High-Resolution Computed Tomography in Middle Ear Cholesteatoma: How Much Do We Need It?

Background and Objectives: The diagnosis of cholesteatoma is usually clinic, and the only efficient treatment is surgical. High-resolution computed tomography (HRCT) is not considered absolutely necessary for the management of an uncomplicated cholesteatoma, but unsuspected situations from a clinical point of view can be discovered using the scans, warning the surgeon. Our objective is to compare HRCT scan information with intraoperative findings in patients with cholesteatoma and analyze the usefulness of a preoperative HRCT scan from a surgical point of view. Materials and Methods: This is a prospective descriptive study conducted in the Department of Otolaryngology, Victor Babes University of Medicine and Pharmacy Timisoara, Romania, from May 2021 to April 2022. It was carried out on 46 patients with a clinical diagnosis of cholesteatoma who were consequently operated on in our department. All patients received full clinical and audiological examinations. In all cases, an HRCT scan was performed preoperatively as a mandatory investigation. Preoperative HRCT scans were analyzed, and their findings were compared to the intraoperative notes. The two sets of observations were analyzed using standard statistical methods. Results: Extensive cholesteatoma was the most common type of disease, involving 46% of the patients, followed by pars flaccida cholesteatoma (35%) and pars tensa cholesteatoma (19%). Eroded scutum was the most frequent lesion involving 70% of the patients, followed by incus erosion (67%). Comparison of the HRCT and intraoperative findings revealed a very good correlation for tegmen tympani erosion, sigmoid plate erosion, scutum and malleus erosion, and a moderate-to-good correlation for lateral semicircular canal erosion, incus and stapes erosion, and fallopian canal erosion. Conclusions: HRCT is a valuable tool in the preoperative assessment of cholesteatoma, helping in making surgical decisions. It can accurately predict the extent of disease and is helpful for detecting unapparent dangerous situations. However, it is not very accurate in detecting fallopian canal and stapes erosion.

Leiomyoma with Uncommon Localization-Incisive Papilla and Palatal Fibromucosa: A Case Report.

The current paper presents a case of a 33-year-old female with an uncommon localization of a leiomyoma in the oral cavity-the anterior palatal fibromucosa and the incisive papilla. The patient referred to the Oro-Maxillo-Facial Surgery Clinic of Emergency City Hospital Timisoara, Romania, complaining of a slight discomfort in the act of mastication and the occurrence and persistence of a diastema between the upper central incisors, due to the presence of a nodule located in the anterior palatal mucosa, between the upper central incisors, without any changes of the subjacent bone structure in the anterior hard palate visible on a cone beam computed tomography image (CBCT). The lesion was removed using a surgical excisional biopsy and a histopathological examination was performed using morphological Hematoxylin-Eosin (HE) staining and additional immunohistochemical (IHC) reactions, in order to confirm the diagnosis. On microscopic examination, bundles of spindle cells were found with eosinophilic cytoplasm and vesicular nuclei, with finely granular chromatin. The immunohistochemical reactions were positive for smooth muscle actin (SMA) and desmin and negative for vimentin. The treatment of choice for leiomyoma of the oral cavity is surgical excision with clear margins, followed by periodical clinical monitoring.

Benign tumors of the superficial lobe of the parotid gland.

