Septic Cavernous Sinus Thrombosis Secondary to Acute Bacterial Sinusitis: A Retrospective Study of Seven Cases

Background

Septic cavernous sinus thrombosis (SCST) is a rare but severe complication of acute bacterial sinusitis. Evaluations of advances in imaging techniques as well as in medical and surgical treatment are hampered by the lack of recent studies.

Objective

We aim to report our experience in the management of SCST in patients with acute bacterial sphenoid sinusitis over the past 10 years and to discuss the initial work-up and treatment strategies.

Methods

We performed a retrospective study of patients admitted for SCST related to acute sinusitis at a tertiary care center between 2003 and 2013. Clinical charts were reviewed for demographics, clinical presentations, imaging and microbiologic findings, medical and surgical treatments, and outcomes.

Results

Seven patients were treated for SCST. Sphenoid sinus was involved in all cases. The most frequent presenting signs included headache (100%), cranial nerve impairment (86%), fever (71%), and orbital symptoms (71%). Diagnosis was confirmed by a cerebral contrast-enhanced CT scan in all cases. Four patients (57%) had an additional intracranial complication. The average time between clinical onset and diagnosis was 13.7 days. All patients were treated by high-dose i.v. antibiotics, anticoagulation therapy, and surgical endoscopic drainage of the infected sinuses. This treatment strategy resulted in a mortality rate of 0%, but four out of the seven patients developed transient or permanent neurologic deficits, including one with permanent unilateral visual loss.

Conclusion

The combination of high-dose i.v. antibiotics, anticoagulation therapy, and endoscopic drainage of the infected paranasal sinus is an effective strategy for the treatment of SCST, but long-term sequelae remain frequent.

Critical analysis of recurrences of esthesioneuroblastomas: can we prevent them?

Esthesioneuroblastoma (ENB) involving the anterior skull base is a rare malignant tumour derived from the olfactory epithelium. The gold standard of surgical treatment is currently craniofacial resection (CFR), which allows efficient removal of the tumour but entails significant morbidity. To reduce morbidity combined with good visualization of tumour limits removal, endonasal endoscopy resection (EER) has developed. The objective of this work was (1) to describe the EER surgical procedure, the morbidity, and the limitations of this endoscopic approach as compared with CFR, (2) analyse recurrences to define risk factors of recurrences and (3) to discuss a therapeutic decision algorithm. Retrospective series of 18 patients with ENB endoscopically treated in a university tertiary referral centre over 13 years. Fifteen of those underwent radiotherapy. Epidemiological data, clinical and imaging findings, histology, treatment modalities and outcome of patients were studied. Mean follow-up was 31 months. Morbidity was mainly related to radiotherapy. Three recurrences were detected: one bone and one sylvian metastasis, and a local recurrence in a patient not irradiated. One recurrence spread through leptomeningeal propagation. Dural extension and frontal invasion were significantly associated with recurrences (p = 0.001 and p = 0.019, respectively). Patients with dural extension or frontal invasion should receive aggressive treatment. With a low rate of perioperative morbidity and efficient local control, EER seems to be a promising approach for selected cases of ENB.

Petrous and sphenoid arachnoid cysts: diagnosis and management

BACKGROUND

Intraosseous arachnoid cysts are rare and difficult to diagnose. The purpose of this study was to describe the clinical and radiological semiology of petrous and sphenoid arachnoid cysts and to propose a specific management strategy.

METHODS

This was a retrospective, descriptive study of patients with arachnoid cysts, which utilized CT, MRI, and the patients' medical histories.

RESULTS

Ten patients were included in this study. On CT, the lesions were lytic with bony delineation. On MRI, the lesions exhibited the same signals as cerebrospinal fluid and were not enhanced after contrast. On fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted sequences, the arachnoid cysts' signal disappeared, which is a key feature for eliminating the diagnosis of cholesteatoma. Two patients underwent surgery because of misdiagnosis, either with a meningocele or a cholesteatoma.

CONCLUSION

MRI FLAIR and diffusion-weighted sequences, together with osseous CT scans, help to distinguish arachnoid cysts from meningoceles and avoid unnecessary surgeries with potential complications.

