Pediatric Langerhans cell histiocytosis of the lateral skull base

Langerhans Cell Histiocytosis of the Head and Neck: Experience at a Rural Tertiary Referral Center

OBJECTIVES

Retrospectively analyze head and neck Langerhans Cell Histiocytosis at a rural tertiary referral center and compare results with previously published data.

METHODS

Electronic health record review was performed from 2003 to 2019. Patients with biopsy proven LCH with primary head and neck involvement were included. Demographics, presentation, imaging characteristics, treatment modality, delay in diagnosis (DD, ≥60 days), and outcomes were analyzed and reported.

RESULTS

Twenty-four patients were included. The most common presenting symptoms were otorrhea (n = 6) and scalp pain or swelling (n = 6). All patients had bony involvement. The most common site was facial or skull lesions (n = 20). Most skull lesions (75%) demonstrated CNS risk. Six patients were treated with primary surgery, 15 with primary chemotherapy, and 3 with surgery plus adjuvant chemotherapy. Nine patients experienced relapse of disease with median time to documented relapse of 11.4 months; all were treated with salvage chemotherapy to achieve complete remission (median follow-up: 72 months). Patients most likely to relapse were those with multisystem disease (5/7, 71.4%), temporal bone lesions (4/7, 57.1%), and DD (7/12, 58.3%). Of the 9 total patients who experienced relapse, 78% had a delay in diagnosis.

CONCLUSIONS

LCH is a complex disease process in which diagnosis can be delayed if not considered in the differential. Within the head and neck, the skull, including isolated temporal bone involvement, is the most common site of involvement. Treatment modality does not appear to have an influence on relapse rates. Relapse was more likely to occur in the first year after treatment and close monitoring is required.

Case report: Langerhans cell histiocytosis of the temporal bone in children: Challenging diagnosis of a rare disease with some pitfalls

A 4‐year‐old girl was admitted to hospital with disturbance of balance. After being questioned, parents remembered an otitis with effusion 3 months earlier. CT‐scans revealed destruction of both temporal bones. Initial biopsy showed granulomatous, necrotic inflammation, which led to comprehensive differential diagnoses. A second tissue sample confirmed Langerhans cell histiocytosis.

Otologic Manifestations of Langerhans Cell Histiocytosis: A Systematic Review

OBJECTIVE

To perform a systematic review to investigate common otologic manifestations of Langerhans cell histiocytosis, the incidence of these findings, methods for diagnosis, as well as medical and surgical management.

DATA SOURCES

PubMed/MEDLINE, Embase, and Cochrane Library.

REVIEW METHODS

A search of PubMed/MEDLINE, Embase, and Cochrane Library for all articles published between 1963 to 2020 was performed with variations and combinations of the following search terms: Langerhans cell histiocytosis, eosinophilic granuloma, Letterer-Siwe, Hand-Schüller-Christian, otitis, otologic, ear. A review of the references of all included articles was also conducted.

RESULTS

Sixty-two articles encompassing 631 patients met inclusion criteria. Otologic symptoms at presentation were found in 246 (39%) patients in the reported studies with 48% reporting bilaterality. The mean age was 14.8 years with a male predominance (64%). The most common otologic presenting symptom was otorrhea (46%). A majority had the multisystem variant (52%). The most common treatment modalities were chemotherapy (52%), followed by surgery (50%), systemic steroids (45%), and radiotherapy (31%). Surgery was performed in 75.8% with unisystem involvement and in 50.6% with multisystem involvement. The most effective treatments included radiotherapy (56% success rate, 17% of treated patients), systemic steroids (44% success, 20% treated), chemotherapy (41% success, 21% treated), and surgical modalities (36% success, 19% treated).

CONCLUSIONS

Otologic manifestations that occur with the multisystem variant or are at high risk for central nervous system involvement necessitate systemic treatment. For unifocal lesions, surgery is recommended. Lastly, radiotherapy should be reserved for extensive lesions involving vital structures or presenting in older patients.

