Infantile Myofibromatosis With Cutaneous, Visceral, and CNS Involvement: A Multimodal Approach to Therapy

BACKGROUND

Infantile myofibromatosis (IM) is a rare benign tumor of infancy. Cases with solitary and multicentric disease usually spontaneously regress, but multicentric disease with visceral involvement carries a poor prognosis. Few cases of multicentric disease with central nervous system (CNS) involvement have been reported, and none report survival.

OBSERVATIONS

We present a newborn with multicentric IM with cutaneous, visceral, and CNS involvement. She was treated with vinblastine, methotrexate, and the novel addition of intrathecal methotrexate with treatment response after 1 year of therapy.

CONCLUSIONS

Multicentric IM with CNS involvement can be successfully treated with a multimodal approach of chemotherapy with the addition of intrathecal methotrexate and surgery.

Pyoderma gangrenosum in an infant: A case report and review of the literature

Pyoderma gangrenosum is a neutrophilic dermatosis that is rare in infancy, with only 20 cases reported in the literature. We present a case of infantile pyoderma gangrenosum refractory to topical steroids, tacrolimus, and dapsone as well as systemic steroids and infliximab that is currently well controlled with the addition of oral tacrolimus. To our knowledge, this is the first report of the effective, safe use of oral tacrolimus in combination with infliximab for infantile pyoderma gangrenosum. We review all current cases of infantile pyoderma gangrenosum, as well as tacrolimus and its role in the treatment of this condition.

Audit of GP Referrals for Tonsillectomy to the ENT Clinic Using Present HIQA Guidelines

Recurrent sore throat for possible tonsillectomy is the commonest clinical entity referred to the ENT outpatient department. The numbers involved represent a large clinical burden on the service. Not all of these patients require surgical intervention. Patients who fit the criteria for tonsillectomy are faced with two stage obstacles; the long waiting time until assessed by the Otolaryngologist at OPD and the time spent on long operative waiting lists. The aim of this study was to analyze the percentage of referred patients with sore throats requiring tonsillectomy versus those not needing surgery, using the present HIQA guidelines for this operation.

General practitioner ENT referral audit

BACKGROUND

During 2009, there were 3.3 million outpatient attendances at outpatient clinics across Ireland. Up to 20 % of these are directed towards ENT services.

AIMS

To determine the compliance rate of general practitioners with the ICGP referral guidelines.

METHODS

One-hundred referrals received were compared to the ICGP standardised form and graded accordingly. Each referral letter was graded to a maximum of 37 points.

RESULTS

The average score recorded for referrals was 16/37. The referrer detail section scored the highest with a mean of 75.42 % (paediatric referrals) and 72.9 % (adult referrals). The clinical information provided demonstrated compliance rates of 34 % (paediatrics) and 35 % (adults). In total, only 32 letters made any reference to findings on examination. Both paediatric and adult referrals scored an average of 42 % when patients' details are considered.

CONCLUSION

This study demonstrates poor compliance rates with the introduced ICGP standardised referral form, which has implications for the accurate grading of referral letters received.

Chronic phototoxicity and aggressive squamous cell carcinoma of the skin in children and adults during treatment with voriconazole

BACKGROUND

Voriconazole is a broad-spectrum antifungal agent associated with photosensitivity and accelerated photoaging. A possible link with aggressive squamous cell carcinoma (SCC) has also been reported.

OBJECTIVE

We sought to determine the incidence and frequency of cutaneous SCC among patients undergoing long-term treatment with voriconazole who also manifest features of chronic phototoxicity.

METHODS

We conducted a retrospective review of patients who developed one or more squamous cell neoplasms during long-term treatment with voriconazole at 3 academic dermatology centers.

RESULTS

A total of 51 cutaneous SCC were identified in 8 patients (median age 34.5 years, range 9-54) treated with chronic voriconazole (median duration 46.5 months, range 13-60). Underlying diagnoses included graft-versus-host disease, HIV, and Wegener granulomatosis. Signs of chronic phototoxicity and accelerated photoaging included erythema, actinic keratoses, and lentigo formation.

LIMITATIONS

The retrospective nature of the study cannot determine the true population risk of SCC associated with voriconazole therapy. A prospective cohort study is needed.