Abstract B72: Combination therapy by Toll-like receptor 3 activation and chemotherapeutics synergistically induces cancer cell death

Toll-like receptors (TLRs) recognize molecular motifs of microbial origin and initiate innate immune response. TLR agonists are already being used in clinical studies because of their ability to induce apoptosis and activate the immune system. We have previously shown that TLR3 activation by synthetic dsRNA [poly (I:C)] in the pharyngeal cancer cell line Detroit 562 induced caspase-dependent apoptosis. Additionally, when combined with chemotherapeutics this treatment acts synergistically by enhancing cancer cell death. In this study we tried to decipher the mechanism of poly (I:C) and chemotherapeutics synergy. Cell survival was determined by using cytotoxicity assay and colony formation assay while protein expression was obtained by western blot. We demonstrated that combination of poly (I:C) and cisplatin is TLR3-dependent while methotrexate and hydroxyurea act through other dsRNA receptors (RIG-I and MDA5). Subsequently, we showed that poly (I:C) had more complex effects on Detroit 562 cells than previously thought: while it induces pro-apoptotic events it also triggers anti-apoptotic mechanisms, for example an increase in the expression of c-IAP2. Combined treatment by poly (I:C) and c-IAP inhibitor significantly decreased cell survival even at low concentrations. However, poly (A:U), which stimulates only TLR3 and not other dsRNA receptors, when combined with c-IAP inhibitor induced cell death only at high concentrations suggesting that RIG-I and MDA5 are also involved. Conversely, the combination of c-IAP inhibitors with poly (I:C) and chemotherapeutics did not result in a stronger cytotoxic effect against malignant cells. One explanation seems to be the fact that cisplatin abrogated c-IAP2 expression induced by poly (I:C) in the Detroit 262 cells thus shifting the balance towards apoptosis. Our conclusion is that future investigations should explore combinations of poly (I:C) with either cisplatin or c-IAP inhibitors. When we used laryngeal cell line SQ20B stably transfected with inducible shRNA for TLR3, we confirmed that synergistic effect of poly (A:U) and cisplatin on cell death is TLR3-dependent. Additionally, as SQ20B is radiation resistant cell line, we have shown here that they can be sensitized to radiotherapy by treatment with poly (I:C). In conclusion, synthetic dsRNAs like poly (I:C) have the potential to help overcoming the resistance of some human malignant cells to classical modalities of radiotherapy and chemotherapy.

Citation Information: Mol Cancer Ther 2013;12(11 Suppl):B72.

Citation Format: Tanja Matijevic Glavan, Benjamin Verillaud, Pierre Busson, Jasminka Pavelic. Combination therapy by Toll-like receptor 3 activation and chemotherapeutics synergistically induces cancer cell death. [abstract]. In: Proceedings of the AACR-NCI-EORTC International Conference: Molecular Targets and Cancer Therapeutics; 2013 Oct 19-23; Boston, MA. Philadelphia (PA): AACR; Mol Cancer Ther 2013;12(11 Suppl):Abstract nr B72.

Specific detection of Epstein-Barr virus microRNAs in plasma samples from nasopharyngeal carcinoma patients: Correlation with tumor mass assessed by MRI

6079

Background: Epstein-Barr virus (EBV) microRNAs of the BART family can be detected in the plasma of at least a fraction of nasopharyngeal carcinoma (NPC) patients. Our aim was to investigate the specificity of plasma BART detection in NPC patients and the correlation with viral DNA load and/or clinical characteristics. Methods: Hsa miR484 and 4 miR-BARTs (ebv-miR BART 2-5p, 5, 9 and 18) were assessed by RT-PCR following RNA extraction in 37 plasma samples including 20 NPC, 8 non-NPC head and neck squamous cell carcinoma (SCC) patients and 9 healthy EBV carriers. EBV DNA copy numbers (viral load) were measured in the same samples. To explore correlations of BART concentrations with tumor mass, MRI-based volume analysis was designed and performed on a subset of 13 patients with non metastatic NPC. In addition, longitudinal variations of BART concentrations were studied in 9 NPC patients for whom we had sequential plasma samples. Results: The cellular hsa miR-484 was detected in all plasma samples with a slightly higher average concentration in plasma samples from NPC and SCC patients. On the other hand, the miR-BARTs were undetectable or at a very low level in samples from SCC patients and healthy carriers contrasting with a high level in most NPC patients. There was an overall positive correlation between EBVDNA copy numbers and plasma concentrations of each miR-BART. However substantial amounts of plasmatic miR-BARTs were observed in several patients for whom no plasma EBV DNA was detected.Their concentration was apparently not correlated to the initial tumor volume but their longitudinal variations were parallel with clinical evolution in all but one case. Conclusions: To a large extent, detection of plasma miR-BART-2-5p, 5, 9, and 18 is specific of NPC patients. Their concentration does not seem to correlate with tumor mass, at least in localized NPC patients. In a fraction of patients without initial detection of plasma EBV DNA, the kinetics of plasma BARTs may provide informations on early tumor response under treatment and may have prognostic value.

