Tumescent solution: a game changer in excising refractory arteriovenous malformation

Arteriovenous malformations of the head and neck are rare and inborn errors of vascular morphogenesis. They pose therapeutic challenges owing to their bleeding tendency and a high chance of recurrence. Treatment modalities include digital subtraction angiography with embolisation as a primary treatment or can be done preoperatively followed by surgical excision. We present a case of recurrent arteriovenous malformation of the postauricular region in an adolescent male who was taken up for upfront surgical excision with the help of a tumescent solution, thereby eliminating the need for embolisation and drastically reduced intraoperative blood loss.

Post-traumatic transocular retained foreign body in the infratemporal fossa: a near miss

The infratemporal fossa is an uncommon site for lodgement of foreign bodies. Fast-moving projectiles and displaced teeth may get impacted and have been described in the literature. However, foreign body lodgement in the retromaxillary space after transorbital passage is rare. The trajectory of the foreign bodies in such cases is difficult to predict and may not be suspected in the absence of overt clinical features. The authors present a case of a wooden splinter lodged within the infratemporal fossa after the patient sustained a lid injury with an orbital floor fracture. Imaging was equivocal; hence, endoscopic surgical exploration was undertaken, revealing the foreign body. A high index of clinical suspicion and rapid intervention is needed since unsuspected foreign bodies may cause further visual, infective or neurovascular complications. Approaches should be tailored on a case-by-case basis.

Isolated left sternocleidomastoid pyomyositis: a rare presentation of cervical sepsis

An elderly gentleman self-presented to A+E with a 7-day history of significant and progressive left-sided neck pain, swelling and fevers, despite oral antibiotics from his general practitioner. Examination revealed a large left-sided neck mass involving levels 2-5 of the neck that was firm to palpate, with erythematous overlying skin.An urgent CT scan demonstrated a large collection throughout the length of the left sternocleidomastoid muscle (SCM), measuring 13×5.5×4 cm, with extensive adjacent inflammatory change. He was subsequently taken to theatre for washout and debridement, during which the collection was found to be loculated and isolated to the SCM, with surrounding structures spared.Postoperatively, he was managed with intravenous fluids and a total of 2 weeks of intravenous antibiotics. The wound partially dehisced during healing and the cavity was packed with flaminal and regularly dressed with input from the tissue viability team. This was then left to heal by secondary intention and the patient was followed up in clinic over the following weeks to ensure resolution.

Vocal cord dysfunction causing hypoxaemia in the postanaesthesia care unit

Hypoxaemia in the postanaesthesia care unit is common and the majority is caused by hypoventilation or upper airway obstruction due to the (residual) effects of anaesthetic and analgesic agents. We present a case of upper airway obstruction caused by vocal cord dysfunction, a less frequently occurring aetiology. The patient's case suggests a notable relationship between procedural laryngeal stimulus and the onset of symptoms. Approach to the diagnosis and flexible laryngoscopy to either rule-in or rule-out several relevant differentials are discussed.

Low-dose nivolumab and cabozantinib in recurrent intestinal-type papillary adenocarcinoma of the sinonasal region

Intestinal-type sinonasal adenocarcinoma is a rare epithelial malignancy primarily treated with surgery and chemoradiation. The combination of low-dose immunotherapy and a tyrosine kinase inhibitor in recurrent disease has not been previously studied.A man in his 20s with papillary adenocarcinoma of the sinonasal region, following surgical resection, was treated with six cycles of concurrent chemoradiotherapy, followed by four cycles of docetaxel, cisplatin and capecitabine. While on treatment, he was found to have extensive residual disease and he was started on low-dose nivolumab and cabozantinib. Repeat imaging after ten months of treatment revealed a significant reduction in lesions.Non-squamous head and neck cancers are often excluded from major trials, and the effect of immunotherapy in these histologies is poorly understood. The response seen with low-dose immunotherapy underscores the need for further research in this setting.

