Bisphosphonate-induced osteonecrosis of the ear canal: our experience and a review of the literature.

BACKGROUND: Oesophageal disorders and osteonecrosis of the jaw are recognised complications of the commonly prescribed medication bisphosphonate. Despite these diagnoses being seen comparatively frequently within the ENT clinic, osteonecrosis of the external ear is a less well reported complication. METHODS: The current literature is reviewed and our experience with six cases of bisphosphonate-related ear canal osteonecrosis is presented. RESULTS: Six cases were identified as suffering from ear canal osteonecrosis as a result of bisphosphonate treatment. One of our cases suffered bilateral ear canal osteonecrosis after only 20 months of oral alendronic acid treatment. Management ranged from bisphosphonate cessation and topical treatment, to surgical debridement in the operating theatre. CONCLUSION: Bisphosphonate-related ear canal osteonecrosis is undoubtedly under-diagnosed. For such a commonly prescribed medication, the risks and side effects of bisphosphonate should be better known and long-term treatment should be avoided if possible.

Descending necrotising mediastinitis: a safe treatment algorithm.

Descending necrotising mediastinitis can complicate oropharyngeal infection and has a high associated mortality. We present three cases treated in our department and propose a treatment algorithm based on our experience and literature review. The primary oropharyngeal infection was peritonsillar abscess in two cases and odontogenic abscess in one. Two patients underwent cervicotomy and later thoracotomy. The third underwent cervicotomy with transcervical mediastinal drainage and later required pericardial drainage via a subxiphoid incision. All recovered fully and were discharged within 6 weeks. To enable successful treatment, diagnosis needs to be prompt and surgical drainage adequate. Thoracic management of the chest is essential.

Mediastinitis: a life-threatening complication of acute tonsillitis.

Acute tonsillitis is a common condition and usually runs a benign course. However life-threatening complications do still occur, even in this postantibiotic era. Infection can spread downwards into the mediastinum through the anatomic cervical spaces, causing widespread cellulitis, necrosis, abscess formation and sepsis. We present a case of descending mediastinitis in an 18-year-old woman, arising from her first episode of tonsillitis and treated successfully by surgical drainage. We believe that an awareness of this complication, early diagnosis using computed tomography scanning, and prompt, adequate surgical drainage will reduce morbidity and mortality.

Aggressive treatment of metastasis to the parotid.

OBJECTIVES: Assess the value of aggressively treating metastatic lesions in the parotid, taking into account the histology of the disease. STUDY DESIGN: Retrospective analysis of 13 patients diagnosed with metastasis to the parotid treated by one surgeon in a tertiary referral head and neck unit in the United Kingdom. METHODS: The following variables were reviewed and tabulated: age, sex, histology, latent period to secondary tumour, treatment instituted, postoperative facial nerve outcome, follow-up and survival. RESULTS: Twelve patients were treated aggressively with at least total parotidectomy and adjunctive therapy, whilst one patient required only a superficial parotidectomy. Ten patients had metastatic cutaneous tumours, and three had metastatic adenocarcinoma. Seven of these 13 patients (53.8 %) are alive and well (six had metastatic cutaneous tumours, one had metastatic adenocarcinoma). Four patients succumbed to tumour (two had metastatic cutaneous tumours and two had metastatic adenocarcinoma), and two patients succumbed from unrelated medical causes (both had metastatic cutaneous tumours). The mean follow-up for those alive is 65.9 months and mean follow-up for those deceased is 15.3 months. CONCLUSIONS: In the absence of systemic spread, parotid metastases from primary cutaneous squamous cell carcinoma should be treated aggressively, while metastases from non-cutaneous primary tumours should be approached with caution.

Pharyngo-laryngo-oesophagectomy and gastric pull-up for post-cricoid and cervical oesophageal squamous cell carcinoma.

