[Maxillary sinusitis of odontogenic origin: surgical treatment]

PURPOSE

The frequency of maxillary sinusitis of dental origin (MSDO) is under estimated. The medical and surgical treatment has improved thanks to endoscopic guidance. We report our experience and strategy in the treatment of MSDO.

PATIENTS AND METHODS

Twenty-two patients presenting with MSDO were treated between 1998 and 2008. The results were evaluated on clinical, functional, sinusal, and odontologic signs.

RESULTS

MSDO accounted for 16% of surgically managed sinusitis. CT was performed in 95% of cases. The etiologies were apical leakage in seven patients, migration of a tooth or root during extraction, or presence of ectopic tooth in the sinus in nine patients, a cyst in three patients, and oroantral communication in three patients. Surgery was performed after antibiotic and NSAID treatment. The first surgical step was the treatment of the odontogenic source. The second step was sinus drainage by endoscopic treatment in 64%, Caldwell-Luc in 23%, and drainage by oroantral communication enlarged then closed in the same operative time in 13%. The follow up ranged from 3 months to 10 years. Early postoperative superinfection was observed in two patients. Two patients presented with recurrent sinusitis. The postoperative sequels were hyposmia in three patients, dental pulpotomy, and trigeminal neuralgia in five patients treated by Caldwell-Luc surgery.

DISCUSSION

Nasal endoscopy has improved the surgical management of MSDO. It makes curettage and exclusion of sinus cavities obsolete. It is reliable and has a low rate of complications. The best treatment remains prevention.

Comparative virulence of Pyrenophora teres f. teres from Syria and Tunisia and screening for resistance sources in barley: implications for breeding

AIMS

The aim of this study is to investigate the pathogenic diversity and virulence groups among Pyrenophora teres f. teres isolates, sampled from Syria and Tunisia, and to identify the most effective source of resistance in barley that could be used in breeding programmes to control net blotch in both countries.

METHODS AND RESULTS

One hundred and four isolates of P. teres f. teres were collected from barley in different agroecological zones of Tunisia and Syria. Their virulence was evaluated using 14 barley genotypes as differential hosts. The UPGMA clustering identified high pathogenic variability; the isolates were clustered onto 20 pathotypes that were sheltered under three virulence groups, with high, intermediate and low disease scores. According to susceptibility/resistance frequencies and mean disease ratings, CI05401 cultivar ranked as the best differential when inoculated with the Syrian isolates. However, CI09214 cultivar was classified as the best effective source of resistance in Tunisia.

CONCLUSIONS

All P. teres f. teres isolates were differentially pathogenic. CI09214 and CI05401 cultivars were released as the most effective sources of resistance in Syria and Tunisia.

SIGNIFICANCE AND IMPACT OF THE STUDY

National and international barley breeding programmes that seek to develop resistance against P. teres f. teres in barley should strongly benefit from this study. This resistance cannot be achieved without the proper knowledge of the pathogen virulence spectrum and the sources of host resistance.

Primary sinonasal meningioma

INTRODUCTION

Primary meningiomas of the sinonasal tract are rare tumors. Their positive diagnosis is difficult to establish. From one case observation, we report the clinical features, the diagnosis difficulties and the therapeutic modalities of primary meningioma of the sinonasal tract.

CASE REPORT

A seventeen-year-old girl consulted for a left unilateral nasal obstruction with progressive evolution without episodes of epistaxis, smell disorder or headaches over a year. Physical examination revealed a grayish polypoid tumor in the left nasal fossa. CT scan evidenced an isodense lesion of the left nasal fossa slightly enhanced pushing back the lateral nasal wall without invasion or intracranial connection. Biopsy was in favour of an inverted papilloma. The tumor was resected via endoscopic approach. Pathological examination established the diagnosis of meningothelial menigioma. The prognosis was favourable without recurrence after a six-month follow-up.

CONCLUSION

The positive diagnosis of primary sinonasal meningioma is difficult to establish because of their infrequent occurrence in this ectopic site and of their non-specific clinical appearance. The final diagnosis rests on the histological examination. Immunohistochemical studies are helpful to establish the accurate diagnosis. Imaging confirms the primitive nature of these tumors. Prognosis is excellent after complete surgical extirpation without the necessity of adjuvant therapy.

