Ectopic Parathyroid Adenoma in Piriform Sinus: Case Report and Review of the Literature.

During routine blood work, a 53-year-old female patient was noted to have asymptomatic hypercalcemia and subsequently found to have hyperparathyroidism. Localization studies for a suspected parathyroid adenoma included 99mTc Sestamibi scintigraphy, Single Photon Emission Computed Tomography (SPECT)/computed tomography (CT) study, and ultrasound of the neck, which were initially read as negative for parathyroid adenoma. A contrast-enhanced CT scan of the neck was performed to locate the suspected parathyroid adenoma and demonstrated a soft tissue lesion within the right piriform sinus. Flexible fiber optic nasolaryngoscopy revealed a submucosal lesion in the right piriform sinus. Following these findings, the initial 99mTc Sestamibi scintigraphy and SPECT/CT were reviewed with confirmation of a focal area of increased activity superior to the right thyroid lobe, corresponding to a nodule in the right piriform sinus that demonstrated increased activity on SPECT/CT. The patient was brought to the operating room for surgical management where a laryngoscope and operating microscope were utilized. The encapsulated lesion was dissected and excised in total. The parathyroid hormone and ionized calcium levels normalized postoperatively. Pathology confirmed a parathyroid adenoma. Parathyroid adenomas are the most common cause of primary hyperparathyroidism. Sixteen percent of parathyroid adenomas can be situated in an ectopic location. Ectopic parathyroid adenomas in the piriform sinus are rare with only a few previously documented cases. We document a rare case of ectopic parathyroid adenoma in the piriform sinus overlooked on initial imaging studies. These lesions can be challenging to localize, however, an understanding of embryology, close scrutiny of possible ectopic locations, and the application of complementary imaging techniques may prove useful for surgeons and clinicians.

Failed Deglutitive Upper Esophageal Sphincter Relaxation Is a Risk Factor for Aspiration in Stroke Patients with Oropharyngeal Dysphagia

BACKGROUND/AIMS: We attempted to examine the relationship between abnormal findings on high-resolution manometry (HRM) and videofluoroscopic swallowing study (VFSS) of the pharynx and upper esophageal sphincter (UES), and to identify the risk factors for aspiration. METHODS: We performed VFSS and HRM on the same day in 36 ischemic stroke patients (mean age, 67.5 years) with dysphagia. Pressure (basal, median intra bolus, and nadir), relaxation time interval of the UES, and mesopharyngeal and hypopharyngeal contractility (as a contractile integral) were examined using HRM. The parameters of VFSS were vallecular residue, pyriform sinus residue, vallecular overflow, penetration, and aspiration. The association between the parameters of VFSS and HRM was analyzed by the Student's t test. RESULTS: Three (8.3%) and 4 (11.1%) stroke patients with dysphagia had pyriform sinus residue and vallecular sinus residue, respectively, and 5 (13.8%) patients showed aspiration. Mesopharyngeal and hypopharyngeal contractile integrals in patients with residue in the pyriform sinus were significantly lower than those in patients without residue in the pyriform sinus (P < 0.05). Relaxation time intervals in patients with aspiration were significantly shorter than those in patients without aspiration (P < 0.05), and multivariate regression analysis revealed a shorter relaxation time interval as the main risk factor for aspiration (OR, 0.03; 95% CI, 0.01–0.65; P < 0.05). CONCLUSIONS: Manometric measurements of the pharynx and UES were well correlated with abnormal findings in the VFSS, and a shorter relaxation time interval of the UES during deglutition is an important parameter for the development of aspiration.

Dysphagia Post Subcortical and Supratentorial Stroke.