Pharyngo-laryngo-oesophagectomy and gastric pull-up (PLOGP) is a complex and relatively uncommon procedure. The aim of this study is to analyse the results of PLOGP in patients with post-cricoid and cervical oesophageal squamous cell carcinomas. This study was a retrospective review of 26 patients (11 males + 15 females, mean age 63.5 years) who underwent PLOGP from 1988 to 1997. Eighteen (69 per cent) patients were staged as T(3) and eight (31 per cent) T(4). Eighteen (69 per cent) patients had N(0), seven (27 per cent) N(1) and one (four per cent) N(2) disease. Multiple primary tumours were recorded in three (11.5 per cent) patients. Four (15 per cent) patients had pre-operative radiotherapy with poor response and two (eight per cent) required emergency tracheotomy prior to surgery. Feeding jejunostomy was performed on 19 (73 per cent) and neck lymph node dissection in eight (31 per cent) patients. The mean duration of surgery was five hours (range 3.5 to 7.5) with a mean blood loss of 840 ml (range 160 to 1800), a mean stay in ICU of 4.2 days and hospital stay ranged from nine to 84 days (mean 34). Three (11.5 per cent) patients died (pneumonia - one, congestive heart failure - one, pulmonary embolus - one) in the early post-operative period. Eight (31 per cent) patients remain alive from 30 to 136 months (mean 58 months). Two (eight per cent) patients died with no evidence of disease. Thirteen (50 per cent) patients died of their disease between two to 51 months (mean 17.3 months) post-operatively. Kaplan-Meier survival estimates for one year was 65 per cent, for three years 35 per cent and for five years 26 per cent (see Figure 1). Median survival in the whole series was 18 months. Post-operative speech was with an electrolarynx in 16 (62 per cent). One patient (four per cent) used gastric speech and one patient (four per cent) used a Blom-Singer valve effectively. Five (19 per cent) patients had no speech post-operatively. All patients maintained oral feeding. Gastric transposition constitutes a safe and reliable method of restoring the continuity of the upper digestive tract following pharyngo-laryngo-oesophagectomy.

Oesophageal ulceration caused by doxycycline: an unusual complication.

Oesophageal ulceration is an unusual complication of doxycycline treatment (Vibramycin) presenting to an Otorhinolaryngology department. A case report is presented with discussion of investigations and management of the patient.

Myoepithelial carcinoma (malignant myoepithelioma) of the parotid gland arising in a pleomorphic adenoma.

A myoepithelial carcinoma, a rare malignant salivary gland neoplasm, arose in a pleomorphic adenoma of the parotid gland. The initial tumour was a pleomorphic adenoma with epithelial and myoepithelial elements. Subsequently the tumour recurred twice and was characterised by invasion of the mandible. Histological examination of the second recurrence showed a malignant spindle cell neoplasm with an infiltrative growth pattern and a high mitotic rate. There was involvement of local lymph nodes. The immunophenotype was characteristic of myoepithelial differentiation: tumour cells stained positively with anticytokeratin antibodies, S-100 protein, alpha smooth muscle actin, and vimentin. Electron microscopy confirmed myoepithelial differentiation, with small foci of keratinocytic phenotype. Large numbers of tumour cell nuclei were reactive with the anti-p53 antibody, DO-7, in contrast to the two previous resections. Thus malignant transformation of a pleomorphic adenoma may involve myoepithelial as well as epithelial elements. Accumulation of p53 protein, perhaps through mutational events, may have played a role in this malignant transformation.

Does age or sex affect pharyngeal swallowing?

The influence of age and gender on the pharyngeal pressure wave during swallowing was investigated in 73 healthy volunteers using a four-sensor manometry probe. The distal sensor was placed within the upper oesophageal sphincter (UOS) and three proximal sensors were located in the pharynx 2, 4 and 6 cm above the UOS. Twenty-nine variables describing the amplitude and timing of the swallow waveforms for a 5 ml water bolus were recorded from the pharynx and the UOS. Analysis of the results indicated that aging was associated with slowing of the swallow response in the pharynx, impaired opening of the UOS and a marked reduction in resting UOS tone.

Giant cell tumour of the temporal bone presenting as vertigo.

We report a case of giant cell tumour of the temporal bone arising in a 31-year-old man. The presenting symptoms were unusual, being rotational vertigo, unilateral tinnitus, and hearing loss. A computed tomography (CT) scan showed a large mass within the right temporal bone and the infratemporal fossa. The radiological appearance was suggestive of an aggressive primary neoplasm arising within bone. Biopsy and subsequent resection showed a giant cell tumour of bone. The tumour was histological grade 1. At two-year follow-up, there was no evidence of tumour recurrence or metastasis.

Osteomyelitis as a complication of a tracheo-oesophageal puncture.

Two cases of osteomyelitis of the cervical spine complicating tracheo-oesophageal puncture are reported. There was considerable delay between onset of symptoms and diagnosis in both cases due to pre-existing cervical arthritis. Previous radiotherapy was felt to be a contributory factor in both cases.