Langerhans cell histiocytosis in the occipital condyle: a case study and a brief review of the literature

We present a case study of a 5-year-old patient, who presented with left-sided torticollis. Due to persistence of problems, a CT and an MRI were made showing a single osteolytic lesion centred on right occipital condyle. After an open biopsy, histology confirmed it to be Langerhans cell histiocytosis (LCH). Torticollis or restricted range of motion is a presenting feature in 76% of children with LCH with cervical involvement. There remains much debate on the best treatment strategy. The clinical and radiological outcomes of the case study presented on this article support the treatment of LCH with chemotherapy in cases with solitary involvement of the occipital condyle.

Giant skull vault defect in a child caused by Langerhans cell histiocytosis: the "calvaria-eating disease"

Langerhans cell histiocytosis (LCH) is a rare disease of young children that can be difficult to diagnose and treat. Clinical manifestations can sometimes be quite unusual, and bony lesions can reach a large size before treatment is sought. We present a unique case of a 3-year-old male child with a painless giant calvarial defect and cystic swelling. Complete removal of the cyst with curettage of the involved bone margins and cranioplasty was done using bone cement (polymethyl methacrylate, PMMA). However, there was a flare up of the disease due to abnormal inflammatory reaction to PMMA, and cranioplasty bone flap had to be removed. The child did well after PMMA bone flap removal.LCH should be suspected in a male child presenting with a large calvarial defect and no history of trauma. The use of materials, viz., hydroxyapatite, poly-DL-lactide (PDLLA), and PMMA for cranioplasty in LCH, may cause reactivation of the disease process and therefore must be used cautiously in these patients.

A review of pediatric middle ear tumors and analysis of the demographics, management, and survival of pediatric rhabdomyosarcomas of the middle ear

OBJECTIVE

To examine the types of pediatric middle ear tumors and review the demographics, management, and survival of pediatric patients with rhabdomyosarcoma (RMS) of the middle ear.

METHODS

Pediatric patients in the Surveillance, Epidemiology, and End Results (SEER) database were included from 1973 to 2014 based on a diagnosis of middle ear tumors using the ICD O-3 code: C30.1: Middle ear primary site. Patients were included from ages 0-18 years.

RESULTS

Forty pediatric middle ear tumor cases were identified. Twenty patients were female (50%). Twenty-seven (67.5%) cases were rhabdomyosarcomas (RMS). Pediatric RMS patients tended to be diagnosed in early childhood (mean age 5.30 years, standard deviation 2.9, range 1.00-13.00, 59.3% of patients were ages 5 or below). Most pediatric RMS patients received chemotherapy and radiation therapy as part of the treatment regimen (88.8%). Finally, the 5-year overall and disease-specific survival rates were 59% and 63% respectively.

CONCLUSIONS

Pediatric middle ear tumors are rare. Females and male pediatric patients are both at risk for middle ear tumors. RMS is the most common malignant middle ear tumor affecting pediatric patients. Despite the use of multimodality therapies, survival rates for pediatric patients with RMS of the middle ear are low. Physicians may consider including middle ear tumors on the differential diagnosis for pediatric patients with symptoms presenting similarly to non-resolving otitis media.

Cross Sectional Imaging of the Ear and Temporal Bone

CT and MR imaging are essential cross-sectional imaging modalities for assessment of temporal bone anatomy and pathology. The choice of CT versus MR depends on the structures and the disease processes that require assessment, delineation, and characterization. A thorough knowledge of the two imaging modalities' capabilities and of temporal bone anatomy greatly facilitates imaging interpretation of pathologic conditions.

Selected Giant Cell Rich Lesions of the Temporal Bone

Giant cell rich lesions of the temporal bone encompass a wide spectrum of disease that includes infectious, reactive, and neoplastic processes. When dealing with any lesion that can potentially involve bone, it is important to understand both the clinical presentation and to correlate the histologic findings with the radiologic imaging. This review discusses the clinical, the pathologic features including the differential diagnosis, and the treatment of some of the more commonly encountered giant cell rich entities in this region.