Leptomeningeal carcinomatosis is often associated with acoustic nerve and facial nerve involvement, similar to the case in acoustic nerve tumors, hence, distinction between the two is often difficult. We report a patient of leptomeningeal carcinomatosis who was initially treated as a case of acoustic nerve tumor (AT), but was diagnosed after several months during follow-up as a case of leptomeningeal carcinomatosis. An 82-year old man with bone metastases from lung cancer visited us with the complaint of difficulty in hearing on the left side. Soon thereafter, he developed difficulty in moving the left side of the face. Based on the findings of MRI, we assumed the diagnosis of AT and began to treat the patient with steroids. However, the symptoms began to get worse and started to spread to the opposite side. A cerebrospinal fluid examination revealed the presence of atypical cells. Based on this finding, we diagnosed the patient as having leptomeningeal carcinomatosis.
Herein, we report the case of a 57-year-old woman diagnosed as having steroid-responsive sensorineural hearing loss who presented to us with nystagmus of many patterns. The major symptoms were bilateral hearing loss, tinnitus, and vertigo. Laboratory findings revealed increased serum levels of rheumatoid factor, IgG, IgM, and MMP-3, however, the patient had no other evidence of immune disorders or autoimmune disease. The symptoms improved after treatment with prednisolone. Based on this improvement with steroid treatment, the diagnosis of steroid-responsive sensorineural hearing loss was made, although association of vestibular dysfunction and absence of other evidence of immune disorders are rare with this disease. Patterns of nystagmus are different respectively. Nystagmus is only right direction, left direction, or combined right and left direction. The patient developed recurrence soon after discontinuation of the steroid, suggesting that the steroid should be tapered gradually in such cases, similar to the case in patient with autoimmune diseases.
Functional hearing loss is often misdiagnosed as sensorineural hearing loss, and patients may be forced to receive unnecessary treatment. In this study, we examined the clinical characteristics of children with functional hearing loss. A total of 37 children with functional hearing loss (55 ears) diagnosed over the past 7 years were enrolled. The subjects comprised 8 boys and 29 girls, with an average age of 10.7 years (range, 5–17). While 7 of these children were found incidentally to have hearing loss during school health examination, the remaining 30 children visited our hospital with symptoms. Twenty-one children had functional factors, and 16 children were not conscious of their hearing loss. Interestingly, almost a half of the children (51.4%) had only unilateral hearing loss. Pure-tone audiometry showed moderate-severe horizontal-type hearing loss in most cases. In self-recording audiometry by Bekesy, 47% of the ears showed Jerger type V, a unique, but not specific, finding, in cases of functional hearing loss. All children showed normal response in the stapedius reflex (SR) test and auditory brainstem response (ABR). ABR was most useful and SR was useful as a screening test for functional hearing loss. Boys and children with unilateral hearing loss showed a good prognosis, which was not dependent on the severity of the hearing loss.
Cisplatin (CDDP) is widely used as an effective antineoplastic drug for cancers of various organs, and is also known to cause ototoxicity. In this study, we report on the incidence of and factors related to CDDP-induced hearing loss, and the time-dependent change of the hearing level among these patients.
Twenty patients with head and neck cancers treated with chemoradiotherapy using CDDP in our institution were enrolled and analyzed. As chemotherapy, three cycles of concurrent CDDP were administered on weeks 1, 4, and 7 of radiotherapy. Pure-tone audiograms were performed before and 1 week after each course of administration of the CDDP. Adverse events including hearing impairment were assessed through the National Cancer Institute Common Toxicity Criteria (NCI CTCAE) v4.0.
The incidence of hearing loss was 45% in this patient group (Grade1 was reported in 6 patients, and Grade2 was reported in 3 patients). Hearing thresholds at 8 kHz were remarkably worse than at any other frequencies. Furtheremore, hearing loss related to creatinine increased and the white blood cell count decreased.
These results indicate that there were individual differences, for example drug metabolism-related factors, related to CDDP-induced hearing loss.
The aim of this study was to evaluate the differences in music perception in subjects with hearing aids depending on the mode in which the hearing-aid was set. In all, 11 subjects with normal hearing and 6 with hearing impairment were enrolled in this study. The hearing aid was set in two modes: a mode beneficial for speech perception (mode A), and a mode beneficial for music perception (mode B). Perception of music and the speech intelligibility through the hearing aid was examined in the subjects with normal hearing. Subjects with hearing impairment were tested for their music perception with their own hearing aids set in the usual mode.
In the subjects with normal hearing, the perception of music was more positive with the hearing aid set in mode B as compared to that set in mode A. Factor analysis revealed high regression factor scores for “beautiful and powerful” in mode B, while the average score for speech intelligibility was significantly decreased in this mode. On the other hand, in subjects with hearing impairment, music perception was better in bilateral long term hearing-aid users than in subjects who scarcely used hearing aids.
In a nystagmus test under an infrared camera, nystagmus images are not only observed on monitors but also stored in video devices, etc. When they are saved as video images, it is very important to find a way to record the information of the head positions on the video.
We developed a videonystagmography system with head-position recording embedded in it: a USB infrared camera and a motion sensor device are attached to a pair of goggles made by a 3D printer and then the goggles are connected to a computer with a USB cable: the data generated by the sensor create head animation which is correlated with the nystagmus images using the software that we developed.
Herein we report on the system in our clinic which is much lighter in weight and significantly more portable than the existing head-position recording system produced by medical equipment manufacturers because no power supply is required if it is used with a portable computer.
Malignant external otitis is a severe infection of the external auditory canal, most commonly caused by Pseudomonas aeruginosa in elderly patients with diabetes. Due to the host’s immunocompromised state, malignant external otitis may easily lead to osteomyelitis of the skull base, which may be associated with potential life-threatening complications needing urgent treatment.
Treatment of osteomyelitis consists of debridement, systemic antibiotic administration and management of the immunosuppressed state of the patient. However, in the case of skull base osteomyelitis, complete debridement is often difficult because of anatomical constraints.
We present a case of atypical temporal bone osteomyelitis occurring in a healthy woman without diabetes or pseudomonas infection. A 25-year-old woman was admitted to our hospital with the chief complaint of severe right otalgia which could not be controlled even by thrice-daily intake of painkillers. A slightly reddened skin lesion was found in the bony ear canal; however, neither active aural discharge nor inflammatory stenosis of the canal was found. CT scan showed an osteolytic lesion in the right bony ear canal. Malignancy, osteomyelitis or other unspecified lesion was suspected, and exploratory surgery was performed. Elevation of the tympanomeatal flap revealed eroded bones just beneath the reddened skin, which were completely drilled out by retroauricular mastoidectomy. The dissected specimens were composed of eroded bones, with fibrosis and infiltration by lymphoid and plasma cells. Therefore, the patient was finally diagnosed as having osteomyelitis of the temporal bone. Her clinical symptoms resolved immediately after the surgery, suggesting that complete debridement was effective for controlling the disease.
