Primary parapharyngeal tumours: a review of 21 cases.

BACKGROUND: The diagnostic and therapeutic procedures performed in a series of patients with primary parapharyngeal space (PPS) tumours treated at the ENT Departments of San Giovanni Bosco Hospital, Turin, and of the Pugliese-Ciaccio Hospital, Catanzaro, Italy, in the period 2001-2010 are evaluated. MATERIALS AND METHODS: The retrospective review included 20 patients, 11 male and 9 female, average age of 41 years operated on for 21 primary PPS tumours. The most common tumours found were neurogenic neoplasms, while those of salivary origin were the next most common. RESULTS: There were 14 paragangliomas (7 originating from carotid glomus, 5 from vagal and 2 from tympanicum), 1 sympathetic chain schwannoma and 6 pleomorphic adenomas. All the tumours were benign in nature and gave rise to few signs or symptoms. Patients underwent preoperative computed tomography (CT) scan or magnetic resonance imaging (MRI) or both. Most contrast-enhanced masses were submitted to some type of angiography. Most of the surgeries were planned through imaging alone, as preoperative fine needle aspiration (FNA) biopsy was performed only in six cases. Four different approaches were adopted for tumour removal: transcervical, transcervical/transparotid, cervical-transparotid-transmandibular and infratemporal fossa approach. There was no operative mortality, though neurologic morbidity was significant. Follow-up, extended to a maximum of 11 years, did not reveal any recurrences. In conclusion, neurogenic tumours may be the most common of PPS masses. Surgery is the mainstay treatment and external approaches offer the potential for satisfactory tumour resection. Of such external approaches, transcervical and cervical/transparotid are the most often used in benign forms. CONCLUSION: The number of perioperative complications encountered in this series confirms the difficulty of performing surgery in this complex area, even in benign cases. The chances of avoiding vascular damage and saving the trunks or most of the nerve fibres involved depend not only on the skill and experience of the surgeon but also on the anatomy of the lesion, the type of connection between the tumour and the nerve from which it originates and the distribution of neural fibres in or around the tumour mass.

[Benefit of skull vibration-induced nystagmus test in occupational medicine]. / Intérêt du test de vibration osseux vestibulaire en médecine du travail.

BACKGROUND: Nystagmus induced by vibrations (NIV), has been optimized by the present authors this last decade. The skull vibration-induced nystagmus test (SVINT) can be designated as a high-frequency global "vestibular Weber test" and can be considered as an office-based examination to detect vestibular asymmetry. The aim of this study is to define the tolerance of the SVINT as well as its comparison to the simplified caloric test of Veits (CTV) in normal workers during the pre-employment visit at the occupational medicine center. MATERIAL AND METHODS: The vestibular function has been evaluated by the SVINT and the CTV in 87 healthy workers. The tolerance of the two procedures has been evaluated by a 4-items questionnaire (nausea, vomiting, sweating, asthenia). RESULTS: The caloric test was normal in each worker. The SVINT was positive in one patient who had a partial unilateral vestibular dysfunction related to trauma. The mean duration of the procedure was 15 min for CTV and 1 min for SVINT. Side effects (nausea, vomiting, sweating, asthenia) were present in 50% of the workers following CTV and in only one patient after SVINT. The SVINT demonstrated significantly less side effects for each item (p < 0.0001). CONCLUSIONS: SVINT is a valid, rapid, low-cost clinical screening test and does not cause patient discomfort. It is suggested that this test which explores vestibular high frequencies and is not modified by vestibular compensation is useful for the diagnostic screening of workers' vestibular dysfunction, when combined with other vestibular tests and complements the CTV.

[Proposal of entering the mastoid vibration test in health surveillance of workers exposed to industrial solvents]. / Proposta di inserimento del test vibratorio mastoideo nella sorveglianza sanitaria di lavoratori esposti a solventi organici industriali.

