[Epiglottitis: a children's disease seen in adults]. / Epiglottitis: een kinderziekte bij volwassenen.

Two women, aged 58 and 62, developed epiglottitis with acute symptoms of sore throat, respiratory distress, fever, and stridor on inhalation. Both developed an upper respiratory tract obstruction requiring acute intubation to secure an open airway. The symptoms disappeared after administration of intravenous antibiotics and corticosteroids. Both women were discharged without any residual signs of infection. The incidence of epiglottitis in adults is most likely rising. The illness used to be seen almost only in children. A clear explanation for this rise in incidence cannot be given. It is important that the clinical picture be recognized in an early stage by referring doctors; they must be aware of the danger of a quickly developing airway obstruction. Monitoring of the patient during treatment by an otorhinolaryngologist is highly important to safeguard an adequate airway.

Prophylactic gastrostomy placement and early tube feeding may limit loss of weight during chemoradiotherapy for advanced head and neck cancer, a preliminary study.

OBJECTIVES: Most patients with advanced head and neck cancer receiving chemoradiotherapy need tube feeding for at least some weeks. For these periods gastrostomy tubes have advantages over nasogastric tubes. Tube feeding may start earlier and thus loss of weight may be limited if the gastrostomy tube already is in place. The objective of this study is to analyse the results of prophylactic percutaneous endoscopic gastrostomy (PEG) tube placement and early tube feeding. DESIGN: Retrospective chart review. SETTING: Multidisciplinary head and neck oncology team in a general hospital. PARTICIPANTS: Fifty consecutive patients with unresectable stage III and IV head and neck cancer treated with concurrent chemoradiotherapy. In all patients prophylactic PEG placement was performed. Tube feeding was initiated if food-intake became insufficient or loss of weight occurred. MAIN OUTCOME MEASURES: Loss of weight during treatment, complication rate, PEG duration. RESULTS: The mean loss of weight during treatment for all patients was only 2.8%. One complication of tube placement occurred: a colon perforation, treated successfully by surgery. The median duration of the PEG was 178 days. Three of the 17 patients (18%) with no evidence of disease (NED) still had a PEG at their last follow-up visit. Of the 26 patients who died of their cancer, 13 used the PEG until death. CONCLUSIONS: Loss of weight was limited after prophylactic gastrostomy placement and early tube feeding. Moreover, the complication rate was low. In 82% of the NED patients the PEG could eventually be removed.

[The practice guideline 'Otitis media with effusion' (second revision) from the Dutch College of General Practitioners; a response from the perspective of otorhinolaryngology]. / De standaard 'Otitis media met effusie' (tweede herziening) van het Nederlands Huisartsen Genootschap; reactie vanuit de kno-heelkunde.

The revised practice guideline 'Otitis media with effusion' from the Dutch College of General Practitioners constitutes a valuable contribution to the discussion regarding the diagnosis and treatment of this condition. A few critical comments can, however, be made. Pneumatic otoscopy and physical examination are considered to be very valuable. However, many general practitioners do not possess either the means or the skill to perform these investigations correctly. Patients with signs of (serious) hearing impairment should in the first place be referred to an otorhinolaryngologist, who can then refer children with proven perceptive hearing loss to a centre for audiology. This practice guideline recommends referral to an otorhinolaryngologist in case of hearing loss of more than 30 dB; according to otorhinolaryngologists this should be 25 dB or more. However, the duration and severity of the symptoms are more important. Speech and language retardation, behavioural problems at school due to hearing impairment and the possible development of an atelectatic tympanum are important reasons for referral. Otorhinolaryngologists also object to the wait-and-see attitude that is recommended in the practice guideline. Since there is no unambiguous evidence regarding the consequences ofotitis media with effusion in the long term, it would seem more reasonable to take the decision whether or not to treat the condition (and if so, when) in consultation with the parents. It is the parents who can best judge whether the child can live with the negative consequences of an untreated otitis media with effusion.

Antibiotic prophylaxis in clean and clean-contaminated ear surgery.

