Angioedema of the head and neck.

Angioedema is an immunological disorder characterized by the acute onset of edema in a localized area of skin or mucosa. There are many different causes of angioedema, including hereditary, allergic, and idiopathic. Head and neck involvement is frequent and may cause potentially life-threatening airway compromise. Early diagnosis and appropriate management are thus critical. The pathophysiology, clinical presentation, and management of this disorder are discussed.

Endonasal approach for nasal and paranasal sinus tumor removal.

Patients with benign (53) and malignant (22) tumors of the nose and paranasal sinuses were treated for tumor removal via an endonasal approach. Patient selection was based on tumor location (centrally) rather than histology. Tumors attainable by the endonasal approach were located in the nasal cavity, the ethmoid sinus, the sphenoid sinus and the medial wall of the maxillary sinus. Endonasal microscopic techniques including endonasal orbital decompression and endonasal closure of CSF-leaks were combined with surgical navigation tools in selected cases. Surgical trauma and morbidity could be minimized without compromising radicality of tumor removal. Postoperative hospitalization was comparable to the period needed after chronic inflammatory disease. Growing experience with endonasal techniques is leading towards a safe and effective treatment option for centrally located, selected tumors of the nose and paranasal sinuses.

Fine-needle aspiration biopsy.

OBJECTIVES: Fine-needle aspiration biopsy (FNAB) is a technique in which a fine needle is introduced into a mass, cellular material is aspirated, and a cytological diagnosis is rendered. It separates reactive and inflammatory processes that do not require surgical intervention from neoplasia and benign from malignant tumors. FNAB lends itself to the diagnosis of palpable head and neck masses, in particular, those that persist following antibiotic treatment. STUDY DESIGN/METHODS: This clinical state-of-the-art review article is intended to provide an overview of the clinical use of FNAB in the management of head and neck masses. Relevant case histories are used to illustrate this point. RESULTS: Fine-needle aspiration biopsy has a high overall diagnostic accuracy of 95% for all head and neck masses, 95% for benign lesions, and 87% for malignant ones. CONCLUSIONS: There are virtually no contraindications, and complications are minimal. Advantages of FNAB are that it is safe and simple, it can be performed as an outpatient procedure, and it is well tolerated by patients. In the present managed care environment, it also proves cost-effective. The diagnosis is readily known to the clinician, and appropriate treatment modalities can be discussed with the patient. It is recommended as a first line of investigation in palpable head and neck masses.

Traumatic perforation of the tympanic membrane.

Traumatic perforations of the ear drum are often encountered in the emergency room and in the primary care setting. We review mechanisms of injury to the tympanic membrane and elucidate the appropriate evaluation and treatment of this injury.

Base of tongue carcinoma.

Vigilance must remain high in order to detect the rare occurrence of base of tongue carcinoma. The combination of ubiquitous and nonspecific complaints coupled with difficult physical examination of this area contribute to delays in diagnosis, with patients often presenting at an advanced stage. This advanced presentation creates challenging treatment decisions in which adequate tumor control must be balanced with subsequent patient quality of life. The result is controversy over the primary treatment modality--external beam radiation, with or without brachytherapy, alone or in combination with surgical extirpation. Though the role of neck dissection in patients with neck disease is widely accepted, timing and implementation in patients whose neck disease completely responds to radiation are also contentious issues. Although evolving surgical reconstruction techniques and accelerated radiation protocols are improving treatment regimens, the prognosis for this disease remains poor.

Individual monitoring of aspirin desensitization.

