Metástasis de origen sistémico en Otorrinolaringología / Metastases of systemic origin in Otorhinolaryngology

Introducción. En las vías aéreo-digestivas superiores el cáncer siempre es primitivo; éste cáncer es muy frecuente, pero existen cánceres secundarios de extrema rareza. Desarrollo. Se estudian los casos propios, algunos ya publicados: cánceres de riñón de cáncer de mama en hueso temporal y se revisa la bibliografía sobre estas raras metástasis. Conclusiones. Ante todo cáncer otorrinolaringológico hay que realizar una historia detallada del paciente sobre todo investigando anteriores neoplasias. Muy especialmente estudiar y revisar antecedentes de tumores renales de mama y de próstata en cuanto a tumor primitivo y en cuanto a órganos receptor de las metástasis, los senos paranasales y el hueso temporal. El problema difícil es cuando el tumor primitivo existe y no ha sido diagnosticado. Por ello, en todo cáncer de hueso temporal o de senos paranasales debemos antes de emprender ningún tratamiento, practicar un examen de riñón, próstata y mama y de todos los demás órganos supra o infradiafragmáticos en los que podamos sospechar una tumoración. El pronóstico de estas metástasis es muy malo, prácticamente siempre mortal, por lo que muchas veces en vez de tratamientos más agresivos serán sólo paliativos (AU)

Rabdomioma de laringe: Un raro caso de disfonía. Revisión de la literatura / Laryngeal rhabdomyoma: a rare case of disphony. Review of the literature

Los rabdomiomas de laringe son tumores benignos muy raros. Sólo 25 casos han sido bien documentados hasta la actualidad. Se caracterizan por presentar un crecimiento lento. El diagnóstico se basa en los estudios inmunohistoquímicos y de microscopía elec trónica, distinguiéndose tres tipos histológicos: adulto, fetal y fe tal mixoide o genital. El tratamiento consiste en la extirpación quirúrgica. Se presenta un nuevo caso de rabdomioma tipo adulto y una revisión de la bibliografía (AU)

Rhabdomyomas of the larynx are extremely rare benign tumors. Only 25 have been well documented until now. These tumors display a low growing pattern. Diagnosis is based on immunocytochemical studies and electron microscopy. Three histological types are distinguished: adult, fetal and fetal myxoidal or genital. Surgery is the treatment of choice. A new case, adult type, is presented and the literature reviewed (AU)

[Single fibrous tumor of the parapharyngeal space]. / Tumor fibroso solitario del espacio parafaríngeo.

A solitary fibrous tumor (SFT) of the parapharyngeal space presented with local symptoms (hearing loss, nasal obstruction, and paralysis of the soft palate and tongue). SFT, originally described as a mesothelial tumor of the pleura, now is recognized as a mesenchymal tumor that occurs in different locations. In the head and neck region, about 50 cases have been reported. This is the fifth published report of an SFT of the parapharyngeal space. The diagnosis was confirmed by immunohistochemical (positivity for vimentin, CD34, and CD99) and ultrastructural markers (fibroblastic characteristics).

Tumor fibroso solitario del espacio parafaríngeo / Solitary fibrous tumor of the parapharyngeal space

Se presenta un caso de tumorfibroso solitario (TFS) de localización parafaríngea, con un cuadro clínico de afectación locorregional (hipoacusia, obstrucción nasal y parálisis velopalatina y de hemilengua). Se señala que el TFS, descrito inicialmente a nivel pleural y de origen mesotelial, hoy día se reconoce en otras múltiples localizaciones con un origen mesenquimal. En la región de cabeza y cuello se han descrito unos 50 casos y el presente es el quinto caso publicado a nivel parafaríngeo, habiéndose confirmado el diagnóstico mediante marcadores inmunohistoquímicos (vimentina, CD34 y CD99 positivos) y ultraestructurales (hábito fibroblástico) (AU)

A solitary fibrous tumor (SFT) of the parapharyngeal space presented with local symptoms (hearing loss, nasal obstruction, and paralysis of the soft palate and tongue). SFT, originally described as a mesothelial tumor of the pleura, now is recognized as a mesenchymal tumor that occurs in different locations. In the head and neck region, about 50 cases have been reported. This is the fifth published report of an SFT of the parapharyngeal space. The diagnosis was confirmed by immunohistochemical (positivity for vimentin, CD34, and CD99) and ultrastructural markers (fibroblastic characteristics) (AU)

[Ethmoidal metastasis of renal adenocarcinoma]. / Metástasis etmoidal de adenocarcinoma renal.