In cases of prolonged and severe otalgia not responsive to ordinary treatments, osteomyelitis should be considered and CT is recommended for early diagnosis and surgical intervention.
We participated in a clinical trial for a hearing aid system in Japan, “Verification of the efficacy and safety of the middle ear implant MVS (Medel Vibrant System) in conductive and mixed hearing loss”. We present a report of a case that we encountered in our department.
MVS is a Vibrant Soundbridge® (VSB) middle ear implant device that is approved and is in wide use in Europe and the United States. It has been shown to have the potential to provide a high level of acoustic clarity and sound quality. Also, as compared to conventional hearing aids, there is no howling and the distortion frequency is lower. An additional advantage is the excellent transient response.
The patient was a 33-year-old woman, with a history of bilateral hearing loss from birth, who was under observation whilst wearing a hearing aid. In an attempt to improve her hearing, we admitted her to our hospital. Based on the diagnosis of middle ear malformation and mixed hearing loss on both sides, we performed bilateral tympanoplasty. Since the hearing improvement following this procedure was poor on the right side, we prescribed a hearing aid. However, the patient did not adapt satisfactorily to this device. Four years after the initial diagnosis, we performed VSB middle ear implant surgery using the round window stimulation method, placing the transducer in the round window. The postoperative results were good. The speech inspection noise levels in both ears under a free-field, silent setting were 60 dBHL 85%, and 50 dBHL 100%. Thus, the postoperative course was good, the patient’s satisfaction level improved and no adverse events occurred.
VSB is likely to be a useful tool in rescue surgery for refractory middle ear cases. Also, it is useful as a standard rescue procedure in difficult hearing aid cases. In practice, otologic procedures are intended to improve the QOL and meet requirements in both diverse cases and individual patient conditions. Therefore, dissemination of VSB as one of the treatment choices for improving hearing loss is expected in the future.
Ceramic ossicular replacement prostheses have been used for more than 30 years in Japan. The use of these prostheses was limited to certain institutions. Recently, artificial materials, mainly titanium, have come to be used more commonly in Europe and the USA. In Japan also, these new types of prostheses are frequently used to reconstruct the ossicular chain. These prostheses are effective as long ceramics for type IV tympanoplasty and lateralized tympanic membranes. However, there are issues with the surgical method employed to return the lateralized tympanic membrane to its physiological position. In many patients, the tympanic membrane returns to its previous lateralized location after the surgery, resulting in recurrent lateralization. Due to this phenomenon, no desirable amelioration of hearing is observed in some patients. We have reported improvements in hearing with the use of a long ceramic without changing the location of the tympanic membrane. However, there are still patients with extremely lateralized tympanic membranes for whom even the use of the long ceramics proves ineffective for reconstruction of the ossicular chain.
We observed a patient with an extremely lateralized tympanic membrane, which was in such an advanced state, that a finger could easily touch the tympanic membrane through the external ear. We reported a case in which implantation of both P- and T-type ceramics, which were securely stuck to each other with medical Aron-Alpha, into the area between the lateralized tympanic membrane and the stapes improved hearing.
This study was designed to analyze the clinical features of patients who underwent surgery in Seirei Hamamatsu General Hospital for secondary acquired cholesteatoma (SAC). The subjects were 19 patients (19 ears) who underwent surgery for SAC in our hospital from 2001 to 2013. We investigated the age distribution and sex in SAC compared with primary cholesteatoma. There were 6 males (31.6%) and 13 females (68.4%), with a mean age of 55.9 (±19.8) years. SAC had high incidence in elder women compared with primary cholesteatoma. However, in only 2 cases, SAC was seen in children who had a history of insertion of a tympanic ventilation tube. We indicated the history of surgery as one of risk factors of SAC. Based on the site and pattern of invasion of the tympanic membrane (TM) epidermis, the cholesteatoma was classified into two types. The types were the perforation type where the epidermis invaded from the edge of the perforation, and the malleus manubrium type where the epidermis invaded from around the malleus manubrium to the promontory. The TM perforation was smaller in size in the perforation type compared with the malleus manubrium type. The extent of cholesteatoma invasion and destruction of the surrounding tissues were severe in the malleus manubrium type. The canal wall down tympanoplasty with a canal reconstruction procedure was adopted in all cases. The postoperative hearing improvement rate was 83.3% in the perforation type and 88.9% in the malleus manubrium type. There were no cases of recurrence of the cholesteatoma. The pathogenesis of SAC still remains unknown, which is clearly different from that of other types of cholesteatoma, so it is important to elucidate the mechanisms.
The internal carotid artery (ICA) that runs laterally to the lateral aspect of the vestibule is defined as an aberrant ICA. Aberrant ICAs in the middle ear are relatively rare, however, it is important for otolaryngologists to recognize the entity, since common procedures, such as myringotomy, can lead to serious complications. We report herein on three cases with an aberrant ICA in the middle ear.
In Case 1, a 49-year-old female presenting with hearing loss (HL) and pulsatile tinnitus (PT) in her left ear was referred to our hospital with an initial diagnosis of a glomus tumor. Otoscopic examination revealed a reddish pulsatile mass behind the anteroinferior quadrant (AIQ) of the tympanic membrane (TM). A pure-tone audiogram showed bilateral mild mixed HL. In Case 2, a 64-year-old male presented to our hospital with PT in his right ear. Otoscopic examination revealed a reddish mass behind the AIQ of the TM. Her audiogram showed sloping sensorineural HL in the right ear, which was considered to be presbycusis. In Case 3, a 31-year-old female presenting with bilateral HL and PT in her left ear was referred to our hospital. Otoscopic examination revealed a reddish pulsatile mass behind the AIQ of the TM. Her audiogram showed bilateral mixed HL. An auditory brainstem response test and Bekesy audiogram indicated the presence of functional deafness. In all cases, computed tomography (CT) scans of the temporal bone showed characteristic findings of an aberrant ICA: 1) absence of the vertical carotid canal; 2) enlargement of the inferior tympanic canaliculus; 3) an aberrant course of the artery through the hypotympanum and 4) dehiscence of the carotid plate through which the artery enters the horizontal carotid canal.
A careful otoscopic examination should be performed to evaluate patients with PT. CT scans of the temporal bone can provide a definitive diagnosis of an aberrant ICA in the middle ear.
In surgery for carcinoma of the external auditory canal, in cases where the cancer has spread to the surrounding tissues, it is often necessary to resect the parotid gland and mandibular joint together with the auditory canal. After the resection, to fill the defect, free flaps are commonly used, although pedicle flaps and transposed fats are also frequently used. However, in cases with a post-surgical complications such as infection or necrosis, it is often difficult to preserve the morphology and function in follow-up surgeries. Recently, when operating on cases of carcinoma of the external auditory canal, we have been able to preserve the facial nerve function, while removing the ear canal as well as the parotid gland and part of the mandibular joint. We have encountered cases where, after performing a fat transposition procedure in the area, within half a year, the transposed fat becomes infected and necrotic. In such cases, it is often effective to use a pedicle temporalis muscle flap in the follow-up surgery. The temporalis muscle flap may also be used for reconstruction even at the initial surgery for carcinoma of the external auditory canal, and even in cases where it proves difficult to expose the facial nerve, it is possible to preserve the nerve function.