BACKGROUND: Patients with aspirin-sensitive rhinosinusitis, which is frequently associated with intrinsic bronchial asthma, can be desensitized by long-term treatment with oral aspirin. The exact mechanisms of this desensitization remain obscure, but modulations of the eicosanoid pathway occur and can be monitored with the help of a practicable in vitro assay on mixed leukocyte cultures. OBJECTIVE: To monitor the effect of low-dose aspirin desensitization therapy, 100 mg/d, objectively by an in vitro assay. DESIGN: In a prospective study, 30 patients with aspirin intolerance, who were treated following a desensitization protocol with a dose of oral aspirin of only 100 mg/d were followed up for 1 year and reassessed every 3 months clinically and in vitro. RESULTS: Twenty-five patients showed a normalization of in vitro eicosanoid levels during this period, 4 showed some improvement, and 1 showed no therapeutic effect on eicosanoid release. Clinical follow-up revealed a low recurrence rate of nasal polyposis, with recurrent disease only in 4 individuals who also showed no normalization of eicosanoid release levels. Furthermore, a reduction of the average incidence of purulent episodes of sinusitis was seen after 1 year. Of 12 patients with asthma, 9 experienced marked improvement in pulmonary function. Of 16 individuals with a marked impairment of nasal breathing, 14 felt an increase of nasal patency, and 7 of 11 patients with pretreatment hyposmia had an improved sense of smell after 1 year. CONCLUSIONS: Desensitization therapy in patients with aspirin-sensitive rhinosinusitis can be successfully performed with low oral doses of aspirin, and the individual course throughout the desensitization can be monitored with the help of an in vitro analysis of eicosanoid release from mixed leukocyte cultures.

Pleomorphic adenoma.

Pleomorphic adenoma is the most common neoplasm of the salivary glands. Though a benign lesion, proper recognition and management of this process is needed to avoid increasing enlargement of the mass, facial nerve impairment, risk of malignant degeneration, and recurrence after surgical resection. The epidemiology, diagnosis, and treatment options for this neoplasm are discussed.

Sinonasal undifferentiated carcinoma: a review of the literature.

Sinonasal undifferentiated carcinoma is a relatively rare and aggressive malignancy of the nose and paranasal sinuses. It is often difficult to distinguish from other poorly differentiated sinonasal malignancies. Since it was first described in 1986, advances have been made in the understanding of the histology and immunohistochemical markers of sinonasal undifferentiated carcinoma, but the treatment options and prognosis remain poor. Presenting signs and symptoms, patient demographics, risk factors as well as immunohistochemical findings are reviewed. While no treatment is standard for sinonasal undifferentiated carcinoma, several modalities and combinations including chemotherapy, radiation, and surgery have been used with varied success. The several case series reported are examined and future directions of therapy discussed.

Merkel cell carcinoma: an overview and case report.

Merkel cell carcinoma is an extremely rare neoplasm with a high rate of recurrence and metastasis. The lesions predominantly arise on sun-exposed areas of skin in whites between the sixth and seventh decades of life. Within the head and neck region, the cheeks and eyelids are the most common sites. This article outlines the etiology, pathogenesis, and treatment of this rare but highly aggressive tumor.

Primary meningioma of the fallopian canal.

Meningiomas are slow-growing lesions that represent approximately 20% of all intracranial tumors and are the second most common tumor of the cerebellopontine angle. In contrast, primary extracranial meningiomas are found relatively infrequently, and most cases have inadequate radiologic studies to determine if they were actually an extension from a primary intracranial source. Meningiomas of the intratemporal segment of the facial nerve have also been reported, but they are exceedingly rare and their pathophysiology remains unclear. We report a case of a meningioma of the facial nerve in the fallopian canal of a 7-year-old girl and review pertinent literature.

The otologic manifestations of barotrauma.

Barotrauma is defined as an injury due to pressure differences between atmospheric and intratympanic pressures. Human beings are well suited to operate within an environment involving small alterations in atmospheric pressure. Man's persistence in operating outside this environment leads to exposure to large pressure differentials with resulting trauma. External, middle, and inner ear structures can all be injured due to alterations in pressure. The increase in popularity of sport diving and aviation travel has led to an increase in the number of otologic injuries caused by barotrauma. The physics, pathophysiology, symptoms, and treatment of barotrauma are presented.