The sinonasal tract and, more specifically, the ethmoid sinus, are uncommon sites for metastatic tumors. Fewer than 100 cases have been reported in the world literature. We report the case of a 65-year-ol woman who underwent nephrectomy and adrenalectomy for renal cell carcinoma (hypernephroma) with adrenal metastasis. Four months later the patient was seen for repeated epistaxis and nasal obstruction, which was diagnosed as ethmoidal metastasis of renal adenocarcinoma in a second biopsy. The second metastasis was removed by lateral rhinotomy but recurred six months later. Palliative surgery was performed and the patient died eight months later from brain metastases. Therapeutic strategies for metastatic nasal tumors are reviewed.

Acoustic analysis after radiotherapy in T1 vocal cord carcinoma: a new approach to the analysis of voice quality.

PURPOSE: The study of acoustic voice parameters (fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio) in extended vowel production, oral reading of a standard paragraph, spontaneous speech and a song in irradiated patients for Tis-T1 vocal cord carcinoma. METHODS AND MATERIALS: Eighteen male patients irradiated for Tis-T1 vocal cord carcinoma and a control group of 31 nonirradiated subjects of the same age were included in a study of acoustic voice analysis. The control group had been rigorously selected for voice quality and the irradiated group had previous history of smoking in two-thirds of the cases and a vocal cord biopsy. Radiotherapy patients were treated with a 6MV Linac receiving a total dose of 66 Gy, 2 Gy/day, with median treatment areas of 28 cm(2). Acoustic voice analysis was performed 1 year after radiotherapy, the voice of patients in extended vowel production, oral reading of a standard paragraph, spontaneous speech, and in a song was tape registered and analyzed by a Kay Elemetric's Computerized Speech Lab (model CSL# 4300). Fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio were obtained in each case. Mann Whitney analysis was used for statistical tests. RESULTS: The irradiated group presented higher values of fundamental frequency, jitter, shimmer, and harmonics-to-noise ratio. Mann-Whitney analysis showed significant differences for fundamental frequency and jitter in vowel production, oral reading, spontaneous speech, and song. Shimmer only showed differences in vowel production and harmonics-to-noise ratio in oral reading and song. CONCLUSIONS: In our study only fundamental frequency and jitter showed significant increased values to the control group in all the acoustic situations. Sustained vowel production showed the worst values of the acoustic parameters in comparison with the other acoustic situations. This study seems to suggest that more work should be done in this field.

Metástasis etmoidal de adenocarcinoma renal / Ethmoidal metastasis of renal adenocarcinoma

La región naso-sinusal y el etmoides en concreto, son localizaciones excepcionales para tumores metastásicos. Menos de 100 casos han sido descritos en la literatura mundial. Presentamos el caso de una mujer de 65 años intervenida de nefrectomía con suprarrenalectomía por un adenocarcinoma renal (hipernefroma) con metástasis suprarrenal. Cuatro meses después la paciente consultó por epistaxis de repetición y obstrucción nasal, siendo diagnosticada de metástasis etmoidal de adenocarcinoma renal en una segunda biopsia. Esta segunda metástasis fue extirpada por vía para- látero-nasal con recidiva local a los seis meses. Se realizó cirugía paliativa y la paciente falleció a los ocho meses por metástasis cerebrales. Se revisan las estrategias terapéuticas para los tumores nasales metastásicos (AU)

The sinonasal tract and, more specifically, the ethmoid sinus, are uncommon sites for metastatic tumors. Fewer than 100 cases have been reported in the world literature. We report the case of a 65-year-old woman who underwent nephrectomy and adrenalectomy for renal cell carcinoma (hypernephroma) with adrenal metastasis. Four months later the patient was seen for repeated epistaxis and nasal obstruction, which was diagnosed as ethmoidal metastasis of renal adenocarcinoma in a second biopsy. The second metastasis was removed by lateral rhinotomy but recurred six months later. Palliative surgery was performed and the patient died eight months later from brain metastases. Therapeutic strategies for metastatic nasal tumors are reviewed (AU)

[Laryngeal rhabdomyoma: unusual case of dysphonia. Review of the literature]. / Rabdomioma de laringe: un raro caso de disfonía. Revisión de la literatura.

