We report a rare case of avascular necrosis of the maxilla secondary to oral bisphosphonates.

Case report and review of the world literature concerning avascular necrosis as a result of bisphosphonate therapy.

A 62-year-old woman presented with unilateral nasal obstruction, swelling of the cheek and an ulcerating lesion of the upper alveolus. She had a past medical history of osteoporosis, for which she took oral bisphosphonates. Investigation revealed necrosis of the maxilla, and avascular necrosis secondary to oral bisphosphonates was diagnosed.

There have been several documented cases of avascular necrosis of the mandible and maxilla following intravenous bisphosphonates or dental procedures. In our case, bisphosphonates were only taken orally and no dental work had been undertaken. This patient's clinical presentation was highly suggestive of malignancy, and we would like to communicate this unusual case to other otolaryngologists.

A 65-year-old man presented with a nine-month history of swelling in the midline of the forehead. After surgical intervention, this lesion was found to be a tumefactive fibroinflammatory lesion of the frontal sinus. This case report and review aims to report this new location for tumefactive fibroinflammatory lesion, and to discuss whether, in retrospect, there would have been alternative options to surgery.

Case report and literature review.

Tumefactive fibroinflammatory lesions are rare. Although cases in the sinonasal tract have been described, none involving the frontal sinus have previously been reported. A review of the literature suggests that these lesions have an association with other fibroinflammatory lesions, and may be amenable to systemic steroid therapy.

Each case should be managed on its merits, and a biopsy taken followed by subsequent screening for associated fibroinflammatory lesions. In the case of an isolated lesion, a surgical approach is probably favoured in a patient suitable for general anaesthesia.

Intravenous amphotericin or intravenous voriconazole, both followed by oral voriconazole, have previously been given to treat invasive aspergillosis of the skull base.

Exclusively oral voriconazole was used in an immunocompetent patient with biopsy-proven, invasive aspergillosis. She had a large, erosive lesion extending from the central skull base to the right orbit and ethmoid sinus, and displacing the right internal carotid artery. After four months of oral treatment as an out-patient, a repeated computed tomography scan showed a fully treated infection with post-infectious changes only, and treatment was terminated. Two years later, there had been no recurrence.

Substantial cost savings were made by using exclusively oral treatment, compared with the use of intravenous voriconazole or amphotericin, or a switch strategy.

The increased risk of developing lymphoproliferative disorders, mainly linked with Epstein–Barr virus infection, is well documented in patients with cyclosporin-induced immunosuppression following organ transplantation. Lymphoproliferative disease is extremely rare in the non-transplant setting.

We present the first published case of non-Epstein–Barr virus associated lymphoproliferative disease in a patient receiving long-standing cyclosporin therapy for psoriatic arthritis, which presented as a recurrent nasopharyngeal mass.

Histological examination showed lymphoid hyperplasia in repeated biopsies. Macroscopic clearance was persistently followed by aggressive recurrence. Spontaneous regression occurred upon cyclosporin withdrawal.

This rare complication of cyclosporin therapy in non-transplant patients is highlighted from an otolaryngological perspective, as the sole presentation may be a recurrent nasopharyngeal mass. Repeated biopsies showing lymphoid hyperplasia, together with aggressive recurrence, should prompt immediate drug withdrawal to reduce immunosuppression and promote spontaneous regression.

To determine the prevalence and profile of patients who use complementary and alternative medicine, within a cohort of head and neck cancer patients.

Cross-sectional survey.

Ninety-three consecutive head and neck cancer patients being followed up at the department of otolaryngology head and neck surgery were surveyed using an interviewer-administered questionnaire.

The prevalence of complementary and alternative medicine use was 67.8 per cent. Patients who used complementary and alternative medicine were more likely to be female, better educated and younger, compared with non-users. A total of 82.5 per cent (52/63) perceived complementary and alternative medicine to be effective, even though they were aware of the lack of research and endorsement by their physician regarding such medicine.

The use of complementary and alternative medicine by head and neck cancer patients is common, regardless of efficacy or cost. Clinicians should routinely ask patients about their use of complementary and alternative medicine, to facilitate communication and enable appropriate use of such medicine.

