Adeno-tonsillar surgery in Italy.

Indications to surgery for adeno-tonsillar inflammatory disorders and analysis of the effectiveness of surgical treatment, compared with watchful waiting strategy, continue to be the subject of scientific debate. The present investigation focuses on the surgical activity of 14 Italian Otorhinolaryngological Units between 1999 and 2004. Surgical interventions (adeno-tonsillectomy, adenoidectomy, tonsillectomy) on 26915 children (age range: 2-11 years) were considered. Data on adeno-tonsillar interventions were analysed in relation to other interventions of ENT interest, performed in the same units and in the same period. Adeno-tonsillar interventions accounted for 35.4% of all operations of ENT interest. Adeno-tonsillectomy accounted for 56.6% of overall adeno-tonsillar operations, adenoidectomy 31.6%, tonsillectomy 11.8%. The percentage for the three interventions was homogeneous in the period of the study and in the recruited units. The percentage of children who underwent adeno-tonsillar surgery in paediatric units was higher as compared to general units, as far as concerns the overall number of operations performed. In southern Italy, the number of adeno-tonsillar interventions, in general, and of adeno-tonsillectomy, in particular, was higher compared to that in northern Italy. Results of the present study suggest that environmental factors, cultural issues and local health demands, may influence indications and, therefore, the different incidence of the operations under consideration in the units taking part in the investigation.

Two anomalous localizations of mucocele: clinical presentation and retrospective review.

Two Caucasian males (57 and 70 years old) were referred to our attention with parasinus mucoceles, maxillary and frontal mucocele, respectively, that had eroded the orbital rim and caused swelling of the eyelids and brow. Invasion of the orbital space caused several ophthalmic symptoms such as diplopia, proptosis, ptosis, and the formation of a palpable mass. Ophthalmic involvement was the first sign of the mucocele. The mucoceles were completely excised through a skin incision and the diseased mucosa of the sinuses was removed: endonasal fibre optic surgery and the Caldwell-Luc procedure were used in the patient with maxillary mucocele. The cases are described with retrospective review.

Oncological outcome after CO2 laser cordectomy for early-stage glottic carcinoma.

This study aims to define indications for micro-endoscopic laser surgery in early glottic carcinoma (Tis, T1a and T1b), to examine patterns of local recurrences and related retreatment methods. A cohort of 79 patients with previously untreated early glottic carcinoma, subjected to endoscopic CO2 laser excision between January 1993 and October 2000, was retrospectively examined. Patients included in data analysis had a mean follow-up of 39 months. Depth and extension of excisions were graded according to European Laryngological Society Classification, and included 5 types of cordectomy. Actuarial overall survival, determinate survival, disease-free survival, ultimate local control, and laryngeal preservation rates, at 3 years, were 97.5%, 98.7%, 89.9%, 92.4%, and 97.4%, respectively. Survival curves for overall and disease-free survival were calculated from the date of diagnosis using the KaplanMeier method. Of the 8 patients with local recurrences, 5 were managed with larynx-sparing treatment: a second endoscopic CO, laser cordectomy was performed in 2 patients, a supracricoid laryngectomy in 2 patients, and one patient was treated with radiotherapy. The remaining 3 patients were submitted to total laryngectomy, one of whom died due to neck metastases. One patient died from other causes. All other patients were alive and disease-free at the last follow-up. Understanding the diffusion pathways and timing of laryngeal glottic cancer is important both for treatment and prognosis. Correct knowledge of the subsites of the larynx and the routine use of pre-operative and intra-operative diagnostic assessment is useful in the selection of the appropriate type of resection. Microendoscopic laser surgery is efficacious for early glottic carcinoma, with oncological results comparable to those observed following radiotherapy or conventional partial laryngectomy, however, in this case, local recurrences have a greater range of re-treatment options.

Grisel's syndrome: a rare complication following adenoidectomy.