Introduction: It has been reported that invasive fungal infections of the paranasal sinuses can lead to cerebrovascular disorder. Herein, we report two cases of invasive mycosis of the paranasal sinuses in which MRI/MRA revealed stenosis of the internal carotid artery.
Case 1: A 78-year-old male patient presenting with a 4-month history of visual field loss on the left side was diagnosed as having left optic perineuritis. CT revealed bilateral soft-tissue density within the sphenoethmoidal cells. MRI revealed that the lesion spread from the left orbital tip to the cavernous sinus. Bilateral endoscopic sinus surgery (ESS) was performed. We found fungal spores in both the sphenoethmoidal cells and in the defect in the left optic canal bone. Histopathology confirmed that the spores belonged to Aspergillus species, and the patient was started on treatment with oral voriconazole. MRI/MRA performed 1 month post-surgery showed stenosis of the left internal carotid artery siphon. No evidence of cerebral infarction was observed, presumably because of collateral cerebral blood flow. Until now, 4 years since the surgery, follow-up has revealed no evidence of recurrence of the lesion, although MRI/MRA reveals stenosis in the same region.
Cases 2: A 61-year-old male patient presenting with a 2-month history of visual disturbance on the left side was admitted to our ophthalmology department. CT showed a soft-tissue density within the left ethmoid and sphenoid sinuses. MRI revealed orbital and intracranial invasion. Biopsy was performed via endoscopic sinus surgery (ESS), and a final histopathological diagnosis of Mucor infection was made. The patient was started on treatment with liposomal amphotericin B. One month post-surgery, MRI/MRA showed stenosis of the left internal carotid artery siphon. The patient suffered multiple organ failure, and died 131 days after hospital admission.
Conclusion: We report two cases of internal carotid artery stenosis associated with invasive mycosis. Patients diagnosed with invasive mycosis should be considered to be at a high-risk for potential cerebral infarction and cerebral hemorrhage, and undergo cerebrovascular evaluation by MRI/MRA.
We report herein on a case of a copepod parasite identified in the left nasal cavity. An 80-year-old woman visited our hospital with a chief complaint of delusions of parasitosis of the nails, skin, and nasal cavity. A foreign body that looked like a worm was detected in the left nasal cavity and removed. This appeared to be a parasite called a copepod. The patient was diagnosed by the mental health department as having skin delusional parasitosis due to dementia. Although the route of infection to the nasal cavity is unknown, there is a possibility that the patient inserted the copepod into the nasal cavity herself, to justify her symptoms of delusions of parasitosis.
Inverted teeth in the nasal cavity are a rare clinical entity. We report herein on a case with resection via the endoscopic endonasal approach. A mass in the left nasal cavity was incidentally found in a 1-year-old boy at the local otolaryngologist, and the infant visited our department, suspected as having a nasal tumor. Anterior rhinoscopy indicated a peduncular lesion with partial calcification 3 mm behind the cutaneomucous transition site of the left nasal cavity. CT imaging indicated a mass with soft tissue density in the left nasal vestibule. We speculated an ectopic tooth or a teratoma including tooth tissue. We subsequently endoscopically removed the tumor via the endonasal approach under general anesthesia. The post-operative finding was an inverted ectopic tooth in the nasal cavity. Early diagnosis and treatment are required to prevent concomitant nasal symptoms.
Actinomycosis is an unusual inflammatory disease caused primarily by Actinomyces israelii, a Gram-positive anaerobic bacterium. The disease is characterized by board-like swelling with unclear borders, and multiple abscesses; since the swelling can have similar characteristics to those of malignant tumors, the diagnosis can be difficult.
We report one case of actinomycosis of the maxillofacial region associated with carious teeth and chronic osteomyelitis of the mandible.
The patient, an 88-year-old woman, complained of a swelling in the right maxillofacial region with pain and trismus. Purulent parotitis was suspected and treatment was started with a cephem antibiotic. However, the refractory parotitis became worse, with the formation of multiple abscesses in the parotid gland and destruction of the cheek skin. While histopathological examination revealed no evidence of malignancy and pus culture from the cheek abscess showed no significant bacterial growth, Actinomyces was detected on gram’s staining of the pus smear, and the two carious teeth, which were associated with chronic osteomyelitis and destruction of mandible in on the right side, were considered as the source of the infection. The carious teeth were extracted.
The patient was treated with oral AMPC for 4 months, and has since shown no evidence of recurrence of the infection.
Since the characteristics of the lesions in actinomycosis can be similar to those of malignant tumors and the condition is refractory to general treatments given for bacterial infections, it is important for clinicians to make a precise diagnosis of actinomycosis and provide prompt and appropriate treatment.
We report the case of a patient with allergic fungal rhinosinusitis presenting with vision loss. A 49-year-old man presented to the JCHO Osaka Hospital with acute loss of vision in the right eye. Computed tomography showed bony erosion of the right lateral wall of the Onodi cell, close to the optic canal. Emergent endoscopic sinus surgery was performed. Histopathology revealed eosinophilic mucin in the Onodi cell and the sphenoid sinus. The optic canal was not detected due to the edematous mucosa. After the operation, the patient was treated with a systemic steroid for about 1 month. Based on the clinical and histopathological findings, the patient was diagnosed as a case of allergic fungal rhinosinusitis. With treatment, eventually, the visual loss improved.
Histopathological examination is necessary to confirm the diagnosis of allergic fungal rhinosinusitis. Therefore, when endoscopic sinus surgery is perfoemed, the mucin should be examined to confirm its allergic nature. This disease often recurs, therefore postoperative observation is important.
While no cases of allergic fungal rhinosinusitis presenting with acute blindness have been reported previously from Japan, about 20 cases have been reported from foreign countries. The lesions in this condition mainly involve the sphenoid sinus, orbital apex and the cavernous sinus. No cases with Onodi cells have been reported. We have reported a prevalence of Onodi cells of 26% in our report, and of a pneumatized anterior clinoid process in the Onodi cells of 30%. We need to be aware of the presence of Onodi cells and pneumatized anterior clinoid processes so as to prevent damage to the optic canal.
A cranial nerve disorder with sphenoid sinus disease is known to occur in rhinogenic optic neuropathy or orbital apex syndrome, or as a symptom of cavernous sinus thrombosis. Paralysis of the hypoglossal nerve associated with sphenoid sinus disease is a rare complication, and it has never been reported in isolation. We report herein on a case of sphenoid sinus mucocele associated with isolated paralysis of the hypoglossal nerve. A 36-year-old woman who had a headache and difficulty extending her tongue was referred to our hospital. On physical examination, she showed no neurological abnormalities except isolated right hypoglossal nerve paralysis. Computed tomography and magnetic resonance imaging suggested the presence of a single sphenoid sinus mucocele with osteoclastic changes but no other nervous system disease. In this case, the lower portion of the sphenoid sinus had grown inferiorly onto the hypoglossal canal. Therefore, we diagnosed the hypoglossal nerve paralysis as being caused by this sphenoid sinus mucocele. The patient underwent endoscopic sinus surgery on the 2nd day after admission. Her headache vanished immediately after this operation, and complete hypoglossal nerve recovery was achieved 3 months after the surgery.