Retro-pharyngeal liposarcoma.

We present a case of extensive recurrence of a retro-pharyngeal liposarcoma following surgical removal 18 years previously. The surgery and pathology are discussed, and management strategies of head and neck liposarcomas are reviewed.

Juvenile nasopharyngeal angiofibroma in a static population: the implications of misdiagnosis.

We present a 20-year review of juvenile angiofibroma in the relatively static population of Northern Ireland. Seventeen cases were identified and new slides were prepared from the stored paraffin blocks of all their original biopsy material, and re-examined. Five females, a 36-year-old and an 18-year-old male had their diagnoses revised. We suggest clinical criteria, which in conjunction with radiological investigations, should be strictly applied in all cases. Such application would, in retrospect, have identified those cases excluded by pathological re-examination, thus avoiding unnecessary surgery and radiotherapy. Atypical cases which do not satisfy the clinical criteria may be subjected to repeat biopsy but routine initial biopsy is not recommended.

Acute mastoid abscess and cholesteatoma.

A 10-year review of acute mastoid abscess treated surgically in Belfast revealed a total of 24 cases, 12 of which were found to have an underlying cholesteatoma. The surgical management of these 12 cases is outlined but despite a desire to maintain an intact canal wall, 9 of them to date have ended up with an open cavity. The danger of conservative management and the possible association between acute mastoid abscess and cholesteatoma, especially in developed countries, is stressed.

Synergistic effects of sequential carbon dioxide and neodymium:yttrium aluminum garnet laser injuries. Experimental observations and measurements.

The carbon dioxide and neodymium:yttrium aluminum garnet lasers have well documented but characteristically different biological effects, yet little is known about their cumulative, synergistic, or paradoxical effects when used sequentially on living tissue. Using a Merrimack ML 880 laser, a series of superimposed CO2 and Nd:YAG lesions in various combinations were produced on the undersurface of dog tongues. Therapeutic time and power settings were chosen and the number of applications varied, with suitable controls. Observations and measurements were made on acute, healing, and healed lesions. All lesions were excised and submitted for routine hematoxylin and eosin histology. Acute lesions were also assessed for cell viability using rhodamine 123 as a supravital marker. The results show that, even though all the lesions eventually heal, the actual cell damage produced by the Nd:YAG laser is much more than is suggested by the size of the acute lesion. This cell damage can be reduced by the surface carbonization produced by initial application of the CO2 laser. Higher surface temperatures are reached in this combination with less fibrosis and scarring than equal energy counterparts where the Nd:YAG laser was applied first. The knowledge of these synergistic effects can be used to advantage in the clinical setting. The rhodamine 123 technique also appears to be a valid measure of acute thermal tissue injury.

Vestibular nerve section and saccus decompression: an evaluation of long-term results.

The 1972 AAOO committee (Alford, 1972) guidelines brought some uniformity into the evaluation of therapy for Menière's Disease. We have adhered to its recommendations in this long-term follow-up report of 21 saccus decompressions and 29 vestibular nerve sections performed on 46 patients between 1968 and 1977. Comparisons between these and other groups have been possible with regard to: control of vertigo; hearing; tinnitus; and development of hydrops in the contralateral ear. All the vestibular nerve section group have enjoyed sustained relief from vertigo. Class D results (recurrent vertigo) account for 14 per cent of the saccus decompression group at one year and 29 per cent at eight to 10-year follow-up. Hearing levels in both groups deteriorated in parallel as time progressed but tinnitus became less noticeable. Nineteen per cent of the long-term review patients showed evidence of developing cochlear hydrops in the contralateral ear. Conservative surgical procedures should be employed whilst any useful hearing exists, though the emphasis remains on controlling vertigo. Saccus decompression, despite its controversial therapeutic basis, will remain the first-line surgical procedure for many otologists. However, in the fit young Menière's cripple or saccus decompression failure with serviceable hearing, vestibular nerve section remains the treatment of choice.

The anterior marginal perforation.

The anterior tympanomeatal angle remains the main problem area in anterior marginal perforations with both conventional onlay and underlay techniques. Here we describe a variation of Gerlach's quilting technique to overcome the problem and this modification has proven to be both simple and effective. When the graft is prepared a small tag is fashioned anteriorly and later pulled through a small tunnel under the anterior-superior annulus. This prevents the graft falling away anteriorly without producing the blunting associated with more extensive undermining of the anterior annulus.