Necrotic ulcerative stomatitis in a patient with long-standing celiac disease: a case report.

Celiac disease is the most common chronic gastroenterological disease. One of the extraintestinal manifestations of this multifaceted disease are changes in the oral mucosa. However, ulceration leading to the destruction of the soft and hard tissues of the orofacial region has not been reported so far. We report on the development of necrotizing ulcerative stomatitis in a 41-year-old woman with celiac disease. The initial ulcerative lesion was located in the lower lip mucosa. Necrosis of all layers of the left side of the lip and oral commissure progressed very quickly. The resulting defect required plastic reconstructive surgery. We successfully compensated for the defect by applying a combination of two flaps from the remaining tissue of the lower lip. Oral competence was established immediately after the operation, and a very good esthetic appearance two months later.

RENAL CELL CARCINOMA METASTASIS TO THE SINONASAL CAVITY: CASE REPORT.

Renal cell carcinoma accounts for 3% of all adult malignant tumors. Common sites of metastases are lungs, bone, liver, brain and adrenal glands. Metastatic disease to the head and neck ranges from 15% to 30%. The 5-year survival rate after nephrectomy is 60%-75%, but with multiorgan metastases the 5-year survival rate is significantly lower, 0-7%. A case is presented of a female patient diagnosed with renal cell carcinoma metastases to the paranasal sinuses, diagnosed and treated at the Department of ENT and Head and Neck Surgery, Zadar General Hospital, Zadar, Croatia. The tumor was surgically removed. Unfortunately, the patient died one year after the procedure due to multiorgan failure. Although metastases of renal cell carcinoma to the head and neck are very rare, it should be first suspected when investigating a metastatic tumor in this region. Surgical excision offers the best hope for long term survival. In case of unresectable tumor, other treatment options should be considered such as radiotherapy, immunotherapy and chemotherapy.

DESCENDING NECROTIZING MEDIASTINITIS SECONDARY TO RETROPHARYNGEAL ABSCESS.

Descending necrotizing mediastinitis secondary to a nontraumatic retropharyngeal abscess is very rare. This form of mediastinitis in the era of potent antibiotics often ends up with lethal outcome. It usually occurs in immunocompromised patients and requires intensive multidisciplinary treatment approach. We report a case of nontraumatic retropharyngeal abscess complicated by descending necrotizing mediastinitis in a 70-year-old man with insulin dependent diabetes mellitus. The patient was admitted to our hospital after clinical and radiological diagnosis of retropharyngeal abscess. During treatment for retropharyngeal abscess with antibiotic therapy and transoral incision, the patient showed mild clinical improvement but his condition suddenly aggravated on day 4 of hospital stay. He had high fever, chest pain with tachypnea, tachycardia, hypotension, and showed signs of occasional disorientation. Emergency computed tomography (CT) scan of the neck and thorax showed inflammation in the retropharyngeal space, as well as thickening of the upper posterior mediastinum fascia with the presence of air. Emergency surgery including cervicotomy and drainage of the retropharyngeal space and posterior mediastinum was performed. The patient promptly recovered with improvement of the clinical status and laboratory findings. After 16 days of treatment he was discharged from the hospital in good condition. Descending necrotizing mediastinitis can be a serious and life threatening complication of deep neck infection if the diagnosis is not quickly established. Besides inevitable application of antimicrobial drugs, good drainage of the mediastinum is necessary. We believe that transcervical approach can achieve high-quality drainage of the upper mediastinum, especially if it is done timely as in this case. Its efficacy can be verified by intensive monitoring of the patient clinical condition, by CT scan of the thorax, and by laboratory tests. In the case of inefficacy of this type of drainage, subsequently some other, more aggressive transthoracic methods of drainage can be done.

[INCIDENCE AND SURGICAL IMPORTANCE OF PYRAMIDAL LOBE AND TUBERCLE OF THE THYROID GLAND: A PROSPECTIVE STUDY]. / UCESTALOST I KIRURSKA VAZNOST PIRAMIDALNOG REZNJA I TUBERKULA STITNE ZLIJEZDE: PROSPEKTIVNA STUDIJA.

