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S131 – Complicated Community-Acquired MRSA Sinusitis: A Case Series
P120
Otolaryngology-Head and Neck Surgery, Vol 139, No 2S1, August 2008
zinc sulfate (ZnSO4 300 mg/day, or polaprezinc 150 mg/day), and in some cases with iron supplement, herbal medicine, and minor tranquilizers. RESULTS: Idiopathic taste disorder was the most common cause (271 cases, 38.5%), followed by drug-induced (131 cases, 18.6%), post-common cold (83 cases, 11.8%), psychogenic (73 cases, 10.4%), iron-deficiency (37 cases, 5.3%) and others. Deficiency of serum zinc (less than 70 ?g/dl) was found in 50-70% of cases. The recovery rate was 130/183 (71.0%) in idiopathic, 41/61 (67.2%) in post-common cold, and 24/29 (82.8%) in iron deficiency. The recovery period in drug-induced (39.7 weeks) was longer than that in other cases (20.4 weeks). Results of EGM and FPD were not always associated with the severity of symptoms. CONCLUSIONS: Treatment with zinc supplement may be useful for taste disorder. S129 – Analysis of Fine Needle Biopsy for Malignant Lymphoma Naoki Ashimori (presenter); Hiroyuki Mineta, MD; Minako Tsurita, MD OBJECTIVES: To review fine-needle aspiration biopsy(FNAB) diagnosis of malignant lymphoma retrospectively to determine the diagnostic accuracy and pitfalls. METHODS: 68 cases of malignant lymphoma and 52 cases of non-malignant lymphoma were identified between 1997 and 2004. All cases were recognized as cervical lymphadenopathy and evaluated by FNAB. Open biopsies were also performed to obtain final diagnoses. Malignant lymphomas were subclassified according to World Health Organization classifications. We compared the FNAB and final diagnostic results to determine the diagnostic accuracy and examine the false negative cases. RESULTS: 41(60%) cases had a positive diagnosis of malignant lymphoma, 21(31%) had a suspicious diagnosis, and 6(9%) had a false negative diagnosis. On histological examinations, diffuse large B cell lymphomas yielded a high positive diagnosis, whereas follicular lymphoma and Hodgkin’s disease had less positive diagnosis and there were also false negative cases. 14(39%) lymphadenitis cases had a suspicious diagnosis and some cases were difficult to differentiate from malignant lymphoma. CONCLUSIONS: FNAB is considered a useful and efficient method of estimating malignant lymphoma but diagnostic accuracy varied among lymphoma subtypes. We should remain aware of the existence of false negative cases when using this diagnostic method. S130 – Otolaryngologic Manifestations in Penphigus Vulgaris Secundino Fernandez, MD, PhD (presenter); Agustı´n Espan˜a; David Ruba San Miguel; Miren Marquina, PhD
OBJECTIVES: Pemphigus vulgaris is an autoimmune disease characterized by mucocutaneous intraepithelial blisters and pathogenic autoantibodies against desmoglein 3. There are 2 clinical forms: mucosal and mucocutaneous. The frequency of ear, nose and throat involvement in pemphigus vulgaris is not clearly defined. Only a few individual cases have been reported. The objective of this study was to determine the incidence of otolaryngologic involvement in patients with pemphigus. METHODS: We have studied prospectively all 18 patients diagnosed with PV and treated by Otolaryngology and Dermatology departments of the University Hospital of Navarra between 2001 and 2007. They were 10 cases of mucosal pemphigus and 8 cases of mucocutaneous pemphigus. All patients were evaluated by endoscopic examination. RESULTS: 15 patients presented with throat symptoms (83%), 13 pharyngeal (72%), and 8 laryngeal symptoms (44%). 16 patients (88%) had active pemphigus vulgaris lesions localized in pharyngeal and laryngeal mucosa. Laryngeal lesions were most commonly present in mucocutaneous patients. The frequency of nasal symptoms (38%) was lower than active pemphigus vulgaris lesions (63%). Oral symptoms and oral active lesions were the most frequent findings (94%). Only in 3 patients were sown erosions on the external auditory canal. CONCLUSIONS: Endoscopic evaluation in patients affected by pemphigus vulgaris allows to study more extensive areas of mucosa. By obtaining more complete information concerning the extent of the disease, a more accurate diagnosis can be made, better choice of drug and dose may be decided, and ultimately, response to treatment may be improved. S131 – Complicated