Proliferative activity and cytometric characteristics in polyps of the nasal cavity and paranasal sinuses.

Although several investigations have revealed the influence of cytokines, allergy, and environmental factors in polyp development, the etiology of nasal polyps is still unknown. To estimate the biology of this common disease the operative specimens of 50 patients who underwent surgery for polyps of the nasal cavity and the paranasal sinuses were examined; of these, 10 patients had recurrent disease and 23 patients had an allergy. The investigations included routine histology and quantitative DNA measurements, along with immunohistochemical identification of proliferation markers (i.e., MIB-1; proliferating cell nuclear antigen, PCNA). Histologically, most polyps revealed an infiltration with lymphocytes, eosinophilic granulocytes, and plasma cells. Twenty-five percent had a squamous metaplasia of the respiratory epithelium. Quantitative DNA analysis demonstrated diploid stemlines and lack of aneuploid cells with a DNA content exceeding 5c in most cases. Immunohistochemical detection of proliferation markers showed low proliferation rates in all cases. In 27 polyps no MIB-1 expression was detected, and in 7 polyps no PCNA expression was detected. The polyps of the 23 patients with proven allergic diathesis did not reveal higher scores for the parameters of DNA analysis (i.e., ploidy status and percentage of aneuploid cells) and proliferation scores. Nasal polyps of 10 patients with recurrent disease displayed higher scores for proliferation markers, and in five cases aneuploid cells with 5c exceeding rate (5cER) of 1.5-11.7% were detected. According to these results, polyps of the nasal cavity and paranasal sinuses showed low proliferation scores and were diploid. The data demonstrated that there was no increase of proliferation activity or ploidy shift toward aneuploidy in patients with allergy. Nevertheless, in recurrent disease some increase in proliferation activity and some changes in the parameters of the DNA analysis occurred, indicating more aggressive behavior of recurrent polyps in single cases.

The use of acoustic rhinometry in predicting outcomes after sinonasal surgery.

Today's healthcare environment demands objective assessment of surgical outcomes. The recent otolaryngologic literature has established acoustic rhinometry (AR) as a valid instrument to objectively document nasal patency. The purpose of this article is to evaluate the utility of AR in predicting outcomes after sinonasal surgery. All patients scheduled for sinonasal surgery at the Tulane University and University of Mainz Departments of Otolaryngology between 10/1/98 and 12/15/98 were enrolled. All subjects underwent AR and completed a sinonasal outcome survey (SNOT-20) one day before and two months after their surgical procedure. Thirty-one patients were enrolled. The SNOT-20 raw scores improved from a mean of 7.93 (+/- 3.78) preoperatively to 3.35 (+/- 2.33) postoperatively (p < 0.05). The I-notch revealed no significant change postoperatively. The mean bilateral predecongestion C-notch increased from 1.257 cm2 to 1.451 cm2 (p < 0.05). Patients with a bilateral C-notch > 1 cm2 were 1.96 times more likely to have a five-point improvement in the SNOT-20 raw score (95% CI = 1.17, 3.27). The mean value of the C-notch is significantly altered (increased) as a result of sinonasal surgery. Patients with a preoperative cross-sectional area < 1 cm2 are less likely to report large postoperative subjective improvement. These results indicate that patients with poor geometry at the area of the C-notch do not fare as well surgically as those with better preoperative measurements.

PH20: a novel tumor marker for laryngeal cancer.