The pyramidal lobe and tubercles are common anatomic variations of the thyroid gland, and their frequency is highly represented. While pyramidal lobe requires additional seriousness in identifying and its removal, especially in patients with hyperthyroidism and thyroid cancer, the presence of tubercles is desirable. Tubercle is covered by recurrent laryngeal nerve and directs the surgeon in his search and besides this, serves to facilitate detection of the upper parathyroid glands. In this prospective study we analysed 342 patients who underwent total thyroidectomy in the period from January 2009 to March 2015. We looked at the incidence and anatomic characteristics of pyramidal lobe and tubercles of the thyroid gland. The pyramidal lobe was present in 52.3% of the patients with more frequent central and left placement. Bilateral tubercles were present in 14.9%, while position right-sided phenomenon was represented in 39.5% and 18.5% in lower left (64.3% patients). Their prevalence by gender showed no significant difference (p = 0.59; p = 0.2). Associated presence of pyramidal lobe and tubercles on one or both sides is highly represented in our group of patients (34%), also with no differences by gender (p = 0.29). Length of the pyramidal lobe ranged from 1.3 to 4.7 cm (average 2.3 cm), and the size of tubercles in 36% of patients was over 1 cm. Recurrent laryngeal nerve was only in 1.8% placed laterally of tubercles, and the upper parathyroid gland in 95.4% was located above tubercle. Considering that only 16.5% of our patients did not have any of these anatomical variations, their presence during surgery is the rule, not the exception.

[Descendending necrotizing mediastinitis single center experience]. / Descendentni nekroticni medijastinitis iskustvo jednog centra.

The descending necrotizing mediastinitis is a rare but life-threatening inflammation, and occurs as a complication of deep inflammation of the neck. The mortality rate is still high by 40% despite the use of a variety of potent antimicrobial drugs. We describe 7 patients with the descending necrotizing mediastinitis treated in our hospital during the last 12 years. The primary site of infection in 5 patients were tonsils and pharynx, and in the other two patients odontogenic inflammation of the lower molars. Most of the patients belonged to the risk groups (diabetes mellitus, alcoholism), the average age of 60.4 years. After the diagnosis with computed tomography (CT), we surgically intervened in all patients. Deep neck infections are treated with aggressive surgical cervicotomy and high quality mediastinal drainage was performed with transcervical approach in all patients. Perioperative tracheotomy (n=3) was performed for the upper airway edema and postoperative tracheostomy for extended intubation (n = 1).Only in one case, we subsequently conducted a secondary surgical procedure, lateral thoracotomy because of pleural decortication. All patients were successfully cured with an average length of hospitalization was 24.6 days. For successful treatment of the descending necrotizing mediastinitis diagnosis must be set as early as possible and with the use of computed tomography scanning. Treatment requires the simultaneous application of potent antimicrobial drugs, aggressive surgical debridement of the neck and high-quality drainage of the mediastinum, which can be achieved through the transcervical approach.

[Necrotizing fasciitis of the neck]. / Nekroticni fascitis vrata.

Necrotizing fasciitis is a rare and rapidly progressive infection characterized by necrosis of the superficial fascia and spread on the surrounding skin or muscles, which can be fatal. It usually occurs in the limbs, abdominal wall and perineum. In this retrospective review, the authors present 15 patients with cervical necrotizing fasciitis. The patient mean age was 54.7 years and they had one or more comorbid health problems. Five of them had descending necrotizing mediastinitis and three had progressive sepsis with toxic shock syndrome. Broad-spectrum intravenous antibiotic therapy was administered to all patients immediately, and in three of them we used five-day intravenous immunoglobulin therapy for the signs of toxic shock syndrome. After positive computed tomography imaging for necrotizing fasciitis, we used surgical exploration and debridement of necrotic tissue. In five patients, the initial surgery also included mediastinal transcervical drainage. Preoperative tracheotomy was performed in six patients and delayed tracheotomy in one patient. Histopathologically, all cases showed extensive necrosis of debrided fascia and vascular thrombosis of the neck soft tissue. The mortality rate was 6.7% (1/15). The authors point to the importance of early diagnosis and timely surgical management, broad-spectrum antibiotics and intravenous immunoglobulin therapy when patients are too unstable to undergo surgery.

Giant basal cell carcinoma of the forehead: a case report.

Giant basal cell carcinoma (GBCC) is defined as a tumor 5cm or greater in diameter. They present less than 1% of all basal cell carcinomas. We present a case of an 85-year-old male patient with a giant ulcerating tumor of the left forehead (measuring 7x6 cm). Under local anesthesia tumor was surgically excised. No involvement of the underlying periostal or bone structure was noted. Pathohystological exam revealed the giant basal cell carcinoma, with free surgical margins. Giant basal cell carcinomas are rare tumors and are usually result of a long duration and patient neglect. In comparison to the ordinary basal cell carcinoma these tumors have a higher metastatic potential. Surgical resection with negative surgical margin is the best possible treatment option.