In view of the use of solvents and consequently the number of exposed subjects, health surveillance should include instrumental exams to highlight at an early stage alterations of health resulting from exposure. We evaluated 40 workers with chronic exposure to low-level xylene, toluene, fluorene and anthracene, showing that vestibular system was altered in a fair percentage of cases, compared to a control group characterized by 40 workers of the same age not exposed to solvents. The two groups were simultaneously exposed to noise. It is concluded that occupational exposure to industrial organic solvents may lead to chronic alteration of the vestibular system with possible alterations also on work capacity even below the established limits. Second, an assessment of the vestibular system should be introduced in the health surveillance of workers exposed, in which, in our opinion, the mastoid vibration test is a diagnostic tool absolutely valid and simple to perform.

Primary adenocarcinoma of the arytenoid: an ultrastructural study.

Primary adenocarcinoma of the larynx is a rare neoplasm that tends to spread to both regional lymph nodes and distant sites. A case of primary adenocarcinoma of the arytenoid in a 74-year-old man is presented. The tumor was evaluated by light and electron microscopy. A high percentage of intranuclear pseudoinclusions (more than 20% of the neoplastic cells) was a peculiar characteristic of the tumor. To the best of our knowledge, such a feature has not been reported previously and should be considered a hallmark of more aggressive behavior.

Midfacial granuloma syndrome or an inflammatory non-specific disease? A case report.

We report a case of idiopathic midline destructive disease in a 57-year-old man. The patient had a non-specific histological pattern in biopsies obtained from the nose and upper lip, characterized by a granulomatous reaction with progressive destruction of the tissues. The patient's general medical history was non-contributory. Clinical and laboratory data did not support any feasible etiology for this destructive process. The patient was treated with prednisone until the discovery of type II diabetes mellitus (never diagnosed before) and was then in turn treated only with oral antidiabetic therapy. Follow-up controls revealed progressive reduction of the symptoms and of the nasal and lip lesions and total remission of symptoms up to 2 years after the onset of the disease. We discuss the diagnostic and subsequent therapeutic problems in the management of the midline necrotizing lesions.

[Choanal atresia: personal surgical technique]. / L'atresia coanale: tecnica chirurgica di nostro impiego.

Choanal atresia is a rare otorhinolaryngological pathology. It occurs in 1 out of 5,000 children born alive and can be associated with other major or minor congenital abnormalities. The most important associations go under the acronym of C.H.A.R.G.E. (Coloboma, Heart disease, Atresia choanae, Retarded growth and/or development, Genital hypoplasia and Ear anomalies and/or deafness). The authors briefly describe the most salient clinical features and possible, though rare, complications of this anomaly (i.e., prolonged apnea, ab ingestis pneumonia, sinusitis, all the way to death by asphyxia). They also mention the current embryogenic theories advanced to explain the etiology. Foremost of these is the theory based on the persistence or inadequate development of the Hochstetter bucconasal membrane which is normally resorbed between the 35th and the 42nd day of intrauterine life, giving rise to the posterior nostril and primitive choana. The authors then present their personal experience with seven clinical cases of monolateral atresia in children ranging in age from 7 to 13 years, plus one case of bilateral atresia treated surgically 8 days after birth. They describe their surgical technique using intranasal and transseptal microsurgery. The patient undergoes general anesthesia in controlled hypotension. A surgical microscope with a 200-300 mm lens is used as well as the normal instrumentation for endonasal surgery. Access to the atresia lamina is gained through the floor of the nose and the lamina is perforated with a micro-osteotome. The excess bone tissue is removed and the neo-choana is calibrated and lined with the two mucosal flaps previously prepared. Then a silicone tube is positioned and anchored to the septum with a suture and left in place for approximately three weeks. Finally the authors indicate the most salient points of the other surgical techniques currently in use and they discuss their post-surgical treatment to prevent restenosis, comparing it with the experience of other authors.

[Morphological study of the palatine tonsils: clinical and histopathological considerations]. / Considerazioni cliniche ed istopatologiche in uno studio morfologico della tonsilla palatina.

