The Frontal Sinus and Frontal Recess: Anatomical, Radiological and Surgical Concepts

Abstract Introduction The frontal sinus (FS) is the most complex of the paranasal sinuses due to its location, anatomical variations and multiple clinical presentations. The surgical management of the FS and of the frontal recess (FR) is technically challenging, and a complete understanding of its anatomy, radiology, main diseases and surgical techniques is crucial to achieve therapeutic success. Objectives To review the FS and FR anatomy, radiology, and surgical techniques. Data Synthesis The FS features a variety of anatomical, volumetric and dimensional characteristics. From the endoscopic point of view, the FR is the point of greatest narrowing and, to have access to this region, one must know the anatomical limits and the ethmoid cells that are located around the FR and very often block the sinus drainage. Benign diseases such as chronic rhinosinusitis (CRS), mucocele and osteomas are the main pathologies found in the FS; however, there is a wide variety of malignant tumors that can also affect this region and represent a major technical challenge to the surgeon. With the advances in the endoscopic technique, the vast majority of diseases that affect the FS can be treated according to Wolfgang Draf, who systemized the approaches into four types (I, IIa, IIb, III). Conclusion Both benign and malignant diseases that affect the FS and FR can be successfully managed if one has a thorough understanding of the FS and FR anatomy, an individualized approach of the best surgical technique in each case, and the appropriate tools to operate in this region.

What is the impact of positive airway pressure in nasal polyposis? An experimental study

Introduction: It has been hypothesized that increasing the interstitial hydrostatic pressure within the sinonasal mucosa of patients with nasal polyposis (NP) might decrease the size of nasal polyps. Objective: To evaluate the effects of positive airway pressure, delivered by a continuous positive airway pressure (CPAP) device, in patients with NP and in control subjects. Methods: Twelve patients with NP and 27 healthy subjects were exposed to CPAP (20 cm H2O) for 2 hours. Visual analog scale (VAS), Nasal Obstruction Symptom Evaluation (NOSE) scale, acoustic rhinometry (AR), peak nasal inspiratory flow (PNIF) and nasal endoscopy (NE-Meltzer polyp grading system) were performed before and after the intervention, for all patients. Results: The control group showed a significant worsening in nasal obstruction symptoms, as measured by VAS and NOSE (p < 0.01), and a significant decrease in nasal patency, as measured by the PNIF and AR (p < 0.01). For the NP group, VAS, NOSE, and AR did not differ significantly (p = 0.72, p = 0.73, and p = 0.17, respectively), but PNIF values worsened (p = 0.04) after exposure to CPAP. There was a statistically significant reduction in the nasal polyps' size (p = 0.04). Conclusions: Positive pressure worsened the nasal obstruction symptoms and decreased objective parameters of nasal patency in control subjects. In patients with NP, exposure to CPAP reduced the nasal polyps' size, and the nasal patency, asmeasured by PNIF. However, it had no significant effects in AR and in nasal obstruction symptoms (AU)

Breaking paradigms in severe epistaxis: the importance of looking for the S-point / Quebrando paradigmas na epistaxe grave: a importância de procurar o S-point

Abstract Introduction: Since the introduction of nasal endoscopy into the field of Otorhinolaryngology, the treatment paradigm for cases of severe epistaxis has shifted toward early and precise identification of the bleeding site. Although severe epistaxis is usually considered to arise from posterior bleeding, an arterial vascular pedicle in the superior portion of the nasal septum, around the axilla projection of the middle turbinate, posterior to the septal body, frequently has been observed. That vascular pedicle was named the Stamm's S-point. Objective: The aim of this study was to describe the S-point and report cases of severe epistaxis originating from it. Methods: A retrospective case series study was conducted. Nine patients with spontaneous severe epistaxis, where the S-point was identified as the source of bleeding, were treated between March 2016 and March 2017. Results: Male predominance (77.8%) with age average of 59.3 years old were reported. Most cases presented comorbidities (88.9%) and were not taking acetylsalicylic acid (66.7%). A predominance of left sided involvement (55.6%) and anteroposterior bleeding being the principal initial presentation (77.8%) was seen. Six patients (66.7%) presented with hemoglobin levels below 10 g/dL, and four (44.4%) required blood transfusion. Cauterization of S-point was performed in all patients, with complete resolution of bleeding. No patient experienced recurrence of severe epistaxis. Conclusion: The Stamm's S-point, a novel source of spontaneous severe epistaxis, is reported, and its cauterization was effective and safe. Otolaryngologists must actively seek this site of bleeding in cases of severe epistaxis.