CONCLUSION

A high index of suspicion for photosensitivity and SCC may be warranted with chronic voriconazole use when used in the setting of concurrent immunosuppression.

One to make the diagnosis. A case of non tuberculous mycobacterial mastoiditis in a nine year old female

Some members of the Non-Tuberculous Mycobacteria family are free living organisms in the environment. They may be pathogenic in the immunocomprimised or in chronic lung disease. We describe a case of a nine year old of Asian descent who presented with clinical mastoiditis where the pathogenic organism was Mycobacterium Gordonae. The decision was made to give the patient full antimycobacterial treatment and subsequently the patient made a full recovery.

Silver nitrate cauterisation, does concentration matter?

Epistaxis from the anterior septum is frequently treated with a topical application of silver nitrate. There are two concentrations commercially available and in use by otolaryngologists, these are 75% and 95% silver nitrate. The purpose of the present study was to investigate the histological effect of the two different silver nitrate concentrations on mucosal tissue at a fixed contact time of 5 s. Twelve children undergoing routine tonsillectomy were included in this study. Prominent blood vessels on the mucosal surface of the tonsils were identified and a single vessel on each tonsil was selected for application of either 75% or 95% concentration of silver nitrate for 5 s. Depth of penetration across the tonsil tissue was measured following application of the two different silver nitrate concentrations. This study demonstrated a significant difference in depth of tissue penetration with the 95% averaging a twofold increase in penetration depth. It is likely that the increased depth of penetration with 95% silver nitrate may increase the risk of complication of nasal cautery such as septal perforation, particularly in patients undergoing repeated or bilateral nasal cautery.

Cardiovascular hoarseness: an unusual presentation to otolaryngologists

OBJECTIVE

We discuss the case of a 73-year-old woman with a six-month history of hoarseness secondary to an aortic arch pseudoaneurysm.

METHOD

We present the findings of an extensive review of the literature relating to cardiovascular disorders involving the recurrent laryngeal nerve (i.e. Ortner's syndrome).

RESULTS

Ortner's syndrome, also known as cardiovocal syndrome, is a rare condition, with few reports in the literature.

CONCLUSION

This is only the second documented case of Ortner's syndrome in Great Britain and Ireland, and the first demonstrating an aortic pseudoaneurysm.

Virtual laryngoscopy—preliminary experience

PURPOSE

Computed tomographic virtual laryngoscopy is a non-invasive radiological technique that allows visualisation of intra-luminal surfaces by three-dimensional reconstruction of air/soft tissue interfaces. It is particularly useful when the patient cannot tolerate clinical examination, when infection, neoplasm or congenital defects compromise the lumen and for assessment of the sub-glottic region. We have performed virtual laryngoscopy on patients referred because of upper airway symptoms, and compared the findings with those at conventional laryngoscopy.

MATERIALS AND METHODS

Axial scans were obtained using a Toshiba Xpress helical scanner. Virtual laryngoscopy was then performed on a workstation using Toshiba "Fly-thru" software and was completed within 5 min.

RESULTS

Pathology included vocal cord nodules, laryngeal cysts, Reinke's oedema, laryngeal neoplasms and leukoplakia.

CONCLUSIONS

Virtual laryngoscopy displays anatomical detail comparable to conventional endoscopy. Impassable obstructions are no hindrance and all viewing directions are possible. It is especially useful for providing views of the larynx from below.

Guidelines for the medical management of Irish children and adolescents with Down syndrome

Down syndrome (DS) is the most common chromosomal cause of developmental disability in Ireland. Children with DS have a high incidence of associated treatable medical disorders where early intervention carries a better outcome. Currently there are no agreed protocols for the screening and management of children and adults with DS in Ireland. A cross-sectional study of 394 children and adolescents was undertaken in the Eastern Regional Health Authority (ERHA) to assess the medical needs of children and adolescents with DS, in order to develop medical management guidelines. This study provides evidence-based data that children and adolescents with DS have a high incidence of treatable medical disorders, which supports the need for the medical management guidelines presented.

