Relationship of the recurrent laryngeal nerve to the superior parathyroid gland during thyroidectomy

Design: The relationship of the recurrent laryngeal nerve to the superior parathyroid gland during consecutive thyroidectomies was prospectively evaluated. When one structure was noted, careful dissection was performed to locate the other structure, to preserve their natural anatomical relationship. Patients: In total, 103 consecutive thyroid lobectomies were performed on 73 patients. The distance from the superior parathyroid gland to the recurrent laryngeal nerve was recorded. Results: In 88 cases (88.9 per cent), the superior parathyroid gland was identified within 5 mm of the recurrent laryngeal nerve. In 62 cases (62.6 per cent), the gland was within 1 mm of the recurrent laryngeal nerve. The height of the thyroid lobe was positively associated with the distance between the two structures (p = 0.001), as was the incidence of cancer (p = 0.033). The incidence of recurrent laryngeal nerve paresis was less than 4 per cent. Conclusion: In most cases, the recurrent laryngeal nerve was found in close proximity to the superior parathyroid gland. In a thyroid gland with a large height, or in a cancerous lobe, this relationship is less reliable.

Re-irradiation of metastatic disease in the neck from xeroderma pigmentosum

BACKGROUND

Xeroderma pigmentosum, an autosomal recessive disease that occurs with a frequency of 1:250,000, is caused by a genetic defect in nucleotide excision repair enzymes. Mutation of these enzymes leads to the development of multiple basal cell and squamous cell carcinomas.

OBJECTIVES

We present a case of xeroderma pigmentosum in a patient with cervical and intraparotid metastatic disease from recurrent cutaneous squamous cell carcinomas of the face and scalp, treated with neck dissection and re-irradiation. With the illustrative case report, we include a literature review of diagnosis, prognostic factors, and treatment, with emphasis on surgical and radiation treatment of cervical metastatic disease from recurrent skin carcinomas.

CASE PRESENTATION

A xeroderma pigmentosum patient presented to our clinic with a 2-cm right submental and 1-cm right infra-auricular mass after resection of multiple squamous cell carcinomas of the scalp and face, and external-beam radiation therapy to the right face and neck. Fine-needle aspiration biopsy of the submental mass revealed poorly differentiated squamous cell carcinoma. The patient was brought to the operating room for a right modified radical neck dissection and excision of the right submental and intraparotid mass. Surgical pathology revealed 3 level ia and supraclavicular lymph nodes that were positive for metastatic squamous cell carcinoma. Re-irradiation to the entire right hemi-neck and left submandibular nodal region was performed using opposed oblique portals for the upper neck and a low anterior en face hemi-neck portal. The left parotid region was also included in the re-irradiation volume. Treatment was completed without delayed complications or recurrences to date.

CONCLUSIONS

To our knowledge, this is the first case report in the literature of a patient with xeroderma pigmentosum who subsequently developed metastatic disease from recurrent cutaneous squamous cell carcinoma. Because of the rarity of xeroderma pigmentosum, this case report is also the first to describe re-irradiation to treat cervical and intraparotid metastatic disease in a xeroderma pigmentosum patient.

Value of positron emission tomography (PET) scan in treatment decision making for nodal metastases in head and neck squamous cell cancer