Internal jugular vein thrombosis by protein C activated resistance

INTRODUCTION

Jugular vein thrombosis is mainly due to infectious, neoplastic and iatrogenic causes. Activated protein C (APC) resistance is an exceptional cause of jugular vein thrombosis.

CASE REPORT

A 40-year-old woman consulted for left lateral neck swelling present for two weeks. Neck ultrasound revealed left internal jugular vein thrombosis, which was confirmed by contrast CT. The rest of the examination, including routine clotting assessment and inflammatory work-up, was normal. Further investigations demonstrated APC resistance with Factor V Leiden mutation. Treatment consisted of oral anticoagulants with a good outcome.

DISCUSSION

APC resistance is a recently identified and relatively frequent cause of thrombophilia, mostly due to Factor V Leiden mutation. APC resistance is responsible for 20% to 50% of all thrombotic events. The laboratory diagnosis is based on two tests: a phenotypic test based on APTT with and without APC and a genotypic test based on detection of a Factor V Leiden mutation.

CONCLUSION

Screening for APC resistance and Factor V Leiden mutation is now part of the aetiological work-up of thromboses, particularly in subjects younger than 50. Treatment is based on oral anticoagulants.

[Post-radiation mucocele in two patients treated for nasopharyngeal cancer]

A 30-year-old woman, with a history of nasopharyngeal carcinoma, which was treated by radiotherapy nine years previously, presented with occasional diplopia and recent headaches. A nasopharyngeal biopsy showed no recurrence. The imaging revealed a sphenoidal sinus mucocele. Endoscopic marsupialization of the mucocele allowed clinical improvement. A 56-year-old woman presented, five years after radiotherapy for nasopharyngeal carcinoma, with a fronto-orbital mass. CT-scan revealed a fronto-ethmoidal mucocele. Nasopharyngeal biopsy showed tumour recurrence. Marsupialization of mucocele was performed. Recurrence of the carcinoma was treated by radiotherapy and chemotherapy. Sphenoidal sinus mucocele developing after radiotherapy for nasopharyngeal carcinoma has rarely been reported. CT scan and MRI are useful tools in making the diagnosis. Biopsy is required to diagnose recurrence or associated radio-induced tumor. Endoscopic approach gives good results.

Cholesteatoma of the frontal sinus

PURPOSE OF STUDY

Cholesteatoma of the paranasal sinuses is a rare pathology. A review of the literature reported less than 30 cases. These lesions mainly involve the frontal sinus.

CASE REPORT

A 25-year-old man presented with a right painful fronto-orbital mass associated with an ipsilateral eyelid oedema and a fever as high as 40°C. He experienced a general epileptic seizure requiring his admission in an intensive care unit. CT-Scan with iodine injection evidenced the opacification of the right frontal sinus with bone lysis of the posterior wall. Complete surgical resection of a cystic structure containing keratin material was performed via eyebrow incision. The pathological examination confirmed the diagnosis of sinus cholesteatoma. Neurological signs entirely disappeared after surgery. Craniofacial MRI realized 2 months later showed no sign of recurrence. Obliteration of the right frontal sinus was performed 4 months later.

CONCLUSION

Although benign, cholesteatoma can spread to the surrounding structures leading to several complications including infections that can be life-threatening for the patient. CT-scan and MRI are useful examinations for diagnosis and follow-up. Complete surgical resection is required in order to avoid recurrence.

Hypopharyngeal amyloidosis: A case report

Hypopharyngeal amyloidosis is rare. Management depends on etiology. We report a case of hypopharyngeal amyloidosis and review the characteristics of this exceptional pathology. A 60-year-old woman with a history of diabetes and chronic cervicalgia consulted for dysphagia and deteriorated general health status, which had been evolving for 2 months. Clinical examination found two ulcerations of the lateral edge of the tongue and right pyriform sinus salivary stasis. Panendoscopy found regular swelling of the posterior wall of the hypopharynx and cervical esophagus. The pyriform sinuses and larynx were normal. Cervical CT and MRI showed thickening of the posterior wall of the hypopharynx. Biopsy found amorphous acellular eosinophil interstitial deposits, shown to be amyloid on Congo red staining, leading to a diagnosis of amyloidosis. Etiological assessment pointed to myeloma. The patient was managed by chemotherapy associating melphalan and prednisone. Evolution at 12 months' follow-up was good. Localized amyloidosis is a rare lesion of the superior aerodigestive tract, predominating in the larynx. Hypopharyngeal involvement is exceptional. Diagnosis is histological. Management depends on etiology. Local treatment is exceptional other than in case of complication. Systemic forms with associated myeloma are of poor prognosis.

