A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course.

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely.

A rare case of a secondary pituitary abscess arising in a craniopharyngioma with atypical presentation and clinical course.

Pituitary abscesses are very uncommon. They are divided into primary, arising within a healthy gland, and secondary, observed with an underlying pre-existing lesion. Here we present the eighth case reported of a secondary abscess within a craniopharyngioma. A 59-year-old-woman presented with a 3-week history of headache, and fever. Physical examination was unremarkable. An Magnetic Resonance Imaging (MRI) showed a pituitary lesion suggestive of a chronic inflammatory process. She was diagnosed with lymphocytic meningitis with hypophysitis and she was treated with corticosteroids. Two months later she presented with headache and fever again. Control MRI showed enlargement of the pituitary lesion. Therefore, a transsphenoidal biopsy was performed. During the procedure, purulent material was released. Histological study demonstrated a craniopharyngioma and meningeal inflammation. Empiric antibiotics were started. Three months post-operatively, a follow-up MRI showed a suspect minimal residual mass. Secondary pituitary abscesses are rare. The key to successful management is a high index of suspicion. Transsphenoidal surgical evacuation plus antibiotics is the mainstay of treatment. Although most symptoms resolve, endocrinopathies improve only rarely.

Manifestaciones otorrinolaringológicas en pacientes con enfermedad de Behçet / Otorhinolaryngological manifestations in patients with Behçet disease

Introducción y objetivos: La enfermedad de Behçet (EB) es una vasculitis sistémica autoinmune de origen desconocido caracterizada por la aparición de úlceras orogenitales recurrentes, inflamación ocular y lesiones dérmicas. El objetivo de nuestro estudio fue identificar las manifestaciones otorrinolaringológicas asociadas a la EB. Pacientes y métodos: Estudio retrospectivo descriptivo de las manifestaciones otorrinolaringológicas de los pacientes diagnosticados de EB en un hospital terciario público en Cantabria (España) durante 22 años. Se realizó una revisión de la bibliografía de la enfermedad otorrinolaringológica asociada a la EB. Resultados: Treinta y tres pacientes con edades comprendidas entre 17 y 64 años fueron incluidos en nuestro estudio. La mayor parte de los mismos presentaba úlceras orales (97%). Ocho pacientes (24%) presentaron úlceras orofaríngeas. Cinco pacientes (15%) presentaron síntomas audiovestibulares (hipoacusia neurosensorial para altas frecuencias, síndrome vertiginoso e hipofunción vestibular bilateral). Un paciente sufrió un cuadro compatible clínicamente con una neuronitis vestibular como inicio de Neuro-Behçet. En 4 pacientes (12%) la presencia de odinofagia secundaria a la presencia de úlceras orofaríngeas, inicialmente interpretadas como amigdalitis aguda o de repetición, fue la primera manifestación de la enfermedad, sola o asociada a lesiones cutáneas u oculares. Conclusiones: Además de las características úlceras orales, presentes en casi todos los pacientes con EB, son frecuentes la aparición de úlceras en la orofaringe, ocasionalmente interpretadas como faringitis aguda. No son raras las manifestaciones clínicas audiovestibulares durante la evolución de la enfermedad, pudiendo constituir el primer síntoma de una afectación del sistema nervioso central (AU)

Introduction and objectives: Behçet disease (BD) is a systemic immune-mediated vasculitis of unknown origin characterised by recurrent orogenital ulceration, ocular inflammation and skin lesions. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with BD. Patients and methods: Retrospective review of the medical records of all patients diagnosed with BD who attended a tertiary public hospital in Cantabria (Spain) over a period of 22 years. Clinical manifestations, in particular those concerning ENT, were retrieved from medical records. A medical literature review of ENT manifestations was conducted. Results: Thirty-three patients (age range: 17-64 years) were included in the study. Most of them presented oral ulcers (97%). Eight patients (24%) presented oropharyngeal ulcers and 5 patients (15%) experienced audiovestibular symptoms (high frequency sensorineural hearing loss, vertigo and bilateral vestibular hypofunction). One patient had symptoms compatible with vestibular neuronitis as the presentation manifestation of Neuro-Behçet. In 4 patients (12%) the presence of odynophagia secondary to the presence of oropharyngeal lesions, initially interpreted as acute or recurrent tonsillitis, was the first manifestation of the disease, alone or associated with cutaneous or ocular lesions. Conclusions: In addition to the characteristic oral ulcers present in most patients with BD, ulcers in the oropharynx, occasionally interpreted as acute pharyngitis, are also common in these patients. Audiovestibular manifestations frequently appear during the course of the disease and may be the first symptom of central nervous system involvement (AU)

[Otorhinolaryngological manifestations in patients with Behçet disease]. / Manifestaciones otorrinolaringológicas en pacientes con enfermedad de Behçet.