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Background: Management of neck disease in patients with Head and Neck Squamous cell cancer (HNC) who are initially treated with combined radiation and chemotherapy (CRT) remains controversial. Standard treatment options include neck dissection (ND) or close observation. More recently PET scans have been used to stage and monitor response to therapy in patients with HNC. We performed a retrospective analysis of patients diagnosed with HNC stages N2b or higher, treated with combined CRT, and who were monitored for disease response by PET scans. Our observations on the utility of PET scans in monitoring response to therapy and in determining the role of elective NDs in this setting are reported. Methods: A retrospective review of medical records of all patients diagnosed at our institution with HNC Stages TxN2b, N2c or N3 between the years 2002 and 2005 was undertaken. IRB approval was obtained for this study.To be eligible for this analysis, patients must have had baseline and follow up PET scans at the end of CRT and prior to ND. Data regarding age, gender, primary tumor site, stage, baseline and follow up PET scan results, operative pathology of ND when performed, and local control were recorded. Results: Fifteen patients were identified. Median age was 55 years (range 37–76). Male: Female ratio was 13:2. Primary site of tumor was Pharynx (Base of tongue: n = 3, tonsil: n = 11); Lip and oral cavity: n = 1. Stages: IVa : n = 12; IVb: n = 3. N stage: N2b: n = 12; N2c: n = 1; N3: n = 2. Post CRT, all patients were followed with serial clinical examinations, PET ± CT scans. 13 of 15 patients had negative PET activity in the neck at the completion of CRT and remain disease free in the neck at a median follow up of one year. Post treatment PET scans were positive at the primary site in 2 of 15 patients; and positive in the neck in 2 of 15 patients. These 4 patients underwent ND after completing CRT. Operative pathology was positive for nodal disease in 2 of 4 patients who had persistent mild or significant activity on PET scan either at the primary site or in the neck. Conclusions: Post CRT PET negativity in the neck and at the site of primary tumor is associated with continued disease free status in the neck and these patients may be managed conservatively without requiring a neck dissection.

No significant financial relationships to disclose.

Head and neck paragangliomas: an overview

Paragangliomas of the head and neck are unique tumors. Their pathology, tissue of origin, location, genetics, potential for bio-chemical activity, multicentricity, and growth pattern are unusual compared with more common head and neck tumors. Because these tumors are widespread and can appear in the ear, neck, larynx, nose, orbit, and chest, they cross subspecialties of otolaryngology.

The external approach for submucosal lesions of the larynx

OBJECTIVE

The surgical excision of benign submucosal lesions of the larynx can be performed using a variety of techniques including direct laryngoscopy and external approaches. We propose that small submucosal lesions of the larynx can be removed via the external approach without a tracheotomy.

STUDY DESIGN

Retrospective chart review.

SETTING

Six patients at The Long Island Jewish Medical Center and at the New York University School of Medicine underwent an external approach for the removal of benign submucosal laryngeal lesions without tracheotomies. Lesions included a mixed laryngopyocele, an internal laryngopyocele, a mixed laryngocele, a paraganglioma, a neurilemmoma and a lymphoma. Follow-up ranged from 1 to 9 years.

RESULTS

All patients were female with an average age of 72. No patient required a tracheotomy. One patient remained intubated for 24 hours postoperatively to ensure an adequate airway. Mild dysphagia was noted in all patients, but it was short-lived and did not require alternate methods of alimentation. There have been no recurrences of disease.

CONCLUSION

The external approach without tracheotomy allows for good exposure with minimal functional disability for the removal of benign submucosal lesions of the larynx.

Head and neck paragangliomas: physiology and biochemistry

Paragangliomas of the head and neck are derivatives of neural crest cells, comprising part of the diffuse neuroendocrine system. Indeed, paragangliomas encompass a unique subset of tumors of the head and neck. Their biochemistry and physiology are similar to other neuroendocrine tumors unlike tumors based on location. This article discusses their distinct biologic attributes.

Laryngeal and sinonasal paragangliomas

Laryngeal paragangliomas are classified as supraglottic and infraglottic. This article defines each type of paraganglioma, discusses the clinical features and diagnoses, and covers the surgical management. This article also addresses sinonasal paragangliomas, including their clinical features, diagnosis, and treatment.

Laryngeal pyogenic granulomas do not express oestrogen or progesterone receptors

The objective of this study was to determine the presence of oestrogen and/or progesterone receptors in laryngeal pyogenic granulomas and the impact of these receptors on recurrence of pyogenic granulomas. Twenty-two consecutive patients who underwent microlaryngoscopy and removal of pyogenic granulomas were studied retrospectively. The indications for surgery were airway compromise, failure of medical therapy and suspicion of malignancy. Twelve of these patients' granulomas were analysed for oestrogen and progesterone receptors. Charts were analysed for age, sex, location of the lesion, history of trauma, intubation or gastroesophageal reflux disease (GORD), airway symptoms and recurrence. Oestrogen/progesterone receptors were analysed following deparaffinization of specimens and immunostaining with prediluted anti-oestrogen receptor monoclonal antibody and anti-progesterone receptor monoclonal antibody. No sample expressed oestrogen or progesterone receptors. There were too few recurrences to detect if lack of these receptors played any role in determining outcome in this group. Most of the patients had a history of GORD, intubation or laryngeal surgery. There were 12 recurrences in four patients. All of the recurrences improved on prolonged courses of omeprazole. Pyogenic granulomas do not possess oestrogen or progesterone receptors and are unlikely to respond to hormonal therapy. Patients who have, or are being operated on for, laryngeal pyogenic granulomas should be placed on proton pump inhibitors to decrease the likelihood of recurrence.