Tumors of the parotid gland are a rare occurrence among head and neck tumors (only 3-8%), and the vast majority are benign. Most benign tumors of the parotid gland are pleomorphic adenoma (PA), followed by Warthin's tumor (WT) and they occur in the superficial lobe. The only reasonable treatment is considered to be total tumor removal, but the appropriate surgical approach remains a matter of controversy. Over time, it went from enucleation to superficial parotidectomy (SP) and then to extracapsular dissection (ECD). SP is often considered to be the "gold standard"; however, the risk of intraoperative damage to the facial nerve (FN) cannot be ignored. Lately, ECD - which does not expose the main trunk of the FN - has been regarded as a safe technique for the treatment of small benign parotid tumors. PATIENTS, MATERIALS AND METHODS: The study retrospectively reviewed all parotidectomies for benign parotid tumors of the superficial lobe performed in the Department of ENT, Municipal Emergency Clinical Hospital, Timisoara, Romania, between January 2014 and December 2018. The following patient data were collected: age; sex; follow-up duration; extension of the resection; use of FN monitoring and lesion features, including position, pathology, and size. Preoperative investigation protocol included a computed tomography (CT) scan to assess the size and location of the tumor helping the treatment planning. The same surgical team performed both standard SP and ECD for the treatment of these tumors. All cases were confirmed as benign parotid tumors. Recurrences of any kind and tumors involving the deep lobe of the gland were excluded from the study. All patients underwent a macroscopically complete resection of the tumor. The main outcome was the postoperative complications in the two groups. Data regarding these complications were recorded on follow-up visits at one, six, 12 and 24 months. RESULTS: Ninety-five patients with benign parotid tumors were operated by the same surgical team at the Department of ENT, Municipal Emergency Clinical Hospital, Timisoara, between January 2014 and December 2018 but only 89 (38 men and 51 women) met the follow-up criteria and were included in the study. Sixteen (18%) patients underwent ECD, and 73 (82%) patients underwent SP as a primary intervention. The mean lesion size for ECD group was 2.0±0.9 cm and 4.2±1.7 cm in the SP group, and it was statistically significant (p<0.05). As expected, the most common type of tumor was PA but the distribution between the groups was different: in the SP group, PA represents 83% (61∕73) of cases but only 44% (7∕16) of cases in the ECD group. Median follow-up time was comparable in the two groups - 33±8 months for the ECD group and 39±11 months for the SP group. There were also differences between the two groups regarding the postoperative complication rate. There were significantly more transient and permanent FN paralysis, transient and permanent great auricular nerve (GAN) dysfunctions and Frey's syndrome (FS) in the SP group. CONCLUSIONS: A comparison between ECD and SP as surgical procedures for the treatment of benign tumors of the parotid seems inappropriate as their indications do not overlap. ECD showed similar effectiveness and fewer side effects than SP and can be considered the treatment of choice for small, superficial and/or marginal tumors located in the lateral lobe of the parotid gland.

Clinical, ultrasound and histopathological correlation of clinically N0 neck nodes in patients with cancers of the pharynx and larynx.

BACKGROUND: The presence of metastatic cervical adenopathy is essential for treatment planning and prognosis assessment. Treatment of patients with head and neck cancer with clinically negative cervical lymphadenopathy (N0) remains controversial. Neck palpation, as the method used in tumor, node, metastasis (TNM) staging, has limitations and can provide false negative results in some cases. Lymph node metastases are associated with a reduced survival rate but at the same time, neck dissection for the patient with N0 neck is not without risks or complications. OBJECTIVES: In prospective study, we compared palpation, ultrasonography (US) examination of the neck and histopathological examination in patients with cancers of the pharynx and larynx. PATIENTS, MATERIALS AND METHODS: Forty-six patients with cancers of the pharynx and larynx that presented with a N0 neck were prospectively analyzed. They were divided in two groups: 23 patients operated with an external approach including the control of the lymph node areas, and a second group of 23 patients operated using endoscopy and carbon dioxide (CO2) laser, no neck dissection - "watchful waiting policy". All patients have had a flexible endoscopy of the pharynx and larynx, US of the neck and all received surgical treatment for their primary tumor. Imaging was performed in selected cases. All the removed lymph nodes were sent for histopathology. US was also used as a follow-up method. The US features of the examined lymph nodes were: diameters [longitudinal (L) and transverse (T)]; the ratio of the two diameters (L∕T); shape; lymph node area; central hypodensity; regular∕irregular margins; aspect (homogeneous or not). RESULTS: US has detected 25 lymph nodes in the open surgery group and intraoperatively, we excised 31 (sensitivity of 80.6%). Ten lymph nodes showed metastases, with 100% accuracy of US, which have been confirmed both pathologically and immunohistochemically. US in the second group - patients treated with CO2 laser - detected at four patients 10 cervical lymph nodes that did not presented any malignant features. At recurrence alone, the US confirmed 100% presence of nodes metastases. CONCLUSIONS: US was superior to palpation and this method can be recommended as a diagnostic tool in preoperative assessment of patients without palpable metastasis (N0).