[Xanthogranuloma of the parotid gland in adults]

Juvenile xanthogranuloma (JXG) is a cutaneous non-Langerhans cell histiocytosis affecting infants. We report the first case of JXG in the parotid gland of an adult.

CLINICAL CASE

A 52 year-old man consulted for a painful swelling of the left parotid region, progressively increasing. On physical examination, the mass was 4 cm in diameter. A second 1.5 cm diameter tumor was found in the right parotid region. MRI revealed masses with heterogeneous hypodense on T1-weighted images and with hyper dense on T2 weighted images associated with heterogeneous enhancement after gadolinium injection. The superficial and deep lobes of the parotid gland were involved. Per-operative left-side exploration revealed a lipomatous degeneration of the parotid gland and facial nerve. A lower polar parotidectomy was performed. The histological examination identified a parotid xanthogranuloma.

DISCUSSION

The JXG is usually revealed by cutaneous lesions. In fact, the morphological, immunohistochemical, and ultrastructural features of this affection lead to its diagnosis. Extra-cutaneous localizations are less frequent. The differential diagnosis is X histiocytosis.

[Association of Sjögren's syndrome and Plummer Vinson syndrome]

Dysphagia is a common complaint of patients with Sjogren's syndrome, but its mechanism remains a subject of controversy. The association of Sjogren's syndrome with Plummer-Vinson syndrome remains uncommon. We report a 56-year-old women who presented both disorders. The diagnosis of the Plummer-Vinson syndrome was based on the classic triad of dysphagia, iron-deficiency anaemia and oesophageal webs. The diagnosis of Sjogren's syndrome was based on the presence of three Fox criteria. This association should incite us to search for common immuno-genetic pathogenic factors between these two syndromes.

Pendred syndrome in Tunisia

OBJECTIVES

We report a clinical and genetic study of three consanguineous Tunisian families affected by Pendred syndrome.

PATIENTS AND METHODS

Three families from the south of Tunisia were identified as affected by Pendred syndrome. The patients and their families underwent ENT and general examination and audiovestibular and radiological tests. Molecular DNA analysis was performed by the Sfax Human Molecular Genetics Department.

RESULTS

Forty-three patients (mean age: 21 years [2-60 years]) were affected. Tonal audiometry showed bilateral sensorineural hearing loss in 87.5% of cases, and mixed hearing loss in 12.5% with bilateral high frequency sensorineural hearing loss and conductive hearing loss at lower frequencies. Deafness was severe in 21% and profound in 79% of cases. Thyroid goiter was found in 46.5% of cases. Inner ear CT scan found enlarged bilateral vestibular aqueducts in all cases. Hormone analysis was normal and perchlorate test negative in all cases. A single Pendred syndrome (PDS) gene mutation, L445W, was found.

DISCUSSION

Pendred syndrome is the most frequent congenital deafness syndrome. It is characterized by great intrafamilial phenotype variability.

[Acinic cell carcinoma of the nasal septum]

INTRODUCTION

Nasal cavity acinic carcinoma are exceptional and often of turbinal origin. We report a case of acinic carcinoma of septal origin and discuss this histological type rare in this site.

OBSERVATION

A 47-year-old women, with no pathologic history, consulted for right nasal obstruction and hyposmia having evolved for a year. The clinical examination revealed a right nasal cavity lesion adhesive to the septum. Tomodensitometry showed a right nasal cavity and ethmoid opacity without bone destruction. The surgical treatment was endonasal tumor resection. The histological examination revealed a nasal fossa acinic carcinoma completely resected. A postoperative radiotherapy was initiated. The evolution was uneventful without recurrence after 4 years of follow-up.

DISCUSSION

Acinic carcinoma is rarely located in the nasal cavity. Its septal origin is exceptional. It is usually located at the salivary gland level. Curative treatment is surgery associated or not to radiotherapy. The prognosis is related to tumor extension and quality of resection.