Bilateral cochlear implantation in infantile Bartter's syndrome

Bartter's syndrome (BS) is a rare group of hereditary salt losing tubulopathies due to impairment of renal transport mechanism. Herein, we report a boy in early childhood who was diagnosed to have infantile Bartter's syndrome. Laboratory investigations revealed hypokalaemia and metabolic alkalosis which was managed with oral potassium chloride supplementation. The inner ear showed no anatomical abnormalities. Sequential cochlear implantation was performed 4 months apart. Postoperative electrical stimulation yielded good response and a symmetric mapping. The patient was on regular audio-verbal therapy. Cognitive impairment improved over time. Bilateral cochlear implantation showed excellent auditory outcomes.

Chondrosarcoma of the petrous apex with nerve abducens involvement in a woman with pre-existing contralateral amblyopia

We report about a case of a woman in her 50s with a chondrosarcoma of the petrous apex. She has a strabism due to a right-sided amblyopia since childhood and noticed a slowly progressive squint angle in the last months. Her general practitioner (GP) referred her to an ophthalmologist who diagnosed a left abducens paresis and initiated an MRI demonstrating a mass in the left petrous apex. A transnasal endoscopic transsphenoidal biopsy revealed a grade I chondrosarcoma. The patient underwent an endoscopic transsphenoidal anterior petrosectomy approach with complete removal of the tumour. After surgery the squint angle gradually improved to previous levels, so that the patient was able to resume her work. This report demonstrates that even slight changes of a squint angle without diplopia, in this case because of pre-existing amblyopia, could be a hallmark of an intracranial process.

Glomangiopericytoma with CTNNB1 mutation

Glomangiopericytoma (GPC) is a rare tumour, accounting <0.5% of all nasal cavity tumours. It is classified as borderline malignant to indolent and is associated with perivascular myeloid cells. We report a case of GPC in a woman in her 80s who presented with nasal obstruction. The tumour originated from the nasal septum and was resected via endoscopic sinus surgery. Histopathological examination revealed dense spindle-shaped to oval-shaped mesenchymal cells forming tumour nodules with staghorn-like vessel formation. Immunohistochemical analysis revealed that the tumour cells were positive for α-smooth muscle actin, CD34, β-catenin and cyclin D1, whereas they were negative for STAT6. The percentage of Ki-67-positive cells was approximately 2%. Recent studies have demonstrated a high frequency of β-catenin (CTNNB1) mutations in GPC. We report a case of GPC where identifying CTNNB1 mutations (c.94G>C, p.D32H) was crucial for establishing a definitive diagnosis.

Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS): diagnostic contribution of vestibular function tests

Cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS) is a recently recognised but underdiagnosed cause of late-onset hereditary ataxia. Symptoms may vary, and differential diagnoses can span several specialties. We report the case of a man in his 60 s who presented with a 10 year history of imbalance and progressive gait disturbance associated with a chronic spasmodic cough that preceded these symptoms by almost 30 years. He had previously undergone extensive testing for acquired and genetic causes of ataxia without a conclusive diagnosis. Brain MRI revealed cerebellar atrophy, and nerve conduction tests suggested a sensory ganglionopathy. Vestibular function testing was crucial for diagnosis, identifying a severe bilateral vestibulopathy. This led to the consideration of CANVAS, which was finally confirmed by genetic testing. This case raises awareness of this novel genetic disease, highlighting the importance of objective vestibular function tests in establishing an early diagnosis.

Black thyroid gland and tracheal cartilage

A woman in her 70s with a history of chronic minocycline use presented with complaints of a non-tender posterior neck mass. A thyroid gland ultrasound showed a highly suspicious right thyroid nodule. A total thyroidectomy revealed darkened discolouration of the thyroid gland and tracheal cartilage. The pathology report showed dark brown granules representing melanin. Chronic minocycline usage is known to cause pigmentation of nails, teeth, bones and the thyroid gland. Our case highlights the importance of recognising that long-term use of minocycline can cause discolouration of the thyroid and tracheal cartilage. Current case studies do not show any adverse health effects associated with black thyroid and tracheal cartilage. For patients who are to undergo neck surgery, physicians need to be aware of this side effect, and that further intervention, such as surgical resection, may not be required.