Basal cell carcinoma and basosquamous carcinoma, two faces of the same condition?

Basal cell carcinoma (BCC) is the most common locally invasive malignant epidermal neoplasm. It is generally a tumor that runs a slow progressive course and can usually be cured by surgery. Basosquamous carcinoma is considered by some authors a rare subtype of BCC, while others describe it as independent tumor with different evolution from BCC. The aim of the study was to present a very interesting case of initially otherwise ordinary BCC that during its repeated and extensive relapses changed its histopathology in a basosquamous carcinoma, despite the free surgical margins and leading to major surgeries with loss of right eye. We present a case of 75-year-old male diagnosed in 2008 with a tumor located in the right naso-orbital region. The patient underwent surgical treatment, the histopathology being consistent with BCC. He presented recurrences of the tumor in 2009 and 2010 that were excised at approximately 9 and 16 months, respectively, from the first intervention. In 2010, the surgical procedure was radical, with removal of the tumor and the entire right superior eyelid. This approach proved to have negative side effects over the right eye in time. Therefore, after two months, a complete exenteration of the right orbit was necessary. The tumor recurred again for three times, after 20, 30 and 42 months from the first intervention and every time surgical treatment was applied. The microscopic inspection of the biopsies showed similarities between recurrences and initial tumor. In 2013, after 57 months from the first intervention, the patient was readmitted with a lesion in the same region that was excised but that time the histopathology differed from the previous, the tumor being composed of sheets of achromic epithelioid cells, with vesicular nuclei and prominent, eosinophilic nucleoli. The tumor cells were positive for pan-cytokeratin AE1∕AE3 and negative for S100 protein, human melanoma black 45 (HMB45) and vimentin that sustained the diagnosis of basosquamous carcinoma. The paper presented an interesting case with different histopathological features from a recurrence to other, with important implication in diagnosis and prognosis. The transformation of BCC into basosquamous carcinoma sustain that the basosquamous carcinoma is better a rare, aggressive variant of BCC, than an individual lesion.

Extranodal NK÷T-cell lymphoma, nasal type with cutaneous involvement - a rare case associated with chronic C hepatitis and occupational metal dust exposure.

Extranodal natural killer (NK)÷T-cell lymphomas, nasal type are rare and aggressive non-Hodgkin's lymphomas (NHLs), with unknown etiology, rapid evolution and poor prognosis, due to midline tissue destruction and rapid spreading of the tumor. These lymphomas occur commonly in the nasal cavity and upper aerodigestive tract, but can also present involvement of the skin, salivary gland, and testis. We describe a case of nasal type T-cell NHL involving the nasal cavity and determining right thigh cutaneous metastases in a 47-year-old female associated with liver comorbidities and occupational dust exposure. The patient was suffering from chronic type C hepatitis and cirrhosis and she has been occupationally exposed to metal dust for 10 years. Clinical and laboratory investigations were performed. Essential for diagnosis and treatment protocol was nasal endoscopy and biopsy of nasal and cutaneous lesions. The histopathological exam was consistent with NK÷T-cell lymphoma. Patient was diagnosed in Ann Arbor stage IVA. Chemotherapy was initiated with Bleomycin, Etoposide, Adriamycin (Doxorubicin), Cyclophosphamide, Oncovin (Vincristine), Procarbazine and Prednisone, but it was stopped after two cycles because of the liver condition. The treatment plan also included radiotherapy, but soon after initiation, the patient died because of a liver complication. We present a rare case of extranodal NK÷T-cell lymphoma, nasal type, with cutaneous involvement to which the treatment could not be properly applied because of the late diagnosis and liver comorbidities.

Anterior commissure laryngeal neoplasm endoscopic management.

