Unresolved drooling in a previously healthy child caused by a brainstem malignancy.

Drooling occurs commonly in children below the age of two. In a small group of children this persists and an otorhinolaryngology consultation is sought. In children with no neurological abnormality or comorbidity, reassurance and behavioural management is often suggested. We present a case where drooling was the presenting feature of brain stem malignancy. Diagnosis was suggested following a sleep study demonstrating central apnoeas. Magnetic resonance imaging (MRI) showed an intra-axial brainstem tumour. This case highlights the importance of multidisciplinary team (MDT) management of children with persistent drooling of unknown cause.

A novel insight into the immunologic basis of chronic granulomatous invasive fungal rhinosinusitis.

BACKGROUND: Chronic granulomatous invasive fungal rhinosinusitis (CGIFRS) is a rare disease. The underlying immune responses that drive the development of CGIFRS, as opposed to successful pathogen clearance and controlled inflammation, are not currently known. OBJECTIVE: To characterize the immune responses associated with CGIFRS. METHODS: In addition to a battery of basic investigations, more in-depth immunologic testing involves ex vivo whole-blood stimulation with the polyclonal T-cell mitogen phytohemagglutinin and fungal antigens with interleukin (IL) 12, was undertaken to investigate cell-mediated immune responses associated with CGIFRS. RESULTS: Ex vivo whole-blood stimulation with the polyclonal T-cell mitogen phytohemagglutinin and fungal antigens with IL-12 identified reduced interferon gamma and increased IL-17A levels within the supernatant, which indicated increased in vivo T-helper (Th)17 responses and impaired Th1 responses compared with healthy controls. CONCLUSION: These findings suggest that the development of CGIFRS may be associated with an abnormally exaggerated host Th17 response, which caused failure to clear the fungal pathogen with refractory fungal infection of mucosal membranes, resulting in chronic tissue inflammation.

Common airborne fungi induce species-specific effects on upper airway inflammatory and remodelling responses.

OBJECTIVE: Whilst the exact cause of chronic rhinosinusitis (CRS) remains elusive, it is clear that both inflammation and remodelling are key disease processes. Environmental fungi have been linked to airway inflammation in CRS; however, their role in the pathogenesis of this condition remains controversial. The current consensus suggests that whilst fungi may not be directly causative, it is likely that CRS patients have deficits in their innate and potentially acquired immunity, which in turn may modify their ability to react to fungi. This study used a nasal polyp explant tissue stimulation model to study the inflammatory and remodelling responses related to challenge with common airborne fungal species. METHODS: Ex vivo nasal polyp tissue from six well phenotyped CRSwNP patients undergoing functional endoscopic sinus surgery was stimulated with 1, 10 and 100 µg/ml of Alternaria alternata, Aspergillus niger, Cladosporium sphaerospermum and Penicillium notatum and compared with unchallenged polyp tissue as control. Enzyme-linked immunosorbent assay (ELISA) was used to measure the levels of pro-inflammatory cytokines interleukin-6 (IL-6), granulocyte macrophage colony stimulating factor (GM-CSF) and tumour necrosis factor-α (TNF-α); and pro-remodelling cytokines transforming growth factor-b1 (TGF-b1), and basic fibroblast growth factor (bFGF) in the polyp supernatant. RESULTS: Aspergillus niger stimulation increased pro-inflammatory cytokines TNF-α, GM-CSF and IL-6 whilst having little effect on the remodelling cytokines bFGF and TGF-b1. In contrast, stimulation with Cladosporium sphaerospermum, Alternaria alternata and Penicillium notatum reduced pro-inflammatory cytokines TNF-α and IL-6, but induced a dose-dependent increase in remodelling cytokines TGF-b1 and bFGF. CONCLUSIONS: This study shows that common airborne fungi induce species-specific effects on the upper airway inflammatory and remodelling responses. These findings provide further immunological evidence of a disease-modifying role for fungi in CRS.

Treatment of breast adenocarcinoma metastasis to the neck: dedifferentiation of the tumor as suggested by hormone markers.

BACKGROUND: Breast carcinoma rarely metastasizes to the neck, and its management in this area is controversial. There is little published data about whether hormone receptor status changes between primary breast tumors and neck metastasis and whether this influences management. METHODS: We evaluated the demographics and treatment of 13 patients presenting with neck metastasis. We used immunochemistry to assess estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 in the primary and metastatic neck nodes. RESULTS: Hormone receptor status changed in some patients (23% for estrogen receptor, and 31% for progesterone receptor). Three patients had complete excision of their neck disease and subsequent good local control. None of our patients survived despite treatment. CONCLUSION: The change in hormone status could suggest tumor dedifferentiation. Surgical resection, where possible, achieves good local control for these patients, but, because survival is poor, it is only recommended when it results in little significant morbidity.

Thyroplasty type I under general anaesthesia with the use of the laryngeal mask and a waking period to assess voice.

OBJECTIVE: To evaluate a modified technique of type I thyroplasty using general anaesthetic with a laryngeal mask and then local anaesthetic. METHODS: General anaesthesia with a laryngeal mask is used while the delicate marking and windowing of the thyroid cartilage occurs. The patient is then woken, so that vocalisation can be associated to direct visualization with flexible scope to determine the size of prosthesis used to optimise vocal outcome. RESULTS: This modified technique was used in three patients where sedation would be unacceptable. All patients exhibited an improved voice post operatively. The mean maximum phonation time rose to 9.6, 10.6 and 9.3s from 4.3, 4.6 and 5.3s. CONCLUSION: Using sedation for type I thyroplasty is not safe or acceptable in some patient groups. Using general anaesthetic with a laryngeal mask and then a shorter local anaesthetic provides a safe and effective alternative.