[Rhino-orbito-cerebral mucormycosis, surgical treatment, state of the art]

Rhino-orbito-cerebral mucormycoses constitute a severe fungal infection. These infections mostly arise in immunosuppressed patients. The surgery aiming at resecting necrosed hurts showed its interest in term of survival for lung and cutaneous mucormycosis. However, treatment of rhino-orbito-cerebral location of mucormycosis is not well defined. Transnasal endoscopic surgery allows local control of the disease, better post-operative outcomes than transfacial approaches and less sequelae. However, transfacial approaches are sometimes necessary to allow cutaneous resection or exenteration, the indications of which still remain controversial. The retrospective study of 22 patients with mucormycosis allowed to show that radical surgical treatment allowed local control of the disease with an improved survival. Further prospective studies (PHRC MICCA, current) are required to standardize the management of this rare but potentially lethal pathology.

Surgical management of inverted papilloma: approaching a new standard for surgery

BACKGROUND

Inverted papilloma surgery is currently performed primarily with an endoscopic approach, a technique that has a recurrence rate of 12%. However, a recent study reported a recurrence rate of 5% with a strategy based on subperiosteal dissection of the tumor, with limited indications for using an external approach. The aim of this work was to evaluate whether different teams using the same surgical concepts could reproduce the excellent results that were recently reported.

METHODS

This study is a retrospective chart review of 71 consecutive patients with inverted papilloma who were treated during the last 10 years.

RESULTS

In all, 80% of the patients were treated using a purely endoscopic approach. The mean follow-up period was 31.6 months. The recurrence rate was 3.3% for cases with at least a 12-month follow-up.

CONCLUSIONS

This work confirms the results described in recent literature and further supports transnasal endoscopic surgery to manage inverted papilloma.

Abstract 4702: Antitumor activity of a novel histone deacetylase inhibitor S78454 in EBV-associated nasopharyngeal carcinoma

Epstein-Barr Virus (EBV) related nasopharyngeal carcinoma (NPC) is the third leading cause of virus-related human malignancy. On average, NPCs are more radiosensitive and chemosensitive than other head and neck tumors. However, local relapse and distant organ metastases still raise serious therapeutic problems. Histone deacetylase (HDAC) inhibitors have recently emerged as a class of therapeutic agent for the treatment of both hematologic malignancies and solid tumors. In the present study, we investigated the antitumor effects of the novel Pan HDAC inhibitor S78454 in 3 NPC cell lines, namely C666-1 (EBV-positive NPC cell line), HONE1 and CNE1 (EBV-negative). The antiproliferative effects of S78454, used either alone or in combination with cis-platinum or irradiation, were evaluated using MTT assays and clonogenic assays. Combined treatment of S78454 with cis-platinum resulted in a synergistic inhibitory effect on cell proliferation, as well as on cell clonogenic growth. HDAC inhibition also enhanced radiosensitivity of NPC cell lines. Western blot detection of PARP cleavage revealed that the antiproliferative effects of S78454 were only partially related to apoptosis. Western blot analysis was also used to explore molecular mechanisms involved in cellular response to S78454. Quantitative assessment of tubulin acetylation confirmed that S78454 effectively increased protein acetylation, even at low concentrations. As previously reported in other tumors, RAD51 protein levels were significantly decreased after 48H of treatment, suggesting that HDAC inhibitors act, at least in part, by targeting homologous recombination. However, HDAC inhibitor-induced cell death involves not only epigenetic pathways, but numerous other mechanisms, through acetylation of a variety of non-histone and non-chromatin-associated proteins. For instance, the proteasome activity may play a role in the response to HDAC inhibitors, and the amount of HR23B - a carrier protein functionally related to the proteasome - has been identified as a determinant of HDAC inhibitors sensitivity. We found that HR23B protein levels were high in all 3 NPC cell lines. Nevertheless, there was a decrease in HR23B protein levels after treatment with S78454. Altogether, these results demonstrate that the novel HDAC inhibitor S78454, currently in Phase I/II clinical trials for the treatment of solid tumors and hematologic malignancies, has promising antitumour activity in NPC, especially in association with cis-platinum and ionizing radiation, ie the two most widely used antitumor agents in NPC. Experiments are in progress to assess the anti-tumor activity of S78454 on other types of NPC cells, including xenografted NPC tumor lines. The influence of the HDAC inhibitor on the regulation of EBV latency is also under investigation.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4702. doi:1538-7445.AM2012-4702

