鼻腔恶性黑色素瘤（附3例报告）

报告３例鼻腔恶性黑色素瘤患者的临床资料；其中２例进行了手术，１例采用单纯放疗。有２例生存１年６月，１例生存４年，并对其临床症状，治疗及预后进行讨论。     

Malignant Melanoma of the Head and Neck

This study compared outcomes for intermediate-thickness(1.5 to 3.99 mm) head and neck melanomas treated with or without elective lymph node dissection (ELND). The records of all head and neck melanomas treated at Virginia Mason Medical Center from 1974 through 1995 were reviewed and analyzed for outcome by stage and elective or therapeutic lymph node dissection. One hundred seventy-four patients with head and neck melanomas were treated in the study period, of which only 25% had intermediate-thickness lesions. Of 38 clinically node-negative patients with intermediate-thickness lesions followed more than 3 years, 10 underwent ELND, yielding two positive dissections (20%). The rate of distant metastases and the mortality rate were 44% and 35% lower in patients undergoing ELND compared with stage II patients who did not undergo ELND, but the difference did not achieve statistical significance(P = 0.12 and 0.21, respectively). The role of ELND in head and neck melanoma is uncertain. This retrospective study is limited by the small number of intermediate-thickness lesions, yet there appears to be a survival advantage to ELND in head and neck melanoma, even in negative dissections. Conventional histologic stains miss micrometastases detected by immunohistological and polymerase chain techniques. Removal of such micrometastases may explain the improved outcome. A multicenter prospective trial in head and neck melanomas, incorporating the latest techniques of sentinel node biopsy and immunohistological staining of node specimens, is needed to clarify definitive therapy for this increasingly common diagnosis.     

Management Options and Survival in Malignant Melanoma of the Sinonasal Mucosa

Objective/Hypothesis: To determine whether surgery combined with radiotherapy confers any survival benefit on radical local excision alone in the management of mucosal malignant melanoma of the nose and sinuses. Study Design: Retrospective review. Methods: From a cohort of 72 patients treated between 1963 and 1996 within a single unit, complete data were available for 58 individuals who were examined to determine whether there was any significant statistical difference in local control and/or survival between those receiving surgery and those receiving combined surgery and radiotherapy. Results: There were 30 men and 28 women. Their ages ranged from 39 to 90 years (mean, 64 y). Twenty-nine patients underwent surgery alone; 23 patients underwent surgery and radiotherapy; 6 patients received surgery and chemotherapy; and 3 patients received surgery, chemotherapy, and radiotherapy. Primary surgery included lateral rhinotomy (42 cases), maxillectomy (8 cases [orbital clearance in 3 cases]), craniofacial resection (3 cases), total rhinectomy (3 cases), and endoscopic clearance (2 cases). Survival ranged from 1 to 228 months with rapid patient loss due to local (and/or systemic) disease during the first 36 months, irrespective of the treatment modality. Overall 5-year actuarial survival was 28%, and overall 10-year actuarial survival 20%, with a median survival of 21 months. There was no statistical difference in local control or survival between patients receiving surgery alone and those receiving surgery and radiotherapy, irrespective of whether this treatment was given in the early part of the series (i.e., before 1983) or thereafter. The addition of chemotherapy had no impact on survival, nor did the site of the tumor, the surgical procedure, the presence of lymph node metastases or the age of the patient. Conclusion: In this large cohort of sinonasal melanoma, overall survival was poor and did not appear to be improved by the addition of radiotherapy.     

原发性鼻粘膜恶性黑色素瘤病理和免疫组化观察

报道４０例原发性鼻粘膜恶性黑色素瘤（手术和活检标本各２０例）的病理和免疫组化观察，结果显示本瘤大体上１４例呈息肉状。光镜形态以多种细胞类型和组织形态混合存在为主要特点．免疫组化染色显示本瘤Ｓ－１００蛋白和波纹蛋白阳性率分别为９０％和７７．５％，角蛋白阴性。认为本瘤的组织发生可能来自鼻腔粘膜先前存在的黑色素细胞。组织学的多形性和免疫组化Ｓ－１００蛋白及波纹蛋白阳性对诊断本瘤的无色素型有重要意义。     

鼻腔恶性黑色素瘤24例分析

鼻腔恶性黑色素瘤为临床难治疾病之一。对１９７１～１９９１年的临床和病理资料进行回顾性分析和随访，发现鼻腔恶性黑色素瘤２４例，占同期耳鼻咽喉科住院患者的０．２％。其病理特点为在不同的瘤细胞内可见典型的前黑色素体，注意寻找瘤细胞内细小的黑色素颗粒，可避免误诊。手术仍为治疗本病的首选方法，亦可配合放疗，术后创面加激光照射处理，疗效较佳。２０例死亡，存活１～４年；４例健在，分别生存４、３、３、２年。     

Tonsil concretions and tonsilloliths

Although infrequently seen in many clinical practices, tonsillar concretions can be the source of both fetor oris and physical and social concern for the patient. Though stones rarely form in the tonsil or peritonsillar area, the findings of calcified objects or stones anywhere within the body has long been a subject of interest. The salient features of these entities and their relevance to clinical practice are discussed in this article.     