Sphenoid sinus disease may cause paralysis of the hypostatic cranial nerve because the shape of the sphenoid sinus varies amongst individuals. During the course of diagnosis of such paralysis, clinicians should consider the possibility of posterior sinus disease.
Concurrent chemoradiation therapies such as superselective arterial infusion and concomitant radiotherapy (RADPLAT) have been successful in treating sinonasal malignancies. One often neglected side effect of sinonasal chemoradiation therapy is nasolacrimal obstruction due to the proximity of the sinonasal sinus to the orbit. This causes dacryorrhea and the reduction in quality of life is inevitable. A dacryocystorhinostomy (DCR) is an effective method to reconstruct lachrymal passage. To our knowledge, however, there is no report of this method being employed to treat nasolacrimal obstruction caused by radiation therapy of sinonasal malignancies.
We performed DCRs for lachrymal passage reconstruction on 6 patients (5 male, 1 female with median age of 64.5 yr), who had exhibited nasolacrimal obstruction after radiation therapy for sinonasal malignancies. Dacryorrhea completely disappeared in 4 patients within one week postoperatively, and the symptom was alleviated significantly in the other two patients. Although the number of cases studied so far is limited, DCR is probably effective in reducing the symptom rather rapidly. We propose to continue performing DCRs on patients suffering from nasolacrimal obstruction after radiation therapy and to examine its long-term effectiveness.
We report a case of actinomycosis of the maxillary sinus secondary to foreign bodies. A 49-year-old woman was referred to our hospital for maxillary sinusitis with foreign bodies. A plain x-ray and CT showed evidence of left maxillary sinusitis with linear radiopaque shadows. We therefore performed endoscopic sinus surgery, and fungus-like lesions and foreign bodies were removed from the maxillary sinus. The removed foreign bodies were identified as pieces of the root canal filling agent called gutta-percha point. Histopathological examination revealed the presence of actinomyces. We thought that the foreign bodies were accidentally inserted into the maxillary sinus during dental treatment. The patient had a good postoperative course and has been followed up for 18 months after the surgery. In a patient presenting with radiologic evidence of unilateral paranasal sinusitis, actinomycotic sinusitis as well as fungal sinusitis should be suspected. In most cases of foreign bodies in the maxillary sinus, the foreign body is dental material. It is important to perform a detailed medical examination and to consult a dentist.
Dental implant surgery is carried out in edentulous patients to fix the denture on the foundation of a dental implant body embedded in the maxilla. This procedure has become popular over the last 20 years, and one of the complications is the intrusion of the dental implant body into the paranasal sinuses.
Herein, we report the case of a 64-year-old man in whom a dental implant body was found in the ethmoid sinus nine years after the dental implant surgery. The patient complained of discomfort in the right cheek and ipsilateral purulent rhinorrhea. CT revealed a shadow extending from the maxillary sinus to the ethmoid sinus on the right side, representing the dental implant body in the right ethmoid sinus. It is believed that the dental implant body which was fixed on the maxilla had intruded into the maxillary sinus and remained there for a long period, and then advanced into the ethmoid sinus due to chronic sinusitis. Finally, the dental implant body was removed by endoscopic sinus surgery.
It is thought that dental implant interventions will increase in the future, and ENT surgeons need to increase their awareness to prevent complications related to these interventions.
Warthin’s tumor is the second most commonly occurring benign tumor of the parotid gland. Skin ulceration over a Warthin’s tumor is extremely rare. We report the clinical course of a 75-year-old man with Warthin’s tumor of the right parotid gland, who showed ulceration of the skin overlying the tumor. The patient, presenting with a mass of the parotid gland, had been diagnosed 8 years previously as having Warthin’s tumor of the parotid gland. There were no signs of malignancy. One year prior to admission to our hospital, ulceration of the skin overlying the tumor was observed. Although Warthin’s tumor is generally considered as a benign tumor, skin ulceration over a Warthin’s tumor may be suggestive of malignant transformation. Therefore, we performed partial parotidectomy with dissection of the overlying ulcerated skin despite the advanced age and low ADL of the patient. However, histopathology revealed no evidence of malignant transformation. The patient did well postoperatively and did not develop facial nerve palsy.
Lemierre syndrome is a life-threatening disease characterized by infectious thrombophlebitis of the internal jugular vein secondary to an acute oropharyngeal infection, and is frequently associated with multiple septic emboli and/or abscess formation in distant organs.
We describe the case of a previously healthy 17-year-old male patient who was admitted to our hospital with fever and chills, and sore throat caused by a peritonsillar abscess. Computed tomography showed thrombosis in the left internal jugular vein and numerous small nodules in both lungs. Based on these findings, the patient was diagnosed as having Lemierre syndrome. He was treated successfully with 6 weeks of antibiotic therapy and 4 weeks of anticoagulant therapy. The pus culture grew Fusobacterium necrophorum.
As we know, most foreign bodies are often removed easily. We experienced a case of a foreign body removed by transcervical approach. A 61 year-old-male had a sore throat for two days after ingesting a fish. At the first medical examination, we were unable to find the foreign body at his tonsilla palatina, pharynx or larynx, so the patient underwent a follow-up examination. One week later, his sore throat continued, and computed tomography (CT) revealed the foreign body in his oral floor. It was possible to remove it by the transoral approach at that time, and we proposed removing it immediately, but the patient did not accept. Forty three days later, the foreign body moved downwards. We removed it by not via the transoral but the transcervical approach. Granulation tissues had surrounded the foreign body. The patient’s postoperative progress was favorable. There are some points for consideration regarding not performing the operation immediately. There are severe complications associated with foreign bodies; such as abscess formation, vascular injury and so on. Furthermore, the transcervical approach is more invasive than the transoral one. Fortunately, our patient had no complications. On the other hand, he had peristent scars on his neck. From the above, we should perform CT imaging at the first visit, and remove any foreign body as soon as possible.
Hyoid bone syndrome is a disease caused by an abnormality in the apparatus hyoideus, indicated by a variety of symptoms such as a feeling of discomfort in the pharyngolarynx, neck pain, a clicking sound when twisting the neck, etc. We report on two cases of hyoid bone syndrome accompanying an excessively long greater cornu of the hyoid bone.
Case 1 consulted the hospital with the excessively long of discomfort when swallowing along with a clicking sound when swallowing from several years prior. The greater cornu of the hyoid bone on both sides was found to be long upon neck CT, in addition to approaching the transverse process of the fourth cervical vertebra. Case 2 became aware of neck pain from 1 year prior and consulted the hospital due to exacerbation of the symptoms. The excessively long greater cornu of the hyoid bone was observed on both sides of neck on CT imaging, with the greater cornu of the hyoid bone approaching the transverse process of the third cervical vertebra. From the above, the patient was diagnosed with hyoid bone syndrome accompanying an excessively long greater cornu of the hyoid bone on both sides, with prominent improvement in symptoms observed when partial resection of the bilateral greater cornu of the hyoid bone was carried out, yielding good results.