The ultrasonically activated scalpel versus bipolar diathermy for tonsillectomy: a prospective, randomized trial

Among patients undergoing tonsillectomy, the ultrasonic scalpel has been reported to lead to less intraoperative blood loss than cold dissection, and less postoperative pain and faster recovery than monopolar electrocautery. However, the ultrasonic scalpel has not been compared with bipolar diathermy. The present study was a prospective, randomized, single-blind trial, comparing these two techniques with respect to postoperative pain. Twenty-one adults underwent tonsillectomy on one side using the ultrasonic scalpel, and on the other using bipolar diathermy. Pain scores were obtained on postoperative days 1, 2, 7 and week 3. There was no difference between the two treatments at any of the time points (P = 0.6047, 0.4018, 0.6047 and 0.5000, respectively). Inability to control bleeding with the ultrasonic scalpel resulted in the rescue use of an alternative technique of haemostasis in 14 cases. We conclude that the use of the ultrasonic scalpel in adult tonsillectomy is likely to be limited by its substantial costs and difficulties with haemostasis.

Normal nasal mucociliary clearance in CF children: evidence against a CFTR-related defect

Studies on mucociliary clearance (MCC) in cystic fibrosis (CF) have produced conflicting results. This study aimed to differentiate primary (ion transport-related) from secondary (inflammatory) causes of delayed MCC in CF. Nasal MCC was measured in 50 children (CF, primary ciliary dyskinesia (PCD) and no respiratory disease). Nasal lavage fluid was analysed for interleukin (IL)-8 and tumour necrosis factor-alpha. Similar measurements were obtained in adult CF patients with and without chronic sinusitis (CS). Children with CF had neither delayed MCC nor increased levels of cytokines. Conversely, children with PCD had prolonged MCC times (all >30 min) and significantly raised levels of IL-8. CS-positive CF adults had significantly slower MCC than CS-negative subjects, but IL-8 levels were low and similar in both groups. Decreased airway surface liquid and delayed mucociliary clearance are the postulated primary mechanisms in cystic fibrosis. However, the current study reports that cystic fibrosis children have normal nasal mucociliary clearance. Abnormalities appeared in cystic fibrosis adults with symptoms of chronic sinus disease, suggesting a secondary rather than primary phenomenon. Studies to explore this mechanism in the distal, more sparsely-ciliated airways could aid an understanding of pathogenesis and the development of new treatments.

Multiresistant Pseudomonas aeruginosa in a pediatric cystic fibrosis center: natural history and implications for segregation

It has been suggested that cystic fibrosis (CF) patients harboring multiresistant (MR) Pseudomonas aeruginosa (PA) should be seen in separate clinics. The aim of this study was to test the feasibility of this by longitudinally studying the consistency of isolates of MRPA in individuals. We analyzed all respiratory tract cultures undertaken in 1 year from a pediatric CF clinic population (n = 367). PA was classified as MR according to the definition of the American CF Foundation: resistance to all agents in at least two of the following groups of antibiotics: beta-lactams, aminoglycosides, and fluroquinolones. PA was cultured from 96 children during the year of study. Thirty-six were infected with at least one MR strain. Following initial identification of MRPA, MR in subsequent cultures was highly variable. Twenty-three of 36 patients had subsequent cultures in which PA was identified. However, 21 of 23 patients had at least one isolate that was not MR following detection of MRPA. The variability with time in isolation of MR strains from individuals demonstrates the potential difficulties in designing segregation policies based on antibiotic sensitivity patterns.

Airway surface pH in subjects with cystic fibrosis

The cystic fibrosis (CF) transmembrane conductance regulator protein can transport bicarbonate and may therefore regulate airway surface (AS) pH. Disturbances of AS pH could contribute to the pathophysiology of CF lung disease. Five studies were carried out including the following: study 1) nasal pH measurements were made in 25 CF and 10 non-CF adults using an antimony pH probe. Mean nasal pH was significantly lower in the CF group. Nasal potential difference may have been a confounding factor; study 2) in a fresh cohort of CF and non-CF subjects, no significant difference was found between the two groups using a gold pH probe; study 3) simultaneous nasal pH measurements were made in 15 CF and 15 non-CF adults using both probes. In the CF group, there was a trend for the antimony probe to read lower than the gold probe. In the non-CF group, the antimony probe read higher. The pH difference noted in study 1 related to technical factors; study 4) the effect of acute changes in serum acid/base balance on nasal pH was assessed in five non-CF adults. Nasal pH was not altered by either acute respiratory acidosis or alkalosis; study 5) nasal and lower airway pH was measured in five CF and six non-CF children. No difference was found between the groups. There was a correlation between nasal and lower airway pH. The authors conclude that airway surface pH does not differ between cystic fibrosis and noncystic fibrosis subjects and therefore, cystic fibrosis transmembrane conductance regulator may not play a major role in airway surface pH in vivo.