BACKGROUND: Studies have recognized that the damage in the subcortical and supratentorial regions may affect voluntary and involuntary aspects of the swallowing function. The current study attempted to explore the dysphagia characteristics in patients with subcortical and supratentorial stroke. METHODS: Twelve post first or second subcortical and supratentorial stroke patients were included in the study. The location of the stroke was ascertained by computed tomography and magnetic resonance imaging. The characteristics of swallowing disorder were assessed by video fluoroscopic swallowing assessment/fiberoptic endoscopic evaluation of swallowing. The following main parameters were analyzed: oral transit time, pharyngeal delay time, presence of cricopharyngeal muscle achalasia (CMA), distance of laryngeal elevation, the amounts of vallecular residue and pyriform sinus residue (PSR), and the extent of pharyngeal contraction. RESULTS: Eighty-three percent of the 12 patients were found suffering from pharyngeal dysphagia, with 50% having 50%-100% PSRs, 50% having pharyngeal delay, and 41.6% cases demonstrating CMA. Simple regression analysis showed PSRs were most strongly associated with CMA. Pharyngeal delay in the study can be caused by infarcts of basal ganglia/thalamus, infarcts of sensory tract, infarcts of swallowing motor pathways in the centrum semiovale, or a combination of the three. CONCLUSION: Subcortical and supratentorial stroke may result in pharyngeal dysphagia such as PSR and pharyngeal delay. PSR was mainly caused by CMA.

Effect of Chronic Obstructive Pulmonary Disease on Swallowing Function in Stroke Patients

OBJECTIVE: To investigate the prevalence of chronic obstructive pulmonary disease (COPD) in stroke patients, and to assess the difference in swallowing function between stroke patients with COPD (COPD group) and stroke patients without COPD (control group). METHODS: The subjects included 103 stroke patients. They underwent the pulmonary function test and were assigned to either the COPD group or the control group. Their penetration-aspiration scale (PAS) scores and functional dysphagia scale scores were compared by performing a videofluoroscopic swallowing study. The intergroup differences in lip closure, bolus formation, mastication, and the oral transit time, laryngeal elevation, cricopharyngeal dysfunction, oronasal regurgitation, residue in pyriform sinus and vallecula, pharyngeal transit time, aspiration, and esophageal relaxation were also compared. RESULTS: Thirty patients were diagnosed with COPD. The COPD group showed statistically higher PAS scores (4.67+/-2.15) compared to the control group (2.89+/-1.71). Moreover, aspiration occurred more frequently in the COPD group with statistical significance (p<0.05). The COPD group also showed higher occurrence of cricopharyngeal dysfunction, albeit without statistical significance. CONCLUSION: This study shows that a considerable number of stroke patients had COPD, and stroke patients with COPD had higher risk of aspiration than stroke patients without COPD.

[A case report of the difficulty treating an endstage oncologic ENT patient with parenteral nutrition]. / Ein Fallbericht über die Problematik der Ernährung am Lebensende eines onkologischen HNO-Patienten.

The occurrence of cachexia at the end of life of patients suffering from cancer is a common seen problem. Within the last years new definitions, diagnostic criteria and classification systems of cachexia have been developed to improve the clinical practice. Still therapeutic interventions are limited; the role of parenteral nutrition (PN) remains controversial. PN cannot be generally recommended in patients with incurable malignancies, not even in ill-nourished patients with inadequate oral or enteral nutrition due to a changed metabolism. Treating a cachectic endstage patient suffering from head-neck-cancer we were faced with different problems.

Utilidad de un medicamento biorregulador en el tratamiento de la pseudociática por un síndrome del piriforme en corredores de larga distancia / Utility of a inflammation bio-regulator drug in treatment of pseudosciatica for piriformis syndrome in long distance runners

Introducción y objetivo: El objetivo del estudio es demostrar si la inclusión de un medicamento biorregulador de la inflamación (Traumeel S®) en el protocolo médico-manual aconsejado para el síndrome piramidal, mejora la clínica y acorta el proceso de recuperación funcional en corredores fondistas. Material y métodos: Se estudian dos grupos de pacientes(31/31), aplicándose al primero tratamiento manual con masaje, liberación miofascial, estiramientos post-isométricos y técnicas de energía muscular; y al segundo, el mismo protocolo junto a inyecciones semanales de Traumeel S®, en un seguimiento de 10 semanas. Se evalúa el dolor mediante cuatro pruebas exploratorias, y la percepción subjetiva del paciente en una EVA. Resultados: Se analizó la evolución de 62 pacientes, 50%hombres con edad media de 42,8 años (IC95% 41,6-44).Observamos en los pacientes tratados con Traumeel S®: una proporción menor de visitas con dolor (p<0, 0001), y un promedio de dos visitas menos con dolor (14 días) en todos los test evaluados. El tiempo hasta la desaparición del dolor en todos los test, fue significativamente menor (mediana de supervivencia de 6 semanas (IC95% 5,7-6,3) frente a 8 semanas (IC95% 6,8-9,2) en el grupo control (p<0,0001). La valoración del dolor por el paciente fue significativamente mejor en el grupo tratado con Traumeel S® (p<0, 0001). No se observaron acontecimientos adversos. Conclusión: Se demuestra que el tratamiento con Traumeel S® reduce el tiempo con dolor en hasta dos semanas. Al disminuirla inflamación en la articulación sacroilíaca, y en su inserción tendinosa conseguimos una resolución más rápida del espasmo y por tanto del cuadro clínico (AU)