Management of a recurrent right juvenile nasopharyngeal angiofibroma using direct tumorous puncture embolisation and a subtemporal-preauricular infratemporal fossa surgical approach

A juvenile nasopharyngeal angiofibroma (JNA) is a benign vascular tumour that arises from the pterygopalatine fossa. It is seen near exclusively in young males though female cases have been reported. Symptoms are due to their high vascularity and mass effect. Commonly reported symptoms include: nasal obstruction, epistaxis and nasal discharge. The mainstay of treatment is surgical resection either via an endonasal endoscopic approach or open surgical resection. Preoperative embolisation has been shown to decrease intraoperative bleeding. Embolisation may be undertaken via a transarterial (TA) approach or, more recently, via direct tumorous puncture (DTP). Options for recurrent or residual disease may include revision surgery, radiotherapy or close clinical surveillance. The following case presentation describes the management of a recurrent JNA in an adult male using preoperative embolisation via a combination of TA and DTP embolisation and an open surgical resection via a subtemporal-preauricular infratemporal fossa approach.

Undiagnosed laryngocele: an airway emergency

Laryngoceles are rare dilated laryngeal saccules that can present as acute airway obstruction and lead to airway emergencies. A man, presented to the emergency room, with difficulty in breathing and change in voice. An unevaluated pulsatile swelling was present on the left side of neck. Since, the patient was in stridor, an awake fiberoptic bronchoscopy (FOB)-guided intubation was planned with readiness for emergency tracheostomy, if needed. On FOB, an edematous supraglottic area with a narrowed glottic opening was observed. The procedure was abandoned and a surgical tracheostomy was performed to secure the airway. Postoperative contrast-enhanced CT neck revealed a huge laryngocele in left cervical region. We recommend that a high index of suspicion for presence of laryngocele should be kept in mind when a patient presents with stridor with pulsatile neck swelling. Timely aspiration of laryngocele may help in amelioration of the respiratory distress avoiding emergency tracheostomy.

Uncommon aetiology of lymphadenopathy in a healthy child: a sporotrichosis case with painless lymphadenopathy

A 6-year-old boy was referred to the paediatric infectious disease clinic with a 2-month history of enlarged, erythematous, painless cervical lymph nodes. He initially presented to his paediatrician with a painless lesion. At that time, he was treated empirically with clindamycin and azithromycin due to a history of cat exposure. Despite treatment, the lesion evolved into a non-healing linear ulcer with painless, ascending cervical lymphadenopathy. Serologies were negative for Bartonella henselae antibodies. Additional laboratory studies revealed eosinophilia and negative Toxoplasma gondii antibodies. After no improvement following a course of trimethoprim-sulfamethoxazole, further questioning revealed that the patient had fallen into a haystack 1 month before the initial cervical lesion. The patient's parents opted to treat the infection empirically for sporotrichosis with itraconazole rather than undergo lymph node biopsy. At the 2-week follow-up, his lymphadenopathy had resolved and had returned to baseline activity.

Transoral robotic surgical excision of hypopharyngeal ectopic parathyroid adenoma causing primary hyperparathyroidism

Ectopic parathyroid adenomas are a rare congenital anomaly despite the complex migration parathyroid glands undergo during development. Rarer still, these can be found in the hypopharynx, become adenomas and be the cause of primary hyperparathyroidism. We present a case of a woman in her 50s who underwent transoral robotic surgery (TORS) to remove her hypopharyngeal ectopic parathyroid adenoma and cure her primary hyperparathyroidism without complication. This is a radical change in practice compared with traditional open, transverse cervical approaches. We demonstrate the efficacy of using TORS for this unusual case, highlighting its versatility and the need to continue to search for opportunities to best use this advancing technology, especially when it can improve patient outcomes.