A comparison of radiation-induced and presbylaryngeal dysphonia

OBJECTIVE

The goal of this study was to assess voice after radiotherapy compared with patients with presbylaryngeal dysphonia.

STUDY DESIGN AND SETTING

Prospective assessment of 20 patients aged 60+ years who remained free of disease longer than 1 year after radiotherapy for T1 squamous cell carcinoma and retrospective review of 46 patients aged 60+ with presbylaryngeal dysphonia, conducted at a tertiary care, academic hospital. Assessment data included videostroboscopy, spectrography, voice range profile, and Voice Handicap Index.

RESULTS

Eighty percent of the radiotherapy patients reported a voice disorder. Acoustic data and functional measures reflected similar limitations and abnormalities for both groups. A high incidence of glottal gap in all patients may have been associated with increased mucosal stiffness in the radiotherapy group and vocal fold atrophy in the presbylaryngeal group.

CONCLUSION

Patient perception and functional outcome of voice were similar for both groups, despite differences in etiology of abnormal vocal fold vibratory behavior.

SIGNIFICANCE

Radiotherapy in older individuals may yield dysphonia that is no greater than that caused by normal aging.

Immobile vocal fold secondary to thyroid abscess: a case report

Vocal fold paralysis as a result of a thyroid abscess is extremely rare. In this article, we report only the second documented case of such a finding. The paralysis was discovered after our patient, a 40-year-old woman, had come to the office with a complaint of discomfort in the right lower neck. Computed tomography confirmed the presence of an abscess in the posterior thyroid gland. Fine-needle aspiration did not identify any inflammatory or suspicious cells. The abscess was treated with hemithyroidectomy, and the paralysis resolved 3 weeks later. There has been no recurrence after 4 years.

Intralingual dermoid cysts: a report of two new cases

Dermoid cysts of the oral cavity are rare. When they do occur, the most common site is the floor of the mouth. Intralingual dermoid cysts are even more rare, and until now, there were only 15 such reports in the English-language literature. In this article, we describe two additional cases. Magnetic resonance imaging is extremely helpful in establishing a differential diagnosis. Surgical excision is recommended to correct deglutition and speech problems. Its rarity notwithstanding, dermoid cyst should be considered in the differential diagnosis of tongue masses in the younger population.

Mutations in SDHD, a mitochondrial complex II gene, in hereditary paraganglioma

Hereditary paraganglioma (PGL) is characterized by the development of benign, vascularized tumors in the head and neck. The most common tumor site is the carotid body (CB), a chemoreceptive organ that senses oxygen levels in the blood. Analysis of families carrying the PGL1 gene, described here, revealed germ line mutations in the SDHD gene on chromosome 11q23. SDHD encodes a mitochondrial respiratory chain protein-the small subunit of cytochrome b in succinate-ubiquinone oxidoreductase (cybS). In contrast to expectations based on the inheritance pattern of PGL, the SDHD gene showed no evidence of imprinting. These findings indicate that mitochondria play an important role in the pathogenesis of certain tumors and that cybS plays a role in normal CB physiology.