Although such cases may be diagnosed as pharyngolaryngeal paresthesia, when symptoms are observed over a long period of time and the complaint is strong and clear, an in-depth examination including imaging testing is required. Moreover, it was believed that resection of the greater cornu of the hyoid bone is a useful treatment for hyoid bone syndrome.
A 67-year-old patient who had been diagnosed as having an esophageal foreign body and had undergone an unsuccessful endoscopic removal at a different hospital was referred to our department. Esophageal rupture, cervical emphysema and a cervical abscess associated with a foreign body between the hypopharynx and the cervical esophagus caused by unintentional ingestion of a partial denture were diagnosed on close examination. The partial denture between the hypopharynx and the cervical esophagus was removed through a cervical incision. The patient made good progress without having any serious complications. We recommend foreign body retrieval through a cervical incision when an endoscopic approach is difficult.
A 60-year-old male patient developed purpura in the bilateral lower limbs and renal dysfunction during the treatment of a peritonsillar abscess. We consulted the dermatologist and nephrologists. They suspected anaphylactoid purpura and purpura nephritis because of the progress of the disease and the pathologic findings of skin biopsy. Steroid therapy was useful to control the appearance of the purpura, and angiotensin-converting enzyme inhibitor and antiplatelet therapy had an effect on the decrease of urinary protein.
Cases of anaphylactoid purpura are rare in the elderly. Arthritis and abdominal symptoms are less serious and frequent, but renal dysfunction and recurrence of purpura are more serious and frequent in comparison to younger patients. We consider that it is important to treat anaphylactoid purpura with cooperation between dermatologists and nephrologists.
C1 inhibitor (C1-INH) is a protein that adjusts complement functions and thereby controls the blood coagulation system, and its qualitative or quantitative abnormality can recurrently produce local edema. We report herein on a case of angioedema due to C1-INH deficiency which presented with airway stenosis resulting in dyspnea and was successfully treated with lyophilized human C1-inactivator concentrate (Berinert® P).
Our case was a 45-year-old female who had been suffering from swelling of her face and limbs for 15 years. She was referred to our hospital because of persistent swelling of the lips and eyelids even after having the administration of steroids. We gave her an intravenous drip of 300 mg hydrocortisone and 5 mg antihistamine at the first visit because she only presented with face edema. However, dyspneic attacks developed several hours later, and therefore she revisited our emergency room. Laryngoscopy revealed her respiratory tract was constricted by mucosal swelling at the level of the meso-hypopharynx. Readministration of 200 mg hydrocortisone failed to improve her symptoms, and we switched to the administration of Berinert® P because the C4 serum level was observed to be clearly lower. Her breathing disorder improved immediately after this application, and laryngopharyngeal edema had disappeared by the next morning. C1-INH activity demonstrated a low value afterwards, which finally led us to a diagnosis of angioedema due to C1-INH deficiency. We maintain follow-up with the administration of 3000 mg/day of tranexamic acid.
Angioedema due to C1-INH deficiency can be differentiated from other types of angioedema through the low value of complements and C1-INH activity, and C4 is recommended as a screening test. When we see a patient with serious edema especially in the upper airway, angioedema due to C1-INH deficiency should always be kept in mind because we can avoid an unnecessary tracheostomy with the immediate use of Berinert® P.
We carried out successful resection of an elongated styloid process under the guideance of a navigation system. A 58-year-old man presented to us with a 2-year history of an annoying sensation in the throat, otalgia, and left-sided headache. A head CT revealed elongated styloid processes (35 mm in length) on both side. We attempted treatment by navigation-guided transoral resection under general anesthesia.
Left tonsillectomy was performed first. The tip of the styloid process was not palpable through the tonsillar fossa wound, whereas it was easily identifiable by the navigation system. The process was resected to a length of 5 mm. The patient’s symptoms began to improve soon after the resection and resolved completely by 14 days after the surgery.
The advantages of the transoral approach are the limited invasiveness and avoidance of a scar in the neck. The disadvantage is the difficulty of identifying the tip of the styloid process due to the anatomical complexity in the field of surgery. We confirmed that the use of a navigation system is useful to locate the target process with minimal navigation errors.
Arteriovenous malformations (AVMs) in the head and neck region pose therapeutic challenges. We report the case of an elderly patient in whom bleeding from an AVM at the base of the tongue was controlled by a figure-of-eight suture.
An 87-year-old woman suffering from pain in her mandible and oral bleeding was referred to the oral surgery department. She was diagnosed as having AVM based on the findings of enhanced computed tomography. The bleeding subsided without treatment.
Eight months later, the patient developed recurrent re-bleeding from the oral cavity and was referred to our department. She presented with expanded blood vessels in her mandible, neck and oral cavity. Endoscopy revealed exposed vessels at the base of the tongue. The vessels were considered to be the cause of the bleeding. The bleeding again subsided spontaneously. However, 6 days later, the patient suddenly vomited large amounts of blood. She was transported by ambulance to our hospital. Angiography showed that the AVM was supported by the bilateral facial and lingual arteries. We decided against interventional therapy as we could not advance the catheter through the meandering blood vessels. Eventually, the bleeding subsided spontaneously and the patient was discharged.
However, 25 days after her first visit to our department, the bleeding recurred. We decided to undertake surgical intervention in the operation room under general anesthesia. The bleeding point was grasped by mosquito forceps and was occluded with a figure-of-eight suture using 3-0 PDS II® under endoscopic guidance. Tracheotomy was performed to prevent suffocation in the event of a large amount of oral re-bleeding. Fortunately, no persistent bleeding or angiogenesis was noted. At three months after the operation, the hemoglobin value remains normal.
Under limited circumstances, suture hemostasis (finger-of-eight suture) is useful in the treatment of bleeding from an AVM in the head and neck region.
An 80-year-old male patient with multiple laryngeal chondromas is reported. Bilateral thyroid cartilage masses were identified incidentally on CT. The masses remained constant in size over a two-year follow-up period, however, pharyngolaryngeal endoscopy at the end of two years showed submucosal swelling of the false folds of the larynx. A mass lesion measuring 15 mm in diameter in the right lamina of the thyroid cartilage was surgically resected by the cervical approach under local anesthesia. Histopathological examination showed mild proliferation of chondrocytes without nuclear atypia in a hyaline cartilage matrix, based on which the diagnosis of laryngeal chondroma was made. Another mass measuring 7 mm in diameter found in the left lamina of the thyroid cartilage was left unresected and will be followed up.
