Deep Neck Infection: Atypical Presentation of Papillary Thyroid Cancer.

Deep neck infection is defined as an infectious process in the potential spaces and fascial plane of the neck which may result in a fatal complication. Prompt drainage and broad-spectrum antibiotics are the mainstays of treatment. Deep neck infection as the initial presentation of primary head and neck cancer is not common. Nevertheless, head and neck squamous cell carcinoma is the most common primary head and neck cancer, which could present with cervical metastasis and subsequently becomes infected. Papillary thyroid cancer has a naturally indolent course, and most patients present with a thyroid nodule. However, deep neck infection could be an uncommon presentation of papillary thyroid cancer which may obscure the diagnosis of underlying malignancy. This case report aims to present a rare presentation of papillary thyroid cancer which needs meticulous evaluation. Moreover, the pathological examination should be performed in all cases of deep neck infection for early detection and management of underlying papillary thyroid cancer.

Clinicopathologic Findings and Treatment Outcome of Laryngectomized Patients with Laryngeal Cancer and Hypopharyngeal Cancer: An Experience in Thailand

Objective: To evaluate the clinicopathologic findings and treatment outcome in laryngectomized patients with laryngeal cancer and hypopharyngeal cancer. Materials and Methods: The authors retrospectively reviewed the medical records of 212 patients who had been newly diagnosed and treated with laryngectomy between January 2000 and December 2010. The age, gender, clinical manifestations, associated predisposing condition, tumor WHO grade, AJCC tumor stage, maximum tumor size, anatomical involvement, type of surgery, postoperative sequelae, treatment and therapeutic outcome were analyzed. Results: The present study included laryngeal cancer (n = 155) and hypopharyngeal cancer (n = 57). The patients' age ranged from 38 to 84 years, with the mean age of 62.08±9.67 years. The common clinical presentations were hoarseness (73.6%), cervical lymphadenopathy (35.8%), sorethroat (22.2%), and odynophagia (14.6%). The laryngeal cancer commonly involves true vocal cord (86.5%), anterior commissure (65.8%), false vocal cord (56.8%), laryngeal ventricle (53.5%), subglottis (47.1%), and paraglotic space (35.5%), respectively. Fifty-three percent of cases had stage IV cancer. The most common postoperative surgical sequela was hypothyroidism (77.8%). The overall 5-year survivals for laryngeal cancer and hypopharyngeal cancer were 55% and 9%, respectively. The 5-year survival for node-negative cases was 61.8% versus 17% for node-positive cases (p< 0.001). AJCC stage of laryngeal cancer and hypopharyngeal cancer was a significant predictor of 5-year survival (p< 0.001 and p = 0.004, respectively). Conclusions: The advanced AJCC stage, advanced T stage, advanced N stage, extracapsular tumor spread, and tumor invasion of false vocal cord, epiglottis, preepiglottic space, paraglottic space, thyroid cartilage, cricothyroid membrane were found to significantly augment the decrease of 5-year survival in laryngeal cancer. Only advanced AJCC stage was significantly associated with 5-year survival rate in hypopharyngeal cancer.

Efficacy and Safety of Once Daily Fluticasone Furoate Nasal Spray for Treatment of Irritant (Non-allergic) Rhinitis.

