinusitis of dental origin, instead of the Caldwell-Luc procedure, at least in patients with a small to medium-sized oroantral fistula.