Repositioning the hereditary paraganglioma critical region on chromosome band 11q23

Hereditary paragangliomas (PGL, glomus tumors, MIM no.168000) are mostly benign, slow-growing tumors of the head and neck region. The gene (or genes) affecting risk to PGL are subject to genomic imprinting: children of affected fathers exhibit an autosomal dominant pattern of disease inheritance, whereas children of affected mothers rarely if ever develop the disease through maternal transmission. We previously confined the disease gene to an approximately 6 Mb critical region on chromosome band 11q23 (PGL1). Based on haplotype analysis of an extended Dutch pedigree, a 2 Mb sub-region between D11S938 and D11S1885 was proposed as the PGL1 critical interval. In this study, we excluded this interval by analysis of two new single tandem repeat polymorphisms (STRP) contained therein. Instead, we predicted a non-overlapping, more proximal 2 Mb critical interval between D11S1647 and D11S897, and evaluated this new region using nine STRP (D11S1986, five new, closely-linked STRP, D11S1347, D11S3178, and D11S1987). Consistent with our prediction, we observed substantial haplotype-sharing within the Dutch pedigree. We also analyzed four new American PGL families. A recombination event detected in one family further defined D11S1347 as the new telomeric border. We observed significant haplotype-sharing within this new interval among three unrelated American PGL families, strongly suggesting that they originated from a common ancestor. Thus, we confined PGL1 to an approximately 1.5 Mb region between D11S1986 and D11S1347, and showed identity-by-descent sharing for a group of American PGL families.

Fluoroscopically placed percutaneous gastrostomies in the head and neck patient

OBJECTIVE

At our institution, percutaneous gastrostomy tubes have been inserted under fluoroscopic guidance (fluoroscopic cutaneous gastrostomy [FPG]), thereby avoiding the need to traverse the pharynx and esophagus with a large-bore esophagoscope. For this reason, placement in the postoperative patient does not jeopardize the surgical reconstruction.

METHODS

Thirty-five patients underwent percutaneous gastrostomy placement under fluoroscopic guidance. These included 12 patients whose cervical esophagus could not be entered safely because of a lesion in the head neck, 11 patients who had recently undergone resection of a head and neck cancer with pharyngeal reconstruction where traditional percutaneous enteral gastrostomy (PEG) placement was contraindicated, and two patients with postoperative fistulae.

RESULTS

Thirty-four of 35 patients underwent successful gastrostomy or gastrojejunostomy placement. One patient had an intrathoracic position of the stomach, and one patient required repeat placement because the tube dislodged 5 days after insertion. No tube occluded.

CONCLUSIONS

Percutaneous gastrostomy under fluoroscopic guidance (FPG) is an effective, safe method for access for prolonged enteral feeding of the patient whose cervical esophagus cannot be accessed for a variety of reasons. It also allows the safe placement of a gastrostomy catheter when the patient's postoperative course becomes complicated and prolonged enteral nutrition is required.

111Indium pentetreotide scan detection of familial paragangliomas

Approximately 10% of head and neck paragangliomas are familial. Magnetic resonance imaging (MRI) is reported to be the best method for screening these families. 111Indium pentetreotide (Octreoscan) scintigraphy has been shown to be a sensitive indicator of neural crest tumors such as paragangliomas. Early diagnosis and treatment of familial paragangliomas (FP) would decrease the morbidity of tumor excision. Patients from two kindred with FP were scanned 24 hours after intravenous injection with approximately 6 millicuries of 111Indium pentetreotide. The entire body was imaged. Areas of increased uptake were further imaged with MRI. Altogether, five patients had positive 111Indium pentetreotide scans. Two unsuspected glomus tympanicums and bilateral carotid body tumors were identified. Three people tested had no abnormal uptake. There were no untoward reactions to the nuclide. 111Indium pentetreotide scanning is a safe, noninvasive method for early diagnosis of FP and is useful in detecting multicentric lesions. Patients suspect for FP are undergoing 111Indium pentetreotide imaging and followed up with MRI of the involved site if positive.

Osteosarcoma of the larynx

About 11,600 cases of laryngeal cancer were reported in the United States in 1995, accounting for 1% of all reported cancers. Fewer than 1% of laryngeal cancers are sarcomas, osteosarcoma being the rarest type. Twelve cases of laryngeal osteosarcoma have been cited in the literature. A 47-year-old man presented with hoarseness following a benign vocal polypectomy. The entire larynx appeared swollen, although both vocal folds moved well. Biopsies did not reveal pathologic tissue. Computed tomographic imaging revealed a destructive, expansile lesion of the thyroid cartilage. A computed tomography-guided biopsy of this cartilage revealed a high-grade sarcoma. Laryngeal osteosarcoma was diagnosed following total laryngectomy. Laryngeal osteosarcoma is a highly malignant neoplasm with early hematogenous spread. Survival statistics for peripheral osteosarcoma are poor. Limited experience reveals that a combination of surgery and radiotherapy with adjuvant chemotherapy can offer some palliation. The literature and published cases of laryngeal osteosarcoma are reviewed.