BACKGROUND: Ear surgery may be performed in the treatment of chronic otitis media, ossicular chain disorders, tympanic membrane perforations and otitis media with effusion. Postoperative infection in ear surgery may result in: Wound infections Infection of the middle ear or mastoid resulting in discharge from the ear canal Failure of the tympanic membrane to close Labyrinthitis due to infection in, or adjacent to, the inner ear These complications may be associated with discomfort and inconvenience for the patient, an increase in morbidity and an increase in the costs of medical care. OBJECTIVES: The objective of this review was to assess the effects of local and/or systemic antibiotics for preventing complications such as postoperative discharge, graft failure and labyrinthitis in patients undergoing clean or clean-contaminated ear surgery. SEARCH STRATEGY: We searched MEDLINE (searched January 1966 to December 2002), EMBASE (searched January 1980 to December 2002), the Science Citation Index, The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library, Issue 4 2002); the Cochrane Acute Respiratory Infections Group and Cochrane Ear, Nose and Throat Group Specialised Registers and proceedings of scientific meetings. The date of the last search was December 2002. We also contacted investigators in the field (Govaerts, Antwerp). Bibliographies of identified articles were screened for further relevant trials. No language restriction was applied. SELECTION CRITERIA: Randomised or quasi-randomised trials involving: PARTICIPANTS: patients undergoing clean or clean-contaminated types of ear surgery. Skull base surgery was excluded. INTERVENTION: any regimen of local and/or systemic antibiotic prophylaxis administered at or around the time of surgery compared to placebo, no antibiotic, or an alternative intervention group. OUTCOME MEASURES: infection, discharge, graft failure, labyrinthitis, adverse effects of prophylaxis. DATA COLLECTION AND ANALYSIS: When possible, investigators were contacted for additional information on data and methodological issues. At least two reviewers independently extracted data and assessed trial quality. MAIN RESULTS: Eleven studies were included in the review. The methodological quality of the trials was fair to good. However, most studies presented insufficient detail on methodological data. Although definitions of outcome measures were heterogeneous, pooling of results was possible. There were no significant differences between antibiotic prophylaxis groups and control groups in terms of reduction of postoperative infections, graft failures, draining outer ear canals and adverse drug effects. REVIEWERS' CONCLUSIONS: There is no strong evidence that the large scale use of prophylactic of antibiotics in clean and clean-contaminated ear surgery is helpful in reducing postoperative complications such as wound infection, discharge from the outer ear canal, labyrinthitis and graft failure.

[Ototoxicity induced by clarithromycin]. / Door claritromycine geïnduceerde ototoxiciteit.

A 76-year-old man developed a progressive bilateral hearing loss 4 days after starting a high dose of clarithromycin for atypical pulmonary tuberculosis. When the clarithromycin was discontinued the hearing improved subjectively but it worsened again upon reexposure. Halving the dose resulted in both an objective and subjective improvement in hearing, yet the original level of hearing was only obtained once clarithromycin had been permanently withdrawn. It would seem that this adverse effect is dose dependent. This seems to be the first published case study that demonstrates ototoxicity as a result of clarithromycin use.

A phase I study of a fixed dose of cisplatin with increasing doses of raltitrexed (Tomudex) in the treatment of patients with locally advanced or metastatic squamous cell carcinoma of the head and neck.

PURPOSE: A phase I trial of raltitrexed in combination with cisplatin in patients with locally advanced or metastatic squamous cell carcinoma of the head and neck (SCCHN). PATIENTS AND METHODS: Eligible patients had locally advanced or metastatic SCCHN. Cohorts of patients were treated with escalating doses of raltitrexed (2.0 mg/m2 to 3.5 mg/m2) as a 15-minute intravenous infusion immediately followed by cisplatin (80 mg/m2) administered over four hours every three weeks to determine the maximum tolerated dose (MTD). RESULTS: A total of 17 patients was administered 60 courses of an escalating dose of raltitrexed. Starting dose of cisplatin was initially 100 mg/m2 in the first three patients treated at the first dose level. Due to cisplatin-induced nephrotoxicity expressed as a creatinine clearance decrease by more than 50%, the cisplatin dose was reduced to 80 mg/m2 for all subsequent treatment cycles. Dose-limiting toxicity was observed at raltitrexed dose of 3.5 mg/m2 in two out of five patients. Dose-limiting grade 4 (CTC) neutropenia, grade 4 diarrhoea, grade 3 lethargy and elevation of transaminases and bilirubine was seen in these two patients. One patient treated at the level of the MTD, died 23 days after the first cycle with unresolved gastro-intestinal toxicity. In all other dose levels toxicity was very limited. The recommended dose for further study was raltitrexed 3.0 mg/m2 in combination with cisplatin 80 mg/m2. In 15 evaluable patients, we observed 9 WHO objective responses (1 complete and 8 partial). At the recommended dose level 3 partial responses were observed in five evaluable patients. CONCLUSION: The regimen of raltitrexed 3.0 mg/m2 followed by cisplatin 80 mg/m2 on day 1, every three weeks has manageable toxicity and these doses are recommended for phase II evaluation. Results indicate that this combination is active for the treatment of patients with locally advanced or metastatic SCCHN. Recently, a phase II study has been started.