This study examined 71 pediatric tonsillectomy patients through accurate case history and clinical examination, placing particular emphasis on pathologies concomitant to tonsillopathy. In an attempt to find anatomo-clinical correlations, these data were processed together with the results of a histomorphological study of thetonsil epithelium, performed on all tonsillectomy samples. The majority of these patients were females and none more than 13 years of age. Numerous pathologies were found associated with the tonsillopathy and in varying combinations, first and foremost of which was adenoid hypertrophy. Only approximately one fifth of the patients did not show any concomitant pathology of note. All patients presented a history of recurrent pharyngotonsillitis (at least 4 episodes a year) with symptoms arising from 1 to 10 years prior to surgery. The concomitant pathologies included: respiratory, cutaneous and food allergies, asthma, obstructive sleep apnea, rheumatic diseases, etc. From the histomorphological point of view, particular modifications were found in the follicle epithelium and interstitial cells of the palatine tonsil. An exasperated fibrotic interstitial reaction and chronic duration of the disease appeared to prevent tonsil filter function, facilitating chronicization of the tonsillopathy or onset of recurrent infections and concomitant allergies. In the allergic patients the tonsil epithelium was thickened and compact and showed various degrees of chorion edema, in agreement with what is found in the literature. On the contrary, few morphostructural palatine tonsil mutations were found in those subjects which did not present any concomitant pathology or were affected by tonsillopathy of brief duration. All the histomorphological modifications encountered appear related to the individual patient history, confirming the hypothesis that tonsil epithelium can not only condition the evolution of tonsillopathy--reflecting the effect of various factors--but, above all, it directs the immune response, thus playing a role in the development of various concomitant pathologies.

[Description of a particular case of the so-called Schmincke lymphoepithelioma and study of the correlation with Epstein-Barr virus]. / Descrizione di un caso particolare del cosiddetto linfoepitelioma di schmincke e studio delle correlazioni con il virus di Epstein-Barr.

For poorly differentiated rhinopharyngeal carcinomas, the clinical presentation (association with the Epstein-Barr virus, paraneoplastic syndromes, onset of lymphoma) and the histopathological features can be polymorphous and they can confound or delay diagnosis and preparation of an adequate treatment plan (radio-chemotherapy). Often these neoplasms arise as clinically primitive laterocervical metastases, masked by clinical findings and a history that can lead to the mistaken diagnosis of systemic lymphoproliferative processes such as Hodgkin's disease. Here an observation of this type is presented in a young patient (19 years old) who came under observation for a laterocervical tumefaction recurrent from a previous exeresis performed at another hospital and symptoms of serotine febricula, dysphagia and serology positive for the Epstein-Barr virus (EBV). The patient underwent surgery and then radiotherapy and has been under close post-operative follow-up for two years. To date the patient's condition--both local and general--is good. The particular histology of the neoformation lies in the abundant infiltration of plasma cell and lymphocyte eosinophils, at times in blastic form. Moreover, elements with a large clear nucleus and evident nucleolus (Hodgkin-like) and scattered multinucleate Langhans-type giant cells can be seen. Immunohistologically the tumor cells markedly express for cytokeratin and the latent membrane protein (LMP1) of the Epstein-Barr virus (EBV) and show a high growth fraction. Under the electron microscope, the plurinucleate giant cells present large nuclei with morphology similar to that of tumor cells. The clear cytokeratin-positivity of the tumor elements and the histological and ultrastructural features mentioned led to the diagnosis of a massive metastasis from lymphoepithelial carcinoma, the Schmincke variant, plus EBV infection of the neoplastic cells. The authors conclude assuming that the particular granulomatous reaction is due to the host's reaction to the tumor cells, but also to the reaction to the viral antigens. In the former case we find an attempt to limit the carcinomatous process; in the latter it is a response caused by the EBV and is not, apparently, aimed at protecting against the neoplasm rather it facilitates the neoplastic process.

[Upper maxillary cysts: embryogenic and surgical considerations in our cases]. / Cisti del mascellare superiore: considerazioni embriogenetiche e chirurgiche su una nostra casistica.