Resumo Introdução: Desde a introdução da endoscopia nasal no campo de otorrinolaringologia, o paradigma de tratamento para casos graves de epistaxe voltou-se para a identificação precoce e correta do local de sangramento. Embora a epistaxe grave seja geralmente considerada uma hemorragia posterior, um pedículo vascular arterial tem sido frequentemente observado na porção superior do septo nasal, ao redor da projeção da axila da concha média, posterior ao tubérculo septal. Esse pedículo vascular foi chamado de Stamm's S-point. Objetivo: Descrever o S-point e relatar casos graves de epistaxe que se originam nesse local. Método: Um estudo retrospectivo de série de casos foi conduzido. Nove pacientes com epistaxe grave espontânea, na qual o S-point foi identificado como a fonte do sangramento, foram tratados de março de 2016 a março de 2017. Resultados: Houve predominância do sexo masculino (77,8%) com média de 59,3 anos. A maioria dos casos apresentava comorbidades (88,9%), mas sem uso de ácido acetilsalicílico (66,7%). Observou-se predominância do lado esquerdo (55,6%) com sangramento anteroposterior como a principal apresentação inicial (77,8%). Seis pacientes (66,7%) apresentaram níveis de hemoglobina inferiores a 10 g/dL e quatro (44,4%) necessitaram de transfusão sanguínea. Cauterização do S-point foi feita em todos os pacientes, com resolução completa do sangramento. Nenhum paciente apresentou recorrência de epistaxe grave. Conclusão: O Stamm's S-point é relatado como uma nova região de origem de epistaxe grave espontânea e o tratamento feito com cauterização foi eficaz e seguro. Os otorrinolaringologistas devem buscar ativamente esse local de sangramento em casos de epistaxe grave.

Efficacy of syringe-irrigation topical therapy and the influence of the middle turbinate in sinus penetration of solutions / Eficácia da terapia tópica de irrigação com seringa e a influência da concha média na penetração sinusal de soluções

Abstract Introduction: Topical therapies are the best postoperative treatment option for chronic rhinosinusitis, especially those with high volume and pressure, such as the squeeze bottles. However, they are not an available option in Brazil, where irrigation syringes are used. Objective: To investigate the efficacy of topical sinonasal therapy with syringe and the influence of the middle turbinate on this process Methods: Intervention study in training models (S.I.M.O.N.T.). After standard dissection, three interventions were performed (Nasal Spray 4 puffs, 60-mL syringe and 240-mL Squeeze Bottle) with normal and Sutured Middle Turbinate. Images of each sinus were captured after the interventions, totalizing 144 images. The images were classified by 10 evaluators according to the amount of residual volume from zero to 3, with zero and 1 being considered poor penetration and 2 and 3, good penetration. The 1440 evaluations were used in this study. Results: Considering all middle turbinate situations, the amount of good penetrations were 8.1% for Spray; 68.3% for Syringe, and 78.3% for Squeeze (p < 0.0001). Considering all types of interventions, the Normal Middle Turbinate group had 48.2% of good penetrations and the Sutured Middle Turbinate, 55% (p = 0.01). Considering only the Sutured Middle Turbinates, there was no difference between the interventions with Syringe and Squeeze (76.3% vs. 80.4%; p = 0.27). Conclusion: Topical therapy of irrigation with a 60-mL syringe was more effective than that with nasal spray. The status of the middle turbinate proved to be fundamental and influenced topical therapy. Irrigation with syringe was as effective as the squeeze bottle when the middle turbinate was sutured to the nasal septum.