An 88-year-old woman put dodecyl dimethylammonium chloride (quaternary ammonium salt) in her mouth by accident. She spat it out immediately without swallowing, but thereafter, she developed severe oral pain. Twelve hours later, she also developed dyspnea and visited our hospital. At that time, laryngoscopy revealed severe pharyngo-laryngeal swelling with erosion of the oro-pharyngo-laryngeal mucosa. Emergent tracheotomy was performed. After two weeks, a repeat laryngoscopy revealed improvement of the pharyngo-laryngeal swelling. The patient eventually recovered completely without any complications. We report the progression of the pharyngo-laryngeal swelling as examined by laryngoscopy.
Cancer of the nasal cavity is a rare tumor of the head and neck region. In general, multidisciplinary treatment is employed, including chemotherapy, radiation therapy and surgery. Surgical resection often results in defects of the external nose, which causes a significant deterioration of the quality of life. We report on the case of an elderly patient over 90 years old who underwent resection of cancer of the nasal cavity and successful reconstruction using a median forehead flap.
A 92-year-old woman visited us with the complaint of a nasal mass. Biopsy of the tumor revealed the diagnosis of squamous cell carcinoma. CT examination revealed a mass lesion in the left nasal cavity. Although we initially administered radiation therapy considering the age of the patient, the tumor showed little response to the irradiation. Therefore, we planned less-invasive surgery with simple reconstruction of the nasal defect after sufficient tumor resection. Consequently, the surgery was performed three weeks after completion of the radiotherapy and we utilized a median forehead flap for the one-stage reconstruction. The surgical time was 140 minutes and there were no postoperative complications. The patient remained alive and in good health until the age of 100. She and her family were satisfied with the cosmetic and functional results during the seven and a half years of life after the surgery.
Reconstruction using a median forehead flap is an easy and less-invasive technique. Therefore, it is a valid option for the reconstruction of the nasal defects, and is especially suitable for patients of advanced age with complications.
We report a case of hypopharyngeal lipoma resected by transoral surgery. A 64-year-old woman who was found to have a throat abnormality in a screening examination performed 4 years ago consulted us. The abnormality could not be detected during an upper gastrointenstinal endoscopy performed at an internal medicine hospital in the patient’s neighborhood. However, two years later, a repeat upper gastrointestinal endoscopy at the hospital revealed a huge polypoid lesion in the thoracic esophagus to the esophageal inlet portion, it was removed to mouth side endoscopically. Since the patient had no subjective symptoms she was kept under observation. She developed discomfort again two years later, and as there was also a risk of suffocation, she was referred to our hospital. Based on the findings on CT, MRI and flexible endoscopy, the condition was diagnosed as hypopharyngeal lipoma. For ensuring complete endoscopic removal of a hypopharyngeal lipoma, it may be useful to insert the flexible endoscope under a curved-type Sato laryngoscope for obtaining a better field of view. The patient had an uneventful postoperative course. We may include this condition under expended indications of laryngoscopic surgery in the future.
Angioleiomyoma is a benign tumor composed of smooth muscle cells and vascular endothelial cells that sometimes arises in the head and neck region. We treated a 68-year-old man with angioleiomyoma of the nasal vestibule. The patient visited our hospital because of a mass in his left nasal vestibule. MRI showed a well-circumscribed mass (T1WI low intensity, T2WI high intensity) in the same area. The mass was removed through an incision in the oral vestibule under general anesthesia. Grossly, the mass was an encapsulated solid tumor. Immunohistochemical study revealed positive staining of the tumor cells of α-SMA, desmin, vimentin, and CD31 based on which the diagnosis of angioleiomyoma was made. Follow-up examination performed one year after the surgery revealed no evidence of tumor recurrence.
Herein, we report a rare case of metastatic sphenoid sinus tumor from hepatocellular carcinoma (HCC). Transcatheter arterial embolization to treat the metastatic sinus tumor resulted in a marked reduction of the tumor size in this case.
A 60-year-old male patient who had underwent several sessions of transcatheter arterial chemoembolization and radio-frequency ablation for multiple HCC, was referred to our department because of FDG accumulation detected in his left sphenoid sinus and portal lymph nodes by PET-CT. MRI and CT revealed surrounding bone destruction by the sphenoid sinus lesion. Although we attempted biopsy of the sphenoid sinus tumor under endoscopic guidance, sufficient tissue could not be obtained for diagnosis because of excessive bleeding. A subsequent angiography revealed that the tumor received good blood supply from the left maxillary artery, therefore, transcatheter arterial embolization of the maxillary artery with a platinum coil was performed to reduce potential bleeding during biopsy. On the day after the embolization, re-biopsy of the sphenoid sinus tumor was successfully performed without any significant bleeding. Since the obtained tissue revealed the same pathological features as the portal lymph nodes, the sphenoid sinus tumor was diagnosed as metastatic HCC.
Two months after from the embolization procedure, a MRI scan revealed a reduction of the size of the sphenoid sinus tumor to less than 50% of its original size. A follow-up PET-CT after additional palliative chemoradiotherapy no longer showed FDG accumulation in the sphenoid sinus tumor. The sphenoid sinus tumor showed no re-growth nor was associated with any symptoms during 4.5 years, follow up period until the patient’s death, which was due to recurrence of the portal lymph node metastases and femoral bone metastases.
It is suggested that the transcatheter arterial embolization for the metastatic sphenoid sinus tumor from HCC caused a reduction of the tumor size as well as minimized bleeding during a biopsy.
We report two rare cases of lipoma in the nasal cavity and pharynx.
Case 1: A 9-year-old girl was brought to our hospital with the chief complaint of a mass in the left nasal cavity. CT revealed a smooth mass with fat density in the left nostril. The mass was attached to the anterior part of the nasal septum and was resected using a rigid endoscope under general anesthesia. Case 2: A 36-year-old woman noticed a yellowish and smooth mass in the right side of the oropharynx. MRI demonstrated the mass in the right side of the oropharynx, and fat suppression imaging revealed the diagnosis of lipoma. The mass was located below the right palatine tonsil and was removed with a Weerda laryngoscope.
The tumors were histopathologically diagnosed as lipomas in both cases. In case 1, additional plastic surgery is being planned in the future for a residual tumor. In case 2, the clinical course has remained uneventful since the surgery.
Epithelial-myoepithelial carcinoma (EMC) is a rare tumor, most commonly arising from the parotid gland. We present the case of an 80-year-old woman who presented with the chief complaint of nasal bleeding and was diagnosed as having EMC of the nasopharynx. Fiberopic endoscopy revealed a mass with erosion on the left side in the posterior wall of the nasopharynx. Computed tomography (CT) and magnetic resonance imaging (MRI) showed a tumorous shadow limited to the nasopharynx, not extending into the surrounding tissue. Histological and immunohistochemical examination of biopsy specimens confirmed the diagnosis. Full-dose radiation therapy was administered. The tumor disappeared completely, and no evidence of recurrence or metastasis has since become apparent. We considered that radiation therapy is one of the valid treatment options for patients with inoperable EMC.
Purpose: To retrospectively assess the safety profile of chemoradiation (CRT) with S-1 for oropharyngeal and hypopharyngeal squamous cell carcinoma (SCC).