Rhabdomyomas of the larynx are extremely rare benign tumors. Only 25 have been well documented until now. These tumors display a low growing pattern. Diagnosis is based on immunocytochemical studies and electron microscopy. Three histological types are distinguished: adult, fetal and fetal myxoidal or genital. Surgery is the treatment of choice. A new case, adult type, is presented and the literature reviewed.

[Metastasis of systemic origin in otorhinolaryngology]. / Metástasis de origen sistémico en otorrinolaringología.

INTRODUCTION: In the upper respiratory-digestive tract cancer is always primary. Such cancer is very common, but other extremely rare secondary cancers may be found. DEVELOPMENT: We studied our own patients and some published in the literature: cancer of the kidney with metastases in the paranasal sinuses and cancer of the breast metastasizing to the temporal bone. We review the bibliography on these rare metastases. CONCLUSIONS: In all cases of otorhinolaryngological cancer a detailed history should be taken, with special reference to previous neoplasms. It is particularly important to study and review any history of renal, breast or prostate tumors with regard to the primary tumor and the receptor organs of metastases, the paranasal sinuses and temporal bones. The most difficult problem occurs when the primary tumor is present but undiagnosed. Therefore, in all cases of cancer of the paranasal sinuses and temporal bones, before treatment is started the kidney, prostate, breast and other organs above and below the diaphragm where tumor may be present should be examined. The prognosis of these metastases, which are almost always fatal, is very poor so that often treatment is only palliative rather than aggressive.

[Secondary brain herniation. A case report]. / Meningoencefalocele secundario. A propósito de un caso.

A 47-year-old woman with left temporal bone herniation had a history of treatment of chronic cholesteatomatous otitis media. After clinical and radiological diagnosis, the defect was repaired using a middle fossa craniotomy approach and a Vicryl-collagen(R) plate. There were no postoperative surgical complications and the repair was successful. The sequellae of herniation of the temporal lobe and dura are potentially lethal and difficult to correct surgically.

[Cerebral abscess of otogenic origin located simultaneously in the temporal and cerebellar regions]. / Absceso cerebral de origen otógeno. Localización simultánea temporal y cerebelosa.

A 28-year-old male was seen for chronic left ear disease. A brain abscess appeared in the left temporal lobe and later spread to the cerebellum. Diagnosis was clinical and radiological. Intravenous antibiotic treatment resulted in resolution of the temporal abscess on CT. However, a new abscess that appeared in the left cerebellar hemisphere required neurosurgical debridement. The patient's microbiological cultures and history suggested an otological origin. Brain abscess is a serious complication of ear disease that requires early diagnosis and treatment.

p21WAF1/Cip1 expression is associated with cell differentiation but not with p53 mutations in squamous cell carcinomas of the larynx.

p21WAF1/Cip1 is a recently identified gene involved in cell cycle regulation through cyclin-CDK-complex inhibition. The expression of this gene in several cell lines seems to be induced by wild-type, but not mutant, p53. p21WAF1/Cip1 expression has been studied at both mRNA and protein levels in a series of 49 normal mucosae and squamous cell carcinomas of the larynx. A significant association was found between mRNA and protein expression in tumours (P < 0.0001). p21WAF1/Cip1 expression was strongly associated with squamous cell differentiation of carcinomas, because six of seven (86 per cent) undifferentiated carcinomas (grade 4) showed very low levels of p21WAF1/Cip1 expression, whereas 41 out of 42 (98 per cent) carcinomas with squamous cell differentiation (grades 1-3) had normal or high levels of p21WAF1/Cip1 expression (P < 0.0001). In addition, p21WAF1/Cip1 expression was topologically related to the squamous differentiation of tumour cells with a distribution similar to that seen in normal squamous epithelium. No correlation was found between p21WAF1/Cip1 expression and the global S-phase of the carcinomas. p53 mutations (exons 5-9) were found in ten carcinomas with p21WAF1/Cip1 expression, but no p53 mutations were detected in three p21WAF1/Cip1-negative tumours. In conclusion, p21WAF1/Cip1 expression is frequently upregulated in squamous cell carcinomas of the larynx and is associated with tumour cell differentiation. p21WAF1/Cip1 expression in these tumours is independent of p53 gene mutations.