INTRODUCTION: The safety and efficacy of fluticasone furoate nasal spray (FFNS) for the symptoms of seasonal and perennial allergic rhinitis have been previously demonstrated in several clinical studies. The objective of this pilot study was to compare the efficacy and safety of FFNS 110 mcg once daily with placebo in patients with irritant (non-allergic) rhinitis triggered predominantly by air pollution. METHODS: This was a randomized, double-blind, placebo-controlled, 4-week study of subjects in Thailand with irritant rhinitis who received either FFNS 110 mcg (N=53) or placebo (N=49) once-daily. Subjects with a ≥2 year history of air pollution as their predominant rhinitis trigger, negative skin test to local seasonal/perennial allergens, positive histamine skin test, and normal sinus radiograph were enrolled if they met minimum reflective total nasal symptom score (rTNSS) ≥4.5 (maximum=9) and a nasal congestion score of ≥2 (maximum =3). All were assessed for nasal eosinophilia at study entry and completion. Air quality was monitored throughout the study. The primary efficacy endpoint was the mean change from baseline over the treatment period in daily rTNSS, the average of the morning and evening rTNSS. The key secondary measure was the mean change from baseline over the entire treatment period in morning pre-dose instantaneous total nasal symptom score (iTNSS). RESULTS: The Air Quality Index (AQI) during the study generally did not reach unhealthy levels. Baseline daily rTNSS scores were similar between treatment groups (FFNS=6.7; placebo=6.4). The least square mean change from baseline in rTNSS was -2.17 and -2.10 for FFNS and placebo, respectively, with a difference of -0.065 (p=0.845). Gradual improvements were seen in both treatment groups for iTNSS; however, the treatment difference (-0.075) was not statistically significant (p=0.827). Additionally, there were no statistically significant differences between treatment groups for AM and PM rTNSS, individual nasal symptoms, daily reflective, AM and PM reflective and AM pre-dose instantaneous total ocular symptom scores (TOSS) or individual ocular symptom scores. Nasal cytology at baseline found more than two-thirds of subjects had <20% eosinophils. Adverse events were few and similar between groups and noted as mild in intensity. CONCLUSION: Subjects receiving FFNS had similar improvement to placebo in their rhinitis symptoms. The lack of a treatment effect may be in part due to the overall good air quality present throughout the study or an insufficient dose or duration of FFNS. The safety findings showed FFNS 110 mcg once daily to be well tolerated.

Vascular endothelial growth factor a and proliferation marker in prediction of lymph node metastasis in oral and pharyngeal squamous cell carcinoma.

OBJECTIVE: To explore the effect of Ki-67 and vascular endothelial growth factor A (VEGF-A) expression on the risks of advanced T category (T3,4) and positive lymph node involvement (N+) in oral and pharyngeal squamous cell carcinoma (SCC) compared with laryngeal SCC. DESIGN: Immunohistochemical analysis of prospectively recruited patients. SETTING: University-affiliated hospital. PATIENTS: A total of 147 previously untreated patients with different stages of SCC in the oral cavity, pharynx, and larynx. MAIN OUTCOME MEASURES: Relative risks of T3,4 tumor and N+, a risk ratio comparing risks under high vs low marker expression. RESULTS: A significant association of Ki-67 and VEGF-A expression with tumor T category was observed for oral and pharyngeal SCC and for laryngeal SCC (P < or = .006). Regarding nodal status, Ki-67 expression was a significant risk factor for N+ in all tumors (P < or = .009), whereas VEGF-A expression was related to N+ in oral and pharyngeal SCC only (P < .03). Analytically, Ki-67 expression alone in oral and pharyngeal SCC was associated with a relative risk of N+ of 3.83 (95% confidence interval, 1.22-11.99; P = .009), and additional expression of VEGF-A raised the value to 6.12 (2.09-17.93; P < .001). Moreover, the combined expression of both markers was 3.25 times more effective in predicting N+ for T1,2 tumor compared with T3,4 tumor. CONCLUSIONS: Proliferative status was a common risk factor for N+ in all of the tumors in this series. Exploitation of VEGF-A in lymph node metastasis in addition to proliferation by oral and pharyngeal SCC but not by laryngeal SCC explains the clinical aggressiveness of oral and pharyngeal SCC, especially the early lymphatic invasion. In the management of cervical lymph nodes, combined expression of Ki-67 and VEGF-A may help identify patients at risk for occult metastases. This study suggests anti-VEGF-A therapy, an additional intervention to the classic antiproliferative regimen, for preventing lymphatic progression of oral and pharyngeal SCC.

Evaluation of direct immunofluorescence test for diagnosis of upper respiratory tract infection by Chlamydia pneumoniae.

