Surgical Management of Dysphagia Due to Anterior Cervical Osteophytes.

PURPOSE: The present study was performed to share personal experiences and to discuss the advantages and disadvantages of anterior cervical osteophytes surgical procedures. METHODS: The operative records of anterior cervical osteophytes patients who did not benefit from conventional treatments and underwent osteophytectomy were analyzed retrospectively. Transoral and transcervical anterolateral methods were applied, considering both the localization of the osteophyte and the patient's preference. RESULTS: Five patients were operated with the transcervical anterolateral method, and 3 patients were operated with the transoral procedure. Those using the transcervical method were likely to encounter complications, however, being comfortable for patients. Although the transoral procedure is much safer, the patients may face postoperative pain, long healing time, and morbidities as hematoma, cervical instability, and infection after surgery. CONCLUSIONS: Both transcervical and transoral methods will improve the functional swallowing pathologies and decrease aspiration-penetration. Transoral approach is not recommended due to slow healing times and postoperative pain, although it creates easier access to the spine.

Effect of antibiotic use on bacterial flora of tonsil core in patients with recurrent tonsillitis.

The aim of this study was to investigate the effects of commonly used antibiotics on bacterial flora of the tonsil core. Patients who underwent tonsillectomy for recurrent chronic tonsillitis were included in the study. Three groups were formed: group 1 was treated for 10 days preoperatively with amoxicillin/clavulanic acid; group 2 was treated for 10 days preoperatively with clarithromycin; and group 3 included patients who underwent tonsillectomy without preoperative antibiotic use. The removed palatine tonsils were sent to our microbiology department in sterile tubes for bacteriological analysis. Seventy-three patients (group 1 = 19, group 2 = 20, group 3 = 34 patients) aged 3-18 years (mean 7 years) were included in the study. At least one bacterium was isolated from all tonsils, except for two cases in group 1; the difference in single bacterial growth among groups was not significant (p = 0.06). On the other hand, the numbers of patients with pathogenic bacterial growth was significantly lower in group 2 (n = 2) compared with group 1 (n = 10) and group 3 (n = 27) (p < 0.001). The bacterium isolated most frequently from the tonsils was Streptococcus viridans. Pseudomonas aeruginosa was the only pathogenic bacterium that grew in all three groups. Clarithromycin was more effective than amoxicillin/clavulanic acid in eradicating pathogenic bacteria in the tonsil core. Pseudomonas aeruginosa might be responsible for resistant or recurrent tonsil infections. To prevent endocarditis, antibiotic prophylaxis toward S. viridians, which is the most prevalent bacterium in the tonsil core, should be kept in mind for patients with heart valve damage.

Types of endoscopic endonasal resections for sinonasal malignancies.

AIM: The aim of this study was to define the types of endoscopic endonasal resection for sinonasal malignancies according to their origin and extension. METHODS: Patients who underwent endoscopic endonasal surgery for the removal of malignant tumors of the nasal passages, paranasal sinuses, and the anterior cranial base between 2003 and 2010 were included in the study. Patients' data were collected retrospectively. Patients were grouped according to types of endoscopic tumor resection as follows: type I: en bloc resection, type II: resection of intranasal free part piecemeal and origin of tumor en bloc, type III: resection of intranasal free part and origin of tumor piecemeal with curative intent, and type IV: resection of intranasal free part and origin of tumor piecemeal with palliative intent or removal of tumor with positive margin. The follow-up period varied from 2 to 7 years (mean, 4.35 years). RESULTS: Twenty patients were included in the study. Five patients underwent type I, 6 patients type II, 4 patients type III, and 5 patients underwent type IV resection. No local tumor recurrence was seen after types I, II, and III resections, whereas 2 patients (10%) with the type IV resection had a local recurrence. Distant metastasis was observed in 4 patients (20%) postoperatively (1 patient in type I, 1 patient in type III, and 2 patients in type IV resection). Disease-specific death was 15% (1 case in type I and 2 cases in type IV). CONCLUSION: Classification of endoscopic tumor resection used in the present study may help preoperative planning.

Predictors of surgical approaches for the repair of anterior cranial base encephaloceles.