OBJECTIVE: To determine whether levels of PH-20, a hyaluronidase similar to that found in human sperm, are elevated in laryngeal cancer tissue. DESIGN: In this case-control study. reverse transcription polymerase chain reaction was used to measure levels of PH-20 messenger RNA in tissue taken from laryngectomy specimens. SETTING: A university medical center. PATIENTS: We compared tissue samples taken from 11 patients with laryngeal cancer, and from 2 metastatic lymph nodes, with samples of normal, healthy laryngeal tissue and prostate cancer tissue (positive control). MAIN OUTCOME MEASURE: PH-20 complementary DNA expression as quantified by densitometric analysis. RESULTS: Expression of PH-20 was significantly higher in nonirradiated laryngeal cancer specimens than in normal laryngeal tissue (P<.01). Metastatic lymph nodes also had higher levels of PH-20 expression than did primary laryngeal cancer tissue (P = .11) and normal laryngeal tissue (P<.01). Irradiated laryngeal cancer specimens had PH-20 levels comparable to normal. CONCLUSIONS: We report the first data on PH-20 expression in laryngeal cancer tissue. PH-20 expression is significantly elevated in primary laryngeal cancer tissue and seems to be even higher in metastatic lesions compared with normal laryngeal tissue. PH-20 may be a useful tumor marker and prognostic tool for laryngeal cancer.

Recurrent aphthous stomatitis.

Recurrent aphthous stomatitis is the most common oral mucosal disease in North America but it is commonly misdiagnosed and poorly understood. Pediatricians, internists, otolaryngologists, oral surgeons, and dentists may all be expected to treat this illness but little formal training in oral medicine may be offered to many of these health care professionals. This article reviews current evidence regarding etiology, pathogenesis, natural history, and treatment of this disorder.

Radiofrequency volumetric tissue reduction (RFVTR) of inferior turbinates: a new method in the treatment of chronic nasal obstruction.

Twenty-two Caucasians (16 male and 6 female) with chronic bilateral nasal obstruction due to hypertrophic inferior turbinates were followed up over a three-month period. They were assessed by clinical examination, as active anterior rhinometry, and acoustic rhinometry before and after topical decongestion, preoperatively and three months after surgery. All patients were treated by application of radiofrequency-volumetric-tissue reduction (RFVTR, or somnoplasty) to both inferior turbinates. Initial postoperative edematous response disappeared during the first week after RFVTR. Three months postoperatively 20 of 22 patients (91%) reported subjective improvement of nasal patency. The average cross-sectional area for both sides of the nasal cavity (measured at the head of the inferior turbinate (C-Notch) before decongestion) increased in 15 of 22 patients (68.2%). This means a significant improvement from 1.24 to 1.49 cm2 for both sides of the nasal cavity (p = 0.0054). We conclude that RFVTR can safely reduce turbinate volume in a precise manner in patients with nasal obstruction due to hypertrophic inferior turbinates.

Subacute effects of ozone exposure on cultivated human respiratory mucosa.

This study was designed to investigate subacute effects of long-term exposure of both healthy and chronically inflamed human respiratory mucosa to ozone. Functional and metabolic effects on ciliary beat frequency (CBF), release of interleukin 8 (IL-8), interleukin 4 (IL-4), and gamma interferon (g-INF), as well as cellular viability and cytotoxicity, were monitored. Cell cultures of 60 specimens (healthy mucosa: n = 30, inflamed mucosa: n = 30) were exposed to synthetic air and to ozone-enriched synthetic air in different concentrations of 100, 500, and 1000 micrograms/m3. Continuous expositions were performed using an air/liquid interface cell culture technique for a period of 4 weeks. CBF was monitored using video-interference contrast microscopy and cytokine release was quantified by enzyme immunoassays. Cellular viability and cytotoxicity were controlled by measuring lactate dehydrogenase activity, cytosolic activity of esterases, and by staining of nuclear DNA. Synthetic air had no influence on CBF during the 4 weeks of exposure. IL-8 release was continuously diminished in unaffected and in chronically inflamed mucosa. Within the first week of continuous exposure with any ozone concentration neither CBF nor release of IL-8 were affected in healthy or in inflamed mucosa. During the second and the following weeks of exposure CBF and the release of IL-8 were reduced in both tissues. Release of IL-4 or g-INF were not detectable at any time during the 4 weeks of ozone exposure. At higher ozone concentrations of 500 and 1000 micrograms/m3 there was an increase of cytotoxicity which was greater in chronically inflamed than in healthy mucosa. In conclusion, ozone had no measurable effect on those parameters measured in human upper respiratory epithelium after one week of in vitro exposure to different concentrations, but did after longer periods of exposure. Chronically inflamed mucosa had a tendency toward a higher susceptibility to intermediate and high concentrations of ozone that did not reach a level of statistical significance under the conditions used in this study.