Upper maxillary cysts are a chapter in otorhinolaryngological pathology which have been relatively neglected by the Literature. The reason for this most likely lies in the difficulty in producing a nosographic picture of these pathologies which border on other surgical fields (dentistry, maxillofacial surgery), and because they show significant clinical and etiopathogenic polymorphism. The elements that characterize upper maxillary cysts as a separate clinical entity are basically their cystic nature and origin within the upper maxillary bone, although they can expand widely within the medio-facial region (nasal vestibule, oral vestibule, nasolabial region, palate, maxillary sinus). After having reviewed the various classification schemes proposed over the years, and briefly examining the main clinical and etiopathogenic characteristics and principles for surgical treatment, the present work offers a surgical case study, together with the related iconography. Moreover this work does not neglect embryogenic considerations which are indispensable for the study of some of these pathologies. In this manner the results for 35 surgical procedures on upper maxillary cysts performed from 1989 to 1996 are presented and classified following the Cudennec classification module (1991). This study shows the variety of possible clinical manifestations for these pathologies. Such a variety makes correct diagnosis imperative--today facilitated by modern imaging techniques--and requires diversifying the surgical approach, conditioned not only by the site, extension and nature of the specific lesion, but also by the related symptoms. The significant progress in surgical techniques has made increasingly functional surgery possible and led to the abandonment of such conventional radical techniques as the Caldwell-Luc procedure. Moreover, CT and NMR have provided good image definition, specifying precisely the limits and extensions and, in most cases, facilitating diagnosis of the nature of the disorder with direct and indirect signs of the cystic nature of the lesions whenever the clinical data proves inadequate.

[Laryngeal tuberculosis: considerations on the most recent clinical and epidemiological data and presentation of a case report]. / Tubercolosi laringea: considerazioni sui più recenti dati clinici ed epidemiologici e presentazione di un caso clinico.

According to the "Global Tuberculosis Control" performed in 1999--the third complete, international, global report on tuberculosis infection--173 countries reported their infection data to the WHO; of these countries 102 met the criteria for "DOTS programs" at the end of 1997. The DOTS programs are the only control strategy able to produce a cure rate of 85%. Both at the national and international (Centers of Disease Control) levels, guidelines have been drawn up to improve and coordinate the fight against tuberculosis. New indicators and methods of analysis should be developed to quantify the full impact on the control of infection transmission, incidence, prevalence, mortality and prevention of drug resistance. In addition, two significant world-wide events have affected the increase morbidity rate seen in the last decade in the more highly industrial countries: immigration from countries outside the European Community and HIV infection. The tuberculosis infection worsens the evolution of HIV, facilitating viral replication. In the present work the authors discuss the most recent epidemiological data regarding tuberculosis infection and review the Literature on the primary laryngeal location of the disease. Then they present a clinical case which recently came under observation. This case is a typical example of the clinical picture of the laryngeal tuberculosis seen today. It must not be forgotten that in recent years there has been an increase in morbidity in Italy, in both the pulmonary and extrapulmonary forms of the disease, although in our country the problem of delayed or incomplete reporting is quite widespread. The data show that the age ranges with the highest incidence of both pulmonary and extrapulmonary forms are the 25-35 and 60-70 year groups. Distribution by sex, on the hand, shows that the pulmonary forms are most often seen in males while the extrapulmonary forms have practical the same frequency in both sexes. In recent years the clinical and morphological aspects of tubercular laryngitis have changed significantly from what they were before chemotherapy and the most common clinical form is pseudotumoral tuberculosis. This form requires a differential diagnosis to distinguish it from neoplasms because they present a similar objective picture and have no signs of simultaneous or previous pulmonary involvement.

[Biphasic hypopharyngeal synovial sarcoma: ultrastructural, cytofluorometric and immunohistochemical study and brief review of the literature]. / Sarcoma sinoviale bifasico a localizzazione ipofaringea: studio ultrastrutturale, citofluorometrico ed immunoistochimico e breve revisione della Letteratura.