p16MTS1/CDK4I mutations and concomitant loss of heterozygosity at 9p21-23 are frequent events in squamous cell carcinoma of the larynx.

We have examined the presence of p16MTS1/CDK4I gene deletions, mutations and methylation status, and 9p21-23 deletions in a series of 46 squamous cell carcinomas of the larynx and paired normal mucosa previously characterized for cyclin D1 gene amplification and overexpression. pRb expression was also examined by immunohistochemistry. p16MTS1/CDK4I mutations were found in 10/46 (22%) carcinomas and hypermethylation in 2/31 (7%). Loss of heterozygosity at 9p21-23 was found in 24 out of 42 (57%) carcinomas examined. All p16MTS1/CDK4I mutated cases and the two hypermethylated carcinomas showed 9p21-23 loss of heterozygosity. The loss of heterozygosity correlated with advanced local invasion (P=0.0045), lymph node metastases (P=0.0326), stage IV of the tumors (P=0.0058), and existence of cyclin D1 amplification/overexpression (P < 0.03). Only one out of 37 carcinomas was negative for pRb expression. No alterations in p16 gene or 9p21-23 loss of heterozygosity were detected in this case. These findings indicate that p16MTS1/CDK4I is frequently inactivated by gene mutation, hypermethylation, and allelic deletions in a significant subset of squamous cell carcinomas of larynx. Since 9p21-23 loss of heterozygosity was more frequently detected than p16MTS1/CDK4I mutations, and mutated carcinomas invariably had loss of heterozygosity, allelic losses probably precede the p16MTS1/CDK4I mutations. Their association with cyclin D1 deregulation in advanced carcinomas could indicate a possible cooperative effect in the progression of these neoplasms.

Effects of anesthetic technique on the hemodynamic response to microlaryngeal surgery.

Our aim was to study the attenuation of the hemodynamic response to microlaryngeal surgery by beta-blocking agents used as support drugs to the anesthetic technique. The study was carried out in 30 patients randomly allocated to one of three groups. The control group received only anesthetic drugs. The second group received labetalol hydrochloride 0.3 mg/kg 3 minutes before induction and 0.15 mg/ kg 2 minutes prior to the start of suspension of the larynx. The third group received esmolol hydrochloride 500 micrograms/kg 3 minutes prior to induction and a continuous infusion of 300 micrograms/kg during the surgical procedure. Hemodynamic data in the three groups were compared by analysis of variance. A statistically significant difference (p < .05) was found in hemodynamic data among the two groups treated with blocking agents and the control group. The addition of beta-blocking agents to the anesthetic technique attenuates the hemodynamic response to suspension laryngoscopy.

[Phyolaryngocele: a case report and review of literature]. / Piolaringocele. Presentación de un caso y revisión de la literatura.

A case of pyolaryngocele presented as a lateral cervical mass that produced acute dyspnea requiring tracheotomy. The diagnosis was by direct laryngoscopy, which revealed outflow of purulent material with pressure on the tumor, and was confirmed by CT. Broad-spectrum antibiotic treatment was given and the pyolaryngocele was excised by lateral extramucosal tyrotomy. The literature on laryngocele and pyolaryngocele was reviewed.

Follow-up study in head and neck cancer: cure rate according to tumor location and stage.