Resumo Introdução: Terapias tópicas são a melhor opção de tratamento pós-operatório da rinossinusite crônica, principalmente com alto volume e pressão, como os squeeze bottles. Porém, não são opções disponíveis na realidade brasileira, na qual frequentemente são usados seringas para a irrigação. Objetivo: Averiguar a eficácia da terapia tópica nasossinusal com seringa e a influência da concha média nesse processo. Método: Estudo de intervenção em modelos de treinamento (S.I.M.O.N.T.). Após dissecção padronizada, três intervenções foram feitas (spray nasal 4 puffs, seringa de 60 mL e squeeze bottle de 240 mL) com a concha média normal e suturada. Foram capturadas imagens de cada seio após as intervenções, totalizando 144 imagens. As imagens foram classificadas por 10 avaliadores de acordo com a quantidade de volume residual de zero a 3, sendo zero e 1 considerados penetração ruim e 2 e 3, penetração boa. As 1.440 avaliações foram utilizadas neste estudo. Resultados: Considerando todas as situações de concha média, a quantidade de penetrações boas foi de 8,1% para spray; 68,3% para seringa e 78,3% para squeeze (p < 0,0001). Considerando todos os tipos de intervenção, a concha média normal obteve 48,2% de penetrações boas e a concha média suturada, 55% (p = 0,01). Considerando apenas concha média suturada, não houve diferença entre as intervenções seringa e squeeze (76,3% vs. 80,4%; p = 0,27). Conclusão: A terapia tópica de irrigação com seringa de 60 mL foi mais eficaz do que com spray nasal. O status da concha média mostrou-se fundamental e influenciou a terapia tópica. A irrigação com seringa foi tão eficaz quanto a com squeeze bottle quando a concha média foi suturada ao septo nasal.

Thyroid gland invasion in advanced squamous cell carcinoma of the larynx and hypopharynx / Invasão da glândula tireoide no carcinoma espinocelular avançado de laringe e hipofaringe

Abstract Introduction: Squamous cell carcinoma of the larynx and hypopharynx has the potential to invade the thyroid gland. Despite this risk, the proposition of either partial or total thyroidectomy as part of the surgical treatment of all such cases remains controversial. Objectives: To evaluate the frequency of invasion of the thyroid gland in patients with advanced laryngeal or hypopharyngeal squamous cell carcinoma submitted to total laryngectomy or pharyngolaryngectomy and thyroidectomy; to determine whether clinic-pathological characteristics can predict glandular involvement. Methods: A retrospective case series with chart review, from January 1998 to July 2013, was undertaken in a tertiary care university medical center. An inception cohort of 83 patients with larynx/hypopharynx squamous cell carcinoma was considered. All patients had advanced stage disease (clinically T3-T4) and underwent total laryngectomy or total pharyngolaryngectomy in association with thyroidectomy. Adjuvant therapy was indicated when tumor or neck conditions required. Frequency of thyroid cartilage invasion was calculated; univariate and multivariate analysis of demographic, clinical and pathological characteristics associated with cartilage invasion were performed. Results: The overall frequency of invasion of the thyroid gland was 18.1%. Glandular involvement was associated with invasion of the following structures: anterior commissure (odds ratio = 5.13; 95% confidence interval 1.07-24.5), subglottis (odds ratio = 12.44; 95% confidence interval 1.55-100.00) and cricoid cartilage (odds ratio = 15.95; 95% confidence interval 4.23-60.11). Conclusions: Invasion of the thyroid gland is uncommon in the context of laryngopharyngeal squamous cell carcinoma. Clinical and pathological features such as invasion of the anterior commissure, subglottis and cricoid cartilage are more associated with glandular invasion.