Abstract 522: Cooperative effect of the TLR3-agonist Poly(A:U) combined to a Smac-mimetic against malignant nasopharyngeal carcinomas cells

Nasopharyngeal carcinomas (NPC) are malignant epithelial tumors of the nasopharyngeal cavity. They are consistently associated with the Epstein-Barr virus (EBV). Though NPCs are on average more radiosensitive and chemosensitive than other tumors of the upper aero-digestive tract, many therapeutic challenges remain. In this context the development of therapeutic approaches taking better account of biological characteristics of NPC and well defined biological targets remains a priority. We have previously reported a cooperative effect of the TLR3-agonist poly(I:C) combined to a Smac-mimetic against NPC cells. (Friboulet et al., Neoplasia 2008, 10: 1183-1194 and BMC cancer 2010, 10: 327). However Poly(I:C) is a ligand not only for the TLR3 but also other receptors of double-stranded RNAs, like RIG1 and PKR. In contrast Poly(A:U) is much more specific for TLR3. In addition, Poly(A:U) has less secondary effects in patients and has already been successfully used in a phase III clinical trial against breast cancer (Salaun et al., Cancer Res. 201, 71: 1607-14). Therefore one aim of this study was to explore the therapeutic potential of the treatment of NPC cells by Poly(A:U) combined to an inhibitor of IAPs (“inhibitor of apoptosis proteins”). Another aim was to assess the expression of TLR3 by NPC cells, an aspect of their phenotype which - to our knowledge - has never been previously described. The expression of TLR3 was assessed in a series of EBV-positive NPC tumor lines (C666-1, C15, C17, C18) and a series of NPC clinical specimens by Western blot and immunohistochemistry, respectively. In vitro TLR3 was consistently detected in malignant NPC cells at a high level by comparison with non-NPC control lines. In all NPC biopsies, TLR3 expression was detected in a substantial fraction of malignant NPC cells. The effects of poly(A:U) as single agents were tested on the EBV-positive NPC cells lines C666-1 without significant effects on cell growth and cell survival at least at concentrations compatible with clinical use. In contrast, growth inhibition and apoptosis induction were obtained by combination of Poly(A:U) with RMT 5265, an IAP inhibitor based on Smac-mimicry which targets c-IAP1, c-IAP2 and XIAP. It is noteworthy that these effects were obtained using concentrations of Poly(A:U) of 1 μg/ml or less and concentrations of the IAP inhibitor (RMT 5265) of 100 nM or less. These data confirm that TLR3 expression is a factor of vulnerability for NPC cells as it is the case for other head and neck carcinomas (Rydberg et al., Immunology 2009, 128: e601–e611; Umemura et al., Cancer Res. Online 2011). Until now, Smac mimetics and Poly(A:U) have been the subject of separate therapeutic trials. In light of our observations, combined use of both types of compounds should be considered for treatment of EBV-associated nasopharyngeal carcinomas.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 522. doi:1538-7445.AM2012-522

Endoscopic endonasal skull base surgery

Skull base surgery has been transformed by the development of endoscopic techniques. Endoscopic procedures were first used for pituitary surgery and were then gradually extended to other regions. A wide range of diseases are now accessible to endoscopic skull base surgery. The major advantage of the endoscopic endonasal approach is that it provides direct anatomical access to a large number of intracranial and paranasal sinus lesions, avoiding the sequelae of a skin incision, facial bone flap or craniotomy, and brain retraction, which is inevitable with conventional neurosurgical incisions, resulting in decreased morbidity and mortality and, indirectly, decreased length of hospital stay and management costs. Moreover, the increasing number of publications in this field illustrates the growing interest in these techniques. This paper provides a review of endoscopic skull base surgery. The indications and general principles of endoscopic endonasal skull base surgery are described. Progress in exposure and especially reconstruction techniques is described. This progress now allows more extensive resections, while maintaining acceptable morbidity. The limits of this surgery are also discussed; in particular, although this surgery is often described as "minimally invasive", it is not completely devoid of morbidity.

