Double-blind, placebo-controlled trial with esomeprazole for symptoms and signs associated with laryngopharyngeal reflux.

OBJECTIVE: To determine the efficacy of proton pump inhibitor (PPI) therapy with esomeprazole on symptoms and signs associated with laryngopharyngeal reflux (LPR). STUDY DESIGN AND METHODS: Prospective, double-blind, randomized, placebo-controlled study. Sixty-two patients with a reflux finding score (RFS)>7 and a reflux symptom index (RSI)>13 were enrolled and received either esomeprazole 20 mg twice daily or placebo for three months. RSI and RFS were assessed at baseline, after six weeks, and after three months. RESULTS: Reductions of total RSI and RFS as well as of several subscores were significantly higher in the treatment group compared to placebo after three months (P<0.05 each). The difference between study groups was most pronounced for posterior commissure hypertrophy (P<0.01). CONCLUSION: In the treatment of LPR-related symptoms a high placebo effect can be observed. However, compared to control, twice-daily PPI treatment for three months demonstrated a significantly greater improvement in laryngeal appearance and LPR symptoms.

HER3 expression in cutaneous tumors.

BACKGROUND: In order to elucidate the role of the receptor tyrosine kinase HER3, the expression characteristics in different tissues of cutaneous malignancies and in normal skin were compared. MATERIALS AND METHODS: In this study HER3 expression was evaluated by RT-PCR analysis and immunohistochemistry from different tissue specimens of cutaneous tumors like nevi, primary malignant melanomas, basal cell carcinoma, squamous cell carcinoma and malignant melanoma metastases and normal skin samples and graded into weak, moderate and strong expression. Associations of tumor thickness in these specimens with HER3 expressions were also analyzed. RESULTS: HER3 expression was found in 63% (10/16) of the basal cell carcinomas, in 4/5 of squamous cell carcinomas and in one Merkel cell carcinoma. Within the group of different malignant melanomas, HER3 expression was detected in 35% of the nodular malignant melanomas (6/17) and in 9/19 of the superficial spreading melanomas, including 2 lentigo malignant melanomas. The majority of melanomas with a higher tumor thickness expressed HER3, and 85% of melanoma metastasis were HER3-positive. CONCLUSION: HER3 expression was associated with hyperproliferate tumor stages and suggested that HER3 expression could reflect an increased malignant potential in cutaneous lesions.

Fibrous dysplasia of the frontal bone.

Fibrous dysplasia typically occurs in patients between the ages of 5 and 15 years. We report the case of a middle-aged woman with longstanding monostotic fibrous dysplasia who responded well to conservative treatment. She had presented with a very long (15 yr) history of frontal headache and pressure over the frontal sinus. On examination, a protuberance was noted in the region of the right frontal sinus. No other symptoms were evident, and findings on the ENT examination were normal. Computed tomography (CT) detected a widening of the frontal bone with osteolytic changes of the cancellous bone of the diploe. Partial multiphase skeletal scintigraphy and single-photon emission CT of the cranium showed increased bone metabolism in the area of the right frontal bone. No other hot spots were seen. In view of the absence of any complications, no tissue biopsy was performed. The patient was prescribed bisphosphonates for symptom relief. Follow-up CT 1 year later revealed no progression of the lesion. Overtreatment of fibrous dysplasia should be avoided because most patients respond to conservative management. In those cases that are refractory to medical treatment, surgery--in experienced hands--can result in a good functional and cosmetic outcome.

Cervical metastases of microcystic adnexal carcinoma in an otherwise healthy woman.

Microcystic adnexal carcinoma is a rare cutaneous neoplasm characterized by slow but locally aggressive growth, which normally does not lead to systemic metastasis. Frequent local recurrences are reported, which are most likely due to insufficient operative technique. We present the fourth case of cervical ipsilateral metastatic microcystic adnexal carcinoma in an otherwise healthy woman. The patient presented with a previously diagnosed but not completely resected microcystic adnexal carcinoma in the area of the right posterior scalp and two palpable ipsilateral lymph nodes. The tumor was resected using intraoperative snap frozen histological evaluation of the resection borders. In the same procedure two lymph nodes were resected from the right neck. The lymph nodes were histologically assessed and showed infiltration by small strains of tumor cells. After exclusion of a second primary tumor, e.g., mammary carcinoma, as the cause for cervical lymph node metastases, we performed a modified radical neck dissection with resection of the sternocleidomastoid muscle and the accessory nerve, which was histologically proven to be perineurally infiltrated by tumor cells. In this second procedure the histological evaluation of the specimen showed no sign of remaining tumor infiltration. After exclusion of distant metastasis the patient was irradiated with 60 Gy. The patient is well 1 year after the initial treatment without signs of recurrence.

Oropharyngeal metastasis of a Merkel cell carcinoma of the skin.

