Routine nasopharyngeal biopsy in adults presenting with isolated serous otitis media: is it justified?

Nasopharyngeal malignancy accounts for less than 2 per cent of all head and neck cancers. Serous otitis media (SOM) causing deafness is a recognized indicator of nasopharyngeal obstruction and the possibility of a nasopharyngeal malignancy must be considered in all adults. Examination under anaesthesia (EUA) and biopsy of the nasopharynx is routinely undertaken in many centres to rule out nasopharyngeal malignancy in adults with SOM. The purpose of this 10-year retrospective study was to evaluate the case records of all adult cases of SOM, including their presentation, clinical findings, management and nasopharyngeal biopsy results. Eighty-five patients were included in the study. Fifty-nine presented with unilateral SOM and 26 with bilateral SOM. The primary presenting complaint in all cases was hearing loss. A nasopharyngeal mass was documented in 55 patients (69 per cent). Four nasopharyngeal masses were noted to have irregular or exophytic mucosa on flexible nasendoscopy. All patients underwent a EUA of the ears and a nasopharyngeal biopsy. The four patients with suspicious-looking masses were all found to have malignancies (two squamous cell carcinomas, one B-cell non-Hodgkin lymphoma and one adenocarcinoma). Three of these patients presented with unilateral SOM and one with bilateral SOM. All other patients with masses were found to have benign lymphoid hyperplasia. In total, 4.7 per cent of the adults with conductive hearing loss secondary to SOM were found to have a malignancy on nasopharyngeal biopsy. We would advocate a high index of suspicion of a nasopharyngeal tumour in adults presenting with SOM. If a mass is found in the nasopharynx then it should be biopsied. If no mass is found then it is not necessary to biopsy; however, close follow up, with repeat fibre-optic nasendoscopy, is advised.

The importance of dedifferentiation in recurrent acinic cell carcinoma.

The biological activity of acinic cell carcinoma is uncertain. Histological dedifferentiation is one possible reason for recurrent disease, and this study was undertaken to assess its importance in acinic cell carcinoma. The initial and recurrent specimens from five patients with acinic cell carcinoma were assessed histologically and using flow cytometry, AgNOR estimation and morphometric analysis for evidence of dedifferentiation. No objective evidence of a change in biological aggressiveness in recurrent acinic cell carcinoma was identified. In this limited series of a rare salivary gland tumour, it would appear that factors other than dedifferentiation, such as close/involved margins, histological type and stage have a more meaningful effect on the likelihood of recurrence and prognosis.

Ischaemic optic neuropathy following bilateral neck dissection.

Two cases of ischaemic optic neuropathy, which occurred as a complication of oncological neck surgery, are reported. These cases are submitted because of the apparent scarcity in the literature of this complication after head and neck surgery. They are also unusual because they presented with different clinical manifestations of ischaemic optic neuropathy after separate forms of bilateral neck dissection. A literature review identifies a small number of similar cases and risk factors and preventative measures are discussed.

Surgical landmarks of the spinal accessory nerve in modified radical neck dissection.

We designed a study to identify useful landmarks for the preservation of the spinal accessory nerve during modified radical neck dissection (MRND). Eighteen consecutive patients undergoing 23 MRNDs were enrolled in the study. The distance of the accessory nerve from the greater auricular nerve, where it crosses the posterior edge of the sternocleidomastoid muscle (greater auricular point), was noted. The vertical distance between the point of entrance of the accessory nerve into the trapezius muscle and the clavicle was also measured. The mean distance between the greater auricular point and the accessory nerve was 10.7 mm, SD +/- 6.3. In all cases the accessory nerve was above the greater auricular point. The mean distance between the point of entrance of the nerve into the trapezius and the clavicle was 51.3 mm, SD +/- 17. The greater auricular point is a reliable landmark for the identification of the accessory nerve during modified radical neck dissection. Distance above the clavicle was less helpful.

Helicobacter pylori and tonsillectomy.

Tonsillar tissue is a component of mucosa-associated lymphoid tissue (MALT), which has evolved to protect vulnerable mucosal surfaces. Helicobacter pylori, implicated as an aetiological factor in duodenal ulcers and gastritis, induces the appearance of lymphoid aggregates (MALT) in the stomach. This organism is cytotoxic via a nitric oxide synthase cascade. The possibility that tonsillar tissue processes Helicobacter pylori or that Helicobacter pylori can colonize the palatine tonsils is explored. The study design was that of a prospective study. We determined if Helicobacter pylori (i) forms part of the normal microenvironment of the tonsil, (ii) plays a role in the pathogenesis of tonsillitis and (iii) is associated with increased expression of inducible nitric oxide synthase (iNOS) in macrophages of the tonsil. Serology for Helicobacter pylori was performed on 50 patients undergoing tonsillectomy. Tonsillar specimens were monitored for urease activity by CLO test (a sealed plastic slide holding an agar gel, which contains urea and detects the urease enzyme of Helicobacter pylori), and immunocytochemically probed for Helicobacter pylori and iNOS expression. The mean age of this patient group was 17.2 years (3-36 years). Fourteen (28%) were sero-positive for Helicobacter pylori but no evidence of this pathogen was found in any tonsillar specimen. The number of macrophages staining for iNOS, per field, under a magnification of x40, was increased in sero-positive patients (13.3 +/- 1.3 versus 9.9 +/- 0.7; P = 0.01). Helicobacter pylori does not appear to colonize the tonsil. We believe that Helicobacter pylori primes the tonsils by inducing macrophage iNOS expression. The higher expression in sero-positive patients is a reflection of a pro-inflammatory reaction to Helicobacter pylori that is both local and systemic.

