The use of biopsy in the evaluation of pediatric nasopharyngeal masses

Pediatric nasopharyngeal tumors are rare, and few clinicians possess more than anecdotal experience. The differential diagnosis includes a diverse group of benign and malignant tumors, but can be narrowed further based on the clinical and radiographic appearance of the mass. Nasopharyngeal angiofibroma has such characteristic angiographic and CT imaging that many authors suggest biopsy is not essential in the evaluation of this lesion. We present a case of a pediatric nasopharyngeal neoplasm with angiographic, CT, and clinical findings consistent with angiofibroma. We then discuss the preoperative evaluation of, operative approach to, and postoperative staging and treatment of the biopsy-proven embryonal rhabdomyosarcoma. A review of the literature pertinent to this case is presented, and recommendations made concerning biopsy of lesions resembling juvenile nasopharyngeal angiofibroma. We believe this report reaffirms the use of histologic study whenever possible, in addition to radiographic imaging, in the diagnosis of pediatric nasopharyngeal masses.

Juvenile myasthenia gravis: an unusual presentation

Myasthenia gravis is a disease characterized by muscular weakness and fatigability which afflicts 2-10 patients per 100,000 with 20% of cases presenting in childhood. Muscles innervated by cranial nerves are frequently involved with ptosis and diplopia being the most frequent presenting complaints. We review the literature and report a case of a 20-month-old infant presenting with inspiratory stridor and cyanosis, resembling foreign body aspiration.

Sleep apnea--an historical perspective

In this article the authors have attempted to give the reader a brief overview of some of the development of recognition of obstructive sleep disorders and early aspects of their surgical therapy. They have avoided detailed descriptions of radiographic and other diagnostic measures, since many of these are summarized in other articles.

Facial nerve paresis as the presenting symptom of leukemia

Leukemic involvement of the temporal bone is not uncommon and may present in a variety of ways including auricular or external canal skin lesions, red or thick tympanic membrane, middle ear effusions, otitis media, hearing loss or mastoiditis. Symptomatic facial nerve involvement, on the other hand, is extremely unusual. We discuss a pediatric patient whose sudden onset facial nerve paresis was the presenting symptom that led to her diagnosis of leukemia. At the time of mastoidectomy, a granulocytic sarcoma or chloroma was noted to be overlying the VIIth nerve.

Surgical management of obstructive sleep apnea

The authors have reviewed the surgical management of patients with OSA. They have emphasized not only surgical techniques but also the method of preoperative evaluation of the patients and have presented some considerations in the postoperative management of patients in an attempt to avoid catastrophic results. As our diagnostic techniques improve, we should have fewer problems with the determination of the amount of tissue to remove and also the selection of the appropriate procedure. The advent of flexible laryngoscopy, cineradiography, and cine CT may indeed improve our diagnostic and therapeutic capabilities.

The anterior cricoid split. Clinical experience with extended indications

A recommended approach to postextubation infant subglottic stenosis secondary to subglottic edema employs the recently described anterior cricoid split (ACS) procedure. This technique provides an expanded subglottic airway with minimal paratracheal dissection and does not require concomitant tracheotomy. We applied this procedure in managing extubation difficulty in pediatric as well as neonatal patients. Five of ten patients in our series did not fulfill the traditional criteria for ACS. Relief of stridor and avoidance of tracheotomy were accomplished in nine of ten patients. One patient in whom mechanical ventilation was reinstituted developed an interesting complication. In properly selected infants with subglottic airway compromise, the ACS appears to be an effective adjunct in facilitating extubation.

Arthrogryposis multiplex congenita: otolaryngologic diagnosis and management

Arthrogryposis multiplex congenita (AMC) is an uncommon congenital disorder characterized by multiple fixed joint deformities and non-progressive neuromuscular dysfunction. A small fraction of these infants will present with otolaryngologic problems resulting from cranial nerve weakness, muscle dysplasia, or structural dysharmony of the head and neck. The charts of 50 patients with AMC were reviewed to determine the incidence of these findings. A summary of the literature is presented discussing the etiology, pathophysiology, diagnosis and management of this interesting clinical problem.

The "Pinocchio" nasal deformity--hemangioma vs. angiolipoma: esthetic correction and etiology

The author presents the first reported case of a nasal angiolipoma presenting as "Pinocchio" nasal tip deformity. The two types of angiolipomas (infiltrating and non-infiltrating) are discussed as are two surgical approaches to this deformity. The author feels that the external rhinoplasty technique is an excellent way to approach this problem, especially in patients who are suffering severe emotional stress due to peer pressure.