Community-Acquired MRSA Sinusitis: A Case Series Christian L Stallworth, MD (presenter); K Christopher McMains, MD; Frank Miller, MD OBJECTIVES: Participants should 1) understand the similarities and differences between nosocomial methicillin-resistant Staphylococcus aureus (MRSA) and its community-acquired counterpart (CA-MRSA); 2) recognize MRSA as an evolving member of the bacterial pathogens responsible for acute bacterial rhinosinusitis (ABRS); and 3) raise suspicion of CAMRSA in the differential for cases of progressive sinusitis, with or without complications, despite conventional first-line antimicrobial therapies. METHODS: Following the retrospective review of patients presenting to an urban tertiary care institution, those patients presenting with complicated sinusitis were identified. Data collected from chart review included age, sex, presenting signs and symptoms, onset of illness, therapy initiated prior to emergent presentation, operative procedures performed and operative findings, culture organisms and sensitivities, postoperative course, and final outcomes. RESULTS: 9 patients presented with periorbital complica-
tions following an antecedent sinusitis. All 9 patients developed infectious orbital complications including periorbital cellulitis, lid abscess, orbital abscess, and 1 case of ipsilateral blindness. Cultures identified CA-MRSA as the primary pathogen which was characteristically sensitive only to vancomycin, clindamycin, doxycycline, and trimethoprim/sulfamethoxazole. All patients were treated with vancomycin with subsequent transition to oral antibiotics. In addition, all patients required early surgical intervention to manage their disease. CONCLUSIONS: While the vast majority of ABRS is easily treated using the guidelines established by the Sinus and Allergy Health Partnership, clinicians should consider CAMRSA sinusitis in those patients who fail to respond or who suffer disease progression. This presentation discusses the diagnosis and treatment of CA-MRSA sinusitis with emphasis on bacterial resistance and appropriate antibiotic selection. S132 – Toll-like Receptors in Salivary Glands Farnaz Dezfoulian, MD (presenter); Meghnad Ganesh Joshi, PhD; Gert Henriksson; Suchitra Sumitran Holgersson, MD; Paer Stjarne, MD, PhD; Lars Olaf Cardell, Prof OBJECTIVES: 1) To understand pathophysiology of sialoadenitis. 2) To examine the expression of Toll-like receptor 1-10 in human salivary glands, focusing on changes induced by sialoadenitis since recent research has given them a key role in the induction of various inflammatory disorders. METHODS: Biopsies from parotid and submandibular glands were obtained from patients undergoing surgery due to benign neoplastic tumours or chronic/recurrent inflammation caused by sialolithiasis. In the former, a normal part of the gland was excised as far away from the tumour as possible and was used as control. In the latter, a biopsy was taken close to the centre of the inflammation. The mRNA expression of TLR 1 to 10 was quantified using real-time polymerase chain reaction and the corresponding proteins were assessed using immunohistochemistry. RESULTS: A constant expression of TLR 1, 2, 3, and 5 were found in all specimens and an up-regulation of TLR2 was seen in biopsies from patients with chronic sialoadenitis. The immunohistochemistry revealed moderate expression of TLR 3, 5, and 6 in serous glands and an intense TLR 2 expression in mucous acini. CONCLUSIONS: Our results suggest that a TLR-mediated inflammatory component might be involved in the development of sialoadenitis, perpetuating lymphocytic infiltration and cytokine production. S133 – Boron Neutron Capture Therapy for Melanoma in Nasal Cavity Norimasa Morita, MD (presenter); Teruhito Aihara; Uno Msako; Koji Ono, MD, PhD; Tamotsu Harada, MD
