Adriano Santana Fonseca

Clinical versus computed tomography evaluation in the diagnosis and management of deep neck infection

CONTEXT Deep neck infections have high potential for severe complications and even death, if not properly managed. The difference between clinical and computed tomography findings may demonstrate that clinical evaluation alone underestimates disease extent, which may lead to conservative treatment with worse prognosis. OBJECTIVE To compare clinical and computed tomography findings from neck spaces affected by deep neck infections and to determine the main clinical and radiological features associated with these. TYPE OF STUDY Non-randomized retrospective study. SETTING Department of Otolaryngology and Head and Neck, Universidade Estadual de Campinas. METHODS Medical charts of 65 patients with deep neck infections were evaluated. Age, gender, clinical complaints, physical findings, computed tomography scan and x-ray imaging, microbiology, treatment and outcome were analyzed. All clinical signs and symptoms were evaluated and stratified in order of frequency. The frequency of neck space involvement in such infections was also assessed from the clinical and tomographic evaluation. All clinical and computed tomography findings were compared with surgical observation. RESULTS The most frequent clinical findings were neck swelling, local pain, erythema and locally increased temperature. Physical evaluation showed that the most affected site was the submandibular triangle (49.2% of cases). However, computed tomography showed this to be the lateropharyngeal space (65% of cases) and that more than one deep cervical space was compromised in 90% of cases, as demonstrated by the extent of swelling and increased contrast signs in soft tissue. DISCUSSION The most frequent clinical symptoms of deep cervical infections were cervical pain, increased cervical volume and fever. The important signs seen via computed tomography were increased contrast in soft neck tissues and swelling. Such examination is the most important method for correct evaluation of cervical spaces involved in infection, and thus for correct surgical drainage. CONCLUSIONS The most frequent clinical findings were cervical mass, neck pain, local erythema and locally increased temperature. Computed tomography demonstrated that the lateropharyngeal space was the most affected neck space. More than one deep neck space was compromised in 90% of cases. Clinical evaluation underestimated the extent of deep neck infection in 70% of patients.

Surgical Treatment of Non-embolized Patients with Nasoangiofibroma

UNLABELLED Juvenile nasopharyngeal angiofibroma (JNA) is an uncommon tumor of the sphenopalatine foramen. Surgery combined with preoperative embolization has been the treatment of choice for JNA patients without intracranial invasion. This study aims to assess the viability of surgically treating non-embolized patients with JNA (types I-III according to Fisch). MATERIAL AND METHOD This is a retrospective, descriptive study based on the medical records of 15 patients with histologically confirmed JNA (Fischs types I- III), who underwent surgical treatment without pre-op embolization in our institution between 2000 and 2005. RESULTS Seven of the fifteen patients were approached endoscopically, four through the transantral approach, three were treated with the combined transmaxillary and endoscopic approach, and one with the combined transmaxillary and transpalatal approach. Six patients required intraoperatory blood transfusion, averaging volumes of 1.3 unit/patient. There were no cases of death or significant morbidity. Eleven of the fifteen patients were followed for an average of twelve months and 27% of them relapsed. Four patients did not comply with the follow-up scheme. CONCLUSION Resection of JNF types I-III was safely completed in non-embolized patients. The observed levels of intraoperative bleeding, occurrence of complications, and rates of recurrence were close to those seen in embolized patients as found in the literature.

Correlação entre tontura e disfunções do metabolismo da glicose

INTRODUCTION: Impaired glucose metabolism is characterized by conditions of hypo and hyperglycemia. AIM: The objective of the present study was to asses whether or not there is a relationship between impaired glucose metabolism and dizziness. In the clinical laboratory settings, patients were examined using vectoelectronystagmography in association with glycemic levels. METHODS: 33 patients were divided in 3 groups: diabetics; patients with dizziness and a control group. RESULTS: 65% of the patients with dizziness showed impaired glucose metabolism. 40% of the patients with dizziness had alterations in their vectoelectronystagmography results. CONCLUSION: Dizziness is a good indicator of glucose metabolism alterations and these may be a good indicator of alterations in vectoelectronystagmography responses. The study of glycemic levels after glucose overexposure is a good prognosis factor to evaluate dizziness and shows the same results as insulin level studies after glucose overexposure.