Transoral excision of a parapharyngeal space tumor: case report.

Tumors of the parapharyngeal space are rare tumors comprising less than 1% of all head and neck neoplasms. They are mainly salivary gland or neurogenic tumors. Clinical presentation is very variable. Surgical resection by different approaches remains to be the best possible treatment option. We present a case of 45 years old female patient admitted at the ENT Department due to the unilateral hearing loss and swallowing difficulties. Clinical examination revealed the diagnosis of a pleomorphic adenoma of the parapharyngeal space. Tumor was surgical (transorally) excised. Two years following the surgery there is no recurrence of the initial symptoms and primary disease.

Non-functioning parathyroid gland carcinoma: case report.

Parathyroid gland carcinoma is a rare malignancy. The tumor is mostly functioning, causing severe hyperparathyroidism, with high serum calcium level and severe bone disease. Non-functioning parathyroid carcinomas are extremely rare. We report on a 60-year-old male patient admitted to ENT Department due to a large neck tumor mass compressing the thyroid and trachea. Preoperatively, thyroid hormone, parathyroid hormone (PTH) and calcium serum levels were normal. The following immunohistochemical markers (DAKO, Denmark) were used: bcl-2; CD-10; Chromogranin-A; Cyclin-D1; EMA; Ki-67; Mdm-2; p-53; PGP-9,5; RCC; Synaptophysin; Thyroglobulin; and TTF-1. Immunohistochemical analysis indicated the diagnosis of a primary parathyroid gland carcinoma. Tumor cells showed diffusely positive immunohistochemical staining with chromogranin-A and PGP-9,5, positive staining of variable intensity with synaptophysin, and weakly positive reaction with EMA. Also, the cytoplasm of tumor cells was diffusely positively stained with bcl-2, while the nuclei showed positive reaction with p-53 oncogene and TTF-1. The remaining markers (CD-10, cyclin-D1, Ki-67, Mdm-2, RCC and thyroglobulin) were negative. Four years after the surgery, the patient died from renal carcinoma pulmonary metastases and liver cirrhosis complications. In conclusion, non-functioning parathyroid gland carcinoma is a very rare disease. Detailed immunohistochemical analysis is needed to distinguish it from other thyroid and parathyroid neoplasms and metastatic carcinoma. Surgical treatment is presently the best mode of therapy.

[Tolosa-Hunt syndrome: a case report]. / Tolosa-Huntov sindrom: prikaz bolesnika.

Tolosa-Hunt syndrome is a nonspecific granulomatous inflammation of the cavernous sinus, superior orbital fissure and apex of the orbit. It involves episodes of unilateral orbital pain which may last several weeks, lesions of cranial nerve III, IV or VI, and rarely II, V, VII and VIII. It is characterized by remissions and exacerbations, and can cause permanent neurological disorder of the affected nerves. We present the course of the disease in a patient whose initial symptom was gradual visual loss in the right eye, followed by neuralgic pain in the right orbit and face. The diagnosis was confirmed by biopsy and corticosteroid therapy was administered. Exacerbation of the disease required repeated surgery, excision of the fibrous tissue of the cavernous sinus, as well as prolonged corticosteroid therapy.

[Reconstruction of the middle third marginal auricular defect]. / Rekonstrukcija marginalnog defekta srednje trecine uske.

Reconstruction of the middle third auricular defect was performed with retroauricular skin flap formed by V incision with base on the damaged ear, and ipsilateral cartilage graft of the concha. This method achieved reconstruction in one act, with adequate auricular circumference and minimal mastoid region scar.

[Thyroglossal duct cyst with laryngeal extension]. / Laringealna ekstenzija ciste duktusa tireoglosusa.

Thyroglossal cyst is frequently located in the thyrohyoid region. In rare cases, it breaches and remodeles anatomical structures of the larynx and manifests with dysphonia and laryngeal obstruction. A 60-year-old patient with a big thyroglossal duct cyst with laryngeal extension and cartilage erosion is described. Computed tomography clearly demonstrated the nature of the cyst and its extension into the larynx.

[Reconstruction of traumatic defect of the upper third of the ear]. / Rekonstrukcija traumatskog defekta gornje trecine uske.

Replacement of defect of the upper third of the ear consequent to a traffic accident was successfully performed using modified Antia-Buch technique. Creation of wider and longer skin-cartilage flaps and their increased rotation allowed formation of the upper edge of the ear without tension and postoperative complications. Although the repaired ear is a bit smaller to attain adequate relief and matching color, the use of this method achieved a satisfactory esthetic result.

