Biphenotypic Sinonasal Sarcoma with Orbital and Skull Base Involvement Report of 3 Cases and Systematic Review of the Literature.

Biphenotypic sinonasal sarcoma (BSNS) is a rare malignant tumour of the upper nasal cavity and ethmoid sinuses that presents predominantly in middle aged female patients and show a characteristic infiltrative and hypercellular proliferation of spindle cells that demonstrate a specific immunoreactivity. We present three cases with BSNS that had different presenting complaints, either sinonasal or orbital problems, underwent endoscopic surgical treatment and/or radiotherapy and have been disease free on long follow up. A systematic review of all published cases was performed to identify all BSNS cases known at present. BSNS requires prompt and correct diagnosis with accurate surgical resection as well as consideration of radiotherapy. Our three cases confirm the findings of the literature and support that BSNS is an aggressive but treatable malignant disease of the sinonasal tract.

Case report: An unusual case of 'black' larynx.

Ulcerative necrotic supraglottitis is a rare entity of laryngeal infection leading rapidly in laryngeal necrosis, systematic complications and potentially fatal outcomes. We present a case of a 50-year-old gentleman with ulcerative necrotising supraglottitis and no co-morbidities who presented in Ear Nose and Throat Service in the Accident and Emergency department due to dysphagia and weakness. He was treated with an emergency tracheostomy with neck exploration and washout and received appropriate supporting antibiotic regime. He improved and was eventually decannulated, able to breathe phonate and swallow appropriately. After a thorough review of the literature regarding necrotising infections of the laryngeal cavity, only 7 cases have been reported, all in immunocompromised patients with severe complications. Our case report is the first ulcerative necrotic supraglottitis in a healthy individual who was treated early and aggressively with impressive results.

Intracapsular coblation tonsillectomy versus extracapsular coblation tonsillectomy: a systematic review and a meta-analysis.

PURPOSE: To assess all available data regarding the comparative benefit of intracapsular coblation tonsillectomy (ICT) versus extracapsular coblation tonsillectomy (ECT) in children. METHODS: MEDLINE, the Cochrane Library and Springerlink databases as well as other sources were searched by two independent reviewers. Controlled studies comparing ICT versus ECT in paediatric patients with obstructive sleep apnea (OSA) or recurrent tonsillitis were included. Overall postoperative pain was the primary outcome. Secondary outcomes were postoperative hemorrhage, diet and activity, duration of operation and tonsillar regrowth. In case of homogenous, processable data (I2 < 60%), a meta-analysis was performed. RESULTS: Six studies met the inclusion criteria. The analysis showed significant difference between the two methods in terms of late postoperative pain with the ICT being less painful (SMD - 0.78, 95% CI [- 1.03, - 0.53]). However, there was no significant difference in early postoperative pain (≤ 48 h) between the two techniques (SMD - 0.18, 95% CI [- 0.47, 0.12]). All the rest of the secondary outcomes are presented in a qualitative synthesis due to published data limitations of the included studies. CONCLUSION: Intracapsular coblation tonsillectomy appears to be a less painful operation in comparison to extracapsular coblation tonsillectomy. This seems to occur due to prevention of late pain flare up that normally happens several days after the procedure (described as postoperative dip) and not due to reduced pain at the immediate postoperative period. However, as all studies published are small sized, high-quality, large-sample studies need to be performed in the future for more concrete conclusions.

An unusual case of a glottic carcinoma metastasis to the tracheal lumen.

Various mechanisms such as second primary lesion, tumour seeding or lymphogenous and haematogenous metastasis could be proposed to explain the nature of dual malignant lesions. We report the case of a glottic laryngeal carcinoma combined with a secondary endotracheal tumour. Following the imaging modalities, the patient underwent total laryngectomy and wide excision of the trachea. Histopathology ultimately established that the tracheal lesion was a metastatic tumour secondary to regional lymphatic spread of the glottic tumour. To our knowledge, there is no previous report in the English literature concerning tracheal lymphogenous metastatic involvement in the context of laryngeal malignancy. Paradoxical lymphatic spread must always remain an issue of head and neck oncology.

Endoscopic Resection of Sinonasal Inverted Papilloma: Systematic Review and Meta-Analysis.

Background Pure endoscopic surgery (functional endoscopic sinus surgery) has been increasingly replacing external approaches in the management of sinonasal inverted papillomas. Objective To analyze and compare the effectiveness of pure endoscopic procedure with external or combined procedures to paranasal inverted papillomas, including the experience from two institutions in North Greece, over a 20-year period. Methods Systematic literature searches of MEDLINE (1952-2016), EMBASE (1974-2016), and the Cochrane Central Register of Controlled Trials. Review of all English-language studies comparing endoscopic and open techniques. Odds ratios (ORs), risk ratio, 95% confidence intervals (CIs), and tests for heterogeneity were reported. Recurrence rates according to initial tumor stage. Results In total, 2451 patients had been enrolled in the 23 studies, published between 1992 and 2014. All the included articles are graded as level IV evidence. Among the 1526 patients of the endoscopic group, 212 (13.8%) had recurrence, with the mean time of recurrence to range from 14 to 46.6 months. In the external approach group, 111 (18.7%) of the 592 patients had recurrence, with the time of recurrence to range from 7 to 92 months. The recurrence rate in the combined approach group was 12.9%. The occurrence rate of recurrence attributable to the surgical choice was significantly different between endoscopic and external group (OR: 0.61; 95% CI: 0.40-0.92; P = 0.02; 14.9% vs. 18.8% in endoscopic and external group, respectively). Conclusions The present systematic review and meta-analysis indicates that endoscopic approach seems a favorable treatment option of sinonasal inverted papillomas and confirms the global recommendation that is the gold standard in the treatment of such nose lesions, revealing a lower recurrence rate compared to external approaches.