Grisel's syndrome, defined as subluxation of the atlanto-axial joint, not associated with trauma or bone disease, is found primarily in children. There are few references to this syndrome in the ENT literature but it may occur in association with any condition that results in hyperaemia and pathological relaxation of the transverse ligament of the atlanto-axial joint. Several common otolaryngeal conditions have been associated with the syndrome: pharyngitis, adenotonsillitis, tonsillar abscess, cervical abscess, and otitis media. Moreover, the syndrome has been observed after numerous otolaryngologic procedures such as tonsillectomy, adenoidectomy and mastoidectomy. Non-traumatic subluxation of the atlanto-axial joint should be suspected in cases of persistent neck pain and stiffness. X-rays and computed tomography scans of the cervical spine can confirm the diagnosis. Early management, consisting of cervical immobilization and medical treatment, is considered the key factor for a satisfactory outcome. Inappropriate treatment may result in a permanent and painful neck deformity that may even require surgical fusion. Neurological complications have been reported in the literature, with outcome ranging from mild paresthesia, clonus, to quadriplegia or acute respiratory failure and death. The case is described of an 8-year-old boy who developed Grisel's syndrome following adenoidectomy. The pathogenesis, classification, diagnosis, and treatment of this condition are discussed.

Prognostic relevance of cell proliferation in major salivary gland carcinomas.

Several proliferation markers, such as DNA ploidy, Ki67, MiB1 and proliferating cell nuclear antigen have been shown to correlate with clinical course and prognosis in several epithelial tumours and lymphomas. In the present study, the prognostic relevance of these markers was evaluated in major salivary gland carcinomas. A sample of 36 cases out of 85 patients submitted to surgery for major salivary gland carcinomas at our institution between 1987 and 1997 were studied. The sample comprised 8 adenoid-cystic carcinomas, 6 ductal carcinomas, 11 mucoepidermoid carcinomas and 11 acinic cell carcinomas. Follow-up ranged from 1 to 12 years (mean 6.2). In some patients, DNA ploidy (euploid or aneuploid) was studied by flow cytometry. In others, proliferation activity was studied by means of monoclonal antibody MiB1, identifying cells in the proliferative cycle. In some patients, both techniques were used. Follow-up was related to these indices, TNM and stage. Even if ploidy suggested a favourable outcome in diploid cancer (13 favourable vs. 2 unfavourable) and poor outcome in aneuploid cancer (4 favourable vs. 5 unfavourable), the difference was not statistically significant with p = 0.06 in Fisher's exact test. Instead, the proliferative tumour cell fraction, evaluated by MiB1, was statistically correlated with prognosis. Comparing survival curves by Log rank Test it yielded p = 0.007 using an MiB1 cut-off of 5. Applying a cut-off of 20 yielded p = 0.001. Of particular interest were MiB1 values in acinic cell carcinomas for which grading is challenging and lacks consensus. In our group of acinic cell carcinomas, survival correlated with values of MiB1 > or < 15 with p = 0.009 in Log rank test. In conclusion, despite a trend towards correlation between ploidy and prognosis, the present study yielded p = 0.06, whereas the proliferative fraction assessed by MiB1 was significantly correlated with outcomes. Indeed, "growth fraction" in acinic cell carcinomas may stratify different classes of risk.

Schwannoma of cervical sympathetic chain: assessment and management.

Schwannoma arising from the cervical sympathetic chain is an uncommon benign nerve tumour. This tumour most often presents as an asymptomatic solitary neck mass, with slow-growing and rare malignant degeneration. Definitive pre-operative diagnosis may be difficult and investigations are not usually helpful. The carotid artery and internal jugular vein may be displaced anterior-laterally. Diagnosis relies on clinical suspicion and confirmation is often obtained by means of surgical pathology. Surgical excision is the treatment of choice for this tumour, with recurrence being rare. Homer's syndrome is a common post-operative neurological consequence, but does not appear to cause problems to the patient. The case is described of a 42-year-old male who presented an asymptomatic left neck mass. Diagnostic studies included computed tomography, magnetic resonance imaging, and ultrasound which confirmed a circumscribed mass in the upper left portion of the neck next to the thyroid gland. The mass was excised through a transverse left cervical skin incision. Post-operatively the patient showed clinical findings of Horner's syndrome. The pathologic and radiological evaluations, treatment and postoperative complications of this neoplasm are discussed.

Meningioma of the internal auditory canal.