Inflammatory endobronchial polyps in childhood: clinical spectrum and possible link to mechanical ventilation

Inflammatory polyps of the airways are now regarded as histopathologically distinct nonneoplastic endobronchial lesions, which in adults are associated with a variety of chronic inflammatory insults. However, their clinical presentation in the pediatric population is extremely rare, with the etiology of such polyps poorly defined. The clinical and histopathological data from four pediatric patients, identified in the histopathology files of the Royal Brompton Hospital, were retrospectively reviewed. Three out of 4 patients had a history of mechanical ventilation in the neonatal period. In these 3 patients, the polyps were all situated in the proximal airways on the right side. These 3 patients presented at 6 weeks, 7 weeks, and 2 years, respectively, and were successfully treated by polypectomy at rigid bronchoscopy, with subsequent return to normality. One patient, presenting at 12 years of age without history of iatrogenic intervention, underwent a left lower lobectomy for a polyp sited in a segmental bronchus. Presentation in 3 of the 4 patients was with lobar collapse. The fourth patient presented with hyperinflation. We conclude that inflammatory endobronchial polyps may be associated with a history of mechanical ventilation in the neonatal period, polyp formation perhaps being secondary to airway trauma. The small caliber of the main airways in neonates may also be a contributory factor in presentation.

The potential of virtual laryngoscopy in the assessment of vocal cord lesions

Virtual laryngoscopy is a useful adjunctive radiological tool in the assessment of laryngeal lesions. A total of 10 patients requiring direct laryngoscopy for the investigation of laryngeal lesions underwent preoperative virtual laryngoscopy using three-dimensional reconstruction of two-dimensional computerized tomography (CT) images. All lesions were correctly diagnosed on virtual laryngoscopy before direct laryngoscopy. Its main advantages are that it does not require general anaesthesia, it allows three-dimensional visualization of the airway beyond areas of narrowing and it gives a highly accurate representation of vocal cord lesions, both in terms of definition and spatial representation. Its disadvantages are that it does not provide histology, it requires an air-mucosa interface to produce an image and it cannot identify functional lesions of the vocal cords.

The problem of seeing hospital staff without G.P. referral--the otolaryngological experience

Over a three month period, a record was kept of the number of hospital staff who approached the E.N.T. team requesting help for a medical problem. Staff members included doctors, nurses, clerical staff, paramedical staff and porters. The total number of employees in the hospital was recorded. The average General practitioner public patient list (General medical Service cardholders) for South Dublin was recorded (our hospital is in south west Dublin). The total number of hospital staff seen by E.N.T. in 3 months was seventy seven. The total number of hospital staff seen by other surgical specialties was approximately one hundred and sixty seven. Extrapolation of numbers seen by E.N.T. service in three months to numbers seen over a one year period is 308 patients. The numbers seen by the E.N.T. service in three months corresponds to 11.7% of the average South Dublin General Practitioner Medical card list. It has been estimated that approximately 20% of all problems the average General practitioner sees in a week are E.N.T. related. Those practices with a smaller paediatric population would have approximately 15% of the total practice concearned with E.N.T. problems. Therefore as 15% of 2,400 (total hospital staff) = 360, there is potentially a small General Practice which is 'hidden' within the hospital.

The use of fibrin glue in refractory coagulopathic epistaxis

Epistaxis can be particularly difficult to treat when a patient has a coagulopathy, even if the area bleeding is visible. Where routine measures fail to arrest the bleeding (e.g., nasal cautery and packing), the application of fibrin glue is successful in stopping the bleeding without having to address the underlying coagulopathy. Ten patients with epistaxis secondary to an underlying coagulopathy were treated by local application of fibrin glue to the area bleeding. The bleeding stopped immediately in all patients when the fibrin glue was applied. No patients suffered complications. Fibrin glue application should be considered as a cost-effective means of controlling epistaxis from an identifiable area in the nasal cavity in patients with a coagulopathy.