Opening a dacryocystorhinostomy into the opposite nasal cavity in a case of hemiarhinia

Heminasal agenesis is an exceedingly rare congenital anomaly which is frequently associated with disorders of eye, lacrimal drainage system and face. At times, a proboscis may also be noted with this condition. Herein, we present a case of a 13-year-old boy who presented to us with heminasal agenesis with concomitant microphthalmos, leucomatous corneal opacity, blepharoptosis, dacryocystocoele and maxillary hypoplasia. The child underwent a modified transeptal external dacryocystorhinostomy with placement of a lacrimal stent. There was significant improvement of epiphora and discharged following surgery. Heminasal aplasia with dacryocystocoele is surgical challenge; however, a well thought out surgical approach can yield satisfactory outcomes.

Unusual metachronous presentation of bilateral frontoethmoid sinus mucoceles

A case report of a patient with bilateral frontoethmoid mucoceles with no obvious predisposing factors and each side presenting three years apart, with no ongoing nasal or paranasal signs of disease in the interim.Bilateral paranasal sinus mucoceles have rarely been described in the literature; this case is unique, as it is the first description of a metachronous presentation. Additionally, the absence of any predisposing factors such as trauma, surgery or chronic sinusitis in either presentation is unusual.

Management of two rare cases of dermatofibrosarcoma protuberans arising in the parotid region

Dermatofibrosarcoma protuberans (DFSP) is a rare cutaneous tumour, accounting for less than 1% of malignant tumours of the head and neck region. This tumour rarely presents metastatic disease, but has a high recurrence rate. Therefore, wide surgical excision with microscopically free margins is the therapeutic gold standard. Only five cases are described in literature of this tumour arising in the parotid region, a site that presents challenges both in achieving a wide demolition and in reconstructing the resulting defect. Here we describe two cases of DFSP arising in the parotid region that were treated surgically, achieving microscopically free margins. Reconstruction of the vast skin defect was achieved by means of a supraclavicular artery island flap, with good functional and aesthetic results.

Invasive pneumococcal disease: a diagnostic challenge due to multiple portals of causative bacteria

A 64-year-old woman was transferred to our hospital because of fever, painful swelling in upper jaw, back pain and dysuria. She was in shock and physical examinations revealed tenderness on maxillary sinus, cellulitis in the right foot, hypoesthesia in both lower extremities and groin, mild weakness in both lower extremities, and bladder and rectal dysfunctions. Blood examination showed elevated white cell count and C reactive protein, and urinalysis revealed urinary tract infection. Spinal MRI detected spondylodiscitis with epidural abscess. After detection of Streptococcus pneumoniae by cultures of blood and fluid from lumbar abscess, she was consequently diagnosed with invasive pneumococcal disease likely secondary to acute exacerbation of chronic sinusitis. Pyogenic spondylitis or epidural abscess is a rare but serious complication of invasive pneumococcal disease. Furthermore, S. pneumoniae should be suspected as a causative organism when seeing a patient with severe infectious diseases complicated with sinusitis.

Uncommon presentation and complications of herpes zoster infection involving the cervical, vagus and accessory nerves which caused a delay in diagnosis and treatment

A 70-year-old man with a history of invasive anal squamous cell carcinoma treated with excision and chemoradiation presented to the emergency department with right-sided neck pain and submandibular lymphadenopathy. CT imaging of the head and neck was unrevealing. The patient eventually developed cranial nerves X and XI dysfunction, manifesting as severe vocal cord paralysis (dysphonia), dysphagia, asymmetric palate elevation/deviation and trapezius muscle atrophy, in addition to scalene muscle atrophy. After an extensive workup, the patient's symptoms were determined to be due to sequelae of varicella zoster infection, which was confirmed with antibody titers. The patient's dysphagia and dysphonia eventually improved with vocal cord medialisation injection and Botox injection. However, despite delayed treatment with acyclovir and valacyclovir, the patient continued to have neuropathic pain and exhibit signs of CN X and CN XI paresis, in addition to scalene muscle atrophy.