A comprehensive literature search identified only 14 well-documented cases of intracanalicular meningioma. A case is presented of meningioma confined to the internal auditory canal which was excised using a sub-occipital retrosigmoid approach. Preoperative MRI and CT scans were suggestive of intracanalicular vestibular schwannoma. Only the intraoperative findings, which were confirmed by the histological data, revealed that the tumor was a meningioma. We review the literature and discuss the diagnostic and therapeuticissues relating to these tumors.

5-fluorouracil + folinic acid with cisplatinum and bleomycin in the treatment of advanced head and neck squamous cell carcinoma.

Thirty-six patients with advanced squamous cell carcinoma of the head and neck (SCCHN) were treated with a regimen including cisplatinum (CP) 30 mg/m2 i.v., 5-fluorouracil (5-FU) 500 mg/m2 i.v. bolus, folinic acid (FA) 200 mg/m2 i.v. in a continuous one-hour infusion, and bleomycin (B) 15 mg i.m. on the first and second days and repeated every 28 days. Thirty-three patients (25 with recurrent disease and 8 untreated) are evaluable for objective response. Of these, 4 (12%) achieved CR and 15 (45%) PR. All of the untreated patients responded. The mean duration of response in the patients with recurrent or metastatic disease was 5.5 months (range 2-10+). Remission of symptoms, such as pain and dysphagia, was obtained in 58% and in 44%, respectively. Subjective remission occurred almost exclusively in objectively responsive patients. The major side effects were leukopenia (55%) and nausea/vomiting (58%). This regimen is active in the treatment of advanced SCCHN. The quality of life may be improved in responsive patients.

Jugular bulb diverticula.

Jugular bulb diverticula may extend either laterally in the tympanic cavity or medially towards the petrous pyramid close to the inner ear. In the first case, this leads to subjective symptoms related to the presence of a mass at the level of the tympanic cavity and the external auditory canal and thus to conductive hearing loss and pulsatile tinnitus. In the second case, vertigo, pulsatile tinnitus and sensorineural hearing loss occur. 4 cases of jugular bulb diverticula are described (1 medial type, 3 lateral type).

Mucoepidermoid tumour of the parotid gland: a very difficult prognostic evaluation.

The correct management of mucoepidermoid tumours is still debatable because of their unpredictable biological course. The issue discussed is that of identifying biological characteristics of these tumours which may have predictive value. Sixteen patients with a mucoepidermoid tumour of the parotid gland, treated at the ENT Clinic of Bologna University over a 15-year period, were reviewed. The follow-up of each patient has been related to the surgical management, in order to evaluate whether superficial parotidectomy provides adequate treatment. No prognostic differences were noted between total and superficial parotidectomy when the latter was clinically appropriate. The histopathological specimens from these patients were reviewed in an attempt to correlate the histological grade of tumour with the course of the disease. Our data suggest that histological evaluation of malignancy alone is insufficient for accurate prognosis. We think that the clinical presentation (facial nerve palsy, pain, etc.) predicts the prognosis with greater accuracy.

A case of tonsillar leishmaniasis.

Primary mucous leishmaniasis of the tonsil with satellite lymphatic spread but without visceral diffusion is presented. From fragments of the tonsils and from the satellite cervical lymph nodes it was possible to find, isolate and culture a strain of Leishmania Donovani 'BO 72'. The diagnostic problems are discussed caused by the lack of specific clinical findings and the rarity of mucous leishmaniasis in an area frequently the site of other pathological processes.

Metastatic malignant melanoma in the parotid gland.

3 cases of metastatic malignant melanoma to the parotid gland are reported. Diagnosis before surgery was not possible because of the particular characteristics of the primary lesions. Neither physical examination nor sialography or ultrasonography provided any differential diagnostic assistance. A thorough case history allowed us to trace a pigmented lesion in 2 cases: in the first case it had been removed about 1 year prior to our examination, whereas in the second case it had regressed spontaneously leaving no trace. In the 3rd case the presence of multiple surgical scars, due to reconstructive plastic surgery for multiple burns of the scalp contracted 30 years earlier, might have concealed a primary malignant melanoma. The path of diffusion (either direct or retrograde) towards the parotid gland as well as treatment procedures are discussed on the basis of recently published data. Moreover, the authors underline the value of thorough case histories aimed at identifying suspect cutaneous lesions of the head and neck, in all cases of parotid swellings, where the possibility of metastases is considered.