Atypical presentation of stroke in a diabetic hemodialysis patient

Cerebrovascular disease is a major cause of death in patients with end-stage renal disease, particularly in those with diabetes mellitus. Cardiac disease frequently presents itself atypically in diabetic patients. This awareness has led to earlier detection and treatment of cardiac disease in diabetic patients. Whether cerebrovascular disease may also present itself in a highly atypical fashion in the diabetic patient with end-stage renal disease has never been addressed. We report the case of a diabetic hemodialysis patient who had an extremely unusual manifestation of stroke. A 67-year-old diabetic hemodialysis patient had marked distress secondary to the sudden onset of a foreign body sensation in the oropharynx. Results of a laryngoscopy were negative; x-rays of the neck and computerized tomography of the head and neck showed no abnormalities. Neurologic evaluation revealed an inability to detect oropharyngeal stimuli and an absent gag reflex but no other deficits. Magnetic resonance imaging of the brain revealed an infarction in the left corona radiata that extended to the thalamocapsular region and external capsule, and a lacunar infarct in the right pons. Cerebrovascular disease in the diabetic patient with end-stage renal disease may present itself atypically, and we suggest that cerebrovascular disease in these patients merits the same level of suspicion as cardiac disease.

Fine mapping of an imprinted gene for familial nonchromaffin paragangliomas, on chromosome 11q23

Hereditary nonchromaffin paragangliomas (PGL; glomus tumors; MIM 168000) are mostly benign, slow-growing tumors of the head and neck region, inherited from carrier fathers in an autosomal dominant fashion subject to genomic imprinting. Genetic linkage analysis in two large, unrelated Dutch families assigned PGL loci to two regions of chromosome 11, at 11q23 (PGL1) and 11q13.1 (PGL2). We ascertained a total of 11 North American PGL families and confirmed maternal imprinting (inactivation). In three of six families, linkage analysis provided evidence of linkage to the PGL1 locus at 11q23. Recombinants narrowed the critical region to an approximately 4.5-Mb interval flanked by markers D11S1647 and D11S622. Partial allelic loss of strictly maternal origin was detected in 5 of 19 tumors. The greatest degree of imbalance was detected at 11q23, distal to D11S1327 and proximal to CD3D. Age at onset of symptoms was significantly different between fathers and children (Wilcoxon rank-sum test, P < .002). Affected children had an earlier age at onset of symptoms in 39 of 57 father-child pairs (chi2 = 7.74, P < .006). However, a more conservative comparison of the number of pairs in which a child had > or = 5 years earlier age at onset (n = 33) vis-a-vis that of complementary pairs (n = 24) revealed no significant difference (chi2 = 1.42, P > .2). Whether these data represent genetic anticipation or ascertainment bias can be addressed only by analysis of a larger number of father-child pairs.

Post-tonsillectomy hemorrhage: an assessment of risk factors

Hemorrhage is the most frequent complication of tonsillectomy and is responsible for the majority of post-tonsillectomy fatalities. The incidence of this hemorrhage has been reported to be as high as 20% [6]. Despite continued efforts to reduce this problem, it remains a persistent risk. The charts of 1138 patients who underwent tonsillectomy with or without adenoidectomy from 7-1-89 to 6-30-93 were reviewed. Post-tonsillectomy hemorrhage occurred in 36 patients (3%). Preoperative, intraoperative and postoperative risk factors were assessed. Postoperative bleeding occurred more often in older patients (69% over age 11 years). Seventy-five per cent of these patients were operated on for chronic tonsillitis as compared to 11% operated on for upper airway obstruction. The majority of these patients presented after postoperative day 1 (83%). Four patients required blood transfusions. Postoperative hemorrhage occurred in 14% of patients with elevated postoperative mean arterial pressures. Intraoperative blood loss that exceeded 50 cm3 was also a significant risk factor for post-tonsillectomy hemorrhage. It is concluded that older age, a history of chronic tonsillitis, excessive intraoperative blood loss and elevated postoperative mean arterial pressure are significant risk factors for post-tonsillectomy hemorrhage. An awareness of these risk factors can help identify patients with potential to bleed postoperatively.