Panendoscopy and bronchial washings: role and efficacy in detection of simultaneous primary head and neck cancers.

The phenomenon of multicentricity in head and neck squamous cell carcinoma affects survival rates. We evaluated the use of panendoscopy/triple endoscopy and, in particular, the place of bronchial washings in the initial staging assessment of head and neck tumours. In a prospective panendoscopic study, a second primary rate of 4.8 per cent was discovered. All four bronchial tumours--both index and simultaneous primary cases--were obvious on bronchoscopy and chest X-ray, despite 50 per cent of them being clinically silent. A self-limiting complication rate of 2.4 per cent was encountered. The issue of bronchial washings was debated and our sensitivity (50 per cent) and specificity (97 per cent) results assessed. We advocate the inclusion of bronchoscopy as part of a panendoscopic work-up of head and neck tumours. The rationale for this is discussed. Bronchial washings, although cheap and easy to process, did not change the management of any patient in the study group and contamination could complicate assessment. Overall, panendoscopy is a safe worthwhile procedure.

Paraganglioma of the external auditory canal: an unusual case.

Primary paraganglioma of the external auditory canal is a rare otological finding. To date, only three cases have been reported in the world-wide literature. Such a tumour is now described in a 42-year-old female. The clinical and histopathological features of the case are discussed. The role of immunocytochemistry in defining diagnosis, from a large list of differentials, is illustrated. We present the first magnetic resonance images of this rare tumour and highlight the benefit of intra-operative frozen section in limiting surgery to canal excision.

Nerve monitoring in thyroid surgery: is it worthwhile?

This study analysed the use of the commercially available Neurosign 100(R) Nerve Monitor during thyroidectomy. Consecutive patients undergoing thyroidectomy were monitored. The nerve response prior to and after thyroidectomy were compared as were the relative benefits of mono and bipolar electrodes. Twenty-one consecutive patients over 9 months were assessed. The threshold for stimulation of the recurrent laryngeal nerve was never more than 0.5 mA (range 0.2-0.5 mA) for the bipolar and 1.5 mA (range 0.2-1.5 mA) for the unipolar electrode. The threshold for the superior laryngeal nerve was 1 mA and 1.5 mA, respectively. Following resection, stimulation levels of the laryngeal nerves were unchanged. Use of the Neurosign 100 Nerve Monitor is helpful in laryngeal nerve localization and confirmation. The bipolar electrode set at 30 Hz. and 0.5 mA for the recurrent laryngeal nerve and 1.0 mA for the superior laryngeal nerve is recommended. Threshold comparison before and after resection would appear to have a prognostic value.

Absence of Epstein-Barr virus encoded RNA and latent membrane protein (LMP1) in salivary gland neoplasms.

A series of 55 (42 benign and 13 malignant) salivary gland tumours were investigated by immunohistochemistry, to detect Epstein-Barr virus (EBV) latent membrane protein (LMP1) and by in situ hybridization for EBV-encoded RNA. Non-neoplastic gland from all the patients with tumours and 15 control glands were also examined. All cases, both neoplastic and non-neoplastic were negative for LMP1 and failed to show any positive signal by in situ hybridization for EBV RNA. One undifferentiated carcinoma from a European patient was included in the group. These results confirm previous reports of an ethnic association between EBV and undifferentiated carcinomas of the salivary gland. They do not support an aetiological role for EBV in other salivary gland tumours.

The accuracy of fine-needle aspiration biopsy in the diagnosis of head and neck masses.

Patients presenting with a mass in the head and neck region require a tissue biopsy in order to make a histological diagnosis. Fine needle aspiration (FNA) offers a safe, well tolerated and inexpensive method of obtaining such a biopsy. When the patient is first seen in the clinic, the FNA can be performed, the result read and appropriate management instituted. The results of FNA biopsies of head and neck masses performed between May 1993 and June 1995, at the Department of Otolaryngology, Head and Neck Surgery in Saint James's Hospital, Dublin were reviewed. Of the 130 patients who had FNA biopsies performed, 78 went on to have surgical excision of the mass. To determine the accuracy of FNA biopsy in the diagnosis of head and neck masses at our unit, we compared the cytology result and the final histology report of these 78 patients. The overall accuracy rate of FNA cytology was 95 per cent, when compared to the final histology result. The accuracy rate was 87 per cent for malignant lesions and 95 per cent for benign lesions. No complications were encountered in this study. Based on our results and those of other studies, we recommended performing FNA in all patients presenting with a mass in the head and neck region.

