This report provides detailed guidelines for the surgical removal of a cholesteatoma using the canal wall-up (CWU) method. Five techniques for the CWU method are available to reduce the risk of complications and development of recurrent or residual cholesteatoma.
(1) The operation method must be decided prior to the operation by reference to computed-tomographic images.
(2) The cholesteatoma membrane must be pushed out from the back and removed en bloc.
(3) Two communication routes between the tympanic cavity and mastoid antrum (an anterior and a posterior route) must be created to provide a wide surgical field.
(4) A transcanal endoscope must be used to approach the cholesteatoma around the field of the tympanic sinus.
(5) A 1/2 to 1/3 filleted cartilage must be used for scutumplasty or tympanoplasty.
During cholesteatoma surgery, the canal wall-down (CWD) method or the canal wall reconstruction (CWR) method are sometimes used to reconstruct the external auditory meatus using soft tissue or temporal muscle tissue. These methods are appropriate if growth of the mastoid cavity is apparent or if indicated by the physical condition of the patient. However, the choice between the CWU and CWR method in terms of safety is a matter left to the judgment of the physician. If the external auditory meatus is destroyed, the CWD method must be chosen for re-operation after cholesteatoma recurrence. This greatly improves the postoperative quality-of-life (QOL) of the patients. Preservation of the external auditory meatus is extremely important, and it is imperative that every physician seeks to preserve it.
Newer quinolones such as garenoxacin (GRNX) and levofloxacin (LVFX) are widely used in clinical practice, and both are considered to be useful antibiotics. We conducted a multicenter randomized open-label trial to compare the usefulness of GRNX and LVFX for acute exacerbation of chronic otitis media.
We prospectively analyzed 21 patients with chronic otitis media, and assigned them randomly to receive one of the two antibiotics, which was taken orally for seven days. We used subjective symptoms and objective findings to evaluate the improvement.
Both the subjective symptoms and objective findings improved significantly after treatment in both the groups, and there were no significant differences in the evaluation scores between the two groups. The clinical efficacy as judged by the prescribing physician after the treatment course also did not differ significantly between the two groups.
We report the case of an HIV-seropositive patient with Ramsay Hunt syndrome. A 55-year-old bisexual man diagnosed as being HIV-seropositive was started on anti-retroviral therapy (ART), because his CD4+T cell count had decreased to under 200/μL over a period of 2 months. A week after the start of ART, he was diagnosed as having Ramsay Hunt syndrome, based on the presence of herpes zoster oticus and a positive serological test for VZV antibody. We speculate that the facial palsy was associated with the immune reconstitution inflammatory syndrome (IRIS), as follows. The decrease of the CD4+T cell count induced reactivation of VZV in the geniculate ganglion, but facial palsy did not develop. With the reconstitution of the immune system associated with increase of the CD4+T cell count by the ART, the reactivated VZV in the geniculate ganglion elicited an inflammatory response; the associated release of cytokines caused injury to the facial nerve.
Intraosseous hemangioma is a rare disease, accounting for 0.5% to 1% of all osseous neoplasms. If only osseous neoplasms in the cranium and facial bone are oconsiderd, this disorder would account for only 0.2% for all cases.
We describe the case of a 48-year-old female who was referred to our hospital, complaining of nasal congestion and excessive lacrimation. CT of the nasal and paranasal space showed a honeycomb appearance of the left inferior nasal concha. We performed surgical excision, and postoperative histopathology revealed the diagnosis of cavernous hemangioma.
For the treatment of hemangioma of a facial bone, one of several strategies may be used, including surgical excision, embolization, laser ablation, or observation. The selection needs to be made on a case-by-case basis. If the tumor is complicated by hemorrhage, cosmetic problems or mass effect, surgical excision is needed as soon as possible. In our case, we chose excision because of excessive lacrimation caused by the tumor.
The postoperative course was uneventful, and the patient has shown no recurrence and symptomatic improvement during the two years since the surgery.
Deep neck abscess is a life-threatening complication of odontogenic and oropharyngeal infections that can progress to descending necrotizing mediastinitis. On the other hand, phlegmonous pharyngo-esophagitis is very rare, with only a very few reports in the literature. Therefore, this disease is difficult to diagnose definitively, and no method of treatment has been established yet.
Herein, we present a case of phlegmonous pharyngo-esophagitis complicated by a deep neck abscess that was managed by systemic antibiotic treatment and surgical intervention on two occasions.
The subject was a male aged 68 years old, who was admitted to our hospital complaining of sore throat and pain on swallowing. Computed tomography (CT) revealed thickening of the hypopharyngeal and esophageal walls, with an intramural low-density area. After intravenous broad-spectrum antibiotic treatment, a drainage procedure was accomplished: open dissection of the neck via video-assisted thoracic surgery. However, due to persistence of the CT findings and elevation of the serum C-reactive protein level, a secondary surgical intervention was executed via a mediastinoscope; this led to successful discharge of pus from inside the esophageal wall.
The treatment strategy for phlegmonous pharyngo-esophagitis should include systemic antibiotic treatment, appropriate surgical drainage and adequate supportive care.
We report a case of metastasizing pleomorphic adenoma of the parotid gland that was diagnosed from a renal metastasis.