The use of botulinum toxin in otorhinolaryngology

In recent years, the use of botulinum toxin has become more popular for the treatment of a wide variety of diseases in the head and neck. It offers the possibility of non-invasive treatment of conditions whose aetiology lies in neuromuscular dyskinesis.

An unusual complication of minitracheostomy

A 72-year-old woman had a minitracheostomy inserted for sputum retention. This was undertaken by a relatively junior resident who opted to use an early model minitracheostomy kit Minitrach II. The following day the patients condition deteriorated and intubation was warranted, at which time it was apparent to senior staff that the minitracheostomy had been malpositioned. Ten days later, formal tracheostomy was performed under general anaesthesia. After incision, an abscess in the thyroid gland was found. Histology subsequently revealed a Hurthle cell tumour of the thyroid. Thyroid abscess is exceedingly rare. It typically occurs in abnormal thyroid tissue and with a focus on infection. The combination of Hurthle cell adenoma and a foreign body (the minitracheostomy) was evidently causative in this instance. This complication of minitracheostomy insertion has not to our knowledge, previously been reported.

Reducing need and demand for medical services in high-risk persons. A health education approach

We undertook this study to identify persons with high medical use to target them for health promotion and self-management interventions specific to their problems. We compared the reductions in cost and health risk of a health education program aimed at high-risk persons with a similar program addressed to all risk levels. We compared health risk and use in 2,586 high-risk persons with those of employee (N = 50,576) and senior (N = 39,076) groups and contrasted results in specific high-risk disease or behavior categories (modules)--arthritis, back pain, high blood pressure, diabetes mellitus, heart disease, smoking, and obesity--against each other, using validated self-report measures, over a 6-month period. Interventions were a standard generic health education program and a similar program directed at high risk individuals (Healthtrac). Health risk scores improved by 11% in the overall high-risk group compared with 9% in the employee group and 6% in the senior group. Physician use decreased by 0.8 visits per 6 months in the high-risk group compared with 0.05 and 0.15 visits, respectively, per 6 months in the employee and senior groups. Hospital stays decreased by 0.2 days per 6 months in the high-risk group compared with 0.05 days in the comparison groups. The duration of illness or confinement to home decreased by 0.9 days per 6 months in the high-risk group and 0.15 and 0.25, respectively, in the employee and senior groups. Using imputed costs of $130 per physician visit, $1,000 per hospital day, and $200 per sick day, previous year costs were $1,138 in direct costs for the high-risk groups compared with $352 and $995 in the employee and senior groups, respectively. At 6 months, direct costs were reduced by $304 in the high-risk group compared with $57 and $70 in the comparison groups. Total costs were reduced $484 in the high-risk groups compared with $87 in the employee group and $120 in the senior group. The return on investment was about 6:1 in the high-risk group compared with 4:1 in the comparison groups. Effective health education programs can result in larger changes in use and costs in high-risk persons than in unscreened persons, justifying more intensive educational interventions in high-risk groups.

Cancer of the pyriform fossa: hyperfractionated radiotherapy as a primary treatment modality

Carcinoma of the pyriform fossa carries one of the worst prognoses of all head and neck cancers. A prospective trial was set up to study the efficacy of hyperfractionated radiotherapy as a primary treatment modality in the management of these patients. Seventeen patients entered the trial and were followed for up to 3 years. Results for local control, regional control and survival compare favourably with patients treated primarily with surgery with or without radiotherapy. Hyperfractionated radiotherapy offers a logical and standardized approach to the management of this tumour and reduces the significant morbidity associated with the use of surgery as a primary treatment.

Congenital nasal dermoids in children

The case of a 27 month old male with a congenital midline nasal dermoid cyst is presented. The child attended the Ear, Nose and Throat outpatient's department in July 1995, with an external midline nasal swelling, which had been present at birth and was noted to be gradually increasing in size. Magnetic resonance imaging (MRI) showed a central defect of the nasal bones, with a soft tissue mass at the upper part of the nasal bridge expanding the nasal septum. There was no radiological evidence of intracranial extension. The child had the nasal mass removed under general anesthesia, through an external rhinoplasty incision. Histopathology confirmed that the mass was a fully excised nasal dermoid cyst. Current investigation and management of this condition is discussed.