Evidence-based applications of mitomycin C in the nose.

BACKGROUND: Mitomycin C (MMC) is an antimitotic drug that may, when applied topically, prevent postoperative stenosis. Its use remains controversial. This review aims to provide otolaryngologists with an update of the evidence on the applications of this agent in the nose and sinuses. METHODS: A systematic review was performed. Inclusion criteria were as follows: English literature, original articles, reviews, and case series. Exclusion criteria were as follows: animal and in vitro studies, nonendoscopic and nonsinonasal applications of MMC, and external lacrimal surgery. Studies that used other ways of dilating stenoses in conjunction with MMC were excluded. RESULTS: Out of 48 studies published, 9 fulfilled our inclusion criteria, totaling 322 patients. Eighty-five percent were primary and 15% were revision cases. Follow-up ranged from 1 to 42 months. Main outcome measures used were endoscopic examination, anatomical measurements, radiological scoring systems, dye tests, and subjective symptom resolution. Main overall outcomes from studies where extrapolation of data was feasible were (1) patency rate, which ranged from 63% to 94.4% (mean, 81.3%); (2) adhesions: 5.1% (MMC) vs 15.05 (control); and (3) stenosis: 14.05% (MMC) vs 32.6% (control). CONCLUSIONS: There appears to be a favorable short-term effect of MMC, but no robust evidence regarding long-term prevention of restenosis. Larger homogenous and multicenter randomized trials are needed to assess the long-term effects of MMC in sinonasal surgery.

Influence of audit on clinical practice: multidisciplinary team data documentation for cutaneous head and neck malignancy.

BACKGROUND: Prognosis of cutaneous head and neck malignant neoplasms is related to type, site, and histologic feature but may also be influenced by delays in the referral process. Treatment aims to address the primary lesion and when necessary the secondary disease but at the same time maintaining quality of life and minimizing cosmetic deformity. The management plan should ideally be the "product" of a multidisciplinary team (MDT) approach of dermatologists, surgeons, oncologists, pathologists, and radiologists. AIMS: The purposes of the study were as follows: (i) to review current documentation practice of cutaneous head and neck malignancies in a district hospital, (ii) to generate an MDT-approved data collection proforma, and finally (iii) to reaudit documentation of head and neck skin lesions based on the "new" standardized proforma. The MDT-approved proforma was instituted in an effort not only to collect data in a coherent and structured way but also to achieve early diagnosis and avoid delays from urgent referral to treatment with the aim of curing disease and restoring patients to as near-normal appearance and quality of life as possible. METHODS: The notes of patients with head and neck cutaneous lesions were prospectively audited for a 6-month period (August 2006-January 2007). The presence and absence of a minimal standardized data set required for MDT discussion and review were recorded. RESULTS: Documentation was deficient and a need for change in practice emerged. An MDT-approved data collection standardized proforma was designed and distributed throughout the hospital departments involved in management of patients with head and neck cutaneous lesions. The notes of these patients were prospectively reaudited through a second cycle for a 6-month period (February 2007-August 2007). The completion and deficiency of sections of the MDT-approved data collection standardized proforma were recorded, resulting in closure of the audit loop. CONCLUSIONS: The data documentation for head and neck cutaneous lesions has significantly improved after the implementation of an MDT-approved data collection standardized proforma. This has resulted in improved patient quality of care and progression on appropriate management plans.

Lemierre's syndrome: A systematic review.

OBJECTIVES/HYPOTHESIS: Lemierre's syndrome is characterized by a history of recent oropharyngeal infection, clinical or radiological evidence of internal jugular vein thrombosis, and isolation of anaerobic pathogens, mainly Fusobacterium necrophorum. It was once called the forgotten disease because of its rarity, but it may not be that uncommon after all. This review aims to provide physicians with an update on the etiology, management, and prognosis of Lemierre's syndrome. METHODS: Systematic review using the terms: Lemierre's syndrome, postanginal septicemia, fusobacterium, internal jugular vein thrombosis. INCLUSION CRITERIA: English literature; reviews, case reports, and case series. EXCLUSION CRITERIA: variants or atypical Lemierre's syndrome cases, negative fusobacteria cultures, and papers without radiological evidence of thrombophlebitis. RESULTS: Eighty-four studies fulfilled our inclusion criteria. The male to female ratio was 1:1, 2, and the ages ranged from 2 months to 78 years (median, 22 years). Main sources of infection were tonsil, pharynx, and chest. Most common first clinical presentation was a sore throat, followed by a neck mass and neck pain. The most common offending micro-organism was F. necrophorum. Treatment modalities used were antimicrobial, anticoagulant, and surgical treatment. Morbidity was significant with prolonged hospitalization in the majority of patients. The overall mortality rate was 5%. CONCLUSIONS: Lemierre's syndrome may not be as rare as previously thought. This apparent increase in the incidence may be due to antibiotic resistance or changes in antibiotic prescription patterns. Successful management rests on the awareness of the condition, a high index of suspicion, and a multidisciplinary team approach.