Surgical approaches to the anterior cranial base have changed considerably with the introduction of endonasal endoscopic surgery. This study aims to define the factors which help in selecting the optimal surgical approach for the treatment of anterior cranial base encephaloceles. Patients who received treatment for anterior cranial base encephaloceles at our department between 1996 and 2011 were included in the study. Patients' charts were reviewed retrospectively to collect the necessary data. Treatment periods were classified as before 2000, between 2000 and 2005, and after 2005. The relationship between the treatment period, localization of encephalocele, symptoms related with the lesion, size of skull base defect, and selected treatment modality were investigated. Twenty-five patients, aged between 1 and 61 years with anterior encephaloceles were included in the study. Patients with small asymptomatic frontonasal and trans-ethmoidal encephaloceles (n = 5) were followed without surgery. An external approach with or without subfrontal craniotomy was mainly preferred for resection of sincipital encephaloceles (n = 10), especially with facial deformity. A subfrontal craniotomy approach was used for resection of basal encephaloceles in two cases before 2000. Two cases with sincipital encephaloceles and six cases with basal encephaloceles underwent pure endonasal endoscopic surgery after 2000. Cranial base defects of every size could be repaired using the endoscopic approach. Hydrocephalus and meningitis were the two complications seen after craniotomy in a follow-up period of 13-26 (mean 14.5) months. An external approach with or without craniotomy is needed for encephaloceles with external mass and facial deformity. Otherwise, sincipital and basal encephaloceles can be repaired successfully using the endonasal endoscopic approach.

[An evaluation of histopathological changes in ethmoid sinus mucosa after endoscopic sinus surgery]. / Endoskopik sinüs cerrahisi sonrasi etmoid sinüs mukozasindaki histopatolojik degisikliklerin degerlendirilmesi.

OBJECTIVES: This study aims to evaluate postoperative histopathological changes in ethmoid sinus mucosa in patients undergoing limited or extensive endoscopic sinus surgery (ESS) due to chronic rhinosinusitis. PATIENTS AND METHODS: A total of 120 patients (74 males, 46 females; mean age 33 years; range 18 to 56 years) with chronic rhinosinusitis who underwent limited ESS (n=40), extensive ESS (n=40) and septoplasty or septorhinoplasty (n=40) in our clinic between May 2009 and October 2010 were enrolled. The control group consisted of patients who underwent septoplasty and septorhinoplasty alone. We took samples from the anterior ethmoid sinus mucosa at postoperative sixth months for the patients who underwent ESS and intraoperatively for the control patients. Tissue slices of mucosa samples were investigated under light microscope in terms of epithelial erosion, squamous metaplasia, submucosal fibrosis, basal membrane thickening, submucosal edema and submucosal inflammation. Histopathological findings of limited and extensive ESS groups were compared to each other and the control group. RESULTS: The incidence of squamous metaplasia and submucosal fibrosis was significantly higher in extensive ESS group, compared to limited ESS group (p=0.003 and p<0.001, respectively). Both of ESS groups had significantly higher incidences of epithelial erosion, submucosal fibrosis, basal membrane thickening, submucosal edema, submucosal inflammation, compared to the control group (p<0.001). CONCLUSION: Our study results show that ethmoid sinus mucosa may be still abnormal at the postoperative sixth month following ESS, regardless of the extension of ethmoidectomy. These patients should be followed closely, as they may have recurrent rhinosinusitis in the postoperative period due to impaired mucociliary activity.

A case of rhinoorbital mucormycosis in a leukemic patient with a literature review from Turkey.

Mucormycosis (Zygomycosis) is a rare, invasive, opportunistic fungal infection of the paranasal sinuses, caused by a fungus of the order Mucorales. We report a case of rhinoorbital mucormycosis caused by Rhizopus oryzae in an acute lymphoblastic leukemia patient and review the 79 Mucormycosis cases reported in the last decade from Turkey. In our case, the diagnosis was made with endoscopic appearance, computerized tomography of the paranasal sinuses, and culture of the surgical materials. Following aggressive surgical debridement and parenteral amphotericin B therapy, the patient recovered completely. In Turkish literature, rhinocerebral manifestations were the most common form of the mucormycosis (64 cases), followed by pulmonary form (6 cases). The most common risk factor was hematologic malignancies (32 cases) and diabetes mellitus (32 cases), similar to those reported from the rest of the world. The etiologic agents responsible for the review cases were Rhizopus sp., Mucor spp., Rhizomucor spp., Rhizopus oryzae, Mucor circinelloides, and Lichtheimia corymbifera. Although various treatment modalities were used, amphotericin B was the mainstay of therapy. Mortality rate was found to be 49.4% in review cases. It seems that strong clinical suspicion and early diagnosis, along with aggressive antifungal therapy and endoscopic sinus surgery, have great importance for better prognosis in mucormycosis.