P121 OBJECTIVES: Boron neutron capture therapy (BNCT) is one of the radiation therapies known to have a selective lethal effect on tumor cells. Thermal neutrons are captured by the 10B atom, resulting in the emission of linear recoiling Alfa particles and 7Li nuclei, with traveling ranges of ⬃9 and ⬃5 micrometers respectively. These particles are high linear energy transfer (LET) radiation and lethally damage DNA. BNCT for cutaneous melanoma, using 10B-para-boronophenylalanine (BPA) as the boron delivery agent, was developed and successful BNCT treatment of 18 melanoma patients has been reported by Mishima et al. METHODS: Based on their treatment regimen and with the approval of the Nuclear Safety Bureau of the Japanese government and the Medical Ethics Committees of Kawasaki Medical School and Kyoto University, we have conducted BNCT clinical trials on patients with mucosal melanomas in head-and-neck at the Kyoto University Research Reactor (KUR) and the Japan Research Reactor No. 4 (JRR-4) since 2005. RESULTS: To date, we have treated 6 patients with mucosal melanomas in the nasal cavity with BNCT. 4 patients showed a complete response (CR) by 6 months and 2 patients showed a partial response (PR) 3 months after BNCT. None of the patients showed any serious damage in normal tissue surrounding tumor site. One patient from this study died due to distant metastasis. However, no local recurrence of melanoma has been observed in all CR patients and no regrowth of melanoma in all PR patients. CONCLUSIONS: BNCT thus is a promising treatment for achieving local control of mucosal melanomas. S134 – Active MMP-7 Expression in Buccal Cancer Hui-Ching Chuang, MD (presenter); Chih-Yen Chien, MD; Chao-Cheng Huang, MD OBJECTIVES: To evaluate the active MMP-7 expression in buccal cancer and correlate the expressions with clinicopathological features. METHODS: Tissue microarrays, immunohistochemistry, and Western blotting were used to detect the expression of active MMP-7 in oral tumor from 24 patients with buccal squamous cell carcinoma (BSCC). RESULTS: Total MMP-7 was detected on Western blots in 9 of 15 tumor tissue samples (60%) and in 2 of 15 normal mucosal samples (13.3%); this difference was significant (p ⫽ 0.008). Moreover, the active form of MMP-7 was expressed in 8 (88.9%) of the 9 tumor samples that expressed MMP-7, and in none of the normal tissue samples, regardless of the expression status of the pro-form. Immunostaining of total MMP-7 was observed histologically in both tumor and non-neoplastic epithelium, but immunostaining of active MMP-7 was present only in tumor nests. Expression of active MMP-7 was associated with larger tumor size (p ⫽ 0.022) and was significantly higher in BSCC with skin or bone invasion (p ⫽ 0.036).
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Otolaryngology-Head and Neck Surgery, Vol 139, No 2S1, August 2008
zinc sulfate (ZnSO4 300 mg/day, or polaprezinc 150 mg/day), and in some cases with iron supplement, herbal medicine, and minor tranquilizers. RESULTS: Idiopathic taste disorder was the most common cause (271 cases, 38.5%), followed by drug-induced (131 cases, 18.6%), post-common cold (83 cases, 11.8%), psychogenic (73 cases, 10.4%), iron-deficiency (37 cases, 5.3%) and others. Deficiency of serum zinc (less than 70 ?g/dl) was found in 50-70% of cases. The recovery rate was 130/183 (71.0%) in idiopathic, 41/61 (67.2%) in post-common cold, and 24/29 (82.8%) in iron deficiency. The recovery period in drug-induced (39.7 weeks) was longer than that in other cases (20.4 weeks). Results of EGM and FPD were not always associated with the severity of symptoms. CONCLUSIONS: Treatment with zinc supplement may be useful for taste disorder. S129 – Analysis of Fine Needle Biopsy for Malignant Lymphoma Naoki Ashimori (presenter); Hiroyuki Mineta, MD; Minako Tsurita, MD OBJECTIVES: To review fine-needle aspiration biopsy(FNAB) diagnosis of malignant lymphoma retrospectively to determine the diagnostic accuracy and pitfalls. METHODS: 68 cases of malignant lymphoma and 52 cases of non-malignant lymphoma were identified between 1997 and 2004. All cases were recognized as cervical lymphadenopathy and evaluated by FNAB. Open biopsies were also performed to obtain final diagnoses. Malignant lymphomas were subclassified according to World Health Organization classifications. We compared the FNAB and final diagnostic results to determine the diagnostic accuracy and examine the false negative cases. RESULTS: 41(60%) cases had a positive diagnosis of malignant lymphoma, 21(31%) had a suspicious diagnosis, and 6(9%) had a false negative diagnosis. On histological examinations, diffuse large B cell lymphomas yielded a high positive diagnosis, whereas follicular lymphoma and Hodgkin’s disease had less positive diagnosis and there were also false negative cases. 14(39%) lymphadenitis cases had a suspicious diagnosis and some cases were difficult to differentiate from malignant lymphoma. CONCLUSIONS: FNAB is considered a useful and efficient method of estimating malignant lymphoma but diagnostic accuracy varied among lymphoma subtypes. We should remain aware of the existence of false negative cases when using this diagnostic method. S130 – Otolaryngologic Manifestations in Penphigus Vulgaris Secundino Fernandez, MD, PhD (presenter); Agustı´n Espan˜a; David Ruba San Miguel; Miren Marquina, PhD