The purpose of this clinical study was to analyze a long-term follow-up of all the patients with head and neck cancer in our institution. Between 1973 and 1993, 1,355 consecutive cases of head and neck cancerwere diagnosed, treated and followed up regularly. All were subjected to a multidisciplinary approach, and followed up until death or for 10 years with no event of disease. The local relapse rate was 20% and the node-regional relapse rate 15%. Distant metastases were observed in 6% of the patients mainly arising from the nasopharynx (23%) followed by the hypopharynx (11%). The main organ involved was the lung (50%). Median follow-up of the group was 10 years (range 4 months to 15 years). Cancer cure was observed after 5 years in glottic and supraglottic laryngeal carcinoma, oral and nasopharyngeal cancer and after 2.5 years in patients with cancer of the oropharynx and hypopharynx. The highest cure rate was 80% in the glottis, followed by 70% in the supraglottic area, 45% in the mouth, 30% in the nasopharynx, 25% in the oropharynx, and 20% in the hypopharynx. A second primary tumor was observed in 7% of the patients and a third primary in 0.6% of the patients. Only in 7 patients, the second or third primary was seen after 5 years of follow-up. Curability should be observed after 5 years from definitive therapy of glottic, supraglottic, oral and nasopharyngeal and earlier in oropharyngeal and hypopharyngeal cancer. Further follow-up should be discontinued. Second and third neoplasias are the main problems after 5 years of follow-up but their incidence is low.

Hyperplastic lesions of the larynx. Experience of the Barcelona group.

Squamous carcinoma of the larynx arises from pre-existing lesions, the so-called "preneoplastic lesions". Hyperplastic lesions represent a part of their spectrum, from both clinical and biological points of view. On morphologic grounds, the most characteristic feature with prognostic value in the evaluation of preneoplastic lesions is dysplasia. It is not only nuclear alterations that are seen in the process of malignant transformation, the cytoplasmic pattern of cytokeratins changes through neoplastic progression, with a progressive reduction of the molecular weight of the produced species. Dysplasia also associates with gross alterations of the DNA content. This is in agreement with our finding of alterations of genes participating in the control of the cell cycle, p53 and p21(WAF1/cip1). p53 overexpression is detected in non-invasive squamous lesions (even in the absence of obvious dysplasia) and p21(WAF1/cip1) shows a dramatic change in the pattern of expression in dysplastic epithelium compared with the normal. However, not all genes participating in the control of the cell cycle are altered in early lesions. Overexpression of cyclin D1, a common phenomenon in advanced carcinomas, is not likely to participate in the early phases of neoplastic development.

[Endoscopic approach to the treatment of subperiosteal orbital abscess]. / Abordaje endoscópico para el tratamiento del absceso subperióstico orbitario.

The treatment of orbital complications of nasosinusal processes has seen numerous modifications. Traditionally, cases with purulent collections were treated by external drainage. Currently, the introduction of new optical systems allows such complications to be approached from within the nasal cavity. We report a case of a 3-year-old girl with a subperiosteal orbital abscess secondary to ethmoiditis, which was cured by minimally aggressive endoscopic management and medical treatment.

[Equilibrium and auditory disorders in patients affected by HIV-1]. / Trastornos del equilibrio y de la audición en pacientes infectados por el VIH-1.

It is thought that about 10% of the patients with advanced human immunodeficiency virus (HIV) infection have otoneurological symptoms, although up to 41% of these patients have general otorhinolaryngological symptoms. The otological changes may be divided into those of balance and those of hearing, to improve classification, although these symptoms are often to be found together in the same patient. We studied 30 seropositive patients with stage II and stage III disease, carrying out studies of oculomotricity, electronystagmography and audiometry (both conventional and high frequency). Oculomotricity changes were seen in 27% of the patients, whilst the caloric test were mainly normal. Conventional audiometry was normal, but high frequency audiometry showed neurosensorial deafness in 23% of the patients. These findings indicate probable changes in the vestibular and oculomotor pathways, with little change in the peripheral sensor for balance.

Radiotherapy in the maxillary hemangioma.

We present the case of a large maxillary hemangioma treated by radiotherapy. Only 4 cases managed by radiotherapy have been reported in the literature, and most authors negate the radiosensitivity of the tumor. In our patient, the outcome was excellent; by 6 months tumor reduction was more than 50%. This is the first case referred to in the literature whose radiotherapy response was evaluated by magnetic resonance imaging. We describe the clinical and imaging findings of this very rare tumor and its evolution. We also comment on the literature reviewed.