Online script concordance test for clinical reasoning assessment in otorhinolaryngology: the association between performance and clinical experience

OBJECTIVE

To report on the creation and administration of an online Script Concordance Test (SCT) for ear, nose, and throat (ENT), the ENT-SCT.

DESIGN

Prospective study.

SETTING

Two tertiary care university centers.

PARTICIPANTS

In total, 132 individuals were asked to test an ENT-SCT of 20 cases and 94 questions based on the major educational objectives of the ENT residency program.

MAIN OUTCOME MEASURES

Three levels of experience were tested: medical students, ENT residents, and board-certified otorhinolaryngologists as the expert panel. The test's construct validity-whether scores were related to clinical experience-was statistically analyzed. Reliability was estimated by the Cronbach α internal consistency coefficient. Participants' perception of the test was assessed with the use of a questionnaire.

RESULTS

The 65 respondents with usable data were medical students (n = 21), ENT residents (n = 22), and experts (n = 22). Total mean (SD) test scores differed significantly: 76.81 (3.31) for the expert panel, 69.05 (4.35) for residents, and 58.29 (5.86) for students. The Cronbach α coefficient was 0.95. More than two-thirds of the participants found the test to be realistic and relevant for assessing clinical reasoning. The test was also considered fun, interesting, and intuitive.

CONCLUSIONS

The Web-based ENT-SCT is feasible, reliable, and useful for assessing clinical reasoning. This online assessment tool may have applications for residency programs and continuing medical education.

Juvenile Nasopharyngeal Angiofibromas: Does an External Approach Still Make Sense?

Objective: Endoscopic removal has recently become the standard procedure in the case of small juvenile angiofibromas. However, large lesions encroaching the skull base remain a challenge. The aim of this work is to define extensions which at present cannot be addressed reasonably endoscopically.

Method: Retrospective review based on cases treated from 2000 to 2010. Ratio of endoscopically treated patients has been analyzed together with staging and topographic description of these lesions.

Results: Fifty-nine patients were treated from 2000 to 2010, of whom 31 were treated endoscopically. Ratio of endoscopic procedures raises from 37% (n = 10) for the 2000 to 2005 period to 84% (n = 26) for the 2006 to 2010 period. This trend, analyzed according to the staging following Radkowski, is not related to earlier diagnosis of smaller tumors, since ratio of stage IIIA is similar. Indeed, development of approaches to pterygopalatine fossa, infratemporal fossa, temporal fossa, inferior orbital fissure, orbital apex, and even cavernous sinus allowed control of deep and far-seated lesions.

Conclusion: Refinement of hemostasis techniques and 4-hands surgery (Castelnuovo) allows the treatment of lateral-seated tumors, even if large. Posterior extensions may be reached through a transpterygoid approach. Only lesions which engulf the ICA or the optic nerve need further evaluation to choose between open approach or incomplete, subtotal removal.

The Learning Curve of Video-Assisted Thyroidectomy

Objective: Minimally invasive video-assisted thyroidectomy (MIVAT) has been demonstrated to be a safe procedure for the removal of small thyroid nodules in order to improve cosmetic results and reduce pain. The aim of this study was to evaluate the learning curve of this procedure.

Method: Thirty-four patients were consecutively operated by MIVAT and were arbitrarily split in 2 groups: group 1 (n = 17) for the first 17 patients who underwent MIVAT and group 2 (n = 17) for the following 17 patients. MIVAT was performed through a unique cervical incision of 2 cm length.

Results: Twenty-one lobectomies and 13 total thyroidectomies were performed. The mean operative time was significantly shorter in group 2 (59 ± 22 min) than in group 1 (81 ± 33 min) ( P = .03). There was neither significant difference between groups for the occurrence of postoperative complications nor for the other outcome measurements: scar length was 2.1 ± 0.2 cm and 1.85 ± 0.4 cm in group 1 and 2 respectively, postoperative pain was 2.7 ± 1.5 and 2.2 ± 1.8 in group 1 and 2 respectively, and the mean time of hospital stay was 2.8 ± 1.0 days.

Conclusion: MIVAT requires a learning curve. This study showed that the surgical time was significantly shortened with experience. Recommendations should define the number of lobectomies and the training program to be performed for the surgeon and assistants in order to lower mean operative time and reduce complications for MIVAT.

Online Script Concordance Test for ENT

Objective: The Script Concordance Test (SCT) involves the use of authentic clinical scenarios to compare a medical trainee’s judgment skills with those of experts. The aim of this work is to produce valid, reliable SCT for the ear, nose, and throat (ENT) discipline.