Fascin is an actin-binding protein which is expressed in the basal areas of healthy squamous epithelium. Although overexpression of fascin has been shown in many tumours, the relationship between fascin and laryngeal squamous cell carcinoma has not previously been investigated, to the best of our knowledge. This study aimed to investigate the relationship between fascin expression and tumour behaviour in 30 cases of laryngeal squamous cell carcinoma.

For all lesions, a section of paraffin-embedded tissue was immunohistochemically stained for fascin. The percentage of positive, stained cells was scored from one to five (one = 0–5 per cent, two = 6–25 per cent, three = 26–50 per cent, four = 51–75 per cent and five = 76–100 per cent), and the staining intensity from one to three (one = mild, two = moderate and three = strong). A total immunohistochemical fascin expression score was obtained by multiplying the staining percentage and intensity. The relationship between the total fascin score and each case's age, sex, tumour localisation, tumour–node–metastasis stage and differentiation was evaluated statistically.

Various amounts of fascin expression were observed in all cases. There was a statistically significant relationship between high levels of fascin expression (i.e. a total fascin score of 10 or more) and the cases' tumour stage (p = 0.022), node stage (p = 0.024) and clinical stage (p = 0.014). In addition, worsening tumour differentiation was associated with an increasing fascin score, but this finding was statistically insignificant.

These results suggest that laryngeal squamous cell carcinomas with high levels of fascin expression may be more aggressive than those with low expression levels. Further studies with larger series are needed to support these results and to clarify rationales.

We report two rare cases of high and dehiscent jugular bulbs protruding into the external ear canal; one case was silent, the other symptomatic.

The cases are presented and the relevant literature reviewed and discussed.

A 52-year-old woman underwent mastoid exploration for suspected cholesteatoma. On raising the tympanomeatal flap, while still lateral to the annulus, brisk venous bleeding occurred from a high, dehiscent jugular bulb in the external ear canal. The second patient, a 42-year-old man, underwent imaging for suspected glomus tumour. A high, dehiscent jugular bulb was found protruding into the external ear canal and hypotympanum.

High jugular bulbs in the middle ear have been reported many times. To our knowledge, there has only been one previous report of a high jugular bulb in the external ear. These cases illustrate the importance of full, accurate assessment of high resolution computed tomography images, and of appropriate, immediate management of bleeding.

We present a novel, previously undescribed technique of obtaining a biopsy from an inaccessible parapharyngeal space mass.

A modified endo-cavitary ultrasound probe was utilised to obtain an intra-oral, image-guided core biopsy of a parapharyngeal tumour. The parapharyngeal mass was not accessible to percutaneous ultrasound-guided biopsy due to its anatomical location.

To our knowledge, this is the first such modification of the conventional endo-cavitary probe technique described in the literature. The technique permits accurate, well controlled biopsy of lesions located high in the parapharyngeal space, under general anaesthesia.

We report two cases of plastic bronchitis presenting with acute respiratory failure and mimicking foreign body inhalation.

The clinical findings, differential diagnoses and radiological investigation are discussed.

Plastic bronchitis is an uncommon condition, particularly in children. The condition may present to otolaryngologists with symptoms mimicking foreign body inhalation. It is important to consider plastic bronchitis as a differential diagnosis, based on its clinical and radiological signs. Early intervention, in the form of bronchoscopy, can be both diagnostic and therapeutic.

Plastic bronchitis is uncommon and its clinical and radiological features are non-specific. The recommended management is early bronchoscopy to establish the diagnosis and enable therapeutic intervention.

We report a new approach to benign parapharyngeal space tumours: a single, subcondylar mandibular osteotomy.

Case report and review of the world literature concerning parapharyngeal space access and the various types of mandibular osteotomy.

The use of a single, subcondylar mandibular osteotomy achieves good exposure and satisfactory aesthetic and functional results, using a simple, easily performed technique that is fast and has minimal morbidity. In addition, this technique preserves the submandibular gland and avoids lip-splitting and post-operative intermaxillary fixation.

To our knowledge, this is the first report of this approach to the parapharyngeal space. We propose this approach as the first choice for resection of benign neoplasms of the parapharyngeal space.

To determine (1) the preferred adenoidectomy technique among UK ENT consultants, and (2) the need for revision adenoidectomy following the standard technique of blind curettage with digital palpation.

Postal questionnaire.

We included 539 consultant members of the ENT–UK.

Commonly used adenoidectomy techniques, and whether revision adenoidectomy was considered a problem.