INTRODUCTION AND OBJECTIVES: Behçet disease (BD) is a systemic immune-mediated vasculitis of unknown origin characterised by recurrent orogenital ulceration, ocular inflammation and skin lesions. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with BD. PATIENTS AND METHODS: Retrospective review of the medical records of all patients diagnosed with BD who attended a tertiary public hospital in Cantabria (Spain) over a period of 22 years. Clinical manifestations, in particular those concerning ENT, were retrieved from medical records. A medical literature review of ENT manifestations was conducted. RESULTS: Thirty-three patients (age range: 17-64 years) were included in the study. Most of them presented oral ulcers (97%). Eight patients (24%) presented oropharyngeal ulcers and 5 patients (15%) experienced audiovestibular symptoms (high frequency sensorineural hearing loss, vertigo and bilateral vestibular hypofunction). One patient had symptoms compatible with vestibular neuronitis as the presentation manifestation of Neuro-Behçet. In 4 patients (12%) the presence of odynophagia secondary to the presence of oropharyngeal lesions, initially interpreted as acute or recurrent tonsillitis, was the first manifestation of the disease, alone or associated with cutaneous or ocular lesions. CONCLUSIONS: In addition to the characteristic oral ulcers present in most patients with BD, ulcers in the oropharynx, occasionally interpreted as acute pharyngitis, are also common in these patients. Audiovestibular manifestations frequently appear during the course of the disease and may be the first symptom of central nervous system involvement.

Síndrome de Horner secundario a cirugía cervical / Horner's syndrome after neck surgery

El síndrome de Horner (oculosimpatoparesis) consiste en la clásica triada de ptosis palpebral, miosis pupilar y anhidrosis facial ipsilateral. El síndrome resulta tras la interrupción de la inervación simpática del ojo y de los anexos oculares a diferentes niveles, siendo una complicación poco frecuente de la cirugía cervical. Describimos los casos de 6 pacientes que presentaron síndrome de Horner tras cirugía cervical en nuestro servicio en los últimos 5 años y una revisión de los diferentes procedimientos cervicales que producen dicha entidad(AU)

Horner's syndrome (oculosympathetic paresis) is characterised by the classic triad of ipsilateral palpebral ptosis, pupillary miosis and facial anhidrosis. The syndrome arises from the interruption of sympathetic innervation to the eye and adnexa at varying levels. It is a rare complication of neck surgery. We describe 6 patients who presented with Horner's syndrome after a neck procedure in our department during the last 5 years and review the different neck procedures that can cause it(AU)

Manifestaciones otorrinolaringológicas en pacientes con granulomatosis de Wegener (granulomatosis con poliangeitis) / Ear, nose and throat manifestations of Wegener's granulomatosis (granulomatosis with polyangiitis)

Introducción y objetivos: La granulomatosis con poliangeitis (GPA), previamente llamada granulomatosis de Wegener, es una vasculitis de pequeños vasos que con frecuencia se asocia a manifestaciones clínicas de cabeza y cuello, y en ocasiones constituyen los síntomas de presentación de la enfermedad. El objetivo de nuestro estudio fue identificar la afección otorrinolaringológica asociada a dicha enfermedad y proponer un protocolo diagnóstico de los pacientes con sospecha clínica o confirmada de la misma. Pacientes y métodos: Se realizó un estudio retrospectivo descriptivo que incluyó los pacientes diagnosticados de GPA que recibieron asistencia por el Servicio de Otorrinolaringología de un hospital público de tercer nivel de Cantabria. El período de inclusión fue de 20 años. Se recogieron de la historia clínica diferentes variables clínicas concernientes al área de cabeza y cuello. Resultados: Veinticinco pacientes con edades comprendidas entre 30 y 81 años de edad fueron incluidos en nuestro estudio. El 88% de los mismos presentaron manifestaciones otorrinolaringológicas en algún momento de la evolución de la enfermedad, y en un 28% constituyeron la forma de presentación de la misma. Los síntomas nasosinusales fueron los más frecuentes (52%), seguido de los otológicos (32%). Un paciente desarrolló un carcinoma de nasofaringe 3 años después del tratamiento con ciclofosfamida. Conclusiones: Los pacientes con GPA presentan con frecuencia manifestaciones clínicas de cabeza y cuello. Es necesario realizar una exploración sistemática otorrinolaringológica en los pacientes con sospecha o diagnóstico confirmado de GPA, tanto para contribuir al diagnóstico de la enfermedad, si esta no estuviese confirmada, como para establecer el grado de afección sistémica de pacientes con esta vasculitis(AU)