A systematic review of outcomes following surgical decompression for dysthyroid orbitopathy.

OBJECTIVES: To systematically review and compare the surgical outcomes of orbital decompression for dysthyroid orbitopathy. METHODS: Data sources used were PubMed, EMBASE, and Cochrane search for English-language literature from January 1990 to April 2008, combined with manual review of citations within article bibliographies. Citations acquired from the targeted search were filtered independently by two researchers. Relevant articles were reviewed to obtain information including interventions and outcome measures. Articles were then assigned level-of-evidence grades as defined by the Oxford Centre for Evidence-Based Medicine. RESULTS: A total of 516 citations were generated from which 135 abstracts were regarded as potentially relevant. After other relevant articles identified from the bibliography and duplicate articles excluded, 56 studies were available for analysis. Fifty studies were identified as level 4 and six as level 3 evidence. A total of 2,315 patients were pooled, from which 4,176 orbits were decompressed. Fifteen different surgical techniques were broadly identified. The most common surgical indication was cosmesis. Decompression by combined transpalpebral-endoscopic technique resulted in the highest average reduction in postoperative proptosis. The largest improvement in visual acuity was after coronal approach orbital decompression. The overall complication rate was 9.3%. The most significant complications were vision loss and cerebral vascular accident. The highest complication rate was associated with combined endoscopic and transpalpebral decompression. CONCLUSIONS: There are myriad techniques in practice for decompressing the orbit, but no one technique has yet to achieve consistently good outcome and low complication rates. The reporting of outcomes should conform to a minimum dataset. Laryngoscope, 2009.

Challenging airways in deep neck space infections.

Skilful airway management is critical in deep neck space infections. Although relatively uncommon, this spectrum of disease presents a clinical challenge for otolaryngologists and anesthetists. There is currently no universal agreement on the ideal method of airway control for these patients because this depends on various factors including available local expertise and equipment. We review the literature and discuss the available options of airway management in these head and neck emergencies. Special consideration is given to awake fiberoptic intubation and tracheotomy under local anesthesia. Relevant anatomy, route of spread and microbiology of deep neck space infections are also briefly discussed.

Unusual complications of tonsillectomy: a systematic review.

AIMS: Common complications of tonsillectomy are well recognized and are frequently explained to patients during the process of informed consent. This systematic review serves as a reminder of the unusual complications of this routine procedure. METHODS: Studies were located using systematic searches in Medline, Embase, Cinahl, and the Cochrane Library electronic databases, together with hand searching of key texts, references, and reviews relevant to the field. Keywords used included the terms tonsillectomy, complications, unusual, and rare. References from the relevant articles were also searched for. INCLUSION CRITERIA: The review was limited to English-language articles. Because of the low incidence of these complications, all cases were included regardless of age. EXCLUSION CRITERIA: Complications of tonsillectomy in children with various syndromes were excluded. RESULTS: Based on our criteria, 20 articles were identified. Only 10 articles were found suitable for review. All articles were either single case reports or small case series. Because of the small study cohort, the patients' ages ranged widely, from 3 to 21 years, with no sex dominance. The complications were categorized into intraoperative and immediate postoperative (<24 hours), intermediate (<2 weeks), and long-term (>2 weeks) unusual complications. Rare complications reviewed include intraoperative vascular injury, subcutaneous emphysema, mediastinitis, Eagle syndrome, atlantoaxial subluxation, cervical osteomyelitis, and taste disorders. CONCLUSIONS: It is important that the otolaryngologist is aware that although the complications discussed are rare and interesting, they are associated with significant morbidity and mortality risks. Tonsillectomy, a very common ear, nose, and throat procedure, may not be so straightforward after all.

The sensitivity and specificity of an epiphora score at predicting a blocked sac washout following dacryocystorhinostomy.

In a prospective observational study, the sensitivity and specificity of an epiphora score, in predicting a patent sac washout following dacryocystorhinostomy are determined. Patients were examined in a joint otolaryngology/ophthalmology clinic for lacrimal syringing and nasal endoscopy. They completed a 0-10 visual analogue score to grade post operative symptoms. We conclude that due to the high specificity and low sensitivity of the score it is not a good predictor of patency following surgery and therefore no substitute for examining the patient.