Two unusual presentations of cervicofacial actinomycosis and review of the literature.

Cervicofacial actinomycosis is the most common clinical form of actinomycosis. This bacterial infection is rare. Diagnosis is difficult, often it is definitive only after surgical excision of the cervicofacial mass. Personal experience is reported concerning two cases of cervicoactinomycosis. Diagnosis, in both cases, has been based on histological findings, not on clinical symptoms. A review of the literature shows that mainly males are affected by this condition and, in fact, both patients described here are males. Symptoms of acute infection were absent. Both patients denied any history of oromaxillofacial trauma or recent dental extraction or oral manipulations. Imaging techniques--ultrasonography and computerized tomography--were not effective in making the diagnosis, in either of these patients. Furthermore, fine needle aspiration cytology did not provide a definitive diagnosis. Both patients underwent surgical excision of the mass. Penicillin was the drug of choice in post-operative long-term treatment (one month). In one of the two men, intravenous steroids were administered. As in several reports in the literature, the definitive diagnosis was histological and not clinical.

Mixed laryngocele: a case report and review of the literature.

Laryngocele is a rare, benign dilatation of the laryngeal saccule that may extend internally into the airway or externally through the thyrohyoid membrane. Many laryngoceles are asymptomatic; sometimes they may cause a cough, hoarseness, stridor, sore throat and may present as a swelling on one or both sides of the neck. Laryngocele may be associated with supraglottic squamous cell carcinoma. Computed tomography scan is the most effective imaging method for diagnosis. Surgery is the treatment of choice. A case of large mixed laryngocele in a 75-year-old male is described together with surgical management and followup. A review of the literature is also presented.

Centripetal approach to the facial nerve in parotid surgery: personal experience.

There is particular interest in parotid surgery on account of the close relationship between the gland and the extrapetrous facial nerve. The seventh cranial nerve is generally located by means of an anterograde or proximal surgical identification technique aimed at identifying the facial nerve at its point of exit from the stylomastoid canal. There are very few reports in the literature on retrograde or centripetal identification techniques, which may be adapted to the morphology of the neoformation limiting surgical access, in order to isolate the nerve from its peripheral rami. The present report deals with personal clinical experience, describing a technique for retrograde detection of the facial nerve. Between 1990 and 2001, 313 parotid surgery procedures were performed at the ORL Clinic of the Università del Piemonte Orientale in Novara. In 308/313 cases, corresponding to 98% of the operations, the technique chosen for the identification of the extrapetrous facial nerve was anterograde, proximal or centrifugal; in 5 cases alone, retrograde or centripetal exploration of the orbicular branch was undertaken, on account of difficulty in locating the main trunk, due to the presence of a post-inflammatory fibrosis in three patients and a stylomastoid emergency, arising from a malignant neoformation, in the other two. The decision to resort to the identification of the orbicular nerve of the eye is supported by the regular course and adequate size of this facial branch in its peripheral area, which enable it to be easily located.

[Merkel cell carcinoma]. / Tumore a cellule di Merkel.

The authors present 2 cases of Merkel cell carcinoma in the head and neck district, evaluating the characteristics and evolution. Merkel cell carcinoma is a rare, highly aggressive neuroendocrine cutaneous neoplasm which is often located in the head and neck district. This carcinoma has the same characteristics as small cell tumors and tends to significant metastatization both through the lymph nodes and through the blood. It is also prone to frequent recurrence. Today diagnosis is facilitated by electron microscopy and immunohistochemistry to search for neurofilaments and cytocheratin 20. The treatment of choice is radical surgery ensuring a tumor-free edge of at least 3 cm, associated with supplementary local radiotherapy. Recurrence is quite frequent despite the treatment strategies applied.

Post-thyroidectomy superior laryngeal nerve injury.

Voice dysfunction after thyroidectomy may be caused by damage to laryngeal nerves or lesions to strap muscles with laryngo-tracheal movement impairment. Injury to an external branch of the superior laryngeal nerve (EBSLN) is sometimes difficult to recognize clinically and its electromyographic incidence ranges from 0% to 58%. In this study we evaluated, 12-18 months postoperatively, 45 patients who had undergone thyroid surgery (6 total lobectomy, 5 subtotal thyroidectomy, and 34 total thyroidectomy), using a subjective interview, laryngeal videostroboscopy and spectrographic analysis with a multidimensional voice program. Vocal parameters included fundamental frequency, jitter, shimmer, noise-to-harmonic-ratio (NHR) and degree of sub-harmonics. Laryngeal electromyography (LEMG) of the cricothyroid (CT) muscles was performed in 21 subjects with voice problems (35 EBSLNs) using a modified method for the CT recording. In 3 patients of this group (14%) LEMG documented a unilateral EBSLN injury. Easy voice fatigue and decreased pitch range were the most common symptoms after surgery. Average values of vocal parameters pre- and postoperatively in patients without neural damage (n = 42) were: jitter 0.64% and 0.78%, shimmer 3.25% and 3.54%, and NHR 0.12% and 0.13%, respectively (P > 0.05). Acoustic analysis revealed altered patterns in some patients with no objective evidence of damage to EBSLNs, suggesting an extralaryngeal cause of vocal dysfunction, such as laryngo-tracheal fixation or lesions to strap muscles. We conclude that laryngeal videostroboscopy and spectrographic analysis are very useful to assess voice problems after thyroidectomy, including in patients without LEMG-proven neural lesions, in order to suggest early speech rehabilitation, especially in professional voice users.