Synovial sarcomas account for 7-10% of all soft tissue malignancies and the rare head and neck region location accounts for an average 5% of them. A brief review of the data in the Literature has shown that not more than one hundred cases of cervical-facial synovial sarcoma have been reported. In the head and neck locations this form of tumor is significantly less aggressive, with a higher survival rate and a recurrence rate much lower than the 60-70% shown for other locations in the limbs. After a brief review of the Literature, Authors present a rare clinical case of hypopharyngeal synovial sarcoma which recently came under observation. Despite the accurate diagnostic procedure, after surgical removal of the tumor by CO2 laser microlaryngoscopy, diagnosis required the use of histological and ultrastructural techniques. CT and NMR of the neck using contrast medium showed that the structure of the neoformation was similar to that of the soft tissues, it was 3-4 cm in diameter, located in the hypopharynx and had an extensive surface in contact with the left glossoepiglottic groove. The lesion appeared to involve the free edge of the aryepiglottic fold, coming into contact with the free edge of the epiglottis; it could not be dissociated form the epiglottis and obliterated both the homolateral glossoepiglottic vallecula and the pyriform sinus. Structural analysis after radiography with a contrast medium showed a marked impregnation of the lesion, indicative of high degree of vascolarization. Ultrastructural, cytofluormetric and immunohistochemical analyses were performed on the neoplasm in order to process all these data together with the clinical parameters; in other words a multi-parameter evaluation was performed, as suggested by other Authors, to determine the therapy and arrange more accurate monitoring of this patient, victim of a neoplasm with a high potential for metastases.

[Epistaxis: emergency treatment approach]. / Epistassi: approccio terapeutico in urgenza.

After a brief summary of the causes of severe epistaxis and the surgical choices available for treatment, the authors present their own cases study. Starting from a brief description of the anatomy involved in the system of arterial irrigation of the nasal cavities, they focus on two fundamental concepts: the basis for a proper topographic picture of the site of bleeding and the success of surgery. First and foremost is the emergence of two arterial branches from the sphenopalatine formen; this differs from what is asserted in the classical treatise on anatomy and in line with what has been stated in the Nomina Anatomica, approved during the X World Congress on Anatomy (Tokyo 1975). Secondly, focus is placed on the existence of two important anastomotic systems in the arterial circulation of the nasal cavities: the one between nasal septum and anterior-posterior ethmoid arteries and the one between the lateral-posterior nasal and nasoseptal arteries. In the literature the failure of surgery in treating severe epistaxis is explained by the onset of supplementary anastomotic circulation. The indications for surgical treatment of epixstaxes are: copious bleeding in hospital or after the packing has been removed; underlying pathology or general status which has been aggravated by the packing; patient which has already been staunched several times. The results of 31 epistaxis procedures are presented: 8 (25.81%) upper and 23 (74.19%) posterior. The upper epistaxes were treated as follows: 3 cases with anterior ethmoid ligature, two of which failed; 2 cases with combined ligature of the anterior and posterior ethmoid; 3 cases of successful septoplasty. The posterior epistaxes were treated as follows: 11 cases of ligature of the lateral-posterior nasal artery, 2 of which failed; 12 cases of successful combined ligature of lateral-posterior nasal and nasoseptal arteries. These results confirm that it is possible to effectively resolve surgically severe epistaxis using microsurgery or transnasal endoscopy based on in depth knowledge of the complex architecture of the arterial circulation within the district of the paranasal sinuses, possible anatomic variations and collateral circulation.

[Benign extracranial cervical-facial schwannomas: anatomo-clinical and diagnostic considerations on our case reports and review of literature]. / Schwannomi benigni extracranici del distretto cervico-facciale: considerazioni anatomo-cliniche e diagnostiche su una nostra casistica e revisione letteraria.