Simultaneous double laryngeal tumours: a diagnostic and therapeutic challenge

Leiomyosarcomas are soft tissue tumours that rarely occur in the larynx. This case report describes the presentation and management of a 77-year-old man referred to the otolaryngology clinic with hoarseness who was found to have a large supraglottic leiomyosarcoma after panendoscopy and biopsies. He subsequently underwent laryngectomy for treatment of this tumour but, unexpectedly, the histological analysis of the laryngectomy specimen revealed a second primary tumour in the larynx-a squamous cell carcinoma (SCC). The patient had further treatment with neck radiotherapy. Three years after treatment, there are no signs of recurrence of either tumour. This case report discusses the very few similar cases of leiomyosarcoma coexisting with SCC in the larynx, collating the evidence surrounding the treatment of this rare presentation.

Bilateral vocal cord paralysis in Miller Fisher syndrome/Guillain-Barre overlap syndrome and a review of previous case series

Miller Fisher syndrome (MFS), an acute demyelinating neuropathy, is characterised by a triad of areflexia, ataxia and ophthalmoplegia. It is the most common variant of Guillain-Barre Syndrome (GBS). In about 5.6%-7.1% of MFS cases, patients also suffer from progressive motor weakness of the limbs. This condition is termed MFS/GBS overlap syndrome. Whether it is in MFS or GBS, bilateral vocal cord paralysis (BVCP) is a rare manifestation with limited cases reported in the literature. We report an extremely rare case where a 65-year-old man developed BVCP in an MFS/GBS overlap syndrome. We have also reviewed previous case reports in the literature for comparison.

Eosinophilic chronic rhinosinusitis and concurrent Kimura's disease treated with mepolizumab

Kimura's disease is a rare, benign, chronic inflammatory disorder characterised by its eosinophilic infiltrate. Patients often present with one or more progressively enlarging subcutaneous lymph nodes in the head and neck region or enlarging salivary glands. We describe the case of a 26-year-old man presenting with severe peripheral eosinophilia and upper airway inflammatory symptoms, who later developed cervical lymphadenopathy and formally diagnosed with Kimura's disease. Based on our English-language MEDLINE literature search, to our knowledge this is the first case report describing treatment of Kimura's disease with mepolizumab.

Bilateral vocal fold paresis: the only presenting sign of anti-MUSK antibody myasthenia gravis

A previously fit and well 53-year-old man was referred to the otolaryngology clinic with intermittent stridor and was found to have bilateral vocal fold paresis. Subsequent airway compromise necessitated emergency surgical tracheostomy. The man was discharged home with tracheostomy in situ and a diagnosis of idiopathic bilateral vocal cord palsy, as all primary investigations were negative. Neurological disease was suspected following readmission to hospital several weeks later with diplopia. Electromyography and serum antibody testing confirmed a diagnosis of anti-muscle-specific tyrosine kinase antibody positive myasthenia gravis (MuSK-MG); a subset of MG where autoantibodies are directed against MuSK. Resolution of bilateral vocal fold paresis was found 8 months after a short course of immunoglobulin (intravenous immunoglobulin (IVIg)) and daily mycophenolate therapy was commenced. Multidisciplinary teamwork between ear, nose and throat surgeons, neurologists and speech therapists enabled successful decannulation of tracheostomy. The patient has recovered well and remains minimally symptomatic.