Castleman disease as a giant parapharyngeal mass presenting with dysphagia.

A giant unilateral parapharyngeal mass from the skull base to the vocal folds is presented in this case. A 20-year-old man experiencing dysphagia for 4 years was admitted, and his magnetic resonance imaging and computed tomographic scans showed a giant parapharyngeal ellipsoid mass from the left jugular foramen to the vocal folds. Its craniocaudal length was 9 cm. The left internal carotid artery was lateralized, and posterior glottic airway was narrowed by the mass. In digital subtraction angiography, 2 aberrant branches of the internal carotid artery were going inside the mass. After the excision, histopathologic evaluation showed the diagnosis, Castleman disease. This is the first case in literature presenting with the only symptom of dysphagia.

Optimum height from the roof of the choana for seeking the sphenoid ostium.

OBJECTIVE: The purpose of this study was to investigate the optimum height that the sphenoid sinus ostium can be probed safely from the roof of choana in a large group of patients. METHODS: The study was performed retrospectively. The 200 sphenoid ostia of the 100 patients whose thin-section computed tomography (CT) including the sphenoid sinus region, made for various reasons, were included in the study. The height of the sphenoid ostium and the skull base from the choana roof were measured on sagittal images of CT. Also, by calculating the ratio of first measurement to the second one, the location of the sphenoid ostium at the anterior wall of sphenoid sinus was determined proportionally. RESULTS: The mean height of the sphenoid ostium from the choana roof was 10.9 (SD, 2.3) mm (range, 5.7-21.5 mm), and the mean height of skull base along the anterior wall of sphenoid sinus from the choana roof was 21.3 (SD, 3.2) mm (range, 13.3-30.6 mm). The ratio of the first measurement to the second measurement was 0.5 (SD, 0.08) (range, 0.29-0.77). CONCLUSIONS: In conclusion, under endoscopic view, the sphenoid sinus ostium can be safely probed between 13.3 mm (the minimum skull base height) and 5.7 mm (the minimum sphenoid sinus ostium height) distance upward from the choana, but determining the height of the sphenoid sinus ostium preoperatively on CTs for each patient separately will increase the chance of success in probing the sphenoid sinus.

Unexpected tumor incidence in surgically removed unilateral and bilateral nasal polyps.

OBJECTIVE: The objective of the study was to investigate the postoperative tumor incidence on routine histopathologic examination of surgical specimens in patients who underwent endoscopic sinus surgery with the preoperative diagnosis of unilateral or bilateral nasal polyposis. METHODS: Patients who underwent endoscopic sinus surgery with the preoperative diagnosis of unilateral or bilateral nasal polyposis between 2000 and 2009 were included in the study as the 2 separate groups. In both groups, tumor incidence that had been noticed on routine postoperative histopathologic examination was recorded retrospectively. Patients who had a preoperative diagnosis other than nasal polyposis, determined on biopsy, were excluded. RESULTS: Of 251 patients included, 197 had the preoperative diagnosis of bilateral nasal polyposis, and 54 had unilateral nasal polyposis. No tumor was diagnosed on postoperative histopathologic examinations in patients with preoperative bilateral nasal polyposis. Seven patients (12.96%) with the preoperative diagnosis of unilateral nasal polyposis had tumors on postoperative histopathologic examinations. Two of these 7 patients had malignant tumors that were reported preoperatively by intranasal biopsy as inflammatory polyps. CONCLUSIONS: Diagnosis of a neoplasia is an extremely rare situation, unless there are special findings of tumor in patients with preoperative diagnosis of bilateral nasal polyposis. On the other hand, histopathologic examinations should be carried out in every case operated with preoperative diagnosis of unilateral nasal polyposis, as the tumor incidence is higher.

Prevertebral corridor: posterior pathway for reconstruction of the ventral skull base.