Patients and methods: Forty-two patients were treated with CRT between April 2004 and March 2014. Definitive radiotherapy was delivered up to a total dose of 60–70 Gy. The patients received 2 courses of S-1 (60–100 mg/day) for 2 weeks followed by 2 weeks of rest while receiving radiotherapy.
Results: Nine patients with stage I or II were treated with CRT alone. Patients with stage III or IV were treated with either induction chemotherapy (IC) with docetaxel, cisplatin, and fluorouracil (TPF) following CRT with S-1 (n=26) or CRT with S-1 alone (n=7). Of these, 92.9% completed the full CRT course. The overall complete response rate was 76.2% (CR: 32, PR: 7). The five-year disease-specific survival rates (DSS) for stages I and II were 100%, and for stages III and IV were 55.1%/58.3% (oropharyngeal/hypopharyngeal). The five-year DSS for patients with stage III or IV who had radical surgery during the same period was 64.6% (n=24). No significant differences were noted in the results between the survival outcomes of CRT (with or without IC) and surgery. Grade 3 and 4 oral mucositis frequently occurred during the CRT regardless of CRT alone or CRT followed IC. However, there was no treatment-related death, and all patients, with the exception of one, received the full radiotherapy.
Conclusion: CRT with S-1 appeared to be a well-tolerated and acceptable regimen even in combination with TPF IC.
Papillary thyroid carcinoma progresses slowly and carries a relatively good prognosis. However, invasion of important adjacent structures, such as the recurrent laryngeal nerve, trachea and esophagus, worsens the patient’s QOL. While cases of thyroid carcinoma invading the trachea are sometimes encountered, cases of advanced thyroid carcinoma are raraly encounterd in which tracheal intubation is impossible. While performing surgery in these cases, sufficient consideration should be given before the operation to methods for maintaining the airway.
Herein, we report a case of thyroid carcinoma invading the trachea, in which tracheotomy needed to be performed under extracorporeal membrane oxygenation (ECMO). A 70-year-old woman presented to a neighborhood doctor with a history of difficulty in breathing. CT showed severe tracheal invasion by a thyroid carcinoma, and the patient was referred to our hospital. A PET-CT revealed its metastases in the lung, liver, and bones. Biopsy of the tumor invading the trachea revealed the diagnosis of papillary carcinoma. Because the airway stenosis was severe, usual tracheal intubation, as well as usual tracheotomy and mediastinal tracheotomy, was difficult. Therefore, we incised the first and second tracheal rings not invaded by tumor and carried out intubation through the tracheotomy stoma. We used ECMO in anticipation of airway obstruction due to bleeding, and were therefore able to maintain the airway. Thereafter, we performed total thyroidectomy, D3c neck dissection, and tracheal fenestration. After the operation, radioactive iodine therapy was administered and the fenestrated trachea was closed by staged operations.
Acute respiratory distress syndrome (ARDS) has been intensively and continuously studied in various settings, however, mortality from this disease remains as high as 30–40%.
A 5X-year-old man presented to the ENT service with a 3-month history of discomfort in the pharynx. Based on the findings of endoscopy and positron emission tomography/computed tomography (PET/CT), the patient was diagnosed as having oropharyngeal carcinoma (T4aN2cM0). Two cycles of TPF chemotherapy (docetaxel, cisplatin and 5-fluorouracil) were administered, which led to no reduction of the tumor size. Therefore, radiotherapy was combined with administration of cetuximab (bioradiotherapy: BRT).
BRT was associated with an enhanced severity of mucositis, resulting in aspiration. The respiratory function deteriorated gradually, and eventually, the patient was diagnosed as having ARDS. Artificial non-invasive positive pressure ventilation (NPPV) was initiated, along with administration of neutrophil elastase inhibitor (sivelestat) and methylprednisolone (1 mg/kg). In response to the treatment, the respiratory function gradually improved and the patient could be weaned off NPPV on the 14th day.
Neuroendocrine tumors is a generic term for tumors arising from neuroendocrine cells. In the present study, we encountered a patient with a Grade 3 laryngeal neuroendocrine carcinoma with liver and bone metastases who was successfully treated with a small cell lung cancer (SCLC) regimen. We report herin on this case with a review of the diagnosis, classification, and management of neuroendocrine tumors. Classically, neuroendocrine tumors have their own classification by the organs involved, and in some previous studies, the histopathology has been inconsistent with the clinical course. Then, in 2010, the WHO advocated a new pathological classification, whereby neuroendocrine tumors were to be stratified into 3 groups: Grade (G) 1, G2 and G3 based on the mitotic count and Ki67 index. A previously reported series of high-grade neuroendocrine tumors were equivalent to G3, and some reports have described that SCLC treatment was given. In our case, the patient was also treated as an SCLC patient, and the response of the primary lesion was evaluated as complete response (CR). Currently, 18 months have elapsed since the completion of therapy, the patient enjoys satisfactory levels of QOL without recurrence. We believe that this classification would be of assistance in discussion about prediction of the prognosis and statistical treatment.
Recently, intracapsular enucleation has been reported as the standard treatment of neurogenic tumors arising from the cervical sympathetic region. In the present study, we performed intracapsular enucleation for two neurogenic tumors derived from the sympathetic chain. Case 1; A 61-year-old female who presented with an asymptomatic cervical mass. Based on the imaging findings, we suspected a neurogenic tumor and performed intracapsular enucleation. Histopathologic examination revealed a schwannoma. After surgery, transient Horner’s syndrome was observed. Case 2; A 32-year-old female consulted for a 10-year history of the left cervical mass. There was no neural deficit. From the imaging findings, and the presence of café au lait spots on the body trunk, the lesion was suspected as being a neurogenic tumor. Intracapsular enucleation was performed, and a histopathologic examination revealed a neurofibroma. Postoperative palsy did not occur. In spite of the same surgeon employing the same method in both the above cases, postoperative palsy occurred in the former, but did not in the latter. Postoperative nerve palsy can sometimes occur, even if intracapsular enucleation was performed. Therefore, adequate preoperative informed consent is required.
We experienced a case of maxillary carcinoma in which pancytopenia occurred after concurrent chemoradiotherapy (CCRT). The patient was a 68-year-old man. He had complained of right cheek pain one and a half months previously, and consulted a nearby otolaryngologist. CT imaging of the paranasal sinus demonstrated an abnormal shadow with bone destruction of the right maxillary sinus anterior wall. The patient was suspected as having maxillary cancer and was referred to our hospital. PET showed high accumulation in the right maxillary sinus and the lesion was diagnosed as a maxillary carcinoma (squamous cell carcinoma, T2N0M0, Stage II) by biopsy under local anesthesia. The patient underwent CCRT using 80 mg/m2 of carboplatin (CBDCA). However, combination therapy with CBDCA was stopped after seven times administration since platelet marker decreased to 28,000. Radiation alone treatment was subsequently continued to 70 Gy. On the day after completing radiation, the patient was diagnosed as having pancytopenia and he also suffered from Methicillin-resistand Staphylococcus auerus infection-mediated pneumonia, pharyngitis, and sinusitis. After three months of intensive treatment, he had almost recovered. However, CT and PET imaging showed multiple metastasis and he died two months later.