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine tumor of the skin characterized by frequent local and regional recurrence, a high incidence of distant metastases and therefore a high mortality. Here, we report a case of an oropharyngeal metastasis of a Merkel cell carcinoma of the skin localized at the left base of the tongue causing dysphagia and the sensation of globus pharyngeus. The unusual metastatic site is presented, and diagnosis and treatment are discussed.

Diagnosis and management of carcinoma of unknown primary in the head and neck.

Carcinoma of unknown primary is defined as the histological diagnosis of metastasis without the detection of a primary tumor. In the literature, the incidence of CUP in all patients with a malignant disease is said to be between 3% and 15%. The most frequent histopathological results of CUP metastases are adenocarcinoma, followed by undifferentiated carcinoma and squamous cell carcinoma. In this retrospective investigation the clinical records of 167 patients were studied. All patients had been admitted and treated for cervical CUP at the Department of Otorhinolaryngology of the Grosshadern Clinic from 1979 to 1998. Cervical swelling was the first noted symptom in all cases, followed by pain and dysphagia. The study group comprised 134 men and 33 women with an average age of 55 years at admission. Squamous cell carcinoma (n=123) was the predominant histopathological finding of the cervical lymph nodes. During the 10-year follow-up, a primary tumor was detected in 36 (21.5%) of the 167 initially diagnosed CUP patients. In over 90% of these cases the tumor was localized in the head and neck region. The most frequent origin of the tumor was the tonsilla palatina (n=7). Neck dissection and additional postoperative radiotherapy was performed in 118 (70.7%) of the 167 CUP patients. Primary radiotherapy was the treatment of choice in 28 patients; eight patients received combined radio-chemotherapy as the primary treatment and seven patients were treated with chemotherapy alone. Six patients had no treatment. Comparison of different treatment protocols revealed a significant difference in patient survival: in comparison with primary radiotherapy alone or neck dissection and postoperative radiotherapy, the survival rate improved significantly in patients that received a bilateral tonsillectomy in addition to neck dissection and postoperative radiotherapy. The treatment of choice in patients with cervical CUP should be a surgical procedure including (radical) neck dissection and diagnostic bilateral tonsillectomy followed by postoperative radiation of the cervical lymph drainage. Bilateral tonsillectomy is especially important and is correlated with a significant improvement of the survival rate in CUP patients. Additional postoperative radiation of the entire pharyngeal and laryngeal mucosa should also be considered in order to treat a possible small primary tumor in this region.

Association of laryngopharyngeal symptoms with gastroesophageal reflux disease.

OBJECTIVES: The prevalence of gastroesophageal reflux disease (GERD) in patients with laryngopharyngeal disorders is probably greater than realized. STUDY DESIGN: Prospective study. METHODS: To investigate the incidence of gastroenterological diseases including GERD in patients complaining of nonspecific laryngopharyngeal symptoms, laryngological examinations and gastroenterological evaluation with esophagogastroduodenoscopy were performed in 30 patients who refused to undergo 24-hour pH monitoring. Therapeutic intervention by behavioural and dietary modifications, antireflux medication, and eradication of Helicobacter pylori were assessed for changes in laryngeal findings and relief of symptoms. RESULTS: Posterior laryngitis was present in 26 patients and in 19 of them was accompanied by erythema and edema of the interarytenoid region. Gastroenterological diseases such as GERD (43%), hiatal hernia (43%), and Helicobacter pylori-positive antrum gastritis (23%) were confirmed in 22 (73%) cases by esophagogastroduodenoscopy and histological examination of biopsy specimens. Medical antireflux treatment and eradication of Helicobacter pylori resulted in a remarkably therapeutic success rate of 90% because there was resolution of laryngopharyngeal symptoms and laryngeal findings in 20 of 22 patients with gastroenterological diseases for the mean follow-up period of 8 months. CONCLUSIONS: Laryngopharyngeal symptoms can be predictors of gastroesophageal diseases and GERD because the most frequent underlying cause is supposed to be associated with posterior laryngitis. Medical antireflux treatment is effective for relief of symptoms and mucosal healing of posterior laryngitis.

Dermoid cyst of the floor of the mouth--a case report.

We report a case of a 30-year-old, previously healthy man who presented at our clinic with complaints of increasing dysphagia and globus sensation for about 2 years. In addition, he noticed an increasing submental swelling. On examination, the patient revealed a massive swelling of the floor of the mouth, which had displaced the tongue cranially. MRI imaging showed the lesion to be a homogeneous, cystic lesion, clearly at a distance from the surrounding mucous tissue. Surgery was performed, and the tumor was resected completely. Histologic examination of the resected tissue was consistent with a dermoid cyst located in the floor of the mouth. Although dermoid cysts are rarely located in the oral cavity, it should be included in differential diagnosis. Surgery is the treatment of choice.