Solitary extramedullary plasmacytoma of the larynx: a rare cause of dysphonia

Solitary extramedullary plasmacytoma (SEP) of the larynx is a rare haematological malignancy and an infrequent cause of persisting dysphonia. We present the case of a 54-year-old woman with a long-standing history of dysphonia. While clinical examination showed a rather inconspicuous prominent right vestibular fold, an MRI revealed a laryngeal mass with erosion of the thyroid cartilage. A biopsy taken during rigid endoscopy demonstrated plasma cell infiltration with light chain restriction amidst amyloid deposits. After exclusion of systemic involvement, the diagnosis of an SEP of the larynx with secondary amyloidosis was made. The patient received primary radiation therapy. Another biopsy taken 3 months after the end of therapy did not show any signs of ongoing neoplastic plasma cell disease. The patient was therefore considered to be in remission. She is currently receiving regular follow-up and has not shown signs of persistent or progressive disease for the past 18 months.

Calcitonin negative medullary thyroid cancer in ectopic thyroid tissue: a rare diagnosis in an unusual location

Medullary thyroid cancer is an aggressive form of thyroid cancer arising from parafollicular C cells. Calcitonin (CT) is a specific and sensitive biochemical marker which typically aids primary diagnosis and disease surveillance following treatment. There are rare cases of calcitonin negative medullary thyroid cancer (CNMTC) documented in the literature; however, to our knowledge, this case is the first report of CNMTC arising in ectopic thyroid tissue. We report a case of a 45-year-old man who attended his primary care physician with painless anterior neck swelling. In the absence of CT secreting disease, we have demonstrated the investigative process and the importance of immunohistochemical analysis to achieve a diagnosis. We also consider the challenges of monitoring disease recurrence in the absence of reliable biochemical markers.

Bacteria-induced nasal necrosis with negative cultures

A 79-year-old man with liver failure, hypertension and hyperlipidemia presented with a 1.5-month history of progressive nasal crusting and pain on the inside of the nose, advancing into a necrotic columella and philtrum. On rigid endoscopy, debris extended to middle and inferior turbinate to midway posteriorly. Initial culture swabs and CT were negative. The patient underwent endoscopic biopsy of the lesion, with histopathological findings revealing abundant acute inflammation and minute fragments of atypical squamous epithelium, favouring reactive atypia. Non-invasive fungal hyphae were identified. Bacterial cultures revealed Staphylococcus epidermidis, Corynebacterium accolens, Curvularia species and Pseudomonas putida A current literature search failed to find other published cases of P. putida nasal infections. P. putida is generally difficult to isolate on swab culture as the surrounding tissue is necrosed; this case highlights the importance of reconsidering bacterial infection and obtaining a tissue biopsy in the case of non-healing necrotic-appearing tissue with negative culture swab and CT without evidence of mass.

Tissue glue: a potential role in the management of intraoperative oesophageal perforation

An 85-year-old man suffering from oropharyngeal dysphagia due to a pharyngeal pouch and cricopharyngeal spasm underwent endoscopic stapling of the pouch under general anaesthesia. During the procedure, an iatrogenic perforation of the oesophagus was noticed. After considering several options, 5 mL of Tisseel tissue glue was used to seal the perforation intraoperatively. The patient was started on intravenous co-amoxiclav, kept nil by mouth and fed via a nasogastric tube. After 4 days of observation mediastinal collection and any leakage was ruled out with a gastrografin contrast swallow procedure. At this point he was considered safe for oral intake.

Conservative surgical management of a supernumerary tooth in the nasal cavity

A 9-year-old girl presented with a foreign body obstruction inside her nose. The condition led to pain and nasal congestion. CT showed the presence of a radiopaque mass similar to a tooth in the right nasal cavity. Diagnosis of a supernumerary intranasal tooth was made and extraction was performed under general anaesthesia. An ectopic tooth in the nasal cavity is rare and surgical removal is recommended to eliminate the symptoms.