When determining the treatment plan for thyroid tumors, aspiration cytology is considered as an important test due to its high accuracy. However, surgery is often performed for cases with imaging findings suggestive of thyroid cancer, even if aspiration cytology clearly rules out malignancy. In the present study, we compared the relationship of the postoperative pathologic diagnosis with the preoperative ultrasound results to examine factors that are useful for differentiating between benign and malignant tumors. Our study included 97 patients diagnosed as having non-malignant tumors (Papanicolaou class I–III) by preoperative cytology, who underwent thyroidectomy during the 11-year period from January 2002 to December 2012. Subjects were divided according to the postoperative histopathology into the benign group (n=79) and the malignant group (n=18). The two groups were compared in terms of the maximum tumor diameter, preoperative serum thyroglobulin level, preoperative Papanicolaou classification, age, gender, and the ultrasound findings (presence/absence of border irregularity of the gland and presence/absence of microcalcifications). The preoperative cytological specimen adequacy rate was 94.9% (186 out of 196 specimens). In the benign group, thd preoperative cytology was class I in 12 patients, class II in 61 patients, and class III in 6 patients. In the malignant group, the cytology was class I in 1 patient, class II in 10 patients, and class III in 7 patients. The malignant group had significantly more class III cases and cases showing irregular borders of the gland on ultrasound.
In the future, abnormal findings other than those examined in the present study should also be examined in detail.
Verrucous carcinoma originating from various sites has been reported since Ackerman first reported an intraoral case in 1948. Histologically, the tumor is composed of atypical low squamous epithelium showing papillary growth, with strong cornification; in regard to the differentiation grade, the tumor is a subtype of well differentiated squamous cell carcinoma. There are scarce reports from foreign countries of verrucous carcinoma arising in the rhinosinus. Extensive resection is necessary, but it is said to be generally associated with a good prognosis. There are many reports recommending against the use of radiotherapy as the treatment modality of first choice, because local control is insufficient and radiotherapy is associated with a high risk of anaplastic transformation of the tumor.
We encountered two cases of verrucous carcinoma of the rhinosinus. Case 1 was a 44-year-old woman with verrucous carcinoma of the left frontal sinus, complicated by a brain abscess. Case 2 was a 78-year-old woman with verrucous carcinoma (T4aN0M0 Stage IVa) of the left nasal cavity, who was treated by radiation plus cetuximab therapy. This verrucous carcinoma showed strong EGFR expression, therefore, cetuximab was effective. There is a case following fatal course in verrucous carcinoma, and it is necessary to pay attention.
Riedel’s thyroiditis is a rare disease of unknown etiology, mainly affecting middle-aged to old females. The condition is characterized by an aggressive fibrosis partly or totally replacing the normal thyroid gland tissue. Herein, we report a case of Riedel’s thyroiditis. A 62-year-old woman presented to us with a mass on the left side of the neck and was admitted to the hospital. On palpation, the mass, 40 mm in diameter, was found to be very hard in consistency and not freely mobile. CT revealed a large mass lesion in the left lobe of the thyroid. At operation, the mass was very hard to palpation and adherent to the trachea and esophagus. Histopathological examination revealed fibrous invasion of the connective tissue and organs surrounding the thyroid gland, and based on the findings, we made the diagnosis of Riedel’s thyroiditis. After surgery, the patient has had an uneventful clinical course.
Anaplastic thyroid carcinoma (ATC) represents only 1–2% of all thyroid malignancies, but it carries an extremely poor prognosis. The reported median survival time is 3–9 months, and very few ATC patients survive for more than 1 year after the diagnosis. We encountered an 82-year-old female patient diagnosed as having ATC who survived for 13 months. Right hemithyroidectomy with D1 dissection was undertaken 9 days after the patient presented to us. The histopathological diagnosis was ATC, T4bN0. Radiation therapy to the whole neck was administered. Because metastasis to the lung was detected four weeks after the surgery, the patient received chemotherapy with monthly CBDCA and weekly PTX. Although partial response was observed, the chemotherapy was discontinued due to the development of myelosuppression. The patient died of respiratory failure 13 months after the surgery. Effective therapeutic mesures for ATC are needed.
Among head and neck tumors, adenoid cystic carcinoma (ACC) of the external auditory canal (EAC) is very rare. However, this disease needs to be treated early and completely because of its characteristics, including its tendency to recur locally, its location near important organs, its low sensitivity to radiation, etc.
We evaluated the data of 5 patients with ACC of the EAC who were treated surgically between 2009 and 2015.
The average age was 60.2 years, and 4 of the patients were male. At the first examination, 80% complained of having suffered from otalgia for more than a year. In 4 cases, the tumor stage according to the TNM classification was T4 and the histopathological grade according to Szanto’s classification was grade 2 or 3. In 3 cases, we performed lateral temporal bone resection; the surgical margin was positive in two of these cases and negative in one case. On the other hand, in 2 cases, we performed expanded extraction, including parotidectomy, and obtained negative surgical margins in both.
Considering the results, early differential diagnosis from inflammation is needed, and expanded extraction with a safety margin should be considered for radical treatment.
Age and comorbidity should be considered while determining the therapeutic strategy and effective perioperative treatment also needs to be established in the future.
Histopathological diagnosis of salivary gland carcinoma is relatively difficult because of the low frequency and variety of histopathological types of this cancer. There is at present no effective immunohistochemically identifiable prognostic marker in cases of salivary gland carcinoma. Since nuclear expression of Y-box binding protein-1 (YB-1) is known to be correlated with the tumor aggressiveness and poor prognosis in various types of cancers, this study was aimed at investigating the relationship between the expression of YB-1 and other relevant proteins (androgen receptor (AR), epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor type 2 (HER2)) and the histopathological grade, clinical parameters and prognostic factors in patients with salivary gland carcinoma.
Immunohistochemistry was performed to evaluate the expression of YB-1, AR, EGFR and HER2 proteins in 66 cases of salivary gland carcinoma. The histopathological types included salivary duct carcinoma (n=37), mucoepidermoid carcinoma (n=24) and adenocarcinoma not otherwise specified (NOS) (n=5).
The expression rate of YB-1 protein was 83.7% in salivary duct carcinoma and 80% in adenocarcinoma NOS. The expression of YB-1 and HER2 were correlated with the presence of lymph node and distant metastasis (p<0.05). AR expression was correlated with the presence of lymph node metastasis (p<0.05). Using univariate survival analysis, YB-1 and HER2 expressions were identified as being correlated with the overall and disease-free survival rates (p<0.05). Furthermore AR expression was identified as being correlated with the disease-free survival rate (p<0.05).
Nuclear expression of YB-1 in salivary gland carcinomas appears to be useful for the histopathological diagnosis of malignancy. Into the clinical significance of immunohistochemistry for AR and HER2 expressions, nuclear YB-1 expression appears to be a prognostic factor in cases of salivary gland carcinoma.