OBJECTIVE: Regional vascularized flaps, such as the pericranial and temporoparietal fascia flaps, are currently used for reconstruction of skull base defects after endoscopic endonasal surgery whenever local vascularized flaps, such as the nasoseptal flap, are not available. Two different transposition pathways, infratemporal transpterygoid and subfrontal, have been proposed for regional flaps. The objective of this study was to describe and assess the feasibility of the transposition of a vascularized pedicled flap from the occipital galeopericranium via the prevertebral space corridor into the nasopharynx. METHODS: Ten heads were injected with colored silicone. An endoscopic endonasal anterior craniofacial resection and panclival approach were performed in each specimen. The occipital flap was harvested using a previously described technique. The prevertebral corridor, extending from the neck to the nasopharynx, was dissected superficial to the paraspinal muscles. Computed tomography-based image guidance was used to assess the relationship between the corridor and adjacent neurovascular structures. Length of the corridor and pedicle and area of the donor flap were measured. RESULTS: The flap was harvested and successfully transposed into the nasopharynx using the proposed corridor in all studied specimens (10 heads, 20 sides). All flaps provided complete coverage of the skull base defects. The average length of the pedicle was 70.5 (SD, 6.5) mm, and the average length and width of the flap were 99.9 (SD, 14.6) mm and 59.3 (SD, 10.9) mm, respectively. The average length of the prevertebral corridor was 49.7 (SD, 4.8) mm. CONCLUSIONS: The occipital flap has favorable anatomic characteristics for use in skull base reconstruction. Transposition of the flap via the prevertebral corridor is a suitable option for vascularized reconstruction of expanded endonasal skull base defects when other local or regional flaps are not available. Additional clinical studies are necessary to define its role in endoscopic endonasal surgery.

Relationship between postoperative recurrence rate and eosinophil density of nasal polyps.

OBJECTIVES: Nasal polyps develop as a result of chronic inflammation, mostly accompanied by pronounced eosinophil leukocyte infiltration. In this study we aimed to investigate the relationship between eosinophil density in nasal polyps and the postoperative recurrence rate of this disease. METHODS: Forty-two patients who underwent endoscopic sinus surgery for massive nasal polyposis by one surgeon were included in the study. The eosinophil leukocyte densities in nasal polyps were determined retrospectively on histologic slides by use of computer-assisted image analysis software. The patients were assigned to group 1, in whom nasal polyps contained up to 3 eosinophils per 1,000 microm2, and group 2, in whom nasal polyps contained 4 or more eosinophils per 1,000 microm2. The postoperative recurrence rates of nasal polyps were compared in the two groups. RESULTS: There were 20 patients in group 1 and 22 patients in group 2. Postoperative polyp recurrence was detected in 5 of 20 patients (25.0%) in group 1 and in 18 of 22 patients (81.8%) in group 2 during the 30-month postoperative followup period (p < 0.05). CONCLUSIONS: The eosinophil density of nasal polyps can be used to get an estimate of the postoperative recurrence risk. Eosinophil-rich nasal polyps have a higher postoperative recurrence rate.

[Ophthalmic complications of paranasal sinus mucoceles]. / Paranazal sinüs mukosellerinin göz komplikasyonlari.

OBJECTIVES: This study aimed to describe ophthalmic complications of paranasal sinus mucoceles and principles of treatment. PATIENTS AND METHODS: The medical records of 25 paranasal sinus mucoceles patients (18 males, 7 females; mean age 35 years; range 20 to 62 years) that had been treated in two different ear, nose and throat clinics between the years January 2004 and June 2009 were evaluated retrospectively. Out of 22 patients of who had developed internal mucoceles in anterior paranasal sinuses, diplopia was observed in five, proptosis in four and partial loss of sight in one. Out of three patients with posterior paranasal sinus mucoceles, two developed diplopia and one developed proptosis, with loss of sight in all three. Eight patients were treated using osteoplastic flap technique and the remaining 17 were treated using endoscopic sinus surgery. RESULTS: In only one patient was loss of sight permanent whereas, in all the other patients eye complications resolved. CONCLUSION: In mucoceles that involve the posterior ethmoid and sphenoid sinuses loss of sight can be observed often because of their adjacency to the optic nerves, and loss can be permanent in advanced disease. It is possible to obtain good results in most patients treated in time with endoscopic sinus surgery and osteoplastic flep techniques.

Impact of endoscopic sinus surgery on sleep quality in patients with chronic nasal obstruction due to nasal polyposis.