The CO2 laser surgery represents a treatment method of laryngeal bicordal and anterior commissure glottic cancer T1b, T2, N0. In Department of ENT, Timisoara, Romania, during 1.01.2001-31.12.2011 were analyzed 781 files from patients with laryngeal neoplasm. One hundred twenty-seven patients presented the tumor that involved both vocal cords and anterior commissure, stages T1b, T2 and T3. Therapeutic options included CO2 laser microsurgical excision for 55 (43.30%) patients, frontolateral hemilaryngectomy for 16 (12.59%) patients, total laryngectomy for 42 (33.07%) patients, radiotherapy for 10 (7.87%) patients, and four (3.14%) patients, initially, refused any treatment modality. Endoscopic laser CO2 microsurgery was the primary and solitary management for curative resection of the glottic cancer. All operations were performed under general anesthesia with orotracheal intubations. The mean follow-up was 58 months, with the range between 36 to 84 months. Suspended microlaryngoscopy with CO2 laser surgery has been performed in 43 (33.85%) patients staged T1bN0Mx and 12 (9.44%) patients staged T2N0Mx. In five (9.09%) patients, we encountered local recurrences. The endoscopic CO2 laser surgery is in our view the elective and preferable surgical method in laryngeal glottic cancer stage T1b and T2 for cure, with oncological and functional results superior to those of conventional surgical procedures.

Mastoiditis and facial paralysis as initial manifestations of temporal bone systemic diseases - the significance of the histopathological examination.

UNLABELLED: Several systemic diseases, including granulomatous and infectious processes, tumors, bone disorders, collagen-vascular and other autoimmune diseases may involve the middle ear and temporal bone. These diseases are difficult to diagnose when symptoms mimic acute otomastoiditis. CASE REPORTS: The present report describes our experience with three such cases initially misdiagnosed. Their predominating symptoms were otological with mastoiditis, hearing loss, and subsequently facial nerve palsy. The cases were considered an emergency and the patients underwent tympanomastoidectomy, under the suspicion of otitis media with cholesteatoma, in order to remove a possible abscess and to decompress the facial nerve. The common features were the presence of severe granulation tissue filling the mastoid cavity and middle ear during surgery, without cholesteatoma. The definitive diagnoses was made by means of biopsy of the granulation tissue from the middle ear, revealing granulomatosis with polyangiitis (formerly known as Wegener's granulomatosis) in one case, middle ear tuberculosis and diffuse large B-cell lymphoma respectively. After specific associated therapy facial nerve functions improved, and atypical inflammatory states of the ear resolved. CONCLUSIONS: As a group, systemic diseases of the middle ear and temporal bone are uncommon, but aggressive lesions. After analyzing these cases and reviewing the literature, we would like to stress upon the importance of microscopic examination of the affected tissue, required for an accurate diagnosis and effective treatment.

The involvement of upper airway in Wegener's granulomatosis - about four cases.

The authors present four cases of Wegener's granulomatosis patients with multiorganic manifestation forms, but with a prevalent involvement in upper-airway. Granulomatosis diseases of the nose include bacterial infections (rhinoscleroma, tuberculosis, syphilis, lupus, and leprosy), fungal infections (rhinosporidiosis, aspergillosis, mucormycosis, candidosis, histoplasmosis, and blastomycosis) and diseases with unspecified etiology (Wegener's granulomatosis, mediofacial malignant granuloma, and sarcoidosis). We consider an interesting experience regarding Wegener's granulomatosis due to its rarity, being an autoimmune systemic disease, with continuous evolution and multiorganic involvement. The beginning of the disease is like upper airway affection, a kind of "persistent cold", being difficult to differentiate it from a common cold in the head, with a prolonged evolution. It is important to mention that we establish the diagnosis of Wegener's granulomatosis starting with Ear Nose and Throat (ENT) clinical exam, followed by other tests and investigations realized in our Clinic and completed with specialty tests (nephrology, internal medicine and dermatology), meaning that we need a close cooperation with these medical specialties. All the patients presented multiorganic involvement. Notably significant for our four cases is the prolonged evolution in a stable condition in one patient.