Introduction and objectives: Granulomatosis with polyangiitis (GPA), previously called Wegener's granulomatosis, is a small vessel vasculitis often associated with clinical head and neck manifestations, which are sometimes the presenting symptoms of the disease. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with GPA and propose a work-up for the management and diagnosis for patients with suspicion or confirmed diagnosis of this ENT pathology. Patients and methods: Retrospective review of the medical records of all patients diagnosed with GPA who were seen at the Department of Otolaryngology from a tertiary public hospital in Cantabria (Spain) over a 20-year period. Clinical and laboratory data, in particular those concerning ENT manifestations, were retrieved from the patients’ medical records. Results: Twenty-five patients (age range: 30-81 years) were included in the study. Of these, 88% had ENT manifestations at some point in the course of the disease. In 28% of the cases, ENT features were the presenting manifestations. The most frequent ENT manifestations were sinonasal symptoms (52%), followed by otological manifestations (32%). Conclusions: Patients with GPA often present with clinical ENT manifestations. Consequently, routine ENT physical examination must be performed in patients with suspected vasculitis to establish a diagnosis of GPA or to better determine the degree of organ system involvement in patients with GPA(AU)

Horner's syndrome after neck surgery.

Horner's syndrome (oculosympathetic paresis) is characterised by the classic triad of ipsilateral palpebral ptosis, pupillary miosis and facial anhidrosis. The syndrome arises from the interruption of sympathetic innervation to the eye and adnexa at varying levels. It is a rare complication of neck surgery.We describe 6 patients who presented with Horner's syndrome after a neck procedure in our department during the last 5 years and review the different neck procedures that can cause it.

[Ear, nose and throat manifestations of Wegener's granulomatosis (granulomatosis with polyangiitis)]. / Manifestaciones otorrinolaringológicas en pacientes con granulomatosis de Wegener (granulomatosis con poliangeitis).

INTRODUCTION AND OBJECTIVES: Granulomatosis with polyangiitis (GPA), previously called Wegener's granulomatosis, is a small vessel vasculitis often associated with clinical head and neck manifestations, which are sometimes the presenting symptoms of the disease. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with GPA and propose a work-up for the management and diagnosis for patients with suspicion or confirmed diagnosis of this ENT pathology. PATIENTS AND METHODS: Retrospective review of the medical records of all patients diagnosed with GPA who were seen at the Department of Otolaryngology from a tertiary public hospital in Cantabria (Spain) over a 20-year period. Clinical and laboratory data, in particular those concerning ENT manifestations, were retrieved from the patients' medical records. RESULTS: Twenty-five patients (age range: 30-81 years) were included in the study. Of these, 88% had ENT manifestations at some point in the course of the disease. In 28% of the cases, ENT features were the presenting manifestations. The most frequent ENT manifestations were sinonasal symptoms (52%), followed by otological manifestations (32%). CONCLUSIONS: Patients with GPA often present with clinical ENT manifestations. Consequently, routine ENT physical examination must be performed in patients with suspected vasculitis to establish a diagnosis of GPA or to better determine the degree of organ system involvement in patients with GPA.

Traumatismos cervicales / Neck injuries

Introducción y objetivo: Los traumatismos cervicales tienen un gran interés clínico dado que se asocian a una elevada morbimortalidad si no son manejados adecuadamente. El objetivo de nuestro estudio fue revisar los traumatismos cervicales externos en nuestro hospital. Material y métodos: Se realizó un estudio descriptivo retrospectivo que incluyó a pacientes que presentaron lesiones penetrantes de cuello tratadas por el Servicio de ORL en un hospital terciario durante 24 años. Resultados: Veintidós pacientes fueron incluidos en nuestro estudio. Un 45% de los casos fueron secundarios a accidentes de tráfico, un 27,3% a una agresión con arma blanca y un 23% a un intento de suicidio. En 15 casos (68%) constituían traumatismos abiertos y en 7 cerrados (31%). El síntoma más frecuente de presentación fue la hemorragia (55%), seguido de trastornos respiratorios (23%). En la exploración, en un 27% de los pacientes se detectó un enfisema subcutáneo. En un 50% de los casos se realizaron técnicas de imagen antes del tratamiento, siendo la más frecuente la tomografía computarizada de cuello (27%). Un 59,1% de los pacientes requirieron tratamiento quirúrgico, precisando una traqueotomía en 6 casos (27%), falleciendo por complicaciones hemorrágicas dos de ellos (9%). Otros 6 pacientes presentaron secuelas permanentes. Conclusiones: Los traumatismos cervicales con afectación de estructuras otorrinolaringológicos son infrecuentes en nuestro medio, siendo las más habituales las secundarias a accidentes de tráfico. Es importante tener protocolizado el manejo de estos pacientes ya que con frecuencia pueden presentar complicaciones severas o incluso la muerte, si no son tratados adecuadamente en un corto período de tiempo (AU)