A matched control study of treatment outcome in young patients with squamous cell carcinoma of the head and neck.

OBJECTIVES/HYPOTHESIS: To determine if there is a difference in overall survival, cause-specific survival, and relapse-free rate between young patients (<40 years of age) with head and neck squamous cell carcinoma (HNSCC) and older patients (>40 years of age). STUDY DESIGN: A matched control study describing the outcome of 185 previously untreated HNSCC patients less than 40 years of age treated at the Princess Margaret Hospital, Toronto, Ontario, Canada, between 1958 and 1992. The young patient group was compared with a control group of older patients (> 40 years of age) which was selected randomly from an entire cohort of patients (n = 10,072) and matched for site, sex, and date of presentation. METHODS: The medical records were reviewed and data abstracted for demographic information, tobacco and alcohol use, family history, primary site, clinical stage, primary treatment, histology, the occurrence of residual or recurrent disease, salvage treatment, development of subsequent primaries, survival, and the eventual cause of death. The patient's TNM stage was reclassified according to American Joint Cancer Committee/Union Internationale Contre le Cancer (AJCC/UICC) 1992 criteria on the basis of the initial clinical description and staging investigations. A multivariate regression analysis was performed. To assess the importance of age as a prognostic factor for survival, the Cox proportion hazard model was used. Smoking status was also tested in the stratified Cox proportional hazard model. RESULTS: Tumor stage and treatment modalities were comparable in both groups. The 5-year, cause-specific survival in both groups was not statistically different (72% vs. 68%, P = .91). The young patient group had a significantly better 5-year overall survival compared with the older patient group (68% vs. 49%, P = .0011). Older patients developed more subsequent primary neoplasms than the younger patient population (18% vs. 8%, P = .005). There were significantly more females, an increased incidence of oral or oropharyngeal cancer, and fewer smokers in the young patient group. Smoking, however, had an important impact on outcome with all but one patient who developed a second primary in the upper aerodigestive tract having smoked. Multivariate analysis showed that only disease stage and cancer site were significant prognostic factors for survival. CONCLUSIONS: Young patients with HNSCC do not have a worse prognosis than a matched older patient group in this case-controlled study (power > 0.75 for a minimal detectable difference of 10% disease-free survival between the two groups).

Complications of the myocutaneous platysma flap in intraoral reconstruction.

BACKGROUND: Pedicled myocutaneous flaps remain important tools in head and neck reconstruction. Evaluation of their complications are necessary to judge their merits. METHODS: From 1985 to 1995, 44 patients underwent a myocutaneous platysma flap reconstruction of the oral cavity or oropharynx. The following potential risk factors for complications were analyzed: age, sex, site of primary tumor, TNM stage, previous treatment, neoadjuvant chemotherapy, and type of operation. RESULTS: Flap-related complications occurred in 18 patients. Only one patient required reoperation for flap failure. Nineteen minor complications occurred in 17 patients. A significant increase in complications was seen in patients in which neoadjuvant chemotherapy was given. CONCLUSIONS: One flap failure was observed in our series. As the platysma flap has several advantages, it should be considered in the reconstruction of small intraoral defects. Contraindications are previous radiotherapy and surgery in the head and neck, neoadjuvant chemotherapy, nodal disease, and large defects.

Myoepithelial carcinoma (malignant myoepithelioma): first report of an occurrence in the maxillary sinus.