Parathyroid cyst: current diagnostic and management principles

BACKGROUND

Parathyroid (PTH) cyst is a rare lesion. Only about 200 cases have been reported to date. The diagnosis of a PTH cyst is difficult, particularly in its differentiation from thyroid cyst. It has clinical significance because PTH cysts can mimic a thyroid mass and can be associated with hyperparathyroidism.

METHODS

This presentation illustrates an additional case of a PTH cyst. The importance of fine-needle aspiration (FNA) in the diagnosis of PTH cyst and its management are discussed.

RESULTS

Fine-needle aspiration of clear fluid containing an elevated PTH hormone level proved to be diagnostic in the patient. Recurrence of the cyst after FNA required surgical resection. The current concepts of etiology and treatment are summarized.

CONCLUSIONS

PTH cyst should be in the differential diagnosis in any patient initially seen with an anterior cystic neck mass. Radiologic imaging and FNA can accurately diagnose PTH cysts. Surgical excision may be needed for recurrent cysts after aspiration.

Cytogenetic analysis of tissues from patients with familial paragangliomas of the head and neck

BACKGROUND

Paragangliomas of the head and neck are slow-growing tumors that originate from neural crest cells. Between 7% and 9% of these tumors have a familial occurrence. The suspected gene for familial paragangliomas (FP) is transmitted with an autosomal dominant mode of inheritance with incomplete penetrance, and appears to exhibit genomic imprinting. It has been demonstrated by family studies that individuals who inherit the gene(s) from their father will develop the disease. Through linkage analysis, the gene(s) for FP has been postulated to be located on the long arm of chromosome 11. The discovery of many different genes has been elucidated through the cytogenetic analysis of affected individuals who carry specific chromosome aberrations. This project was designed to look for chromosome abnormalities in several second-generation family members to further assist in the localization of the gene(s) for FP.

METHODS

This study involved the cytogenetic evaluation of lymphocytes, fibroblasts, and tumor cells of several second-generation family members from a three-generation family with FP of the head and neck to look for chromosome abnormalities generally, and for abnormalities of chromosome 11 specifically. Standard cytogenetic techniques were used for lymphocyte and fibroblast cultures. Tumor cells were cultured in a collagen matrix with F12 medium supplemented with 3% L-glutamine and 10% fetal calf serum.

RESULTS

There were no detectable abnormalities of chromosome 11 in any of the cells. However, nonrandom abnormalities of chromosomes 5 and 7 were seen in some of the tumor cells of one FP patient. To our knowledge, this is the first article which demonstrated the ability to successfully culture FP of the head and neck.

Carcinoma in situ of the glottic larynx

Carcinoma in situ (CIS) is part of the histopathologic spectrum of laryngeal disorders where invasive squamous cell carcinoma is the endpoint of cellular disarray. Few reports consider prognostic indicators that predict which lesions become invasive. Forty-one patients with CIS of the glottic larynx were analyzed for risk factors that would predict invasive cancer. Anterior commissure involvement by CIS resulted in 92% conversion to invasive squamous cell cancer compared to 17% of lesions limited to the mobile fold. Epidermal growth factor receptors were also analyzed and were found not to be helpful in predicting invasion. Lesions of the mobile fold should be removed endoscopically and the patient should be observed closely for recurrence. Anterior commissure involvement that is inaccessible to complete laser ablation should be radiated, and the patient should be observed carefully.

Unusual presentations of lymphangioma

L ymphangioma is a rare but potentially life-threatening disease, particularly in children. Three unusual cases of lymphangioma located in the infratemporal fossa, submaxillary gland, and cervicomediastinal regions are presented. These unusual sites illustrate that lymphangiomas may be found at sites distant from the locations of the embryological lymph sacs. The importance of radiological examination is emphasized. Although there are many modes of therapy for this disease, complete surgical excision when possible is advocated. The literature regarding the embryology, presentation, clinical workup, and current modes of therapy for lymphangioma is reviewed.

