Metin Ibrahimov

Congenital hairy polyp of the soft palate.

Hairy polyp is an unusual developmental malformation that is most frequently seen as a pedunculated tumor in the neonate. They are benign lesions containing elements of both ectodermal and mesodermal origin. The symptoms of hairy polyps relate both to their location and their size. Larger lesions produce symptoms due to feeding difficulties and airway obstruction while smaller lesions cause intermittent symptoms resulting from a ball-valve type of obstruction. We present two cases of a soft palate hairy polyp causing respiratory and feeding difficulties and review the literature.

Laryngotracheal reconstruction at relapsing polychondritis.

Relapsing polychondritis (RP) is characterized by chronic, recurrent episodes of inflammation with eventual degeneration of cartilaginous tissues including the ears, nose, larynx, trachea, and so on. Tracheobronchomalacia and airway stenosis may be seen in RP. In this report, we describe 3 female patients presenting with progressive dyspnea owing to laryngotracheal involvement of RP who underwent laryngotracheal reconstruction.

Management of paragangliomas in otolaryngology practice: review of a 7-year experience.

Background and Aims:Paragangliomas of the head and neck are highly vascular lesions originating from paraganglionic tissue located at the carotid bifurcation (carotid body tumors), along the vagus nerve (vagal paragangliomas), and in the jugular fossa and tympanic cavity (jugulotympanic paragangliomas) and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of these tumors. Materials and Methods:Twenty-six patients with 27 paragangliomas were treated in our institution during a period of 7 years (2000-2007). There were 15 women (57.6%) and 11 men (42.4%) with a mean age of 33.5 years. A painless lateral neck mass was the main finding in 16 patients (61.5%). There was no evidence of a functional tumor. Carotid angiography was performed on all of our patients (100%) to define the vascular anatomy of the lesion. Twenty-two paragangliomas (of the 25 operated paragangliomas; 88%) underwent selective embolization of the major feeding arteries. We performed surgery on 24 (92.3%) patients. Two patients were treated with radiotherapy. Results:Most lesions were paragangliomas of the carotid bifurcation (n = 14 [51.8%]), whereas 6 patients were diagnosed with jugular (22.2%), 1 with a vagal (3.7%), 1 with a tympanic paraganglioma (3.7%), 2 with jugulotympanic paraganglioma (7.4%), and 1 with laryngeal paraganglioma (3.7%). In 1 patient (3.8%), bilateral paragangliomas in the carotid bifurcation were detected. There was an evidence of malignancy in all cases (3.8%). Preoperative embolization has proven successful in reducing tumor vascularity in approximately 22 (of 25 who accepted surgery; 88%) paraganglioma patients. The common preoperative complication was vascular injury, which occurred in 6 (23%) of 26 patients; the main postoperative complication was transient cranial nerve deficit in 4 (15.3%) of 26 patients; and a permanent Horner syndrome was documented in 2 patients (7.6%). Cerebrospinal fluid leak occurred in 1 patient (3.7%). Postoperatively, stroke was occurred in 1 patient (3.7%). Two patients with jugular paraganglioma were treated with irradiation because of skull base extension with significant symptomatic relief. Conclusions:The primary therapeutic option for paragangliomas is complete excision of tumor with preservation of vital neurovascular structures. Combined therapeutic approach with preoperative selective embolization followed by surgical resection is the safe and the effective method for complete excision of the tumors with a reduced morbidity rate.

Schwannoma of the hard palate.

About half of all neurogenic tumors are seen in the head and neck region. The types of neurogenic tumors must be distinguished. Schwannomas originate from Schwann cells of the neural sheath and are solitary, well-encapsulated, slow-growing adjacent to the parental nerve but extrinsic to the nerve fascicles.Approximately 25% to 45% of all schwannomas are seen in the head and neck region and are found rarely in the oral cavity. Most of the intraoral schwannomas are located in the tongue. Other less common locations are the buccal mucosa, palate, base of the mouth, gingiva, and lips.In this study, we report a rare case of schwannoma of the hard palate, which was excised intraorally.

Malignant otitis externa.