Resumo Introdução O carcinoma espinocelular de laringe e hipofaringe tem potencial para invadir a glândula tireoide. Apesar desse risco, a proposição de tireoidectomia parcial ou total como parte do tratamento cirúrgico de todos esses casos permanece controversa. Objetivos Avaliar a frequência de invasão da glândula tireoide em pacientes com carcinoma espinocelular avançado de laringe ou hipofaringe submetidos a laringectomia total ou faringolaringectomia e tireoidectomia; determinar se características clínico‐patológicas podem prever o envolvimento glandular. Método Uma série de casos retrospectivos com revisão de prontuários, entre janeiro de 1998 e julho de 2013, foi feita em um centro médico universitário de cuidados terciários. Uma coorte inicial de 83 pacientes com carcinoma espinocelular de laringe/hipofaringe foi considerada. Todos os pacientes tinham doença em estágio avançado (clinicamente T3‐T4) e foram submetidos a laringectomia total ou faringolaringectomia em associação com tireoidectomia. Foi indicada terapia adjuvante quando o tumor ou as condições do pescoço exigiram. A frequência de invasão de cartilagem da tireoide foi calculada; análises univariada e multivariada das características demográficas, clínicas e patológicas associadas à invasão de cartilagem foram feitas. Resultados A frequência global de invasão da glândula tireoide foi de 18,1%. O envolvimento glandular foi associado à invasão das seguintes estruturas: comissura anterior (odds ratio = 5,13; intervalo de confiança 95%, 1,07‐24,5), subglote (odds ratio = 12,44; intervalo de confiança 95%, 1,55‐100,00) e cartilagem cricoide (odds ratio = 15,95; intervalo de confiança 95%, 4,23‐60,11). Conclusões A invasão da glândula tireoide é rara no contexto de carcinoma espinocelular laringofaríngeo. As características clínicas e patológicas, como a invasão da comissura anterior, subglote e cartilagem cricoide, estão mais associadas a invasão glandular.

Transcanal endoscopic myringoplasty: a case series in a university center / Miringoplastia endoscópica transcanal: série de casos em um serviço universitário

ABSTRACT INTRODUCTION: Transcanal myringoplasty has the advantages of demanding lower operative time and minimal external incisions. It can be performed using the microscopic or endoscopic approach. In the last decade, the use of endoscopes in ear surgery has increased significantly. This technique may allow "around the corner" visualization of small recesses, through narrow spaces, without the aid of canalplasty in unfavorable ear canals. OBJECTIVE: To describe a case series of transcanal endoscopic myringoplasty performed in a university service. The characteristics, advantages, and disadvantages of this technique are also discussed. METHODS: A case series study, based on the chart review of patients submitted to transcanal endoscopic myringoplasty in the period from January of 2012 to October of 2014. RESULTS: Data from 22 patients were analyzed. Tympanic perforation closure three months after surgery was observed in 86.4% of all patients. There was statistically significant improvement in pure tone average thresholds after surgery (p < 0.001). CONCLUSION: Transcanal endoscopic myringoplasty is a feasible, safe, and effective procedure; it can be an alternative to microscopic surgery.

Resumo Introdução: A miringoplastia realizada por via transcanal possui como vantagens a maior rapidez do procedimento e menor incisão externa, podendo ser realizada com auxílio de microscópio ou endoscópio. Na última década tem sido observado um aumento do uso de endoscópios na cirurgia otológica. Essa técnica pode permitir melhor visibilização de espaços encobertos e estreitos, sem necessidade canaloplastia em meatos desfavoráveis. Objetivo: Descrever uma série de casos de miringoplastia endoscópica transcanal, em um serviço universitário, discutindo suas particularidades, vantagens e desvantagens. Método: Estudo de série de casos, baseado na revisão de prontuários dos pacientes submetidos a miringoplastia com uso exclusivo de endoscópio rígido, no período de Janeiro de 2012 a Outubro de 2014. Resultados: Foram analisados os dados de 22 pacientes. Na otoscopia pós-operatória, foi observado fechamento da perfuração timpânica em 86,4% dos pacientes, após 3 meses da intervenção. Para a amostra estudada, foi observada melhora funcional estatisticamente significante da média dos limiares tonais (PTA) após a cirurgia (p < 0,001). Conclusão: A miringoplastia endoscópica transcanal é um procedimento seguro, factível e efetivo, podendo ser realizado como alternativa à cirurgia microscópica.