AIM: We document for the first time the occurrence of a malignant myoepithelioma at a site other than within the major and minor salivary glands. METHODS AND RESULTS: A 67-year-old male presented with progressive symptoms and signs of a space-occupying lesion in the right maxillary sinus. An initial biopsy identified a malignant (myo)epithelial lesion and a radical maxillectomy was performed. Histology, supplemented by immunohistochemistry, confirmed the presence of a malignant myoepithelioma. CONCLUSION: Malignant myoepithelioma is a very rare tumour composed almost exclusively of myoepithelial cells and, to date, has only been described arising in the the major and minor salivary glands. A variety of tumours of salivary tissue have been reported within the head and neck area at sites outside the major and minor salivary glands, probably arising within accessory salivary tissue. We report the first case of a malignant myoepithelioma occurring in the maxillary sinus, also presumably arising in accessory salivary tissue in this location.

[Pott's puffy tumor]. / 'Pott's puffy tumor'.

A 26-year-old man developed a fluctuating swelling of the forehead after twice being treated with antibiotics because of persistent sinusitis complaints. This swelling, a subperiostal abcess diagnosed as 'Pott's puffy tumor', is a complication of a frontal sinusitis, and may lead to serious neurological sequelae. The patient recovered after surgical drainage, ethmoidectomy and intravenous antibiotic treatment; no ablation of affected bone was necessary.

Prognostic significance of computed tomography in tumors of the oral cavity and oropharynx treated with neoadjuvant chemotherapy.

BACKGROUND: Despite its high response rate, the use of neoadjuvant chemotherapy remains controversial. Pretherapeutic identification of subgroups of patients who are likely to respond to chemotherapy is of the utmost importance. PURPOSE: In this study, we have attempted to determine the relationship between specific radiological parameters and the response to neoadjuvant chemotherapy. In addition, we have determined if these parameters could yield prognostic information on recurrence and/or survival. PATIENTS AND METHODS: Fifty-four patients with a squamous cell carcinoma of the oral cavity or base of tongue who had had a contrast-enhanced CT scan and neoadjuvant chemotherapy were included in this analysis. All clinical, radiological, surgical, histological, and radiotherapeutical parameters as well as the follow-up data were analyzed by a chi-square test. The method of Kaplan-Meyer was used to determine disease-free intervals and crude survival. The log-rank method was used for testing differences in local failures and survival. RESULTS: Twenty-eight patients were classified as having isodense nodes and 20 patients as having hypodense nodes. Nodal density was not related to tumor size or primary site. N stage was not correlated with the density of the nodes. Patients with hypodense nodes had a significantly lower disease-free interval and survival than patients with isodense nodes. The relation between overall response to chemotherapy and the hypodensity of the nodes didn't reach a significant level. CONCLUSION: No relation was found between overall response to chemotherapy and N-stage or tumor density. Disease-free interval and crude survival was strongly related to response to chemotherapy.

Complications of endoscopically guided sinus surgery.

The authors reviewed a series of 553 consecutive patients who underwent endoscopically guided sinus surgery. Major complications occurred in six patients (2.2%). There was one death due to incorrect positioning of the frontal drain. One patient developed a cerebrospinal fluid leak which had to be closed with an osteomucosal graft. Two patients who developed severe bleeding after removal of the nasal packing, needed ligation of the sphenopalatine artery and the internal maxillary artery, respectively. Two patients developed a complete stenosis of the nasolacrimal duct, necessitating a dacryocystorhinostomy. Minor complications occurred in 36 patients (13.4%). These included damage to the lamina papyracea (n = 11), severe bleeding after removal of the nasal packing treated conservatively (n = 6), intranasal mucosal adhesions (n = 17), and atrophic rhinitis (n = 2). The aetiology, prevention and treatment of complications during and after sinus surgery are also discussed.

Preservation of function by radiotherapy of small primary carcinomas preceded by neck dissection for extensive nodal metastases of the head and neck.

BACKGROUND: When patients are initially seen with a small primary tumor and regional metastases, the question arises whether the primary can be managed by definitive radiotherapy while treating the neck with surgery and postoperative radiation. The advantage of this is least disturbance of the primary site, while still achieving maximal control of the neck disease. METHOD: A retrospective review was conducted over an 8-year period; of the 619 patients seen during this time, 15 were judged suitable for this approach. Small primaries were defined as T1 or T2 lesions or superficial spreading T3 tumors. Extensive neck disease was defined as at least 3 cm in size. RESULTS: There were no regional recurrences and only 3 local recurrences, 2 of which were successfully salvaged. Four patients died of distant metastases. The arguments for and against this unusual approach are discussed. CONCLUSIONS: It is concluded that, in patients conforming to our criteria, this is a sound oncologic approach.