Ewing's sarcoma of the head and neck

CONTEXT Ewings sarcoma is a rare neoplasm, which usually arises in long bones of the limbs and in flat bones of the pelvis, with the involvement of head and neck bones being very unusual. CASE REPORT a case of Ewings sarcoma occurring in the mandible of a 35-year-old female. Pain and swelling of the tumor were the main complaints. The early hypothesis was an undifferentiated malignant neoplasm, possibly a sarcoma. The CT scan depicted an expansive lesion, encapsulated, with septa and characteristics of soft tissue, involving the left side of the mandible and extending to the surrounding tissues. The patient underwent surgical excision of the lesion, the definitive diagnosis of Ewings sarcoma was established, and the patient commenced on radiotherapy.

Angioleiomyoma of the nasal septum

1 MD. Resident Physician in ENT and HNS Santa Casa de Misericórdia da Bahia. 2 MD. ENT and Maxillo-facial surgeon. Preceptor at the ENT Residency Program Santa Casa de Misericórdia da Bahia. 3 MD. ENT and Maxillo-facial surgeon. Preceptor at the ENT Residency Program Santa Casa de Misericórdia da Bahia. 4 PhD in Surgery USP, Head of the ENT Residency Program Santa Casa de Misericórdia de Bahia. Santa Casa de Misericórdia da Bahia. Send correspondence to: Praça Conselheiro Almeida Couto 500 Nazaré Salvador BA 40050-410. Paper submitted to the BJORL-SGP (Publishing Management System – Brazilian Journal of Otorhinolaryngology) on October 16, 2009; and accepted on December 15, 2010. cod. 6714 CASE REPORT Braz J Otorhinolaryngol. 2010;76(5):675. BJORL

Laryngeal papillary carcinoma with unexpected evolution: case report

CONTEXT According to the literature, laryngeal papillary carcinoma is rare and has a benign prognosis. CASE REPORT In this report we present a surprising case with nodal metastasis at the time of diagnosis. Computed tomography showed infiltration of the lesion and metastatic lymph nodes. The resected specimen was submitted to histopathological study that confirmed the diagnosis of papillary squamous cell carcinoma.

Correlation between dizziness and impaired glucose metabolism.

INTRODUCTION Impaired glucose metabolism is characterized by conditions of hypo and hyperglycemia. AIM The objective of the present study was to asses whether or not there is a relationship between impaired glucose metabolism and dizziness. In the clinical laboratory settings, patients were examined using vectoelectronystagmography in association with glycemic levels. METHODS 33 patients were divided in 3 groups: diabetics; patients with dizziness and a control group. RESULTS 65% of the patients with dizziness showed impaired glucose metabolism. 40% of the patients with dizziness had alterations in their vectoelectronystagmography results. CONCLUSION Dizziness is a good indicator of glucose metabolism alterations and these may be a good indicator of alterations in vectoelectronystagmography responses. The study of glycemic levels after glucose overexposure is a good prognosis factor to evaluate dizziness and shows the same results as insulin level studies after glucose overexposure.

Synovial sarcoma in head and neck: a case report.