Objective Malignant external otitis is a severe infection of the external auditory canal and skull base, which most often affects elderly patients with diabetes mellitus. This disease is still a serious disease associated with cranial nerve complications and high morbidity-mortality rate. Malignant otitis externa requires urgent diagnosis and treatment. The most effective treatment is to control the diabetes and to fight infection with the proper antibiotic and debridement necrotic tissue; sometimes, aggressive surgical management is done. We present our 5-year institutional experience in the management of this disease. The aim of this study was to present our experience with the management of malignant otitis externa. Methods All patients’ records with malignant otitis externa during the last 5 years (2007–2012) were retrieved and reviewed. Diabetes mellitus profile, erythrocyte sedimentation rate, ear swab for culture and sensitivity, computed tomography, and scintigraphy using technetium 99 and gallium 67 were investigated for all patients. Results During the last 5 years (2007–2012), 10 patients with the diagnosis of malignant otitis externa were admitted to our clinic for investigation and treatment. There were 7 men and 3 women, all between 64 and 83 years of age, with severe persistent otalgia, purulent otorrhea, granulation tissue in the external auditory canal, and diffuse external otitis, and there were 4 patients with facial nerve palsy. Nine patients were confirmed to have a diabetes, and 4 of these 9 cases just had chronic renal failure and underwent dialysis; the remainder 1 case had no diabetes mellitus, but with chronic renal failure on dialysis. Ear swabs for culture and sensitivity usually revealed Pseudomonas aeruginosa. Local debridement and local and systemic antibiotic treatment were sufficient to control the disease. Facial nerve decompression was done in facial paralysis. Hyperbaric oxygen therapy was performed in facial nervy palsy cases. Conclusions Malignant otitis externa is still a serious disease associated with cranial nerve complications and high morbidity-mortality rate. The most effective treatment is to control the diabetes and to fight infection with the proper antibiotic, debridement necrotic tissue, and sometimes aggressive surgical management. Monitoring of therapy response is done through normalization of erythrocyte sedimentation rate, control of diabetes mellitus, and improvement of computed tomography and radioisotope scanning.

Heterotopic bone formation (osseous metaplasia) in nasal polyps.

To the Editor: W e want to bring an unusual situation to your attention. A 33-year-old woman was admitted to our clinic with the complain of right-sided nasal obstruction for 3 months. She did not disclose any other nasal symptoms such as rhinorrhea, headache, epistaxis, and facial pain. Physical examination including nasal endoscopy revealed a right nasal polypoid mass filling the middle meatus and upper nasal cavity. An imaging study was carried out using computed tomography of the paranasal sinuses. It showed a mass with a density of the soft tissue; some areas have a density that of the bone. The lesion extends to occupy completely the right maxillary sinus and some homolateral ethmoidal cells (Fig. 1). We performed a punch biopsy under local anesthesia. Microscopic examination showed an inflammatory benign polyp. Shewas operated on by means of endoscopic sinonasal surgery. During surgery, the polypoid lesion was found to be as hard as bone. The definitive diagnosis was nasal polyposis with areas of bony metaplasia (Fig. 2). Heterotopic bone formation (osseous metaplasia) is an extremely uncommon finding in nasal polyposis. Various histologic changes, such as epithelial atypia and squamous metaplasia, can occur in the respiratory epithelium covering nasal polyps. Squamous metaplasia is common, but osseous metaplasia of the stroma is very rare. Calcification in sinonasal polyposis secondary to hypercalcemia has been reported. True osseous metaplasia is much less common but has been reported in mucosal polyps in the stomach, intestines, tongue, and nasal cavities. How this ectopic ossification occurs is unknown. Pluripotential cells present in the stroma of the polyp or dedifferentiation of cells present in the polyp into a pluripotential cell, which may then differentiate along an osteoblastic lineage leading to ossification. Some authors reported that new bone formation occurring in nasal polyps arise from bony remnants left behind during a previous surgery. In our case, had no any history of nasal surgery in past. When faced with findings of bone included within a mass of nasal polyposis, the differential diagnosis must include bone sequestration, osteoma, long-lasting fungal sinusitis, and ectopic bone formation (metaplasia). The most important differential diagnosis that must be ruled out is an inverted papilloma, which shares almost the same symptoms and signs including unilateral nature and the appearance of the lesion. Histologic confirmation remains obligatory for diagnosis. In our case, primarily, we performed punch biopsy under local anesthesia, but the pathological examination showed an inflammatory benign polyp. This is because osseous metaplasia is seen in some areas of the nasal polypoid tissue and it can explain that the low incidence might be due to a low rate of diagnosis.

Primary marginal zone B-cell lymphoma of the larynx.

Extranodal non-Hodgkin lymphomas limited to the larynx are rare, accounting for less than 1% of all laryngeal neoplasms. The most common site of development of primary laryngeal lymphomas is the supraglottic region. In most cases, the presenting symptoms are hoarseness, dysphagia, dyspnea, and cervical lymphadenopathy. In these cases, larynx lymphoma was the mucosa-associated lymphoid tissue type and located in the supraglottic area.

Cavernous hemangioma of the larynx.