Clinical relevance of protein-tyrosine (de-)phosphorylation in head and neck cancer.

Previous studies have shown that protein tyrosine (de)phosphorylation plays an important role in head and neck cancer. Protein-tyrosine kinases (PTK) and protein-tyrosine phosphatases (PTPase) activities in the cytosol of tumor tissue were significantly increased compared to normal tissue of cancer patients as well as controls. Additionally, the enzyme activities in normal tissue of tumor patients were significantly higher than enzyme activities in normal tissue of the control group. In this paper, we have correlated the cytosolic and membranous PTK and PTPase activity of tumor and nontumor tissue with several clinical and histological parameters known to influence the clinical outcome. Furthermore, we have analyzed the value of the enzyme activities as an independent predictor of clinical behavior and occurrence of second primary tumors. We confirmed our earlier observations that cytosolic and membranous PTK activities and cytosolic PTPase activities in tumor tissues are increased compared to activities in nontumor tissues and controls. Moreover, we also confirmed the findings of increased enzyme activities in nontumor tissues compared to findings in control tissues. This finding in histologically proven healthy mucosa is highly interesting because it indicates that these biochemical changes are obviously not (yet) translated into morphological changes. Significant differences were found in membranous PTK activity when the patients were grouped by sex, tumor localization, lymph node metastasis, and previous radiotherapy. During the follow-up period, no relation could be found between enzyme activities in tumor and/or nontumor tissues and disease-free interval or occurrence of second primary tumors.

Aberrant tyrosine phosphorylation in head and neck tumours and potentially premalignant tissues.

Protein tyrosine kinases (PTK) and protein tyrosine phosphatases (PTPase) activity in tumor tissue, obtained from 107 patients with squamous cell carcinoma of the upper aerodigestive tract, was determined. In 79 patients samples were also taken from a histologically proven non-tumourous part of the mucosa. In this extensive study we confirmed our previous findings of increased enzyme activities (cytosol PTK, membranes PTK, cytosol PTPase) in non-tumour tissues compared with control tissues. These biochemical changes suggesting a premalignant mucosa could not be correlated to a higher probability of secondary tumours.

Protein tyrosine (de-)phosphorylation in head and neck squamous cell carcinoma.

Protein phosphorylation plays an important role in signal transduction of both normal and neoplastic cells. Since increased protein tyrosine phosphorylation may be associated with malignant transformation, we studied the activities of protein tyrosine kinases (PTK) and protein tyrosine phosphatases (PTPase) in patients with various head and neck tumors. Furthermore, we determined the patterns of tyrosine phosphorylated protein (P-tyr) in tissues by western blotting. Enzyme activities were studied in tumor and histologically normal, non-tumorous tissues of 54 patients and in 11 controls. P-tyr patterns were determined in 3 patients and 2 controls. PTK and PTPase activities were greater in tumor tissues than in normal tissue of the cancer patients as well as controls. P-tyr levels in tumors were also higher than in normal tissues. Additionally, PTK activity in normal tissue of tumor patients was significantly higher than in normal tissue of the control group. The same trend was observed for the PTPase activity and P-tyr levels.

Nasal discharge and obstruction as presenting symptoms of Wegener's granulomatosis in childhood.

A case with nasal manifestations as presenting symptoms of Wegener's granulomatosis in childhood is discussed. The diagnostic and treatment modalities are reviewed with emphasis on the specific problems concerning the side effects of treatment on the child.

[Acute mountain sickness and Menière disease]. / Mal aigu des Montagnes et crise de Ménière.

A professional mountain guide experienced an attack of vertigo at high altitude (4,000 m). Clinical data and the results of functional tests, were consistent with an attack of Meniere's disease. The physiopathological changes noted at high altitudes, and known as acute mountain sickness, are described. A hypothesis is suggested concerning the mechanism triggering this attack of Meniere's disease at high altitude.