Background: The objective of the study is demonstrate if the inclusion of a bio-regulator drug for inflammation (TraumeelS®) in the medical-manual protocol recommended for the pyramidal syndrome, improves the clinic and shortens the functional recovery process in long distance runners. Methods: Two groups of patients are studied (31/ 31), applying manual treatment with massage, miofascial liberation, postisometric stretches and technics of muscular energy; and to the second group, the same protocol and weekly injections of Traumeel S®, in a 10 weeks follow up. The patient’s pain is evaluated with four exploratory tests, and the subjective perception in a Visual Analogic Scale (VAS).Results: 50% of the patients were male with mean age of 42.8years (CI95% 41,6-44). In patients treated with Traumeel S®we observed: lower proportion of visits with pain (p< 0,0001),and an average of two visits less with pain (14 days) in all the evaluated test. Time until the disappearance of the pain in all the test, was significantly lower: median of survival, 6 weeks (CI95% 5,7-6,3), versus 8 weeks (CI95% 6,8-9,2) in the control group (p< 0,0001). The pain evaluation by the the patient was significantly better in the group treated with Traumeel S® (p<0,0001). No adverse events were observed. Conclusion: We observe that the treatment with Traumeel S® reduces the time with pain in up to two weeks. Upon diminishing the inflammation in the sacro-iliac articulation, and in its tendinous insertion, we got a quicker resolution of the spasm and therefore of the clinical manifestations (AU)

Endoscopic Balloon Dilatation for the Treatment of Cricopharyngeal Dysfunction with Dysphagia

Primary cricopharyngeal dysfunction is a rare, idiopathic, functional disorder of the upper esophageal sphincter (UES) characterized by dysphagia, frequent aspiration, and functional narrowing at the level of UES. It is caused by failure or partial relaxation of the sphincter, lack of pharyngoesophageal coordination, or reduced compliance of the muscular of the UES. We saw a 62-year-old man who presented with dysphagia and UES narrowing on videofluoroscopy swallowing study (VFSS). Physical, neurologic, and laboratory evaluations revealed no abnormal findings. Radiologic evaluation looking for any abnormalities that might provoke dysphagia was within normal limits. VFSS showed laryngeal aspiration, residue in vallecular and pyriform sinuses, and cricopharyngeal narrowing. Balloon catheter dilatation under endoscopic guidance was performed twice, after which, the dysphagia improved. Here, we describe the results of treatment with balloon dilatation in a patient with primary cricopharyngeal dysfunction.

Adult-onset Still's Disease with Dysphagia: Case report

We experienced a case of adult-onset Still's disease with dysphagia of soft tissue origin. A 38-year-old woman was admitted for intermittent high spiking fever, diffuse pain and swelling on anterior neck with dysphagia. Physical examination revealed a thin woman with trismus, board-like hardness of anterior neck, hepatomegaly, and erythematous evanescent rash on leg. Neck CT displayed bilateral cervical lymphadenopathy with soft tissue swelling, and tonsilitis. Chest and abdomen CT showed the inflammatory changes of multiple organs. Laboratory evaluation revealed neutrophilic leukocytosis, slightly increased alanine transaminase, negative antinuclear antibody and rheumatoid factor, and increased inflammatory markers. Skin, liver, colon, and pleural biopsy demonstrated the chronic inflammation. Videofluoroscopic swallowing study revealed laryngeal penetration with large amount residue in vallecular space and pyriform sinus, and incomplete cricopharyngeal relaxation. Gradual improvement in anterior neck pain and pulmonary edema and the decrease of effortful and multiple swallowing were observed with high dose steroid therapy.