Rhinorrhea not responding to nasal corticosteroids.

A woman with multiple illnesses including allergic rhinitis presented for a follow-up visit at our clinic with constant rhinorrhea for 2 weeks despite regular use of nasal corticosteroids. Two weeks earlier, after alcohol drinking and doubling some of her medications for missed doses, she fell on her face. The Emergency Department records documented headache, bradycardia, hypotension, dehydration, and right infraorbital swelling. She was admitted for hydration and observation, and was discharged after two days without radiologic evaluation of the head. At our clinic, physical examination revealed pale turbinates bilaterally and clear watery discharge from the right nostril. Cerebrospinal fluid (CSF) rhinorrhea was suspected, but glucose testing was not available at our clinic. The patient was immediately admitted into the hospital. A beta-2-transferrin test confirmed CSF from the right nostril. High resolution sinus CT revealed fluid in the right sphenoid sinus, a large cyst in the left maxillary sinus, a cribriform plate dehiscence on the right side, and fluid collection adjacent to the middle turbinate. A lumbar drain was placed to release the pressure and antibiotic prophylaxis was started. Nasal endoscopy revealed CSF leak from the cribriform plate with bone dehiscence and a dural tear. A graft from nasal septal cartilage and temporalis fascia was applied using Tisseal fibrin glue. The persistent rhinorrhea resolved and on follow-up visits, the patient remained asymptomatic. Thinking of CSF rhinorrhea in the differential diagnosis of rhinitis would lead to early diagnosis and prevention of serious medical complications and potential legal liabilities.

Total laryngectomy and postoperative radiotherapy for T4 laryngeal cancer: a 14-year review.

OBJECTIVE: The most appropriate treatment of locally advanced carcinoma of the larynx remains to be ascertained. Management of T4 laryngeal cancer patients with postoperative radiotherapy after total laryngectomy is generally advocated and not often debated. However, the effects of this combined treatment approach are poorly documented. We reviewed the oncologic outcome and long-term survival of individuals treated by total laryngectomy and postoperative radiotherapy (TLPR) for T4 carcinoma of the larynx. METHODS: Twenty-eight patients with a pathologic diagnosis of T4 laryngeal cancer treated by TLPR during a 14-year period were studied retrospectively. Median follow-up from treatment until the end of observation was 36 months (range 6 to 123 months). RESULTS: The overall actuarial and disease-free survival rates at 7 years were 43% and 30%, respectively. Local recurrence, regional relapse, and distant metastasis developed in 4%, 4%, and 7% of the cases, respectively. Later esophageal stricture, dental caries, or carotid artery disease in 3 patients (11%) was successfully managed. Multivariate analysis showed patient age, bilateral true vocal cord-anterior commissure involvement by laryngeal cancer (horse-shoe lesion), and any type of treatment failure to be the most predictive variables affecting prognosis. CONCLUSION: Long-term disease control and survival is achievable by TLPR with minimal late toxicity in patients with T4 carcinoma of the larynx.

Salvage treatment of recurrent skin cancer of the midface.

Nine patients with recurrent cutaneous cancers of the midface were treated by definitive surgery (with adjuvant radiotherapy in five individuals). The clinical courses were marked by local and regional relapses in six cases. Although the prognosis may be generally poor, aggressive therapy, as feasible, seems warranted in these patients because death was not typically rapid after reappearance of disease in several patients.

Induction chemotherapy followed by concomitant chemoradiation-induced regression of advanced cervical lymphadenopathy in head and neck cancer as a predictor of outcome.

OBJECTIVE: We sought to determine whether induction chemotherapy followed by concomitant chemoradiation (ICCR)-induced advanced neck disease regression could predict outcome, especially the need for complete neck dissection in patients with N2-3 stage IV head and neck cancer (HNC). METHODS: A retrospective study of 339 patients evaluated for treatment of stage IV HNC during the years 1988 to 1997 revealed 36 individuals with N2-3 cervical lymphadenopathy who were treated with ICCR. Responses to treatment, patterns of failure, and survival rates were analyzed. RESULTS: Primary and regional tumor regressions were complete in 21 patients (58%), partial in 9 (25%), and absent in 6 (17%); the corresponding local failure rates were 5%, 44%, and 33% (P < 0.02). The regional failure rates were 24%, 89%, and 83%, respectively (P < 0.001); distant failure rates were 10%, 0%, and 0% (P > 0.99). The estimated 2-year survival rates for complete and partial/nonresponders were 57% and 20%, respectively (P < 0.02). CONCLUSION: Patients with advanced regional metastases of HNC who respond completely to ICCR have an excellent chance for survival. However, such ICCR-induced complete regression of regional tumor cannot reliably predict ultimate neck disease control.