Non-organic stridor in children

A 4.75-year-old male presented with several episodes of expiratory stridor leading, on one occasion, to a respiratory arrest and intubation. A detailed evaluation emphasizing physiological and anatomical studies revealed no organic basis for the patient's upper airway obstruction. Emphasis is placed on one method found to be helpful in the differentiation of an organic versus a psychogenic type of respiratory disorder. Recognition of functional airway obstruction in children may prevent inappropriate therapy and allow proper psychiatric intervention.

Neonatal respiratory distress secondary to nasal fibrous histiocytoma

A full term one-day-old neonate developed respiratory distress secondary to a right intranasal mass. After exploratory craniotomy revealed no intracranial lesions, the child was observed for 6 months. At that time he experienced severe apnea with cyanosis necessitating removal of the mass, which was diagnosed histologically as a fibrous histiocytoma. Seven year follow-up reveals no further problems. A discussion of fibrous histiocytoma of the nose and paranasal sinuses is briefly given.

Lethal midline granuloma with a novel T-cell phenotype as found in peripheral T-cell lymphoma

Lethal midline granuloma (LMG), initially a clinical description, includes an uncommon group of disorders characterized by a relentless, destructive process involving the upper respiratory structures. Its etiology and pathogenesis are uncertain, probably varied, and the distinction between inflammatory and malignant processes is difficult despite extensive clinical and histopathologic evaluation. The need for new techniques for rapid diagnosis has important therapeutic implications. Using an extensive panel of T- and B-cell monoclonal antibodies the authors describe a patient with clinically and pathologically typical LMG demonstrating an "activated" T-cell phenotype with a "novel" pattern characteristic of peripheral T-cell lymphoma, strongly implying that some cases of LMG are more closely related to neoplastic T-cell lymphoproliferative disorders than to inflammatory conditions. Further studies using these immunotyping techniques may help clarify the pathogenesis of LMG, and may uncover specific diagnostic and prognostic phenotypic patterns.

The surgical treatment of skull-base tumors with intracranial extension

As a discipline, skull-base surgery via the transtemporal route has matured since 1975. Previously considered unresectable, skull-base tumors with intracranial extension can now be successfully removed by means of modification of contemporary exposures with neurosurgical collaboration. Between September 1970 and February 1986, 126 skull-base tumors have been operated on by The Otology Group, P.C. Of these, 49 had intracranial extension. In this article, techniques for tumor removal and dural defect reconstruction are outlined. A single-staged procedure is advised. The advantages of and exceptions to this format are described. Techniques that will prevent postoperative cerebrospinal fluid leakage are highlighted. Results and complications of this surgical series are discussed, and team aspects of this surgery are emphasized.

Mucosal melanoma of the head and neck

Nine cases of primary malignant melanoma of the upper respiratory tract treated at the University Hospital over the past 10 years are presented. Of the 9 cases, 6 had primary lesions located in the nasal cavity with the remaining 3 presenting in the nasopharynx, hard palate, and larynx, respectively. The authors review presenting symptoms, diagnostic evaluation, current therapeutic modalities, and clinical course in these cases. Specific cases are discussed to emphasize items of clinical or therapeutic importance.

Sialadenitis in children

Sialadenitis in children has been discussed. A literature review highlighting salient points in sialadenitis is presented. Classification of sialadenitis is discussed using the categories of several authors. An unusual case involving acute suppurative parotitis in a child is presented. The development of contralateral disease while treatment was in progress was unusual. In this case, association with mumps parotitis was strongly suspected despite previous immunization. Progression of disease with abscess formation is also unusual. Mumps virus parotitis has been rarely reported in association with acute suppurative parotitis. Immunization affords protection, but a definite failure rate exists. Based upon histologic examination, mumps parotitis would seem to be a predisposing factor for bacterial infection.

Laryngeal carcinoma--or is it laryngeal blastomycosis

A patient is described who was evaluated for persistent hoarseness. Although an initial diagnosis of squamous cell carcinoma of the larynx was made, review of the pathology slides revealed pseudoepitheliomatous hyperplasia, acanthosis, and what appeared to be a fungal infection. After a detailed work-up was initiated the patient was treated successfully with ketoconazole for a blastomycosis infection of the larynx. The literature relative to blastomycosis infections of the respiratory larynx is reviewed. The authors emphasize that patients who show evidence of acanthosis and pseudoepitheliomatous hyperplasia along with the diagnosis of squamous cell carcinoma should be suspected as having a potential fungal infection.