The effect of propofol and fentanyl as compared with sevoflurane on postoperative vomiting in children after adenotonsillectomy.

Postoperative vomiting (PV) after adenotonsillectomy in children is a common problem with an incidence as high as 40-80%. Only few studies in the recent literature compared the effect of different anesthetic techniques concerning PV in children. The aim of this study was to compare the incidence of PV in two groups of children who underwent two different general anesthesia techniques in order to determine what type of anesthetic technique is more related to less PV. The clinical trial included 50 children (physical status ASA I, 3-12 years old) divided into 2 groups and monitored for PV 24 hours following the surgery. Group one (G1) consisted of 25 children who underwent general anesthesia with gas mixture 60% nitrous oxide and 40% oxygen and anesthetic propofol, opioid fentanyl and muscle relaxant vecuronium intravenously and group two (G2) included 25 children to whom volatile anesthesia with sevoflurane in the same gas mixture was given. Demographic characteristics (gender, age, weight, history of motion sickness and earlier PV) as well as surgical data (length of surgery and anesthesia, intraoperative blood loss) were recorded. There were no significant differences considering demographic characteristics and surgical data between the investigated groups. The incidence of PV was relatively low 3 children (12%) in G1 group and 5 children (20%) in G2 group. Statistically there was no significant difference between the groups regarding the incidence of PV and both anesthetic techniques can be used equally safe regarded to PV.

[Thyroglossal duct cyst in hyoid bone]. / Intrahioidna cista duktusa tiroglosusa.

The thyreoglossal cyst may be located in the intralingual, suprahyoid, thyrohyoid or suprasternal region. Its position in the hyoid bone is extremely rare. In this paper a 62-year-old patient with a big thyreoglossal duct cyst situated in the corps of the hyoid bone is described. Besides a painless solid swelling in the medial neck region, the patient had swallowing and breathing problems, which is unspecific for thyreoglossal duct cyst. By removing the hyoid bone with thyreoglossal duct cyst, the patient's problems completely disappeared and during 1 year long observation no sickness relapse has been noted.

[Plunging ranula]. / Utonula ranula.

Saliva extravasation from the sublingual gland causes ductal lesion or obstruction and results in the formation of a ranula. It spreads through or behind the mylohyoid muscle situated on the neck. Most frequently it is located in the submandibular or submental region. The diagnosis of plunging ranula is simple if the signs of ranula are present in the intraoral cavity, whereas in case of a ranula localized on the neck definite diagnosis is made by histologic analysis of the pseudocyst that has been surgically excised in toto. Cases are presented of both types of plunging ranula treated by various surgical approaches. Plunging ranula in the submental region was treated by transoral approach, marsupialization and aspiration of the content, whereas the ranula in the submandibular region was treated by exterior cervical approach. In both cases, sublingual gland was removed. During the 3.5-year follow-up, neither recurrence of the disease in the neck area nor the occurrence of simple ranula in the intraoral region was observed.

Retropharyngeal abscess and acute inflammation of the maxillary sinus: transoral procedure as a surgical method of treatment.

A previously healthy man, 65 years of age, was hospitalized for clinical symptoms and signs of retropharyngeal abscess. Computed tomography showed an abscess of the retropharyngeal space and the presence of liquid content in the paranasal sinuses. The patient was completely treated by the administration of combined antibiotics, biopsy procedure and aspiration of the contents by the retropharyngeal transoral procedure.

[Efficacy of administration of 0.3% pefloxacin solution in the treatment of acute diffuse inflammation of the auditory canal]. / Ucinkovitost primjene 0,3%-tne otopine pefloksacina u lijecenju akutne difuzne upale zvukovoda.

Acute diffuse inflammation of the auditory canal skin is most often caused by gram-negative organisms. Bacteriological analysis of swabs of the auditory canal skin in 70 patients with acute inflammation most frequently found P. aeruginosa, in 64% of patients. Administration of 0.3% pefloxacin solution in the treatment of acute diffuse inflammation of the auditory canal achieved statistically significant therapeutic success in the first five days of treatment, compared to the efficacy of locally applied aminoglykoside pharmaceutical products. Therapeutic success of 10-day local administration of 0.3% pefloxacine solution in 35 investigated patients, estimated by clinical examination, resulted in complete cure in all examinees, while in those treated with standard aminoglycoside drops therapeutic success was registered in 74% of patients. Two properties, low pH and antimicrobial efficacy, primarily on P. aeruginosa, make 0.3% pefloxacin solution an effective drug in the local treatment of acute diffuse inflammation of the auditory canal.