Unifocal Langerhans' cell histiocytosis (eosinophilic granuloma) of the petrous apex

Eosinophilic granuloma is a localized form of histiocytosis X, or Langerhans' cell histiocytosis, a benign lesion of proliferating Langerhans' cells. It is the least severe of the histiocytosis syndromes, and is characterized by lytic lesions of one or more bones. Temporal bone lesions usually occur in association with multifocal disease; however, isolated lesions may occur in either the mastoid bone alone, or in the entire temporal bone, without disease elsewhere in the body. We present the first case (to our knowledge) of eosinophilic granuloma, or unifocal Langerhans' cell histiocytosis, limited to the petrous apex. The patient, an 8-year-old girl, presented with facial nerve paralysis. Because of delay in definitive diagnosis, the disease extended beyond its original boundaries and resulted in complete destruction of the temporal bone. We will also review Langerhans' cell histiocytosis, with attention to its involvement of the temporal bone.

Primary salivary gland amyloidosis causing sicca syndrome

Sicca syndrome (SS), consisting of xerostomia and xerophthalmia, may be caused by various disease processes. We present a unique case of SS secondary to primary amyloidosis. Amyloidosis is a rare but definite cause of SS and should be included in the differential diagnosis of any patient who presents with sicca symptoms. A literature review comparing amyloidotic patients with SS and patients with amyloidosis only demonstrates that both of these groups of patients present similarly with regard to symptoms. However, the majority of patients with SS present with sicca symptoms initially in addition to symptoms of amyloidosis. These SS patients also present with proteinuria and negative serology test results. Therefore, patients presenting with sicca symptoms, proteinuria, and negative serologic findings should be suspect for amyloidosis. The importance of distinguishing the diagnosis of Sjögren's syndrome from SS in these patients cannot be overemphasized. There is a significantly higher incidence of developing a lymphoma in Sjögren's syndrome patients. This has important implications for the head and neck surgeon treating these patients.

Otolaryngologic manifestations of phenytoin toxicity

DPH may result in protean head and neck manifestations (Table 1). In some cases these effects are dose related and in others they appear to be idiosyncratic; some occur only at toxic levels (Table 2). Many of the conditions are reversible and withdrawal of DPH or re-establishment of therapeutic levels is the only treatment necessary. Failure to recognize this fact can result in expensive workups or, worse, in aggressive treatment, both of which are unnecessary. The otolaryngologist should therefore be aware of these conditions and consider them in the differential diagnosis.

Extended single transverse neck incision for composite resections: does it work?

Since Crile's original description of neck dissection in 1906 (Crile GW: JAMA 47:1780-1786, 1906), a variety of neck incisions has been described, suggesting that none is sufficiently versatile to satisfy the criteria necessary for the ideal neck flap. Single transverse neck incisions (STNI) for complete neck dissections have been performed since the 1950s but are not as commonly used as trifurcate incisions. A criticism of the STNI is that the perceived difficulty exposing the surgical field may compromise removal of disease and impair normal surgical technique, resulting in a higher incidence of recurrent neck disease and postoperative complications. One hundred nine patients with squamous cell carcinoma of the head and neck were operated using the STNI. There was no incidence of skin necrosis or carotid artery hemorrhage. Fourteen percent developed fistulae and 12% developed wound dehiscences. Recurrence in the operated neck was not identified. Cosmesis was considered good in all patients. We conclude that STNI does not result in an increased incidence of postoperative complications or recurrent neck disease compared with standard trifurcate incisions.