OBJECTIVES: Pemphigus vulgaris is an autoimmune disease characterized by mucocutaneous intraepithelial blisters and pathogenic autoantibodies against desmoglein 3. There are 2 clinical forms: mucosal and mucocutaneous. The frequency of ear, nose and throat involvement in pemphigus vulgaris is not clearly defined. Only a few individual cases have been reported. The objective of this study was to determine the incidence of otolaryngologic involvement in patients with pemphigus. METHODS: We have studied prospectively all 18 patients diagnosed with PV and treated by Otolaryngology and Dermatology departments of the University Hospital of Navarra between 2001 and 2007. They were 10 cases of mucosal pemphigus and 8 cases of mucocutaneous pemphigus. All patients were evaluated by endoscopic examination. RESULTS: 15 patients presented with throat symptoms (83%), 13 pharyngeal (72%), and 8 laryngeal symptoms (44%). 16 patients (88%) had active pemphigus vulgaris lesions localized in pharyngeal and laryngeal mucosa. Laryngeal lesions were most commonly present in mucocutaneous patients. The frequency of nasal symptoms (38%) was lower than active pemphigus vulgaris lesions (63%). Oral symptoms and oral active lesions were the most frequent findings (94%). Only in 3 patients were sown erosions on the external auditory canal. CONCLUSIONS: Endoscopic evaluation in patients affected by pemphigus vulgaris allows to study more extensive areas of mucosa. By obtaining more complete information concerning the extent of the disease, a more accurate diagnosis can be made, better choice of drug and dose may be decided, and ultimately, response to treatment may be improved. S131 – Complicated Community-Acquired MRSA Sinusitis: A Case Series Christian L Stallworth, MD (presenter); K Christopher McMains, MD; Frank Miller, MD OBJECTIVES: Participants should 1) understand the similarities and differences between nosocomial methicillin-resistant Staphylococcus aureus (MRSA) and its community-acquired counterpart (CA-MRSA); 2) recognize MRSA as an evolving member of the bacterial pathogens responsible for acute bacterial rhinosinusitis (ABRS); and 3) raise suspicion of CAMRSA in the differential for cases of progressive sinusitis, with or without complications, despite conventional first-line antimicrobial therapies. METHODS: Following the retrospective review of patients presenting to an urban tertiary care institution, those patients presenting with complicated sinusitis were identified. Data collected from chart review included age, sex, presenting signs and symptoms, onset of illness, therapy initiated prior to emergent presentation, operative procedures performed and operative findings, culture organisms and sensitivities, postoperative course, and final outcomes. RESULTS: 9 patients presented with periorbital complica-
tions following an antecedent sinusitis. All 9 patients developed infectious orbital complications including periorbital cellulitis, lid abscess, orbital abscess, and 1 case of ipsilateral blindness. Cultures identified CA-MRSA as the primary pathogen which was characteristically sensitive only to vancomycin, clindamycin, doxycycline, and trimethoprim/sulfamethoxazole. All patients were treated with vancomycin with subsequent transition to oral antibiotics. In addition, all patients required early surgical intervention to manage their disease. CONCLUSIONS: While the vast majority of ABRS is easily treated using the guidelines established by the Sinus and Allergy Health Partnership, clinicians should consider CAMRSA sinusitis in those patients who fail to respond or who suffer disease progression. This presentation discusses the diagnosis and treatment of CA-MRSA sinusitis with emphasis on bacterial resistance and appropriate antibiotic selection. S132 – Toll-like Receptors in Salivary Glands Farnaz Dezfoulian, MD (presenter); Meghnad Ganesh Joshi, PhD; Gert Henriksson; Suchitra Sumitran Holgersson, MD; Paer Stjarne, MD, PhD; Lars Olaf Cardell, Prof OBJECTIVES: 1) To understand pathophysiology of sialoadenitis. 