OBJECTIVE: The aim of this study was to investigate the effect of endoscopic sinus surgery on sleep quality in a patient group who has chronic nasal obstruction resulting from nasal polyposis. METHODS: Twenty-seven patients with nasal polyposis, filling at least 50% of each nasal passage, were enrolled in the study. Assessment of nasal patency was determined by nasal endoscopy and acoustic rhinometry. All patients underwent endoscopic sinus surgery with polypectomy. Sleep quality was evaluated, using visual analog scale, Epworth sleepiness scale, and polysomnography before and 3 months after the surgery. RESULTS: Nasal resistance decreased significantly after the surgery (P < 0.01). Snoring scores were significantly improved postoperatively (P < 0.01) and completely disappeared in 9 of 27 patients. A significant improvement occurred in mean daytime sleepiness scores in the postoperative period (4.14) as compared with the preoperative values (9.44; P < 0.01). There was no significant difference between preoperative (6.85) and postoperative (5.53) mean values of apnea-hypopnea index (P = 0.55). CONCLUSIONS: Endoscopic sinus surgery with polypectomy significantly improves sleep quality, including snoring and daytime sleepiness in patients with chronic nasal obstruction due to nasal polyposis. However, it has a limited benefit on apnea-hypopnea index scores.

Choanal polyp originating from the nasal septum: septochoanal polyp.

Most of the nasal polyps arise from the lateral walls of the nasal cavity. Nasal polyps originating from the nasal septum with choanal extension are extremely rare. We report a case of large choanal polyp that arised from the posterosuperior aspect of the nasal septum, and extended down to the oropharynx. A 52-year-old woman presented with a two-year history of progressive nasal obstruction and snoring. Findings of anterior rhinoscopy were in normal limits. We think that the term "septochoanal polyp" which, as far as we know, has not been mentioned in the literature before, can be used for this rare lesion.

Spontaneous involution of nasopharyngeal angiofibroma.

There are several studies addressing regression of residual nasopharyngeal angiofibroma after surgery, but spontaneous regression of this tumor has been reported in only 2 cases. We present a case of nasopharyngeal angiofibroma that has involuted spontaneously in the last 5 years. The tumor had been diagnosed at another institute. Computed tomography taken in 2002 had revealed the tumor occupying the entire sphenoid sinus and the pterygopalatine fossa, extending to the cavernous sinus and the infratemporal fossa on the right side. The vascularization of the tumor had been mainly from the internal maxillary artery on angiography. The internal maxillary artery had been occluded with a coil, but branches of internal carotid artery could not be embolized due to high risks of complications. In 2004 the patient was seen at our institute, and this time, repeated angiography revealed rich vascularization from the internal carotid artery. The patient did not accept any treatment and was put on follow-up. He had no complaint in January 2007. The tumor was seen to disappear completely, except a little remnant at the right pterygopalatine fossa on computed tomography. This is the third reported case in the literature with spontaneous regression of nasopharyngeal angiofibroma.

Transnasal endoscopic repair of choanal atresia: results of 13 cases and meta-analysis.

Transnasal endoscopic approach for the repair of choanal atresia (CA) has gained favor in recent years. However, the studied cohorts are too small to make a comprehensive comment on this approach. The aim of this study was to evaluate the effects of different techniques, used for the removal of CA under endoscopic guidance, on surgical outcome and effectiveness of transnasal endoscopic approach in these patients as a whole. We present the results of transnasal endoscopic repair of CA in 13 patients and made a meta-analysis of similar studies in the literature. Mean success rate with transnasal endoscopic repair was 85.3% in a total of 238 cases in 20 studies that met the inclusion criteria. Only the history of previous surgery for CA seemed to significantly decrease the postoperative success rate (P = 0.029). Rate of revision surgery did not significantly differ between mixed, bony, or membranous atresia (P = 0.395). Likewise, simple perforation or complete excision of the atretic plate under endoscopic view (P = 0.513), use or no use of mucosal flap to seal the denuded bone of the choana (P = 0.472), and postoperative stenting or no stenting (P = 0.252) have proved not to considerably have influence on the surgical outcome. Death of perioperative bleeding was the single major complication in 1 case among all of the study groups. In conclusion, types of CA, excision method, and stenting have no significant effect on surgical outcome of CA. Irrespective of the technique used for the excision and the repair of atretic plate, transnasal endoscopic approach with higher success rate and minimal postoperative morbidity is a good choice for the repair of CA.

The effect of nasal polyposis related nasal obstruction on cognitive functions.

