Histiocytic necrotizing lymphadenitis (Kikuchi's disease).

Histiocytic necrotizing lymphandenitis (HNL), or Kikuchi's disease, is a newly recognized disease of unknown origin that causes cervical lymphadenitis, usually in young women. Initially described in Japan, cases of HNL are being reported in the United States and other western countries with increasing frequency. Symptoms of HNL include tender cervical adenopathy, fever, weight loss, and night sweats. Laboratory studies reveal leukopenia with relative granulocytopenia and lymphocytosis. Lymph node biopsy reveals areas with frank cellular necrosis, karyorrhexis, and absence of plasma cells. The histologic features of HNL are distinctive but can be confused with those of lymphoma. We describe two cases of HNL and present recommendations for diagnosis and treatment.

Rapid sequence treatment of advanced squamous cell carcinoma of the upper aerodigestive tract: a pilot study.

A review of the literature suggested that prolonged treatment time may lessen the probability of cure for patients with advanced squamous cell carcinoma of the upper aerodigestive tract. To shorten treatment time, rapid sequence treatment (RST) was devised in which chemotherapy, surgery, and irradation were administered in a total treatment time of 8 weeks. Twelve patients were treated and followed 3 years or longer. Medical complications were minor. Osteonecrosis occurred in each of the first five patients and was the only major complication of the protocol. Surgical techniques were modified, and no additional patient developed osteonecrosis. No patient developed local or regional recurrence. Two patients developed distant metastases and three other patients developed second primaries. Absolute survival was 50%. Rapid sequence treatment is an aggressive and potentially hazardous protocol that yielded encouraging results in this pilot study.

Fibrosarcoma of the mandible following supravoltage irradiation. Report of a case.

Supravoltage irradiation is commonly thought not to be carcinogenic. Several recent studies question this concept, as does our case report. A 50-year-old woman with stage 1 squamous carcinoma of the left side of the tongue was treated in 1973 with 73 Gy of supravoltage irradiation. Twelve years later a painful, ulcerated lesion that eventually was shown to be fibrosarcoma developed in the contralateral mandible. The fibrosarcoma in this case fulfills all criteria for diagnosing radiation-induced neoplasia and demonstrates that supravoltage irradiation, like other forms of irradiation, can cause malignancy. The occasional occurrence of sarcoma should be recalled during follow-up of patients treated with supravoltage radiation. Similarly, the possibility of radiation-induced tumors should be considered in planning treatment for younger patients with tumors that can be treated equally well by surgery or irradiation.

Metastasis from an unknown primary presenting as a tumor in the internal auditory meatus.

A 40-year-old male presented with a 2-month history of sudden hearing loss and tinnitus in his left ear. Mild vertigo was present initially but disappeared spontaneously without treatment. Facial nerve paralysis and retroauricular pain appeared 3 months after the onset of hearing loss on the same side. Computerized tomography and magnetic resonance imaging demonstrated a 1-cm mass in the left internal auditory canal. Translabyrinthine removal of tumor revealed metastatic adenocarcinoma. The patient died 3 months postoperatively from multiple metastatic deposits. A primary tumor was never found. The course of illness in this patient differs significantly from the typical course of other conditions involving the internal auditory canal. A metastatic work-up should be considered for patients with a similar history before a craniotomy is performed.

Horizontal versus vertical block resection for early floor of mouth carcinoma.

Although the literature affirms the superiority of block resection over local excision for the surgical treatment of early squamous cell carcinoma of the anterior floor of the mouth, the best method of block resection is not certain. Two methods are in widespread use; a horizontal procedure (HB) and a vertical procedure (VB). This retrospective study compares these two procedures according to outcome in separate series of patients treated between 1970 and 1984. Patients were followed for a minimum of 3 years with an average follow-up of 6 years. Twenty-five patients underwent HB while 27 underwent VB. Control at the primary site was 100% for HB and 74% for VB. Neck metastasis and distant metastasis occurred with equal frequency. Determinate survivals at 3 and 5 years were 96% and 91% for the HB group and 93% and 65% for the VB group. Local recurrence correlated with tumor growth posteriorally toward the ventrum of the tongue, suggesting an explanation for the difference in outcome between the two procedures. We conclude that the HB procedure is the preferable surgical procedure for stage I and II disease.

Reconstruction of intermediate sized mucosal defects with the pectoralis major myofascial flap.