Introduction and objective: Neck injuries are of great clinical interest because they can induce very significant consequences if not handled properly and can even lead to death. The aim of our study was to analyse external deep cervical trauma in our hospital. Material and methods: A retrospective study of all external deep neck injuries seen in a tertiary hospital over the course of 24 years that involved changes in structures related to otolaryngology. Results: Twenty patients were included in our study. From all the injuries, 45% were secondary to traffic accidents, 27% from assault with a knife and 23% from attempted suicide. The injuries were open in 15 (68%) cases and closed in 7 (32%). The most common symptom was bleeding (55%), followed by respiratory disorders (23%). On examination, the most frequent sign was the appearance of subcutaneous emphysema (27%). Only 50% of patients underwent imaging before treatment, most often a neck CT (27%). 59% of patients needed surgery, with 6 patients (27%) requiring a tracheotomy. Two of them died (9%) and 6 suffered permanent complications. Conclusions: Cervical injuries involving ENT structures are rare in our environment, with the most common cause being traffic accidents. It is important to have standardised guidelines for the management of these patients, because they can often developed severe complications or even die if not treated properly very rapidly (AU)

Neck injuries.

INTRODUCTION AND OBJECTIVE: Neck injuries are of great clinical interest because they can induce very significant consequences if not handled properly and can even lead to death. The aim of our study was to analyse external deep cervical trauma in our hospital. MATERIAL AND METHODS: A retrospective study of all external deep neck injuries seen in a tertiary hospital over the course of 24 years that involved changes in structures related to otolaryngology. RESULTS: Twenty patients were included in our study. From all the injuries, 45% were secondary to traffic accidents, 27% from assault with a knife and 23% from attempted suicide. The injuries were open in 15 (68%) cases and closed in 7 (32%). The most common symptom was bleeding (55%), followed by respiratory disorders (23%). On examination, the most frequent sign was the appearance of subcutaneous emphysema (27%). Only 50% of patients underwent imaging before treatment, most often a neck CT (27%). 59% of patients needed surgery, with 6 patients (27%) requiring a tracheotomy. Two of them died (9%) and 6 suffered permanent complications. CONCLUSIONS: Cervical injuries involving ENT structures are rare in our environment, with the most common cause being traffic accidents. It is important to have standardised guidelines for the management of these patients, because they can often developed severe complications or even die if not treated properly very rapidly.

Papilomas invertidos rinosinusales. Revisión de 61 casos / Inverted sinonasal papillomas. Review of 61 cases

Introducción: Los papilomas invertidos son neoplasias raras localizadas preferentemente en la pared lateral nasal, caracterizadas por la tendencia a recidivar y su potencial transformación en neoplasias malignas. El objetivo de este trabajo es analizar nuestra experiencia en el tratamiento de estas lesiones, especialmente el abordaje endoscópico. Material y métodos: Se realizó un estudio retrospectivo de 61 pacientes tratados en nuestro hospital desde 1983. Se recogieron los datos clinicopatológicos de los pacientes, el tratamiento aplicado y la evolución en el tiempo tras éste. El tiempo medio de seguimiento fue de 51 meses (rango: 6–228 meses). Resultados: Treinta y ocho de los pacientes (62%) eran hombres y 23 mujeres (38%), con una edad media de 58 años (rango: 22–80). El síntoma principal fue insuficiencia respiratoria nasal unilateral en el 91%, seguido de rinorrea en el 46%. La localización más frecuente fue el etmoides (51%), seguida del seno maxilar (28%) y la pared lateral nasal (21%). El 78% de los casos tenía sinusitis asociada y el 43%, poliposis. La clasificación por estadios de Krouse fue del 35% en estadio I, 37% en estadio II, 18% en estadio III y 8% en el IV. El 37% de los pacientes presentaba remodelación ósea en la TAC. Seis de los 42 pacientes operados por cirugía endoscópica nasal (CEN) presentaron recidiva (14%), mientras que de los pacientes a los que se operó por técnicas abiertas, presentaron recidiva 6 de 9 (67%). El tiempo medio a la recidiva fue de 41 meses. Diez de los pacientes presentaron papilomas invertidos malignizados, nueve de ellos fueron diagnosticados desde el principio como neoplasias malignizadas y uno se malignizó durante el seguimiento. Discusión y conclusiones: La CEN es el método de elección para el tratamiento de la mayor parte de los papilomas invertidos con resultados equiparables o, incluso, mejores que con las técnicas abiertas. El estrecho seguimiento de los pacientes por largos períodos de tiempo es necesario para detectar de forma precoz las recidivas y poder practicar cirugías de rescate (AU)

