Globus pharyngis, commonly associated with esophageal motility disorders.

OBJECTIVES: To evaluate the role of gastrointestinal and psychiatric etiology in globus sensation. METHODS: The study population consisted of 32 consecutive patients with globus sensation without dysphagia referred to the Department of Otorhinolaryngology in Helsinki University Hospital. Eleven patients were excluded from the study: two because of advanced age, one prisoner, and six patients refused further studies. Only two patients (6%) were found to have abnormal otorhinolaryngological status. These patients were also excluded from the study. Esophagogastroduodenoscopy, 24-h pH recording, esophageal manometry, and Bernstein acid perfusion test were carried out in 21 patients (13 females, eight males, mean age 49 yr). Psychiatric evaluation was done in 20 patients; one patient refused the psychiatric consultation. RESULTS: Abnormal endoscopy was found in 12/21 (57%) of the patients, with antral gastritis and hiatal hernia being the most common findings. Two patients had esophagitis. Sixty-seven percent demonstrated abnormalities in esophageal manometry, the most frequent finding being a nonspecific esophageal motility disorder (29%). pH monitoring was normal in 16/21 of patients (76%), whereas the Bernstein test showed positive results in 13/21 (62%). With DSM IIIR as the diagnostic tool, five of 20 patients (25%) received a psychiatric diagnosis. CONCLUSIONS: Globus sensation has a multiple etiology, and local reasons are rare but should first be ruled out. Abnormalities in esophageal motility are commonly found, and these patients seem to be sensitive to esophageal acidity. Esophageal manometry and ambulatory 24-h pH recording should be included in the evaluation of a globus patient. The number of psychiatric disorders does not differ from that in the general population. Treatment of globus sensation should be directed toward the abnormality found behind the symptom.

A case of malignant myxoma (myxosarcoma) of the maxilla.

A centrally located maxillary myxoma with malignant histologic appearance and aggressive clinical course is reported in a 40-yr-old man. The gelatinous polypoid tumor mass was diagnosed as a myxoma in the first biopsy. The tumor recurred rapidly (within 3 wk) eroding the bony structures of the maxillary sinus and the hard palate and infiltrating the adjacent soft tissues. In repeated biopsy (as well as reassessment of the first biopsy) the tumor was found to be composed of plump stellate cells, some of which were pleomorphic with atypical and bizarre mitotic figures. The amorphic myxoid matrix contained acid mucopolysaccharides and was completely devoid of lipids. Electron microscopy demonstrated that the tumor cells were identical to fibroblasts, which is consistent with the appearance of myxoma cells. When radiotherapy was unsuccessful, we removed the left maxilla with orbital excenteration and reconstructed the jaw. Three years later the patient died accidentally. At autopsy, no recurrence of myxoma or distant metastases were found. Due to the malignant histologic appearance and the aggressive clinical course, this tumor can be called an odontogenic myxosarcoma and should be added to the WHO classification as a malignant variant of odontogenic myxoma.

Suppressor cells of natural killer activity in normal and tumor-bearing individuals.

Suppressor cells of the human natural killer activity were found in normal peripheral blood and in the blood of patients with untreated primary carcinomas. When lymphocytes from healthy donors were fractionated by Percoll density gradient centrifugation, small lymphocytic, high-density cells inhibited K562 killing in 9/55 consecutively tested cases, and lymphocytes from tumor patients in 1/25 consecutively tested cases. Further fractionation of the suppressor cells was achieved by EA rosetting, since strong suppressor cell activity was seen in the population of cells forming EA rosettes with antibody-coated erythrocytes, whereas the nonrosette-forming cells did not generally suppress. Out of the 33 further fractionated samples from healthy donors, 20 rosette-forming lymphocytic cell fractions exerted strong suppression and out of the 7 samples from tumor patients 2 exerted suppression after EA rosetting. The increase in suppression after EA rosetting was partly due to enrichment of suppressor cells, and partly due to activation of FcR-positive suppressor cells after exposure to immune complexes. The involvement of soluble immune complexes, possibly retained on the suppressor cell surface, was ruled out by the following criteria (i) trypsin and pronase treatment of suppressor cells did not inhibit suppression, (ii) protein A had no effect on the level suppression, and (iii) suppression was also seen with cells which had not been exposed to immune complexes.

Otological manifestations in temporomandibular joint dysfunction.

Forty-seven patients with temporomandibular joint dysfunction were studied. A total of 100 subjective symptoms localized in the ear were encountered in thirty-nine patients. The treatment of dysfunction eradicated or reduced 56% of these symptoms. A hearing defect was established audiometrically in eight cases and the probable cause was outside the masticatory apparatus in seven cases. There was conceviably a causal relationship in one case between the patient's cochlear hearing defect and temporomandibular joint dysfunction. The neuro-otological finding was pathological in nine cases, in three of which the causative agent was independent of the masticatory apparatus. The vestibular disturbance diagnosed in six cases may have originated from temporomandibular joint dysfunction, but this could not be confirmed.

Wegener's granulomatosis in childhood. A clinical report based on 3 cases.

Wegener's granulomatosis is a very rare disease in children; only 10 cases have been reported in the literature. The present report describes 3 cases where Wegener's granulomatosis developed at an early stage, beginning with upper respiratory tract symptoms. All the 3 children have been successfully treated with a combination of azathioprine and corticosteroids.