Localizacao de glandulas paratireoides ectopicas e supranumerarias em pacientes com hiperparatireoidismo secundario e terciario: descricao cirurgica e correlacao com ultrassonografia e cintilografia Tc99m-Sestamibi pre-operatorios / Localization of ectopic and supernumerary parathyroid glands in patients with secondary and tertiary hyperparathyroidism: surgical description and correlation with preoperative ultrasonography and Tc99m-Sestamibi scintigraphy

Introdução: O hiperparatireoidismo é uma consequência metabólica esperada na doença renal crônica (DRC). Paratireoides (PT) ectópicas e/ou supranumerárias podem ser causa de falha cirúrgica nos pacientes submetidos à paratireoidectomia total (PTX). Objetivo: Definir cirurgicamente a localização das PT, em pacientes com hiperparatireoidismo associado à DRC, e correlacionar esses achados com os exames pré-operatórios. Materiais e métodos: Foi conduzido um estudo retrospectivo com 166 pacientes submetidos à PTX. A localização das PT no intraoperatório foi registrada, sendo classificada como tópica ou ectópica. A localização pré-operatória, definida pela ultrassonografia (USG) e pela cintilografia Tc99m-Sestamibi (MIBI), foi comparada com aos achados cirúrgicos. Resultados: Nos 166 pacientes, foram identificadas 664 PT. Foram classificadas como tópicas e ectópicas 577 (86,4%) e 91(13,6%) glândulas, respectivamente. Oito PT supranumerárias foram encontradas (7 tópicas e 1 ectópica). As localizações mais comuns de PT ectópicas foram as regiões retroesofágica e tímica. Associadas, a USG e a MIBI não identificaram 56 glândulas (61,5%) ectópicas. Entretanto, a MIBI foi positiva para 69,7% daquelas localizadas nas regiões tímicas e mediastinal. Conclusão: A presença de glândulas ectópicas e supranumerárias em pacientes com hiperparatireoidismo associado à DRC é significativa. Os exames de imagem pré-operatórios não localizaram a maioria das glândulas ectópicas. A MIBI pode ter importância na identificação de PT nas regiões tímica e mediastinal. .

Introduction: Hyperparathyroidism is an expected metabolic consequence of chronic kidney disease (CKD). Ectopic and/or supernumerary parathyroid glands (PT) may be the cause of surgical failure in patients undergoing total parathyroidectomy (PTX). Aim: To define the locations of ectopic and supernumerary PT in patients with renal hyperparathyroidism and to correlate intraoperative findings with preoperative tests. Materials and methods: A retrospective study was conducted with 166 patients submitted to PTX. The location of PT during surgery was recorded and classified as eutopic or ectopic. The preoperative localizations of PT found by ultrasonography (USG) and Tc99m-Sestamibi scintigraphy (MIBI) were subsequently compared with intraoperative findings. Results: In the 166 patients studied, 664 PT were found. Five-hundred-seventy-seven (86.4%) glands were classified as eutopic and 91(13.6%) as ectopic. Eight supernumerary PT were found. The most common sites of ectopic PT were in the retroesophageal and thymic regions. Taken together, USG and MIBI did not identify 56 (61.5%) ectopic glands. MIBI was positive for 69,7% of all ectopic glands located in the mediastinal and thymic regions. Conclusion: The presence of ectopic and supernumerary PT in patients with renal hyperparathyroidism is significant. Although preoperative imaging tests did not locate most of ectopic glands, MIBI may be important for identifying ectopic PT in the mediastinal and thymic regions. .