Introduction: Inverted papillomas are benign sinonasal lesions that arise primarily from the lateral nasal wall which are characterized by their tendency to recur and propensity to be associated with malignancy. The aim of this work is to analyze our experience in the treatment of these lesions, especially through the endoscopic approach. Material and method: We present 61 cases of sinonasal inverted papillomas that were treated at our hospital since 1983. The patients were studied by age, gender, site of presentation of the tumor, symptoms, radiologic studies, surgical treatment and evolution. The mean follow-up was 51 months (range 6–228 months). Results: Thirty eight of the patients (62%) were males and 23 females (38%). The average age was 58 years (range 22–80). The most common symptom was unilateral nasal obstruction in 91% of the cases, followed by rhinorrhea in 46%. The most frequent location was the ethmoid region in 51% of cases, followed by the maxillary sinus in 28% and the lateral nasal wall in 21% of the cases. 78% of cases had associated sinusitis and the 43% polyposis. Tumours were classified with the Krouse staging system as follows: 35% stage I, 37% stage II, 18% stage III and 8% stage IV. 37% of the patients had bony erosion in the CT scan. Six of the 42 patients treated by endoscopic procedures presented recurrence (14%), compared with 6 of the 9 patients (67%) who were treated by open approaches. The average time to the recurrence was 41 months. 17% of the patients had malignant inverted papillomas, nine of them diagnosed from the beginning as malignant neoplasies and one which became malignant during follow up. Discussion and conclusions: The endoscopic approach is the method of choice for the treatment of the majority of inverted papillomas. The close follow up of the patient for a large period of time is necessary for the early detection of recurrence and to allow for surgical salvage (AU)

[Inverted sinonasal papillomas. Review of 61 cases]. / Papilomas invertidos rinosinusales. Revisión de 61 casos.

INTRODUCTION: Inverted papillomas are benign sinonasal lesions that arise primarily from the lateral nasal wall which are characterized by their tendency to recur and propensity to be associated with malignancy. The aim of this work is to analyze our experience in the treatment of these lesions, especially through the endoscopic approach. MATERIAL AND METHOD: We present 61 cases of sinonasal inverted papillomas that were treated at our hospital since 1983. The patients were studied by age, gender, site of presentation of the tumor, symptoms, radiologic studies, surgical treatment and evolution. The mean follow-up was 51 months (range 6-228 months). RESULTS: Thirty eight of the patients (62%) were males and 23 females (38%). The average age was 58 years (range 22-80). The most common symptom was unilateral nasal obstruction in 91% of the cases, followed by rhinorrhea in 46%. The most frequent location was the ethmoid region in 51% of cases, followed by the maxillary sinus in 28% and the lateral nasal wall in 21% of the cases. 78% of cases had associated sinusitis and the 43% polyposis. Tumours were classified with the Krouse staging system as follows: 35% stage I, 37% stage II, 18% stage III and 8% stage IV. 37% of the patients had bony erosion in the CT scan. Six of the 42 patients treated by endoscopic procedures presented recurrence (14%), compared with 6 of the 9 patients (67%) who were treated by open approaches. The average time to the recurrence was 41 months. 17% of the patients had malignant inverted papillomas, nine of them diagnosed from the beginning as malignant neoplasies and one which became malignant during follow up. DISCUSSION AND CONCLUSIONS: The endoscopic approach is the method of choice for the treatment of the majority of inverted papillomas. The close follow up of the patient for a large period of time is necessary for the early detection of recurrence and to allow for surgical salvage.