Method: In total, 132 participants were asked to test an online ENT-SCT of 20 cases and 94 questions based on the major educational objectives of the ENT residency program. Three levels of experience were tested: medical students, ENT residents, and board-certified otorhinolaryngologists as an expert panel.

Results: The 65 respondents with useable data were medical students (n = 21), ENT residents (n = 22), and experts (n = 22). Total mean test scores significantly differed: 76.81 ± 3.31 for the expert panel, 69.05 ± 4.35 for residents, and 58.29 ± 5.86 for students. The Cronbach alpha coefficient was 0.95. More than two-thirds of the participants found the test realistic and relevant for assessing clinical reasoning. The test was also considered interesting and intuitive.

Conclusion: The web-based ENT-SCT is feasible, reliable, and useful for assessing clinical reasoning. This online assessment tool may have applications for residency programs and continuing medical education.

Frontal Mucocoeles: The Frontal Pick

Objective: Treatment of frontal mucocoeles through an endoscopic approach is a cornerstone of minimally invasive surgery. However lysis of the posterior wall of the frontal sinus may provide significant morbidity. The focus of this study is to propose an algorithm to select mucocele drainage versus sinus obliteration.

Method: Retrospective review based on 37 cases of frontal mucocoeles with erosion of the posterior wall treated from 2000 to 2009.

Results: While most of the cases with extensive posterior wall lysis have been successfully addressed through minimal invasive treatment, two patients presented with a “frontal pick” (ie, localized posterior wall deformity). The first patient underwent intractable CSF rhinorrhea 3 months after endoscopic marsupialization of the cyst. A “frontal pick” could be visualized, which had torn open the dura due to the relief of mucocele counterpressure. A subfrontal approach allowed obliteration of the sinus and performance of a duraplasty. The second patient was identified and successfully approached subfrontally, which allowed dissection of the frontal pick.

Conclusion: When posterior wall of the frontal sinus results in a sharp-angled deformity of the posterior wall, then endoscopic marsupialization may result in CSF rhinorrhea due to tearing of the dura after relieving the counter pressure exerted by the mucocele. A sinus obliteration should then be performed.

[Cervico-facial fascitiis. A major ENT emergency]

Cervical fasciitis is one of the most severe ENT emergencies, requiring immediate management by a multidisciplinary team. Often due to a benign pharyngeal or dental infection, this life-threatening condition leads to extensive necrosis spreading along the fascia of the neck, possibly to the mediastinum. A retrospective analysis of 150 consecutive patients admitted to our institution between January 2001 and December 2006 showed:--a 7% mortality rate;--pulmonary involvement in one-third of cases and hemodynamic failure or mediastinitis in half the patients;--mechanical ventilation for an average of 10 days, intubation for 13 days, tracheostomy for 31 days, intensive care unit management for 17 days, and hospitalization for 26 days; and--functional and esthetic sequelae in about half the patients. These data underscore the extreme severity of cervicofacial fasciitis and the need to pay close attention to any general or functional signs of severe sepsis in patients with apparently mild head or neck infections. Such patients should be urgently referred to a tertiary center for immediate CT scan and surgical drainage of any cervical or thoracic abscesses. Intensive medical care is needed to manage the frequent cardio-hemodynamic failure and secondary pulmonary/mediastinal infections. The only possible predisposing factors so far identified are inadequate initial medical treatment and self-medication with nonsteroidal antiinflammatory drugs.

Reversible cerebral vasoconstriction syndrome in two patients with a carotid glomus tumour

We report two patients with reversible cerebral vasoconstriction syndrome (RCVS) and carotid glomus tumour. The first patient presented with multiple thunderclap headaches. Cervical and cerebral magnetic resonance imaging showed diffuse cerebral vasoconstriction on magnetic resonance angiogram (MRA) and a carotid glomus tumour. The second patient presented with a cervical mass and was diagnosed with a non-secreting paraganglioma of the carotid body. Surgery with pre-operative angiography was followed by thunderclap headaches and MRA showed segmental cerebral vasoconstriction. Both patients were treated with nimodipine and headaches stopped. Both had normal cerebral arteries on the control MRA at 3 months. These two cases suggest that a paraganglioma may increase the susceptibility to develop RCVS. As a consequence, patients with RCVS should be investigated for a carotid glomus tumour, and patients with paraganglioma reporting severe headaches should have a cerebral MRA in order to rule out cerebral vasoconstriction.