Nasal polyposis. Relationships to allergy and acetylsalicyclic acid intolerance.

Allergological, clinical and histological findings in 109 unselected patients, treated for nasal polyps during the period Feb. 1977 to Feb. 1978 are reported. The material was divided into three groups according to clinical findings: 1) Atopy Group; 18 patients with positive history and skin test; 2) ASA Intolerance Group; 25 patients with a definite history of acetylsalicylic acid intolerance; and 3) Intrinsic Disease Group; 66 patients in whom specific etiological factors were not found. On skin testing, positive reactions were obtained in 42 patients. In 23 of the patients, the skin test result agreed with the history. Secretion and tissue eosinophilia, noted in 97 and 102 patients, respectively, correlated in 88% of the patients, whereas correlation with blood eosinophilia was poor (30%). The mean IgE level was 140 in the serum and 731 in the polyp fluid, serum values above 150 occurring in 28 out of 105 patients and fluid values above 150 in 58 out of 84 patients. The predominant histological finding in the polyp biopsies was tissue eosinophilia, which was most abundant in the ASA intolerance group. Squamous metaplasia was seen in 30% but it was marked only in 5 cases. In 10 patients ASA intolerance was confirmed by oral provocation.

Vestibular neurectomy and saccus decompression surgery in Meniere's disease.

Results of vestibular neurectomy, total eighth nerve section, and saccus decompression in 42 patients with Meniere's disease are reported. Vestibular nerve section was found in isolated cases to be a very effective method of abolishing the symptom of vertigo. Hearing is not affected but may be lost owing to opening of the vertical canal or disruption of blood supply. Saccus surgery might be the surgical treatment of choice in early cases with good hearing but in patients with fixed non-fluctuating hearing loss, rehabilitation can be effected only by vestibular neurectomy. In bilateral cases either sac surgery or the use of vestibulotoxic drugs is advised.

Penetration of erythromycin stearate into maxillary sinus mucosa and secretion in chronic maxillary sinusitis.

The penetration of oral erythromycin stearate (Abboticin), administered in a dosage of 500 mg three times a day, into the maxillary sinus mucosa and secretion was studied in 15 patients (22 sinuses) operated on for chronic maxillary sinusitis. The average concentration in serum was 2.3 microgram/ml, 1.2 microgram/ml in secretion, and 1.8 microgram/ml in mucosa. These concentrations are highly effective against diplococci and most aerobic and anaerobic streptococci (MIC value 0.06 microgram/ml) but not against Haemophilus influenzae (MIC value for 80% of 2 microgram/ml).

Influence of Caldwell-Luc operation on developing permanent teeth.

The influence of Caldwell-Luc operation on the permanent teeth of school children was studied in a material of 21 six to 14-year-old children, who had undergone, altogether, 30 Caldwell-Luc operations. Ten of the children had also undergone 23 endonasal antrostomies. The control material consisted of a class of 27 healthy school children, their mean age being 10.2 years. Total anesthesia was found in five teeth on the operated side and in one tooth on the non-operated side. Additionally, the operation had caused slight hypesthesia in part of the teeth, mostly in the first incisors. All sensory disturbances were caused by nerve lesion only, and no tooth had died as a result of the operation. The operation could not be shown to be conducive to caries. Correctly performed, Caldwell-Luc operation does not cause serious dental injuries in school children, and is indicated especially in chronic sinobronchitis when conservative methods of treatment fail.

Preoperative radiotherapy of cancer of the larynx.

A series of 128 patients was treated with preoperative radiotherapy, 3000 to 4500 rd, and surgery in 1968 to 1972 at the Radiotherapy Clinic and Otolaryngological Clinic, University Central Hospital, Helsinki. The absolute three-year and five-year survival rates for the total material were 71.1 and 53.2 per cent, respectively. The postoperative complications were two deaths from pneumonia, one of them after aspiration. In addition, 21.3 per cent of the patients had a postoperative fistula. All the fistulae healed spontaneously.

Preoperative facial paralysis in malignant parotid tumours.

Preoperative paralysis of the facial nerve was found in 145 of 1,029 patients with malignant parotid tumours (14%) treated at nine university clinics in Scandinavia. The incidence of facial paralysis varied between the different clinics. A parellelism between the incidence of the facial paralysis and the impairment of the prognosis of the different tumour types is shown. The presence of preoperative facial nerve paralysis in malignant parotid tumours implies a very poor prognosis but the situation is not as hopeless as has been suggested and therefore one must rely on very radical surgery.

The problem of advanced supraglottic carcinoma.

Sixty-four cases of advanced supraglottic laryngeal carcinoma, and the possible therapeutic errors in these cases, have been analyzed. The available time for the investigation and treatment in these cases is short because of the ease and rapidity of spread of these tumors; thus, it is of great importance: that the nature, site and extent of the tumor is determined quickly; that the patient's general condition is determined and improved as far as possible and the patient receives treatment also for other diseases he may have; and that the tumor is radically eliminated whenever possible without delay. The main causes of poor results have been: late admission for treatment; inadequate (too conservative) surgery; and development of metastases during preoperative treatment which includes radiation.