Sump catheter drainage of parotid abscess: an alternative to surgery

It is a clinical challenge to distinguish patients with parotid abscesses from those with acute sialadenitis. A case of parotid abscess is presented in which a CT scan with intravenous contrast enhancement localized the abscess cavity and guided its aspiration and drainage with an indwelling catheter. By using this percutaneous technique, the need for early surgical intervention by incision and drainage was eliminated. The dense overlying parotid fascia and position of the deep parotid lobe make differentiating between these two clinical entities difficult. Parotid abscesses are readily apparent on computerized tomographic (CT) scanning evaluation with intravenous contrast enhancement, presenting as discrete fluid-filled areas unlike the amorphous appearance of acute sialadenitis. CT scanning with intravenous contrast enhancement has been the preferred radiographic study of choice for evaluating parotid masses or parapharyngeal masses. The treatment of a patient with acute sialadenitis differs from that of a patient with a parotid abscess. Patients with acute sialadenitis will usually respond to vigorous intravenous (IV) hydration, use of sialagogues and appropriate antibiotic coverage. Following a period of conservative treatment with antibiotics and warm soaks, patients with parotid abscesses will usually undergo an incision and drainage procedure, and later, parotidectomy. A case of parotid abscess is presented in which a CT scan with intravenous contrast enhancement localized the abscess cavity and guided its aspiration and drainage with an indwelling catheter. Percutaneous drainage of parapharyngeal abscesses guided by CT has been previously described by Cole. By using this percutaneous technique, the need for early surgical intervention by incision and drainage was eliminated.

Recurrent pleomorphic adenomas of the parotid gland

Twenty-seven patients with recurrent pleomorphic adenomas of the parotid gland were seen. This study confirms that superficial parotidectomy with identification and dissection of the facial nerve greatly decreases the incidence of recurrent benign pleomorphic adenoma, and, in the small number that recur, are easier to cure. All lumps in the parotid area should be approached in the same manner, with the surgeon prepared to isolate the facial nerve and perform superficial parotidectomy. This technique is successful because it avoids dissection near the tumor capsule, which is the major cause of recurrence. The procedure recommended for treatment of patients to remove the first recurrent tumor is total parotidectomy and excision of the previous scar. This vigorous approach is dictated by the increasing difficulty of removing further recurrent tumors. Only 67% of patients with recurrent tumors ultimately achieve a tumor-free status. Experienced surgeons can preserve the facial nerve even after multiple operations.

Traumatic retropharyngeal hematoma

The development of a retropharyngeal hematoma following a whiplash injury is a rare occurrence. The potential for airway compression necessitates rapid assessment and treatment. An 80-year-old man who had been receiving long-term aspirin therapy sustained a retropharyngeal hematoma following a motor vehicle accident. Management consisted of tracheostomy, neck exploration, and evacuation and drainage of the hematoma. To the best of our knowledge, there are less than 20 citations of traumatic retropharyngeal hematoma in the English literature. Retropharyngeal hematoma has been associated with cervical extension/flexion injuries, anticoagulation therapy, great-vessel trauma, and foreign body ingestion.

Hemangioma of the zygomatic bone

Bony hemangiomas of the zygomatic bone are rare. This report represents the tenth citing in the literature. The most common signs and symptoms include swelling and pain or tenderness. Diagnosis can be made by plain radiographic studies followed by CT scanning or MRI. The treatment of choice is surgical excision with a rim of normal bone around the tumor. Malignant degeneration has not been reported unless radiotherapy had been used.

Laser endoscopic treatment of laryngoceles and laryngeal cysts

The laryngocele and saccular cyst are uncommon anomalies of the larynx. Two patients, one with an internal laryngocele and one with a saccular cyst, were successfully treated by endoscopic laser marsupialization of their lesions. Since neither patient was found to be a suitable candidate for prolonged general anesthesia, the patients did not require a tracheotomy and were discharged the day after surgery. Both patients are doing well, with remarkable improvement in their voices persisting in their three year follow-up. The signs, symptoms, diagnosis, treatment, and indications for endoscopic laser treatment of internal laryngoceles and saccular cysts are discussed. Laser marsupialization of internal laryngoceles appears to be an acceptable mode of treatment.

Repair of nasal septal perforations with tragal cartilage and perichondrium grafts

Indications for repair of nasal septum perforations include excessive crusting, recurrent bleeding, whistling, and pain. Large subtotal perforations usually are less symptomatic, but smaller defects (less than 1 cm) may need repair. Tragal cartilage with perichondrium autograft was used to repair these perforations. After the septal defect was debrided, this free graft was harvested and used to fill the defect. This technique was attempted in ten patients with septal perforations, none secondary to systemic illnesses. Nine of these patients had successful closure of their perforations.