Oval window perilymph fistula in child with recurrent meningitis and unilateral hearing loss

A 2-year-old boy presented to Ears, Nose and Throat (ENT) surgeons with unilateral hearing loss. Following a prodrome of upper respiratory tract infection (URTI), he developed two episodes of pneumococcal meningitis in quick succession. This case demonstrates an unusual cause of perilymph fistula diagnosed on imaging and confirmed surgically. He had failed the Newborn Hearing Screening Programme and was therefore referred to audiology, who confirmed profound sensorineural hearing loss in the right ear. MRI showed incomplete partitioning (type 1) of the right cochlea, suggesting cerebrospinal fluid (CSF) leak from the region of the stapes. Exploratory tympanotomy confirmed this, and proceeded to CSF leak repair, obliteration of the Eustachian tube, subtotal petrosectomy, abdominal fat grafting and blind sac closure. Although middle ear effusions are common; particularly in children with recent URTI, the possibility of otogenic CSF leak needs to be considered, especially in cases of recurrent meningitis.

Sinusitis caused by a rare organism, Cedecea lapagei

A 45-year-old man presented with acute sinusitis. He was treated with a 10-day course of trimethoprim/sulfamethoxazole, and a subsequent 14-day course of amoxicillin-clavulanate with no improvement in symptoms. Culture of purulent nasal secretions revealed the rare enterobacter Cedecea lapagei The patient had complete resolution of his symptoms after a 14-day course of gentamicin/dexamethasone nasal rinses. Emerging pathogens have been a timeless concern for physicians, as witnessed by the current SARS-CoV-2 outbreak. C. lapagei has been reported to cause human infection only a dozen times since its discovery, all in severely compromised patients. This is the first documented case of sinusitis reported with C. lapagei and may portend a rising prevalence of disease burden in the general population. This case demonstrates the necessity of obtaining cultures when standard antibiotics result in treatment failure.

Lingual compression for acute macroglossia in a COVID-19 positive patient

We describe a 40-year-old woman with severe, persistent macroglossia following prone positioning as part of treatment for COVID-19. We used the treatment method of lingual compression with satisfactory results.

Septic arthritis of the temporomandibular joint in an unvaccinated adolescent

Septic arthritis of the temporomandibular joint (TMJ) is a rare condition, particularly in the paediatric population. Our case involves a 15-year-old unvaccinated Amish man with acute pain and trismus of the TMJ. The diagnosis was reached after history, clinical examination, radiographic and laboratory examinations were performed. The patient improved after a minimally invasive surgical procedure and medical therapy. Failure to recognise and treat septic arthritis in a timely fashion can result in serious sequalae. Infectious aetiologies should be kept on the differential for any patient with acute TMJ pain.

Laryngeal granular cell tumour: a very rare diagnosis for a child presenting with hoarse voice in the UK

We present a rare case of a paediatric laryngeal granular cell tumour (GCT) of the vocal cord. GCTs are rare clinical entities, thought to arise from Schwann cells. There are only a handful of paediatric laryngeal GCTs in the literature, and therefore, little is known regarding their natural history or preferred management strategies. In this case report, we discuss the incidence, aetiopathogenesis, presentation and management of a laryngeal GCT in an 11-year-old girl, who presented with dysphonia. We believe that this case will aid otolaryngologists in the management of paediatric patients with the common dysphonia.

Aarskog-Scott syndrome: clinical and molecular characterisation of a family with the coexistence of a novel FGD1 mutation and 16p13.11-p12.3 microduplication

Aarskog-Scott syndrome (AAS), also known as facio-genital dysplasia or faciodigitogenital syndrome, is a rare genetic disorder clinically characterised by facial, limb and genitalanomalies. Although also autosomal dominance and recessive patterns have been reported, up to now, only an X linked form associated to mutations of the FGD1 gene has been recognised as causative for this syndrome.In this case report, we describe a large Italian family in which three members across three generations show classical features of the syndrome. The youngest patient, the proband, and his mother were both molecularly studied and characterised for the not previously reported variant c.1828C>T (p. Arg610*) in the FGD1 gene but with the classic phenotype of AAS. Additionally, both the proband and his mother present a 2.5 Mb 16p13.11-p12.3 microduplication, a genetic variant still unclear for the phenotypic consequences: the co-occurrence of the two rare conditions is discussed for the possible clinical significance.