BACKGROUND: Chlamydia pneumoniae causes a variety of respiratory infections and is involved in cardiovascular diseases. Diagnosis of C. pneumoniae infection currently relies on antibody detection by microimmunofluorescence (MIF), which has limited use, and is the retrospective diagnosis for acute infection. OBJECTIVE: Find an effective early diagnosis of acute upper respiratory infection, or use in combination with MIF to accurately diagnose the infection by C. pneumoniae. MATERIAL AND METHOD: Direct immunofluorescence (DIF) was developed to detect C. pneumoniae in nasopharyngeal specimens obtained from patients with upper respiratory tract infection, and normal individuals. IgM and IgG antibodies against C. pneumoniae by MIF were determined for evaluation of the detected C. pneumoniae and seroconversion. RESULTS: DIF gave positive results in 29 of 37 (78.4%) samples from 31 patients. Fifteen samples positive by DIF illustrated antibody titers interpreted as acute C. pneumoniae infection, and eight DIF positive samples showed antibody titers of chronic infection. Negative results by both DIF and MIF were found in two patients and 23 of 25 by DIF but 20 of 25 by MIF in normal subjects. Five paired sera subsequently collected from three of the 31 patients illustrated seroconversion 2-4 months after the primary specimen collection, which gave positive results by DIF but negative for antibodies. Significant association was found between C. pneumoniae detection by DIF and antibodies by MIF when analysis was done in the group of patients and normal subjects (p < 0.001; Pearson chi-square test). CONCLUSION: DIF could be an alternative assay for early diagnosis of C. pneumoniae infection, and may be used in combination with MIF for accurate diagnosis of acute C. pneumoniae infection.

Treatment of Frey's syndrome with botulinum toxin.

BACKGROUND: Frey s syndrome or Gustatory sweating was first described by Baillarger in 1853. Lucie Frey had described a patient as "auriculotemporal syndrome" in 1923. The explanation for this symptom has been an aberrant regeneration of postganglionic parasympathetic fibers feeding the parotid gland that are severed during parotidectomy. After parotidectomy, these cholinergic parasympathetic fibers regenerate and anastomosis with postganglionic sympathetic fibers that supply vessel and sweat gland of the skin. According to a recent study, the treatment of Frey's syndrome has no treatment of choice. The authors investigated the effectiveness of botulinum toxin type A in the treatment of Frey's syndrome for the first time in Thai patients. MATERIAL AND METHOD: The present study was a prospective non-randomized, exploratory study. Nine patients with a median involvement skin area of 4.2 cm2 (1-16.3) were injected intradermal with botulinum toxin type A 2 unit in every 1 cm2 of involved skin. The mean total dose was 10.6 units (range 2-32 unit). RESULTS: All of the patients showed improvement after 4-7 days. Five patients have no Gustatory sweating. In the same way, four patients present with a dramatic decrease in Gustatory sweating. When comparing the skin involvement area, indicated by Minor's iodine starch test and calculated by program ImageJ 1.34s, between before and after injection of botulinum toxin type A using sign test, the result is statistically significant with p = 0.0039. The result lasted for 9.2 months (7-10 months). CONCLUSION: Intradermal injection of botulinum toxin type A for patients with Frey's syndrome is not only effective with no side effect but also minimally invasive. The present report supports that intradermal injection of botulinum toxin type A should be the treatment of choice for Frey's syndrome.

Sinus histiocytosis with massive lymphadenopathy and subglottic stenosis: a case report.

An 18 year-old woman presented with massive cervical lymphadenopathy. She also had bilateral parotid gland enlargement, and later upper airway obstruction from subglottic mass compression. Surgical excision of lymph nodes and bilateral total parotidectomy with facial nerve preservation were selected. Direct laryngoscopy and CO2 laser excision were used to remove the subglottic mass. Airway was secured by tracheostomy and after that it was removed. Histologic finding was Sinus histiocytosis with massive lymphadenopathy (SHML) that involved the subglottic. SHML is very rare, probably less than 1000 cases reported in the literature and this is the 6th case in the literature that involved the subglottic. There are no standard treatment modalities. The treatment is comprised of surgery, steroid, chemotherapy and local control. In the present case the authors chose surgery, steroid and local control of disease in the subglottic by using CO2 laser excision. Now, the disease is under control.

An exotic sinusitis.

We report a case of sinusitis caused by mixed free-living amoebae, Acanthamoeba and Naegleria, in an immunocompetent host; this has not been documented before. Free-living amoebae should be considered in the differential diagnosis of pathogens that cause sinusitis with or without central nervous system involvement, especially when bacteria or fungi are not found by smear, biopsy or culture.