ENT surgery in children with inherited bleeding disorders

Inherited bleeding disorders are frequently considered an absolute contraindication to tonsillectomy and other ENT procedures. Over a 15-year period we have performed ten elective tonsillectomies and five bilateral myringotomies on children with inherited bleeding disorders. All procedures were carried out with the close co-operation of the Haematology Department in the hospital. All patients underwent uneventful surgery. One patient returned after tonsillectomy with a secondary haemorrhage which did not require surgical intervention. We present our team approach to the management of these children and demonstrate that necessary surgical intervention can be undertaken safely in this select group of patients.

Superficial siderosis of the central nervous system

Two patients with superficial siderosis of the central nervous system are reported. Both developed progressive deafness over many years; one with associated anosmia and partial seizures; the other with progressive ataxia and diplopia. The cerebrospinal fluid was xanthochromic in one and the protein was raised in both. Magnetic resonance imaging revealed a hypodense rim around the eighth cranial nerve, cerebellum, brain stem and spinal cord. Despite extensive investigations the cause of the superficial siderosis in both patients remains undetermined.

Surgical management of lymphangiomas in adults

Lymphangiomas are uncommon benign congenital tumours. Most occur in the head and neck region and the vast majority present before the age of two. This paper describes the presentation and management of four cases presenting after puberty and involving the parotid gland. The cases are unusual in that all were intimately associated with the facial nerve and in an older population. The value of selective neck dissection and facial nerve exposure as an approach to these lesions is discussed.

The radio-opacity of fishbones: a cadaveric study

Lateral neck radiographs performed to localize impacted fishbones have a low sensitivity. The differing radio-opacities of the bones of various fish species may be a reason for this. A cadaver head and neck and the rib bones of 10 species of fish were used in this study. A laryngoscope was used to introduce a fishbone into the vallecula and then into the hypopharynx of the cadaver. A lateral radiograph was taken in each case. Ten control films were taken. The radiographs were independently reviewed by a consultant radiologist and otolaryngologist. The presence and position of any bone seen was noted. There was no inter-observer variation. All species of fishbone were visible. One bone was not seen by either observer. Visualization of fishbones is more dependent on position than their degree of radio-opacity. Routine radiography is recommended.

Disseminated acanthamoeba infection in patients with AIDS: case reports and review

Acanthamoeba infection has been described as an opportunistic infection in persons with AIDS. We report two cases of patients with AIDS and acanthamoeba infection and review the manifestations of this protozoan infection in patients infected with human immunodeficiency virus. The diagnosis of this infection requires a high index of suspicion because the clinical and histologic manifestations may be confused with those of disseminated fungal or algal disease. Clinicians and laboratory personnel should be aware of this potentially fatal condition so that appropriate diagnostic studies can be performed and treatment can be urgently administered. Early initiation of therapy may alter the clinical outcome of the disease.

Chondroradionecrosis of the larynx: still a diagnostic dilemma

Following radiation treatment for carcinoma of the larynx it may be very difficult to differentiate between persistent or recurrent tumour and severe radiation effects particularly chondroradionecrosis. Despite repeated negative biopsy it may be necessary to perform total laryngectomy where the concern about persistent cancer remains and the larynx is non-functioning. We report nine cases presenting as chondroradionecrosis over a five-year period. Two patients settled on medical treatment. Of seven patients treated with laryngectomy the histology on two revealed residual or recurrent carcinoma. We outline the dilemmas in diagnosis and propose management strategies to deal with this condition including recommendations for prevention and treatment.

Localized, late-onset, high-grade lymphoma following bone marrow transplantation: response to combination chemotherapy

Non-Hodgkin's lymphoma is the commonest secondary cancer following bone marrow transplantation (BMT). We report the case of a 42-year-old man who developed a laryngeal high-grade B-cell lymphoma 5 years following a matched T depleted BMT for CML. Polymerase chain reaction (PCR) analysis using the microsatellite marker Cyp 19 demonstrated the donor origin of involved tissue. Epstein-Barr virus (EBV) genomic sequences were identified by PCR. Although EBV related B-cell lymphoproliferative disorders (BLPD) post BMT are difficult to treat, there was a complete remission in this patient following three courses of chemotherapy (CHOP) administered with G-CSF. This case of late-onset BLPD appears clinically distinct from the well-defined, aggressive, early post-transplant BLPD.