Schwannoma is a rare neoplasm in the E.N.T. areas although it is characteristic of this discipline. Indeed, examination of the most recent data in the literature shows that approximately 45% of all neoplasms of the peripheral nerve linings occur in the head and neck district, the most common neurogenic tumors are schwannomas and these constitute 35% of all head and neck tumors. In reviewing the literature attention was focused on schwannomas originating in unusual sites, neglecting the most common sites originating in the eighth and seventh pair of cranial nerves. It was seen that the site of origin and clinical manifestation of these lesions varies widely and the four cases presented here are no exception. These are four schwannomas which came under observation between 1994 and 1997. The sites of origin were, respectively: the floor of the mouth, the submandibular region (corresponding to the Warthon duct), the anterior wall of the external auditory canal and the hypopharynx (corresponding to the pyriform sinus). All of these cases proved quite rare in the literature. All the cases underwent accurate anatomopathological examination and the paper discusses the particular histological and immunohistochemical features encountered. Reference is also made to the problems of differential diagnosis vs. other types of soft tissue tumors. Emphasis is placed on the demonstrated difficulty in recognizing schwannomas from the macroscopic and surgical points of view. The absence of mitoses, necroses, invasiveness and specific features--i.e. hyperchromia and pleomorphism of the nuclei or the presence of large atypical cells--are all parameters confirming that the lesions observed in the present study were benign. No anatompathological features were observed that could justify any particular expression of the schwannoma in the specific sites involved. Nevertheless, the authors present these case because a review of the literature indicated that they are extremely rare and because differential diagnosis of these unusual manifestations is so complex.

Measured versus predicted resting energy expenditure in infants: a need for reappraisal.

The reliability of commonly used predictive equations for estimating energy expenditure in infants in both health and disease was assessed by comparing resting energy expenditure (REE, measured by indirect calorimetry) in relation to weight, height, and body cell mass (by total body potassium analysis) with predictive equations (Harris-Benedict, Food and Agriculture Organization/World Health Organization/United Nations University (FAO/WHO/UNU), Schofield weight-only, and Schofield weight-and-height equations) in 36 healthy infants (age 0.43 +/- 0.27 years; 19 male) and in 9 infants with cystic fibrosis (age 0.41 +/- 0.30 years; 4 male). Mean +/- SD REE for healthy boys was 0.205 +/- 0.019 MJ kg-1 day-1 and for healthy girls 0.217 +/- 0.026 MJ kg-1 day-1. Infants with cystic fibrosis had a significantly higher REE (0.258 +/- 0.034 vs 0.210 +/- 0.024 MJ kg-1 day-1; p < 0.005). Compared with measured values, predicted REE values varied markedly among equations, overestimating REE in healthy infants (Harris-Benedict equation, 182% +/- 63% (SD) of measured values; FAO/WHO/UNU equation, 104% +/- 14%; Schofield weight-only equation, 107.5% +/- 14%; and Schofield weight-and-height equation, 106% +/- 11%) and underestimating REE in those with cystic fibrosis (84% to 88% for the FAO/WHO/UNU, Schofield weight-only, and Schofield weight-and-height equations) except the Harris-Benedict equation (152%). On regression analysis both weight and body cell mass were related significantly to REE (r2 = 0.87 and r2 = 0.61, respectively) for normal infants and (r2 = 0.92 and r2 = 0.94) for those with cystic fibrosis. Using a generalized linear model of variance, we saw a significant (p < 0.001) variability among all REE measures. Thus we could rely on none of the predictive equations to give an accurate estimate of REE, and hence energy and fluid requirements, in individual infants. We suggest that when accurate estimates are needed, measurement of REE in individual infants should be attempted, especially in disease states, and that the continued use of current formulas should be reexamined.

The body cell mass and altered protein energy metabolism in cystic fibrosis.

To further investigate the body cell mass (BCM) in CF, as the central metabolically active body compartment, and to determine if measures used as reference standards after comparative differences in protein energy metabolism, BCM was measured by K40 analysis (n= 144 CF, 69 M, 71 F, ages 0.3-17 years) related to age and gender control date (n=1478). Protein synthesis was studied by whole body C13 leucine kinetics (LSYN, n=10 well nourished vs 7 undernourished CFs matched for Ht, Sex and FEV1). Energy expenditure (REE) was studied by indirect calorimetry (n=4 Δ F508 CF infants with no lung disease vs n=12 age, wt, ht and sex matched healthy infants). BCM was <1 sd below 50th centile in 75% of CFs although only 15 and l0% had weights or heights <1 sd below 50th centile. Mean LSYN and REE did not significantly differ between groups in absolute values or corrected for weight, height or surface area, but were accelerated (P<0.01) when corrected for BCM.