Introduction Synovial sarcoma is a malignant tumor of mesenchymal pluripotent cells. Objectives We present a case of synovial sarcoma in the posterolateral wall of the oropharynx. Resumed report The patient, a 23-year-old woman, was admitted with a history of dysphagia and difficulty in breathing for 8 months, resulting in progressive deterioration and onset of snoring, muffled voice, and local pain. An oropharyngeal tumor in the left posterolateral wall touched the base of the ipsilateral tongue. The patient underwent endoscopic pharyngectomy to remove the lesion. Pathologic examination revealed synovial sarcoma with positive margins, and Mohs technique was proposed for margin control. The margins were disease-free, without the need for total laryngectomy. The pharynx was reconstructed with a microvascular forearm flap. The patient developed postoperative stability. Conclusion Despite its name, synovial sarcoma is rarely sourced directly from synovial membranes. It is most commonly found in the vicinity of large joints. The location at the head and neck, a location poor in synovial tissue, is unusual. Synovial sarcoma in the head and neck has an aggressive nature and poor prognosis. Resection with negative margins remains the foundation of therapy, which is not so easily achieved in the head and neck. It is important for the otorhinolaryngologist and head and neck surgeon to be familiar with this aggressive tumor, which carries high mortality and morbidity. The appropriate diagnosis and treatment can improve prognosis and patient survival.

Maxillomandibular myxoma in neonates

1 ENT-HNS HC/UNICAMP. Maxillo-Facial Surgeon Aborl/SBCP/SBCCP. Assistant Professor of Head and Neck Surgery Santa Casa de Salvador Hospital Santa Izabel. Full Professor of Head and Neck Anatomy UNIME. Dysphagologist and Head and Neck Surgeon NOEV/Hospital da Bahia. 2 3rd-year Resident Physician in ENT Hospital Santa Izabel da Santa Casa de Misericórdia da Bahia. 3 Preceptor of Maxillo-Facial Surgery at the ENT-HNS Residency Program Santa Casa de Misericórdia da Bahia. Coordinator Department of Maxillo-Facial Surgery ABORL-CCF. Santa Casa de Misericórdia da Bahia. Send correspondence to: Vanessa Rolim Barreto Cavalcante Praça Conselheiro Almeida Couto 600/405 Bairro Nazaré Salvador BA 40050-410. Paper submitted to the BJORL-SGP (Publishing Management System – Brazilian Journal of Otorhinolaryngology) on September 22, 2009; and accepted on October 20, 2010. cod. 6656 CASE REPORT Braz J Otorhinolaryngol. 2010;76(5):674. BJORL

Bilateral hipoglossal nerve palsy in necrotizing otitis externa.

Necrotizing otitis externa is a potentially lethal infection that starts in the external auditory canal and may progress to the skull base. It happens in elderly diabetic patients and is associated to a high morbi-mortality rate. The major causal agent is Pseudomonas aeruginosa, in 96 to 98% of the cases. The infection extends from the osteocartilaginous junction to the temporal bone by means of the Santorini fissures. The infection may progress towards the skull base and affect the facial, glossopharyngeal, vagus and accessory nerves. It may occasionally affect the hypoglossal, abducens and trigeminal nerves. Symptoms such as otalgia, headache, hypoacusis, otorrhea, in diabetic or immunosupressed patients are very relevant. Laboratory investigation reveals high ESR, with normal or mildly high white cell count. Clinical signs include ulceration on the floor of the EAC. CT scan shows bone destruction, and MRI shows both the location and extension of the infection, intracranial invasion and cranial nerve involvement. Scintigraphy with technetium and gallium has been used in order to assess cure criteria. Technetium scintigraphy is useful to diagnose osteitis, which is positive in cases of acute or chronic osteomyelitis, or trauma. It bears low specificity and may remain positive for one year. Galium-67 scintigraphy is used in the follow up and check of the therapeutic response, since galium has great affinity for acute phase leucocytes and proteins. Germ culture is necessary for proper treatment, however one should not wait for its result in order to start treatment. Two empirical antibiotics are used: aminoglycosides together with ciprofloxacin of cephtazidime. Alternative drugs are cefepime, cefoperazone, imipenem and aztreonam. Treatment lasts between 4 and 6 weeks. Otalgia reduction or cessation is an important control parameter. Most patients may be clinically treated, and surgery bears controversies, such as: progressive pain, cranial neuropathy and granulation persistence in the EAC. Mastoidectomy may be carried out, however in some cases it does not prevent skull base disease extension. CASE REPORT