Biologic characteristics of paragangliomas of the nasal cavity and paranasal sinuses.

Paragangliomas of the nasal cavity and paranasal sinuses are extremely rare. This study was conducted to investigate the biologic characteristics of these lesions on different molecular levels and to estimate their biologic behavior. Operative specimens of three patients who underwent surgery for a paraganglioma of the nasal cavity (one case) or paranasal sinuses (two cases) were investigated by routine histology, quantitative DNA analysis, and immunohistochemical assessment of proliferation markers (i.e., Proliferating Cell Nuclear Antigen, PCNA; Ki67-MIB-1), the expression of cell-surface antigens, which reflect the tumor-stroma interaction (i.e., CD 44 v0.4/5 and 6, CD 54, CD 106), oncogene products (nm-23; p53), and bcl-2 as a marker of apoptosis. Histologically, two tumors were paragangliomas of the adenomatous subtype, one lesion was classified as angiomatous. According to DNA analysis, aneuploid cells were detected in all tumors. Two of three paragangliomas were classified as a DNA type III pattern, implying a high percentage of aneuploid cells and an aggressive behavior. Immunohistochemically, paragangliomas of the nasal cavity showed increased scores for both proliferation markers tested, indicating a rapid growth pattern. According to the expression of cell-surface markers and oncogene products, these tumors displayed an aggressive behavior and an infiltrating growth pattern. The highest value for the parameters of quantitative DNA analysis and highest proliferation scores were found in a tumor of a patient who developed multiple tumor recurrences after radical excision of the lesion with clear margins, and finally died of disease. In conclusion, paragangliomas of the nasal cavity and paranasal sinuses examined in this study should be regarded as suspicious concerning their biologic and clinical behavior. Radical excision, and in cases with highly aggressive biology, postoperative radiation therapy are recommended. Tumor biologic examinations can help to recognize high-risk patients for developing recurrences and possibly lesions with a malignant behavior and to enhance our understanding of the biology of these extremely rare tumors of the nasal cavity and paranasal sinuses.

Drug treatments for tinnitus: the Tulane experience.

It has recently been estimated that 12 million Americans have a severe form of tinnitus and that nearly 40 million Americans suffer from some form of tinnitus-related complaints [1]. The nature of patients' concerns at the time of the initial evaluation is very important in our overall patient management. Specific issues that we address in our practice include the following: (1) Why are patients here? (2) What do patients want and what do they expect of me? (3) Whom have they seen before and what if anything has been tried and proved ineffective in treating their condition? Each of these basic questions must be answered to ensure that we are addressing affected patients' concerns and are targeting our efforts according to individual patients' needs.

Epidural abscess masquerading as lateral sinus thrombosis.

Controversy regarding the use of anticoagulants, the evacuation of the sinus, or the use of medical treatment alone surrounds the treatment of lateral sinus thrombosis. Treatment of an epidural abscess associated with coalescent mastoiditis is much less controversial-drainage is usually recommended. The differing treatments of these complications mandate accurate diagnosis. The advent of more sophisticated radiological studies has facilitated diagnosis of these complications; however, tests are not infallible. We present three cases in which preoperative imaging demonstrates an epidural abscess mimicking lateral sinus thrombosis by compression of the vessel. A false-positive computed tomography (CT) or magnetic resonance imaging (MRI) study may lead to the wrong diagnosis and, consequently, improper treatment. In light of this possibility, we recommend surgical exploration in all such cases.