2) To examine the expression of Toll-like receptor 1-10 in human salivary glands, focusing on changes induced by sialoadenitis since recent research has given them a key role in the induction of various inflammatory disorders. METHODS: Biopsies from parotid and submandibular glands were obtained from patients undergoing surgery due to benign neoplastic tumours or chronic/recurrent inflammation caused by sialolithiasis. In the former, a normal part of the gland was excised as far away from the tumour as possible and was used as control. In the latter, a biopsy was taken close to the centre of the inflammation. The mRNA expression of TLR 1 to 10 was quantified using real-time polymerase chain reaction and the corresponding proteins were assessed using immunohistochemistry. RESULTS: A constant expression of TLR 1, 2, 3, and 5 were found in all specimens and an up-regulation of TLR2 was seen in biopsies from patients with chronic sialoadenitis. The immunohistochemistry revealed moderate expression of TLR 3, 5, and 6 in serous glands and an intense TLR 2 expression in mucous acini. CONCLUSIONS: Our results suggest that a TLR-mediated inflammatory component might be involved in the development of sialoadenitis, perpetuating lymphocytic infiltration and cytokine production. S133 – Boron Neutron Capture Therapy for Melanoma in Nasal Cavity Norimasa Morita, MD (presenter); Teruhito Aihara; Uno Msako; Koji Ono, MD, PhD; Tamotsu Harada, MD
P121 OBJECTIVES: Boron neutron capture therapy (BNCT) is one of the radiation therapies known to have a selective lethal effect on tumor cells. Thermal neutrons are captured by the 10B atom, resulting in the emission of linear recoiling Alfa particles and 7Li nuclei, with traveling ranges of ⬃9 and ⬃5 micrometers respectively. These particles are high linear energy transfer (LET) radiation and lethally damage DNA. BNCT for cutaneous melanoma, using 10B-para-boronophenylalanine (BPA) as the boron delivery agent, was developed and successful BNCT treatment of 18 melanoma patients has been reported by Mishima et al. METHODS: Based on their treatment regimen and with the approval of the Nuclear Safety Bureau of the Japanese government and the Medical Ethics Committees of Kawasaki Medical School and Kyoto University, we have conducted BNCT clinical trials on patients with mucosal melanomas in head-and-neck at the Kyoto University Research Reactor (KUR) and the Japan Research Reactor No. 4 (JRR-4) since 2005. RESULTS: To date, we have treated 6 patients with mucosal melanomas in the nasal cavity with BNCT. 4 patients showed a complete response (CR) by 6 months and 2 patients showed a partial response (PR) 3 months after BNCT. None of the patients showed any serious damage in normal tissue surrounding tumor site. One patient from this study died due to distant metastasis. However, no local recurrence of melanoma has been observed in all CR patients and no regrowth of melanoma in all PR patients. CONCLUSIONS: BNCT thus is a promising treatment for achieving local control of mucosal melanomas. S134 – Active MMP-7 Expression in Buccal Cancer Hui-Ching Chuang, MD (presenter); Chih-Yen Chien, MD; Chao-Cheng Huang, MD OBJECTIVES: To evaluate the active MMP-7 expression in buccal cancer and correlate the expressions with clinicopathological features. METHODS: Tissue microarrays, immunohistochemistry, and Western blotting were used to detect the expression of active MMP-7 in oral tumor from 24 patients with buccal squamous cell carcinoma (BSCC). RESULTS: Total MMP-7 was detected on Western blots in 9 of 15 tumor tissue samples (60%) and in 2 of 15 normal mucosal samples (13.3%); this difference was significant (p ⫽ 0.008). Moreover, the active form of MMP-7 was expressed in 8 (88.9%) of the 9 tumor samples that expressed MMP-7, and in none of the normal tissue samples, regardless of the expression status of the pro-form. Immunostaining of total MMP-7 was observed histologically in both tumor and non-neoplastic epithelium, but immunostaining of active MMP-7 was present only in tumor nests. Expression of active MMP-7 was associated with larger tumor size (p ⫽ 0.022) and was significantly higher in BSCC with skin or bone invasion (p ⫽ 0.036).
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