[Complications in thyroid surgery]. / Le complicanze della chirurgia tiroidea.

Today, when performed applying stringent technique, thyroid surgery can be considered a procedure with low risk of post-surgical complications. Post-surgical hypoparathyroidism is frequent (1.6-53.6% of the cases) although most of these cases are temporary, linked to functional stupor of the parathyroid glands and/or other reversible factors. Analysis of the literature has shown that preservation of 3 or more parathyroid glands is a highly positive (95%) predictive factor for normal post-operative calcemia. The incidence of recurrent definitive paralysis ranges around 0.3-2% of the nerves at risk of iatrogeneous lesions and is usually correlated with thyroid histology and with the extension and type of ablative treatment performed. The authors retrospectively consider a 10-year case study of 218 patients (222 surgical procedures, of which 17 undergoing surgery twice) analyzing endocrinological, hemorrhagic and neurological complications and paying particular attention to any vocal dysfunctions arising at a later date, even in the absence of an ascertained neurological deficit. Considering 116 total and subtotal thyroidectomies, the percentages of acute hypoparathyroidism (AH) and definitive hypoparathyroidism (DH) were, respectively, 43.9% and 6%. Four of the 7 cases of DH presented one of the factors known to increate the risk of complications: malignant thyroid histology, second surgery and/or lymph node dissection. As regards neurological sequele, the authors report an incidence of recurrent definitive paralysis of 1.8% (3 out of 35 nerves at risk examined using EMG of the cricothyroid muscle). Spectroacoustic analysis of samples from 42 subjects showed an alteration in the vocal parameters considered (jitter, shimmer, NHR and DSH) in 14-27% of the cases, even in the absence of any laryngeal nerve deficit. It may be that iatrogeneous lesions and/or scarring of prethyroid strap muscles, known to play a role in phonation mechanisms, are implicated in determining post-thyroidectomy vocal dysfunctions, seen even in patients with anatomfunctionally intact laryngeal nerves.

[Malformations of the first branchial cleft: a case report]. / Le malformazioni del i solco branchiale: case report.

First branchial cleft anomalies are extremely rare and account for less than 8% of all branchial anomalies. They are generally found in infancy although they arise during the embryonal period because of an incomplete closure of the first branchial cleft. In 1972 Work classified first branchial cleft anomalies into two types: Type I, ectodermal cysts, is a duplication of the external auditory duct; Type II, originate in both ectodermal and endodermal components and contain cartilage. The present case report describes a Type II branchial malformation. G.M., a 2-year-old male, presented painful tumefaction in the left parotid area with cutaneous fistulization between the sternocleidomastoid muscle and the mandibular angle. Cranial CT permitted diagnosis and made it possible to stage surgery. The difficulties encountered in recognizing and diagnosing first branchial cleft anomalies are often responsible for application of the wrong surgical approach and the resulting frequency in recurrences.

[Non-Hodgkin's lymphoma of the larynx: clinical cases]. / Linfoma non Hodgkin della laringe: casi clinici.

Non-Hodgkin Lymphoma (NHL) is a relatively frequent lymphatic system tumor in the head and neck region with both nodal and extranodal localizations. The larynx is one of the least frequent extranodal sites. The present study reports three cases of NHL with extranodal laryngeal localization that had recently come under observation. In these cases, the symptoms reported by the patients were aspecific and not particularly significant. Indirect macroscopic laryngoscopy and direct microlaryngoscopy did not prove pathognomonic while definitive histology clearly diagnosed lymphoma. The treatment of choice for primary laryngeal lymphoma is radiotherapy; combined chemo-radiotherapy is indicated in cases of high malignancy and in multifocal cases.

[Pleomorphic adenoma of the nasal septum]. / Adenoma pleomorfo del setto nasale.

Pleomorphic adenoma is the most frequent form of tumor in the major and minor salivary glands. It can occasionally appear in other sites corresponding to areas with ectopic salivary tissue. A case is presented of pleomorphic adenoma of the nasal septum recently observed by the authors. Complete removal of the tumor lesion, with the entire support base, careful histopathological evaluation, a battery of immunohistochemical tests and a long-term follow-up constitute the correct approach to this pathology.