Unusual presentation of submandibular lingual nerve sheath tumour as sublingual stone

A 60-year-old woman was referred to the otolaryngologist for 18 months of left-sided tongue pain and taste changes. Surgeon-performed ultrasound of the submandibular region revealed a hyperechoic mass. Wharton's duct was dilated proximally and the submandibular gland demonstrated normal vascularity. While these findings were highly suspicious for submandibular gland sialolith, an in-office attempt at sialolithotomy suggested an alternate process or mass. After imaging failed to further elucidate an aetiology, surgical exploration revealed a well-circumscribed submandibular mass associated with the lingual nerve. The mass was removed en-bloc and pathology revealed a schwannoma of the lingual nerve.

Dual spinal accessory nerve: caution during neck dissection

Preserving the spinal accessory nerve (SAN) is an important step in the modern-day neck dissection to avoid postoperative functional morbidity in patients. This goal can become technically difficult, especially, when rare anatomical variations are encountered. We present a case of dual SAN in a patient undergoing selective neck dissection for oral squamous cell carcinoma. Both SANs were preserved and patient had no shoulder dysfunction postoperatively. We take this opportunity to emphasise that meticulous dissection is the only proven way to preserve the nerve. And that surgeons should be aware of this anatomical variation. SAN should be subjected to minimal traction during neck dissection to avoid tension neuropraxia and long-term shoulder dysfunction.

Intralaryngeal paraganglioma workup and discussion of surgical approach

Laryngeal paragangliomas are an uncommon presentation of head and neck paragangliomas, with laryngeal paragangliomas along with a synchronous paraganglioma being exceptionally rare. We present two challenging cases of laryngeal paragangliomas with extralaryngeal extension, completely resected through a transcervical approach without endolaryngeal disruption, with one case having synchronous bilateral carotid body tumours. Both patients had excellent results with complete tumour resection and no resultant functional impact. The surgical approaches for large laryngeal paraganglioma are discussed with considerations for endolaryngeal, transcervical and combined approaches as well as decision-making when approaching these rare lesions in the setting of synchronous head and neck paragangliomas.

Extra-skeletal Ewing's sarcoma of the frontal sinus: a rare disorder in pediatric age

Paediatric sinonasal tumours comprise numerous aetiologies. Ewing's sarcoma (ES) consists of a malignancy of neuroectodermal origin. This type of sarcoma affects mainly children and adolescents and can assume the skeletal or extra-skeletal form. Primary ES of head and neck is extremely rare, accounting for only 4%-9% of all cases. So far, as much as we know, only a few cases of sinonasal ES have been reported in literature. The authors present a case of a previous healthy 12-year-old girl who presented with a rapidly growing and expansive frontal mass and unilateral nasal obstruction. Immunohistochemical, molecular and cytogenetic analysis of the lesion showed diffuse expression of CD56 and CD99 on tumour cells and a translocation involving chromosome 22q12, confirming ES diagnosis.

Multiple concurrent atypical parathyroid adenomas: a rare occurrence

We present a case of an 80-year-old patient with three concurrent multiple atypical parathyroid adenomas. The patient was managed with bilateral parathyroid exploration and concurrent parathyroidectomy. Postoperative recovery was uneventful. Atypical parathyroid adenomas are a rare entity that are clinically difficult to distinguish from parathyroid carcinoma. Histological characteristics are similar however atypical adenomas lack complete capsular or vascular invasion and cannot be considered malignant. All reported cases of atypical parathyroid adenoma are solitary lesions. We present the first case of multiple concurrent atypical parathyroid adenomas.