Corpo estranho em Otorrinolaringologia: perfil dos atendimentos em um pronto-socorro de referencia / ENT foreign bodies: profile of the cases seen at a tertiary hospital emergency care unit

A presença de corpo estranho (CE) nas orelhas, nariz ou garganta é uma queixa muito comum. Seu devido reconhecimento, estudo e manejo são necessários para que complicações sejam prevenidas. OBJETIVO: Analisar o perfil dos atendimentos a CE realizados em um pronto-socorro (PS) de Otorrinolaringologia (ORL) de referência, no período de fevereiro de 2010 a janeiro de 2011. MÉTODO: Estudo retrospectivo de coorte histórica com corte transversal, baseado na análise de fichas de pronto-atendimento digitalizadas. RESULTADOS: Foram realizados atendimentos a 827 casos de CE no período, representando 5,3% de todos os casos atendidos no PS-ORL. CE foi mais comumente encontrado em crianças, principalmente em ≤ 8 anos. Não houve diferença significativa entre gêneros. CE se localizaram mais frequentemente nas orelhas (64,4%), nas fossas nasais (19,5%) e na orofaringe (8,9%). A taxa geral de complicações foi 4,5% e a necessidade de anestesia geral para retirada do CE, 4,4%. CONCLUSÃO: CE em ORL é uma queixa comum, sendo mais comumente encontrados nas orelhas, principalmente em crianças. Baixas taxas de complicação e necessidade de anestesia geral foram registradas nos atendimentos realizados pelo otorrinolaringologista. Salienta-se, novamente, a importância do correto manejo de CE em ORL para a prevenção de complicações. .

Individuals often seek help with foreign bodies (FB) in their ears, noses, and throats. Proper recognition, study, and management of foreign bodies is required to prevent complications. OBJECTIVE: To analyze the profile of the patients seen for FB at a reference otorhinolaryngology emergency care unit between February of 2010 and January of 2011. METHOD: Cross-sectional retrospective historical cohort study based on digitized patient charts. RESULTS: FB accounted for 827 cases and 5.3% of all patients seen in the ENT emergency unit. Children were affected more frequently, particularly when aged 8 and under. No statistically significant differences were seen between genders. Foreign bodies were mostly located in the ears (64.4%), followed by the nasal fossae (19.5%), and the oropharynx (8.9%). Complications were seen in 4.5% of the cases, and 4.4% required general anesthesia to have the FB removed. CONCLUSION: In our ENT practice, foreign bodies were more commonly seen in children; the ears were the preferential site of occurrence. Complication rates and use of general anesthesia were low in our practice. It should be stressed that ENT foreign bodies need to be properly managed so as to avoid complications. .

Stage II Chronic Maxillary Atelectasis Associated with Subclinical Visual Field Defect

Chronic maxillary atelectasis (CMA) is characterized by a persistent decrease in the maxillary sinus volume due to inward bowing of its walls. According to its severity, it may be classified into three clinical-radiological stages. Objective: To report a case of stage II CMA associated with subclinical visual field defect. Case Report: A 34-year-old woman presented with a 15-year history of recurrent episodes of sinusitis and intermittent right facial discomfort for the past 5 years. She denied visual complaints, and no facial deformities were observed on physical examination. Paranasal sinus computed tomography (CT) demonstrated a completely opacified right maxillary sinus with inward bowing of its walls, suggesting the diagnosis of stage II CMA. A computerized campimetry (CC) disclosed a scotoma adjacent to the blind spot of the right eye, indicating a possible damage to the optic nerve. The patient was submitted to functional endoscopic sinus surgery, with drainage of a thick mucous fluid from the sinus. She did well after surgery and has been asymptomatic since then. Postoperative CT was satisfactory and CC was normal. Discussion: CMA occurs because of a persistent ostiomeatal obstruction, which creates negative pressure inside the sinus. It is associated with nasosinusal symptoms but had never been described in association with any visual field defect. It can be divided into stage I (membranous deformity), stage II (bony deformity), and stage III (clinical deformity). The silent sinus syndrome is a special form of CMA. This term should only be used to describe those cases with spontaneous enophthalmos, hypoglobus, and/or midfacial deformity in the absence of nasosinusal symptoms...