Exfoliated malignant cells in glove and instrument washings following head and neck surgery.

Loco-regional recurrence following resection of squamous cell carcinoma of the upper aero-digestive tract is a major problem. Cells exfoliated from malignant tumours have been considered capable of implanting and giving rise to local recurrence or metastatic deposits. A prospective study was performed examining washings from the gloves and instruments used in major head and neck operations to determine if exfoliated cells were indeed present. Following removal of the main tumour specimen all surgeons washed their hands in a solution containing a cell fixative and all instruments were soaked in the solution. Samples were then centrifuged and stained using a modified PAP technique. On occasions nuclear fragments consistent with squamous cell carcinoma were present in both glove and instrument washings. We recommend that all surgeons change gloves and instruments following removal of the main tumour specimen and prior to irrigation of the operative field with a tumoricidal agent.

The natural history of globus pharyngeus.

While globus pharyngeus is a common disorder, accounting for 3% to 4% of new otolaryngology outpatient referrals, few long-term follow-up studies have been conducted on patients with this condition. The authors of this study followed 74 patients with a diagnosis of globus pharyngeus for an average of 7 years, 7 months (range: 7 years to 8 years, 10 months). During the follow-up period, 55% of patients were asymptomatic and 45% of patients had persistent symptoms. An in-depth analysis of features at clinical presentation failed to reveal any reliable prognostic indicators. A number of patients developed other conditions during the follow-up period, but no patient developed upper aerodigestive tract malignancy. This study represents the longest follow-up of globus patients to date and, to the authors' knowledge, is the first to address the issue of malignancy in globus.

Migrating foreign body: a new cause of trismus.

A unique case of delayed trismus secondary to an infratemporal foreign body is presented. The pathophysiology and treatment options are discussed.

Clinico-pathological predictors of recurrence for acinic cell carcinoma.

The biological behaviour of acinic cell carcinomas, even if well differentiated, is unpredictable. We studied 45 patients with acinic cell carcinoma followed-up from 10 to 379 months (5 year recurrence-free and survival rate of 69% and 81% respectively), and compared clinico-pathological parameters with outcome. The presence of a predominately solid architecture was strongly associated with a poor outcome (P < 0.01) and this was the only independent prognostic variable when log rank testing was performed. Tumour size (> 2.75 cm) was a significant predictor of recurrent deep parotid lobe involvement, the presence of cervical nodal disease and lymphocytic infiltration, although not significant, factors showed a tendency towards recurrence. For acinic cell carcinoma, the predominant solid architecture would appear to be a strong predictor of recurrence.

Malignant sinonasal tumours: the Dublin Eye and Ear Hospital experience.

We identified 51 patients from pathology and operative records who were treated in the Royal Victoria Eye and Ear Hospital with malignant sinonasal tumours between January 1980 and December 1991. Complete follow up was available in 43 patients. There were 30 males, mean age 50 years, range (10-80) and 13 females, mean age 59 years, range (34-75). Commonest presentations were nasal obstruction, nasal discharge and facial swelling. Patients presented late because of initial non specific symptoms. The maxilla was the site of origin in 18 patients, the ethmoids in 13 patients and the nasal cavity in 12 patients. There was a wide range of histological types with squamous cell carcinoma occurring in 19 patients (44%). All patients were treated with surgery, radiotherapy or a combination of both. Chemotherapy was used as an adjunctive therapy in three patients. Local recurrence occurred in 21 (50%) of the patients. Overall three year survival was 58% and five year survival was 45%. These figures compare favourably with larger series in the literature. A high index of suspicion, early recognition and referral of these patients is required to improve survival.

Recurrent laryngeal nerve palsy secondary to benign thyroid disease.

A recurrent nerve palsy occurring in the presence of a goitre is considered to be caused by thyroid malignancy until proven otherwise. Three cases are described in which benign thyroid disease resulted in recurrent laryngeal nerve paralysis. Recent haemorrhage was implicated histologically as the possible aetiology in all three cases. The importance of identifying and preserving the recurrent laryngeal nerve in the surgical management is highlighted.

The role of total laryngectomy in the management of intraluminal upper airway invasion by well-differentiated thyroid carcinoma.

Intraluminal invasion of the upper airway by well differentiated thyroid carcinoma is very uncommon, and the management can be problematic. Many conservative, reconstructive-type surgical procedures have been advocated to maintain normal laryngeal function. Although voice preservation is desirable, it may not always be in the patient's best interest and radical surgery, including total laryngectomy, may be necessary. We describe three cases in which total laryngectomy was performed, and review the indicators for this procedure in the treatment of this difficult to manage condition.