The response rate was 66.6 per cent (359 respondents). Twenty-seven respondents did not perform adenoidectomy, while 332 did. A total of 312/332 respondents (94 per cent) believed that adenoidectomy had a role in the treatment of chronic serous otitis media. The majority of respondents (232/332; 69.9 per cent) reported examining the postnasal space digitally at adenoidectomy. The preferred routine adenoidectomy technique was blind curettage for 263 respondents (79.2 per cent), suction diathermy ablation for 27 (8.1 per cent) and curettage under direct vision (using a mirror) for 13 (3.9 per cent). In response to the question ‘Do you recognise the need for revision adenoidectomy as a problem?’, 205 (61.7 per cent) respondents replied ‘never’, 39 (11.7 per cent) ‘rarely’, 54 (16.3 per cent) ‘< 2 per cent’ and 36 (10.8 per cent) ‘>2 per cent’.

The most commonly used adenoidectomy technique in the UK is digital palpation followed by blind curettage, according to this postal questionnaire survey. Few respondents reported performing adenoidectomy under direct vision: only 10 per cent used a mirror during the procedure and only 8 per cent used an endoscope.

The frontal sinus outflow tract consists anatomically of narrow channels prone to stenosis. Following both endonasal and external approach surgery, up to 30 per cent of patients suffer post-operative re-stenosis of the frontal sinus outflow tract, with recurrent frontal sinus disease. This paper proposes the surgical placement of a long-term frontal sinus stent to maintain fronto-nasal patency, as an alternative to more aggressive surgical procedures such as frontal sinus obliteration and modified Lothrop procedures.

We present a series of three patients with frontal sinus disease and significant co-morbidity, the latter making extensive surgery a significant health risk. We also review the relevant literature and discuss the use of long-term frontal sinus stenting.

These three cases were successfully treated with long-term frontal sinus stenting. Stents remained in situ for a period ranging from 48 to over 60 months.

Due to the relatively high failure rates for both endonasal and external frontal sinus surgery, with a high post-operative incidence of frontal sinus outflow tract re-stenosis, long-term stenting is a useful option in carefully selected patients.

Community-acquired methicillin-resistant Staphylococcus aureus is emerging as an important pathogen. However, methicillin-resistant Staphylococcus aureus rarely causes nasal septal abscess.

We present a case of severe, community-acquired, methicillin-resistant Staphylococcus aureus infection causing rapidly progressing sinusitis, nasal septal abscess and facial cellulitis.

This report serves to remind the clinician of the expanding spectrum of severe infections caused by methicillin-resistant Staphylococcus aureus, all requiring prompt diagnosis and appropriate medical and/or surgical management.

Chronic nasopharyngeal infection is rare. To our knowledge, no effective treatment for this condition has previously been described. This report documents our experience of using suction ablation diathermy in this clinical setting.

We performed a prospective review of four patients aged 23–65 years (two men and two women) who presented with chronic nasopharyngitis. Initial medical management consisted of regular saline irrigation plus a 14-day course of doxycycline 100 mg daily, combined with rifampicin 200 mg twice daily. When this proved unsuccessful, patients subsequently received a four-week course of omeprazole 40 mg daily, also unsuccessfully. Given these treatments' lack of success, surgery was undertaken.

Following suction diathermy ablation, nasopharyngeal crusting took four to six weeks to settle. After this, all patients ceased to cough up crusts or infected mucus.

Chronic nasopharyngitis is uncommon. If medical management fails, suction ablation diathermy is a useful surgical treatment option.

We present the first reported case in the English language literature of an inflammatory myofibroblastic tumour of the right tonsil in a young, pregnant woman, and we report a management strategy for this enigmatic entity.

A 28-year-old, pregnant woman presented with a 10-day history of odynophagia despite a course of antibiotics. Examination revealed a grade II, erythematous right tonsil with ulceration on the upper pole. A biopsy was arranged, and initial evaluation was suggestive of spindle cell carcinoma. However, this diagnosis was reviewed after immunohistochemical staining confirmed an inflammatory myofibroblastic tumour. Subsequent complete excision was undertaken using CO2 laser.

Clinically, inflammatory myofibroblastic tumour of the tonsil is known to be locally aggressive and can present in a manner not dissimilar to a high grade carcinoma of the tonsil. As a result, the recommended treatment is complete local excision with careful follow up.