Chronic rhinosinusitis with nasal polyposis is a chronic inflammatory disease of the respiratory mucosa of the nasal cavity and paranasal sinuses. The aim of this study was investigate the effect of nasal obstruction related to chronic rhinosinusitis with nasal polyposis on cognitive functions. Patients with chronic rhinosinusitis with nasal polyposis causing bilateral total or near total nasal obstruction were enrolled in the study. Symptoms of nasal congestion, loss of smell, postnasal drip, headaches, snoring, concentration difficulties and blunted affect were evaluated by Visual Analog Scale. Brief symptom inventory test, Stroop test, visual aural digit span, serial digit learning test and P300 test were used to evaluate cognitive functions. Three months after treatment, the tests done before surgery were repeated and the results were compared. A total of 30 patients were included in the study. On the Visual Analog Scale, all symptoms showed significant postoperative improvement in all patients (p < 0.001 for all symptoms). Preoperative nasal congestion accompanied with impaired concentration were detected in 27 patients (90%), and these symptoms recovered in all these patients after treatment (p = 0.035) (correlation coefficient 0.4). Only 22 patients completed the neuropsychological tests. The mean preoperative Stroop test (23.16 ± 5.30), visual aural digit span test (24.68 ± 3.52), and serial digit learning test (16.18 ± 5.35) scores were showed significant improvement compared with mean postoperative Stroop test (21.12 ± 5.69), visual aural digit span test (26.45 ± 2.98), and serial digit learning test (19.31 ± 4.47) scores (p = 0.047, p = 0.022, p = 0.005 respectively). The postoperative P300 latency values improved in 19 (63%) patients. The preoperative and postoperative latency values for P300 showed a significant difference (p = 0.029), whereas the preoperative and postoperative amplitude values for P300 did not differ (p = 0.096). In conclusion, the results of this study indicate that chronic rhinosinusitis with nasal polyposis (CRSwNP) has negative effects on cognitive functions, such as the ability to focus and maintain concentration. These cognitive functions improve after the patients undergo endoscopic sinus surgery to treat their CRSwNP.

Intranasal fungi and chronic rhinosinusitis: what is the relationship?

OBJECTIVES: The aim of this study was to investigate the effects of intranasal fungi on chronic rhinosinusitis (CRS). METHODS: Forty-one patients with CRS were included in the study. The patients were put into 2 groups, with and without intranasal fungi as detected by polymerase chain reaction, and were compared in terms of different laboratory and clinical parameters of CRS. A chi2 test was used to analyze statistical differences between the 2 groups. RESULTS: Serum eosinophilia, eosinophilia in the nasal mucus, prick and intradermal test positivity for fungi, elevated total IgE, fungal-specific IgE, prevalence of symptoms, frequency of bronchial asthma, aspirin sensitivity, and nasal polyposis did not differ significantly between the 2 groups of patients (p > .05). CONCLUSIONS: The findings of this study failed to reveal a clear correlation between the presence of fungi in the nasal passage and various factors that are assumed to be involved in the pathogenesis or clinical course of CRS. If fungi have a role in the pathogenesis of CRS, it may be via other mediators and reactions rather than IgE and type I hypersensitivity. However, the sample size was relatively small, and further studies with more cases are needed on the same topic.

Primary nasolacrymal tuberculosis diagnosed after dacryocytorhinostomy.

Although tuberculosis (TB) is common and well recognized in many countries, unusual presentations of the disease sometimes raise difficulties in differential diagnosis. Primary tuberculosis of the lacrimal sac and the nasolacrimal duct is an extremely rare presentation of extra-pulmonary tuberculosis. Dacryocystorhinostomy alone is not sufficient for the treatment of these patients and an anti-tuberculous therapy has to be added. Here we present a patient with primary tuberculosis, which is limited to the inferior meatus and filled the entire lacrimal sac on the left side. The patient underwent endoscopic dacryocystorhinostomy due to obstruction of the nasolacrimal duct and culture of the granulation tissue, taken from the lacrimal sac revealed mycobacterial tuberculosis. The patient was improved with anti-tuberculous therapy that was added to the surgery. Primary tuberculosis is a rare granulomatous disease of the nasolacrimal system, which should be considered in the differential diagnosis to plan the effective treatment.

A rare cause of parotid swelling: primary hydatid cyst.

Hydatid disease is a zoonotic infection caused by Echinococcus species. Cystic form of this infection mostly involves liver and lung. Hydatid disease of the parotid gland is a very rare entity that may be easily overlooked in daily practice. On the other hand, rupture of the cyst during surgery may give rise to serious complications. We present a case of hydatid cyst of the parotid and discuss the differential diagnosis of this rare condition.