The patient was a 63-year-old man who was referred to our Department of Urology with a right kidney tumor detected on abdominal CT. Right nephrectomy was performed and histopathologic examination of the resected tumor revealed features consistent with pleomorphic adenoma. Careful examination revealed a right parotid tumor, and the patient was referred to our department. The patient had first noticed the right parotid tumor 10 years ago; it had been biopsied then and declared as being non-malignant by neighborhood doctor. The right parotid tumor was excised and the histopathological findings resembled those of the kidney tumor. The patient was diagnosed as having metastasizing pleomorphic adenoma of the parotid gland. In case of metastasizing parotid adenoma, usually, the metastasizing pleomorphic adenoma recurs locally after parotid tumor surgery, and metastasis is confirmed subsequently. Our case was an extremely rare case, in that the patient presented with a renal metastasis even in the absence of a history of surgery. We review some cases of metastasizing pleomorphic adenoma reported in the literature.
We report a case of papillary carcinoma arising from the thyroglossal duct. The patient was a 53-year-old woman who presented with an anterior neck mass. CT revealed a relatively well-delineated tumor in front of the hyoid bone, with minute calcifications observed within the tumor. We performed fine needle aspiration cytology, but were unable to arrive at a definitive diagnosis before operation. As the tumor was suspected to be of thyroglossal duct origin, we extracted it by the Sistrunk method. Postoperative histopathological examination revealed the diagnosis of papillary cancer arising from the thyroglossal duct. Diagnostic imaging is useful for differentiating thyroglossal duct carcinoma from a thyroglossal cyst. On diagnostic imaging, it is necessary to bear in mind the possibility of thyroglossal duct carcinoma, if findings that are not typical of thyroglossal cysts are observed, such as cyst wall thickening or irregularity and solid lesions inside the cyst. In thyroglossal duct carcinomas, solid components and calcifications are often found, and in particular, the presence of microcalcifications seems to be a distinct diagnostic imaging finding of thyroglossal duct carcinoma.
A congenital cartilaginous rest in the neck is rare. It is referred to by various names, such as accessory auricle in the neck and neck cartilage nevus, but recently, “cervical chondrocutaneous branchial remnant” has been the most commonly used.
We report a case with a congenital chondrocutaneous branchial remnant. The patient, a female, was admitted with a left cervical mass present since birth. The mass was located in the lower part of the anterior border of the sternocleidomastoid muscle. There were no symptoms and no other malformations. We performed surgical excision of the mass when the child was 4 years old. Histopathological examination of the resected mass showed elastic cartilage, based on which we made the diagnosis of cervical chondrocutaneous branchial remnant.
Congenital cartilaginous rest of the neck originates in the branchial arches, such as the thyroid cartilage and cricoid cartilage. It rarely remains in an external cervical subcutaneous site. Clinical characteristics include predominance in males, location predominantly in the lower part of the anterior border of the left sternocleidomastoid muscle, and a high frequency of malformations. In our case, while the site was consistent with previous reports, the patient was female and there were no associated malformations. It is important to recognize that some of these cases may have other systemic malformations.
Rosai-Dorfman disease (RDD) is a rare proliferative histiocytic disorder characterized by persistent massive lympadenopathy mimicking malignant tumors. Herein, we describe the case of 78-year-old male patient with RDD of the head and neck. The patient was referred to our hospital with a left neck mass. Computed tomographic (CT) examination revealed a subcutaneous tumor on the left side of the neck. 18F-Fluorodeoxyglucose positron emission tomography (PET)/CT revealed elevated uptake in the mass, the ribs and the thoracic vertebrae. Left cervical lymph node biopsy, as part of a whole-body examination performed bearing in mind the possibility of cancer of unknown primary origin, initially revealed no diagnosis other than reactive lymph nodes. Therefore, a thoracic spinal biopsy was additionally performed. When the lymph node biopsy specimens were reviewed again, the findings were found to be consistent with the diagnosis of RDD. RDD is a rare disease characterized by emperipolesis, in which lymphocytes and erythrocytes are taken up, without degeneration, in histiocytic spheres. The patient was then treated with a steroid, which resulted in improvement of both the neck lymph node swelling and the blood findings.
Methotrexate (MTX) is recognized as a standard therapeutic drug for rheumatoid arthritis (RA). However, with long-term treatment, patients can occasionally develop severe complications, including malignant lymphoma (MTX-related malignant lymphoma). Herein, we report 2 cases of malignant lymphoma of the head and neck, presenting more than 2 years after the start of MTX treatment for RA. Case 1 was a female in her 50s who presented with enlarged, non-tender cervical lymph nodes. Lymph node excision biopsy revealed the diagnosis of typical Hodgkin lymphoma, based on the detection of characteristic Reed-Sternberg cells. Case 2 was a female in her 60s with a past history of iterate and chronic right parotitis, who presented with a soft and solid ipsilateral parotid mass. Biopsy of the right parotid mass revealed MALT lymphoma with clear B cell characteristics of the tumor cells. Considering the possible causal involvement of Epstein-Barr virus (EBV), in-situ hybridization of the lymphoma tissues was performed in both cases, which revealed a positive result for EBV-encoded RNA (EBER) in Patient 1. The tumors in both cases failed to resolve even after discontinuation of MTX, and the patients were immediately referred to our hematology/oncology department for further treatment. Patient 1 was administered chemotherapy with a multi-drug combination regimen, and Patient 2 was treated by topical external beam radiation (38 Gy in 20 fractions) for the parotid tumor. Both patients showed satisfactory response to the respective treatments and have shown no evidence of recurrent disease until now. In this article, we wish to emphasize that it is important for otorhinolaryngologists to bear in mind the possibility of MTX-related malignant lymphoma in the differential diagnosis of head and neck masses, particularly in cases of RA treated with MTX.