Metastatic angiosarcoma to the thyroid

BACKGROUND: Angiosarcoma (AS) in non-alpine areas is exceptionally rare, and so is metastatic AS to the thyroid. The difficulties and controversies associated with its diagnosis and management are highlighted in this case report. METHOD: Case report. RESULTS: A Chinese gentleman with AS metastatic to the thyroid presented a year after radiotherapy to his scalp AS. There was rapid expansion of the metastasis over 2 weeks and invasion of the pyriform fossa caused dysphagia and haemoptysis. The diagnosis was established by paraffin histology of the tumour post-hemithyroidectomy, after repeated fine-needle aspiration cytology was not diagnostic. Patient opted for external beam radiotherapy to the pyriform fossa instead of pharyngolaryngectomy. Residual pyriform tumour was treated with brachytherapy delivered via nasogastric tube. Unfortunately, the patient died 4 months later due to cardiac failure which was unrelated to his oncologic condition. CONCLUSION: AS metastatic to the thyroid is possible. The unexpectedly acute presentation and difficulties associated with diagnosis and management are highlighted. A useful method of delivering brachytherapy to the pyriform fossa is described.     

Metastatic disease to the mandible

Metastatic lesions to the mandible are rare, comprising less than 1% of all malignancies. Twenty-two cases of metastatic disease to the mandible were seen from 1938 to 1985. The records of 17 cases were available for detailed review. The age range was from 27 to 80 years with a female to male ratio of 12 to 5. A mandibular or paramandibular mass or swelling was the most common presenting sign. Three patients presented with mandibular metastasis prior to the discovery of the primary tumor. In the other 14 patients, the mandibular lesion appeared from 2 months to 20 years following discovery of the primary tumor. The mandibular lesion was the initial sign of distant metastatic disease in 11 of the 17 patients. Breast, lung, and colon cancer were the most common primary tumors. When presented with an isolated mandibular mass, a high index of suspicion is necessary to make the diagnosis of metastatic disease. Since plain x-rays may initially be normal, technetium or CT scan may be necessary to demonstrate osseous destruction. Inferior alveolar nerve anesthesia should be considered an indication of tumor until proven otherwise. Treatment is often of a palliative nature because of the presence of widespread metastatic disease; however, surgical resection may be considered in the rare patient with a well-documented, solitary mandibular metastasis.     

Metastatic melanoma to the ethmoid sinus

Malignant melanomas comprise approximately 1.5% of all malignant tumors and one fifth of these will involve the head and neck. The surgeon who operates in this region should be familiar with all aspects of this disease. The most common site of metastasis to the nose and paranasal sinuses is via the maxillary sinus. Often these metastases are of renal origin, with pulmonary metastases being the second most common source. The most frequent presenting symptoms are epistaxis, a nasal mass, or nasal obstruction. Review of the English literature to date has not revealed any reports of isolated metastatic melanoma to the ethmoid sinus. Batson, in 1940, proposed a plausible mechanism of such hematogenous metastasis via a valveless vertebral venous bed.     

Metastatic carcinoma to the temporal bone

We present a case report of a woman with adenocarcinoma of the breast and metastasis to the temporal bone. The diagnosis of metastasis to the temporal bone may be difficult to make, for the symptoms and findings may mimic those of chronic infection. A high-resolution computed tomography scan is mandatory for complete investigation.     

Melanoma metastatic to the head and neck

A 42-year-old man presented with a two-week history of right-sided otalgia, deafness and nocturnal tinnitus. Examination revealed a black mass on the posterior meatal wall. Two years before presentation, he had a malignant melanoma removed from the left hip region. Biopsy of the lesion in the posterior canal wall and another which had developed within two weeks on the anterior wall, confirmed metastatic disease. Treatment with radiotherapy and later chemotherapy were unsuccessful and the patient died 15 months later.     

Tonsil flora in the very young tonsillectomy patient

The tonsil flora of 20 children below the age of 4 years undergoing tonsillectomy, and a control group of 18 children were studied using tonsil swabs and core specimens. The study group had a significantly higher culture rate of anaerobic organisms, whereas there was no significant difference between the groups in respect of aerobic pathogens. Since most anaerobic organisms are relatively resistant to the antibiotics usually prescribed for recurring tonsillitis, the use of more appropriate antimicrobial therapy may be helpful in the prevention of early tonsillectomy.     

Tonsil surgery efficiently relieves symptoms: analysis of 54 696 patients in the National Tonsil Surgery Register in Sweden

Conclusion. Remote cochlear implant (CI) programming is a viable, safe, user-friendly and cost-effective procedure, equivalent to standard programming in terms of efficacy and user's perception, which can complement the standard procedures. The potential benefits of this technique are outlined. Objectives. We assessed the technical viability, risks and difficulties of remote CI programming; and evaluated the benefits for the user comparing the standard on-site CI programming versus the remote CI programming. Subjects and methods. The Remote Programming System (RPS) basically consists of completing the habitual programming protocol in a regular CI centre, assisted by local staff, although guided by a remote expert, who programs the CI device using a remote programming station that takes control of the local station through the Internet. A randomized prospective study has been designed with the appropriate controls comparing RPS to the standard on-site CI programming. Study subjects were implanted adults with a HiRes 90K® CI with post-lingual onset of profound deafness and 4–12 weeks of device use. Subjects underwent two daily CI programming sessions either remote or standard, on 4 programming days separated by 3 month intervals. A total of 12 remote and 12 standard sessions were completed. To compare both CI programming modes we analysed: program parameters, subjects’ auditory progress, subjects’ perceptions of the CI programming sessions, and technical aspects, risks and difficulties of remote CI programming. Results. Control of the local station from the remote station was carried out successfully and remote programming sessions were achieved completely and without incidents. Remote and standard program parameters were compared and no significant differences were found between the groups. The performance evaluated in subjects who had been using either standard or remote programs for 3 months showed no significant difference. Subjects were satisfied with both the remote and standard sessions. Safety was proven by checking emergency stops in different conditions. A very small delay was noticed that did not affect the ease of the fitting. The oral and video communication between the local and the remote equipment was established without difficulties and was of high quality.