Hipertensão arterial, osteoporose, amenorreia e depressão como manifestações da síndrome de cushing acth-independente: evolução após adrenalectomia laparoscópica / Arterial hypertension, osteoporosis, amenorrhea, and depression as presentation of ACTH-independent Cushing's syndrome: follow-up after laparoscopic adrenalectomy

A síndrome de Cushing é caracterizada por excesso de glicocorticóides circulantes. Os tumores suprarrenais secretores de cortisol representam a principal causa desse distúrbio, dentre os quais adenomas, que correspondem a 65% dos casos. A apresentação clínica típica inclui obesidade centrípeta, fadiga, hipertensão arterial de difícil controle, osteoporose, distúrbios menstruais, hirsutismo, equimoses e estrias violáceas. Entretanto, casos de síndrome de Cushing subclínica vem sendo descritos com frequência crescente, o que faz com que essa doença ainda representardesafio diagnóstico na atualidade, pela capacidade de mimetizar outras entidades nosológicas, tais como síndrome metabólica, depressão e alcoolismo. Relata-se o caso de uma mulher de 27 anos, que vinha em tratamento de hipertensão arterial, osteoporose e depressão intensa antes do diagnóstico de síndrome de Cushing ACTH-independente,na qual o tratamento cirúrgico da doença de base resultou abrandamento significativo das comorbidades.

Cushing’s syndrome is characterized by an excess of circulating glucocorticoids. Cortisol-secreting adrenal tumors are the most common cause of endogenous ACTH-independent disease, with adrenal adenomas accounting for 65% of these cases. The typical clinical presentation includes centripetal obesity, fatigue, arterial hypertension, osteoporosis, menstrual disorders, hirsutism, easy bruising, and diffuse violaceous striae. However, subclinical Cushing´s syndrome is being described with growing frequency, still making this disease a diagnostic challenge, due to the ability to mimicother nosologic entities, such as the metabolic syndrome, depression and alcoholism. The authors report the case of a 27-year-old woman, who has been treated for hypertension, osteoporosis and depression before the diagnosis of ACTH-independent Cushing’s syndrome was established, and in whom the surgical treatment of the disease resulted in significant improvement of co-morbidities.

Aspectos clínicos, diagnóstico e manejo dos tumores que produzem catecolaminas: feocromocitomas e paragangliomas / Clinical aspects, diagnosis and management of catecolamin-producing tumors: pheocromocitomas and paragangiomas

Os feocromocitomas e paragangliomas são tumores raros, originários de células cromafins. Os primeiros localizam-se na medula suprarrenal e os últimos podem ser encontrados em qualquer local ao longo das cadeias simpática sou parassimpáticas do sistema nervoso autônomo. Constituem causa potencialmente curável de hipertensão arterial. Usualmente, secretam catecolaminas, incluindo-se dopamina, adrenalina e noradrenalina, responsáveis pela tríade semiológica clássica de manifestações: episódios paroxísticos de cefaléia, diaforese e palpitação. No entanto, a apresentação clínica é muito variável, e um grande número de pacientes pode ser oligo- ou assintomático, sugerindo que a parte significativa dos casos não é diagnosticada. Alta suspeição, uso racional de exames laboratoriais e métodos de imagem apropriados dão o diagnóstico anatômico e funcional preciso. Este artigo traz uma revisão sobre as recomendações mais atuais para abordagem desses tumores endócrinos.

Pheocromocytomas and paragangliomas are rare tumors, originated from chromaffim cells. The first ones are located in the suprarrenal medulla, and the others are found somewhere along the sympathetic and parasympathetic chains from the autonomous neural system. They constitute a potentially curable cause of arterial hypertension. Usually, they secrete cathecolamines, including dopamine, epinephrine and norepinephrine, which are responsible for the classic triad of manifestations: paroxysms of cephaleia, diaphoresis and palpitations. However, clinical presentation is very heterogeneous and a significant number of patients are oligo- or assymptomatic, suggesting that the majority of these cases may not be detected. High suspicion, rational use of laboratorial exams and appropriate imaging methods lead to accurate functional and anatomical diagnosis. The present article brings a revision about the most recent recommendations for management of these endocrine tumors.