Differential diagnosis of cystic neck lesions.

OBJECTIVES: In patients less than 40 years of age who present with an upper anterior triangle cystic mass, branchial cyst is the presumed clinical diagnosis. Squamous cell malignancy is the important differential diagnosis in a patient more than 40 years of age. We sought to identify the range of lesions that can be clinically mistaken for, and removed as, branchial cysts. METHODS: We performed retrospective reviews of 29 neck masses removed as branchial cysts and 47 solitary neck masses diagnosed as cancer between January 2003 and January 2008 across two teaching hospitals in Leeds, England. RESULTS: Of the 29 lesions removed, 23 (79.3%) were confirmed to be branchial cysts. The remainder comprised 2 thyroid papillary carcinomas (6.9%) and 4 benign lesions (13.6%; laryngocele, neurilemmoma, parotid gland cyst, and cystadenoma). Of the 47 cases of metastatic cancer, 3 lesions (6.4%) were clinically mistaken as branchial cysts but were subsequently diagnosed as squamous cell carcinomas. CONCLUSIONS: When presented with a solitary lateral cystic mass, clinicians should consider the possibility of squamous cell carcinoma in patients more than 40 years of age, and thyroid papillary cancer should be considered particularly in the younger age groups. In our series, 30.8% of the neck lesions believed to be branchial cysts in patients over 40 were malignant, in contrast to 5.3% of those lesions in patients under 40.

Severe laryngeal dysplasia in a 20-year-old nonsmoker treated with CO2 laser excision: a case report and review of the literature.

OBJECTIVE: We present the unusual case of a 20-year-old female nonsmoker with severe laryngeal dysplasia managed with endoscopic CO(2) laser resection with frozen-section analysis. We use her case as a platform for discussion of the current evidence surrounding laryngeal dysplasia, particularly etiology and the use of lasers in management. BACKGROUND DATA: Laryngeal dysplasia represents a series of progressive epithelial changes that can eventually lead to invasive laryngeal carcinoma. Typically, most patients are male, in their 50s or 60s, and are smokers; to our knowledge our patient represents the youngest reported case of this condition in a woman with no established risk factors. We discuss the implications of this on her subsequent management with the CO(2) laser. METHODS: With the help of intraoperative photographs, we describe our excisional technique with the CO(2) laser, model 315M Superpulse class 4 (Irradia AB, Stockholm, Sweden) at a 6-W continuous power setting. RESULTS: At 6 months after surgery, our patient remains disease free with good voice quality. CONCLUSIONS: Our patient appears to defy all the usual etiologic stereotypes that usually govern the development of laryngeal dysplasia. CO(2) laser excision plus intraoperative frozen-section analysis remains a safe and reliable method for the treatment of laryngeal dysplasia; the reassurance of histologically clear margins minimizes the extent of radical laser excision necessary and provides good functional results. We provide a comprehensive overview of the current literature on laryngeal dysplasia etiology and treatment, particularly the use of lasers in management.

Actinomycosis mimicking a tonsillar neoplasm in an elderly diabetic patient.

Actinomycosis is a slowly progressive infection that can occur anywhere in the body. Three distinct clinical entities are described: cervico-facial, abdomino-pelvic and thoracopulmonary. Actinomyces are anaerobic, gram positive, non-acid-fast, branched filamentous bacteria that form part of the normal oral, colonic and vaginal flora of humans. The cervico-facial form of the disease is commonest and results from direct invasion of commensal oral actinomyces into local tissues. The most frequently isolated species is A. israelii. We describe a case where Actinomycosis caused massive unilateral hypertrophy of the tonsil, mimicking neoplasia. This is an unusual presentation of Actinomycosis.

Atypical presentation of cutaneous tuberculosis and a retropharyngeal neck abscess.

A 70-year-old Asian man with noninsulin-dependent diabetes presented with a 4-month history of left-sided otitis externa and right-sided facial palsy. Physical examination of the left ear revealed a punched-out ulcerative lesion on the tragus, an edematous and inflamed external auditory canal, and a purulent nonmucoid discharge. Computed tomography of the brain and neck demonstrated a large retropharyngeal abscess, an abscess in the left parapharyngeal space, and a small collection adjacent to the right carotid sheath at the level of C4; the cervical vertebrae and lungs were normal. Microscopy of drained pus and histology of left ear and neck node biopsies identified tuberculosis. The patient was started on antituberculosis drug therapy, but he died within 2 weeks of treatment. We discuss the characteristics of this unusual presentation of tuberculosis infection.

Paediatric epistaxis: Alder Hey experience.

Referrals for epistaxis management constitute a significant proportion of paediatric ENT consultations. A prospective audit of all new referrals to our paediatric ENT department for epistaxis management yielded 88 patients over four months. Parents completed a questionnaire with particular reference to the duration of history and frequency of epistaxis. After assessment some patients were given topical chlorhexidine and neomycin cream (Naseptin), in addition some children also underwent chemical cautery (silver nitrate). Of the 64 children in whom out-patient nasal cautery was attempted it was tolerated by 63 (98 per cent). In response to a follow-up postal questionnaire returned by 65 per cent, most parents (74 per cent) felt that Naseptin was useful. A telephone survey of the patients' general practitioners found that 91 per cent of the children did not consult their general practitioner regarding epistaxis again. We conclude that paediatric epistaxis can be effectively managed with a single out-patient consultation.

Primary extramedullary plasmacytoma of the tongue base. Case report and review of the literature.

BACKGROUND: Primary extramedullary plasmacytomas (PEMP) are rare malignant neoplasms with a predilection for the head and neck. Eighty percent of all PEMP are located in this area. CASE REPORT: The authors present a case of lingual plasmacytoma in a 65-year-old man, diagnosed on biopsy and treated with external beam radiotherapy.