An uncovered pectoralis major muscle flap (PMF) was utilized in 12 patients for reconstruction of mucosal defects of intermediate size. The PMF is nonhair-bearing and thinner and more flexible than the myocutaneous flap. Epithelialization of the PMF occurs slowly but results in a mucosal surface that is nonkeratinized and closely resembles normal. The paddle of the PMF contracts as much as 75% during healing. However, none of our patients developed deficits attributable to contracture of the flap, presumably because only modest-sized defects were repaired. The PMF is useful for reconstruction of intermediate-sized defects approximately 6 x 6 cm, defects that are too large to close with local flaps and tend to be too small to be closed conveniently with a bulky myocutaneous flap. Contracture of the PMF precludes its use for reconstruction of large defects.

Vascular anatomy of the pectoralis major myocutaneous flap.

In a series of 43 pectoralis major myocutaneous flaps (PMMF), five (12%) developed partial or total necrosis. The cause of necrosis was speculative in each case. To evaluate the problem, we studied the vascular supply to the PMMF, specifically, the lateral thoracic artery (LTA) and the pectoral branch of the thoracoacromial artery (TAA-PB). Ten aortic arch angiograms and 35 cadaver dissections were analyzed. The LTA and TAA-PB provided pedicles of comparable size in most cases, and in several the LTA was significantly larger than the TAA-PB. In one angiogram the TAA-PB was totally occluded, probably by atheromatous plaque. Peripheral vascular disease can affect myocutaneous flaps. We postulate that the LTA can nourish the PMMF by itself and sustain flaps that might otherwise develop necrosis.

Squamous carcinoma of the nasopharynx.

Nasopharyngeal carcinoma is an unusual neoplasm among squamous cell carcinomas of the head and neck. The tumor is rare in most parts of the world but is strikingly common in several Asian subpopulations, notably Chinese in Hong Kong and Guangdong Province. The Epstein-Barr virus is intimately related to the disease and elicits the formation of antibodies that are useful for diagnosis and follow-up study. The virus has not been conclusively shown to cause nasopharyngeal cancer, however.Histologically, nasopharyngeal carcinoma is anaplastic in 75% of cases and better differentiated in 25% of patients. All tumors are treated by high-dose irradiation to the primary site and both sides of the neck. Surgical treatment, in the neck only, is reserved for irradiation failures. The prognosis is better in patients younger than 40 years, in patients without clinical cervical nodal involvement and, unexpectedly, in patients with anaplastic tumors.

Anaerobic mastoiditis: a report of two cases with complications.

Aerobic bacteria are responsible for most cases of suppurative otitis media/mastoiditis (OM/M). As many as 20-30% of middle ear aspirates in acute otitis media, however, are reported to be sterile on aerobic culture. Some of these cases may be due to anaerobic bacteria. Two cases of OM/M due to anaerobic bacteria are reported. The first patient had no antecedent ear disease and developed a large Bezold abscess caused by Fusobacterium varium. The second patient had attic retraction pouches bilaterally and a history of otorrhea. This patient developed labyrinthitis and meningitis due to B. fragilis. The clinical progression of disease in both cases indicates that anaerobic OM/M can follow a deceptively asymptomatic course. By contrast, complications of OM/M occur abruptly and extend rapidly in a manner typical of acute aerobic disease. Both cases required surgery for cure.

The globus symptom. Incidence, therapeutic response, and age and sex relationships.

The globus symptom was found to be the seventh most common initial complaint (4.1%) among 4,330 consecutive first-visit patients to a general otolaryngology clinic. Globus is a well-defined clinical symptom that is persistent, difficult to treat, and has a tendency to recur. The incidence is fairly constant among men. Relative to men, women are affected three times more commonly at 50 years of age and below and with equal frequency above 50 years. No seasonal variation in incidence was noted and men and women responded similarly to treatment. The incidence of gastroesophageal reflux symptoms in our patients with globus was 38% v 36% in the general population. Treatment response of the globus symptom was unrelated to treatment response of reflux symptoms even with antireflux therapy. We conclude there is no etiologic relationship between the globus symptom and gastroesophageal reflux.

Letterer-Siwe disease. Presentation as an otologic problem.

Letterer-Siwe disease is one of the three clinical syndromes that are collectively known as histiocytosis X. This is the most aggressive form of histiocytosis and is frequently fatal. Recently, however, early treatment with chemotherapeutic agents and steroids has prolonged survival and has even resulted in remission of a number of cases. This paper draws attention to a persistent external otitis as an early symptom of Letterer-Siwe disease and identifies, histologically, involvement of the external auditory canal.

Perichondritis of the ear as a complication of acupuncture.

A 54-year-old woman developed pain, tenderness, and swelling at the site where a short acupuncture needle had been placed in the helix of the pinna. Staphylococcus aureus was isolated from this LESION. Which was treated with removal of the needle and intravenously administered nafcillin. The patient recovered completely and had no scarring.