To the Editor: A 45-year-old man with hoarseness for 6 months was admitted to our clinic. He had no history of any preceding infection, past intubation, trauma, or voice abuse. An indirect laryngoscopic examination revealed a pink fleshy mass on the right aryepiglottic fold extending to the right vocal cord and the posterior commissure (Fig. 1). The vocal cords were symmetrically mobile. On a videostroboscopic examination, the lesion seemed to be like a large vascular tumor such as hemangioma. The passage to the larynx was free. Other otolaryngologic findings were normal. A provisional diagnosis of a hemangioma was made. The patient was posted for microlaryngeal surgery under general anesthesia. The examination revealed a vascular, collapsible, pedunculated mass. The stalk of the lesion was isolated and excision of the same was done with microscissors. The minimal bleed that occurred was controlled with the application of local pressure. A histopathologic examination revealed the lesion to be a cavernous hemangioma. The postoperative period was uneventful with prompt relief from respiratory embarrassment. Voice rest was advised for a fortnight, followed by speech therapy thereafter. The patient had a normal voice after 3 months of speech therapy. At the time after a 12-month follow-up, there was no evidence of the hemangioma. Laryngeal hemangiomas are relatively rare. Laryngeal hemangiomas can be classified as infantile and adult. Whereas infantile hemangiomas are usually found to occur in the subglottis, adult hemangiomas occur commonly in the supraglottic regions of the larynx. A vascular lesion that may mimic a hemangioma may sometimes result from an organizing hematoma after a hemorrhage on the vocal cords due to voice abuse. Laryngeal hemangiomas also need to be distinguished pathologically from polypoidal vascular granulation tissue that may be produced by laryngeal biopsy, intubation, or trauma. Endoscopy is almost always sufficient for the diagnosis of hemangioma. Other examinations, such as magnetic resonance imaging with contrast and angiography, are reserved for large hemangiomas. The various modalities of therapy are dependent on the age of the patient, the site and the size of the lesion, and the hemodynamic flow of the hemangioma. Systemic steroids, intralesional steroid injection, laser ablation with both carbon dioxide and potassium titanyl phospate lasers, interferon, microdebrider, cryosurgery, and open surgical excision have all been used.

Inflammatory myofibroblastic tumor of the parotid gland.

An inflammatory myofibroblastic tumor, previously known as an inflammatory pseudotumor, is an uncommon neoplasm. This tumor, which has characteristic morphologic and immunohistochemical features, is mostly seen in the lung. We present a rare case of an inflammatory myofibroblastic pseudotumor of the parotid gland. A 45-year-old woman presented with a 4-month history of a swelling in her right parotid region. A partial parotidectomy with preservation of the facial nerve branches was performed. The incidence of inflammatory myofibroblastic tumor in the parotid gland is low, and local resection is currently the best treatment. A prolonged postoperative follow-up period is necessary for patients with inflammatory myofibroblastic tumor. Inflammatory myofibroblastic tumor of the parotid gland is discussed with a brief literature review.

Lymphoepithelial carcinoma of the larynx.

To the Editor: A 58-year-old man was admitted to our department with complaint of hoarseness. On endoscopical examination, a partially ulcerated lesion of the right vocal cord extending to the anterior commissure was detected. The vocal cords were symmetrically mobile. Head and neck examination revealed no palpable neck masses, and the remainder of the otorhinolaryngologic examination was normal. He had no smoking history, and medical history was unremarkable. Magnetic resonance imaging (MRI) of the neck showed a mass involving the right vocal cord extending the anterior commissure. In addition, there was no pathologic lymph node in the MRI scans of the neck (Fig. 1). To gain additional information about the mass and to perform a biopsy for histopathological investigation, the patient underwent direct microlaryngoscopy under general anesthesia. Fragmented tissue biopsies were histologically investigated. Histologically, the surface epithelium is ulcerated by a tumor and infiltrated lesion is present in the subepithelial tissue. The tumor formed syncytial sheets and nests without evidence of squamous or glandular differentiation, and is densely surrounded by inflammatory cells, largely lymphocytes and plasma cells. Tumor cells are composed of epithelial cells, containing large central nuclei with prominent nucleoli and a large eosinophilic cytoplasm. Pathological study of the surgical specimen revealed an undifferentiated carcinoma with aspects of lymphoepithelioma (Fig. 2). The patient was treated with frontolateral laryngectomy. Right vocal cord and anterior commissure including cartilage piece of the left thyroid cartilage lamina as well as one-third anterior part of the left vocal cord were removed. Definitive histopathological diagnosis was a poorly differentiated squamous cell carcinoma with aspects of lymphoepithelioma. In situ hybridization for Epstein-Barr virus (EBV) and PCR EBVspecific amplification proved to be negative. At that time, after 18 months of follow-up, there was no evidence of recurrence. Lymphoepithelial carcinoma of the larynx accounts for 0.2% of all laryngeal cancers. These tumors are an exceedingly rare and aggressive neoplasm with a propensity for early cervical lymph node and distant metastasis. The most common site of development of primary laryngeal lymphoepithelial carcinoma is the supraglottic region. The relationship between EBV and lymphoepithelial carcinoma of the larynx remains controversial. Despite the small number of cases, the initial results suggest that EBV plays a limited role in the etiology of lymphoepithelial carcinoma of the larynx. The clinical course and optimal treatment of nonnasopharyngeal lymphoepithelioma of the head and neck have not been well described. Although most patients have been treated surgically, this tumor is radiosensitive and radiotherapy should be considered as the main treatment. Neoadjuvant chemotherapy may be recommended in patients with early regional adenopathy in order to decrease the distant metastasis rate. Metin Ibrahimov, MD, Mehmet Yilmaz, MD, Mehmet Halil Celal, MD, Marlen Mamanov, MD, Umur Yollu, MD, Husnu Ozek, MD, Istanbul University Istanbul, Turkey metinibrahimov@gmail.com