Undifferentiated nasopharyngeal carcinoma presenting as a parotid mass

Background. Nasopharyngeal carcinoma has a variety of presentations. However, in more than 50% of cases it may present with serous otitis or cervical metastases. Although the metastases usually occur in the neck, the lymphatic network of the parotid may also serve as a site for the metastatic deposits. We present a case in which the initial manifestation of nasopharyngeal carcinoma of the lymphoepithelioma type was a parotid mass. Methods. Case study. Results. A patient who was initially seen with an isolated parotid mass was found to have an undifferentiated carcinoma of the lymphoepithelial type. Further evaluation identified an occult nasopharyngeal carcinoma, and the patient underwent radiotherapy. Conclusions. A diagnosis of a malignant lymphoepithelial lesion of the parotid gland or undifferentiated carcinoma of the lymphoepithelial type mandates a search for an occult primary nasopharyngeal tumor.     

Chronic subdural haematoma associated with nontraumatic CSF rhinorrhea: a management challenge.

We report an unusual case of chronic subdural haematoma (CSH) associated with cerebrospinal fluid (CSF) rhinorrhoea emphasizing the importance of managing both conditions simultaneously. A 59- year-old man presented with watery discharge from the right nostril, of 2 months duration. MRI of the brain showed a CSH in the left fronto-parietal region with significant mass effect. There was an arachnoidocoele with a defect in the planum sphenoidale. He first underwent a burr hole evacuation of the CSH following which the CSF rhinorrhea did not subside, even with bed rest. Transnasal endoscopic closure of the CSF dural fistula was done. On the first post-operative day, he was disoriented and a CT scan showed a recollection of the subdural haematoma that required repeat evacuation. The patient was asymptomatic at discharge. To our knowledge this is the first reported case of CSF rhinorrhoea associated with CSH. Simultaneous closure of the CSF dural fistula at the time of evacuation of a coexisting CSH would be the optimal management.     

Effects of gastric bypass procedures on bone mineral density,calcium, parathyroid hormone,and vitamin d

Weight loss after gastric bypass procedures has been well studied, but the long-term metabolic sequelae are not known. Data on bone mineral density (BMD), calcium, parathyroid hormone, and vitamin D were collected preoperatively and at yearly intervals after gastric bypass procedures. A total of 230 patients underwent preoperative BMD scans. Fifteen patients were osteopenic preoperatively, and three patients subsequently developed osteopenia postoperatively within the first year. No patient had or developed osteoporosis. At 1 year, total forearm BMD decreased by 0.55% (n = 91; P = .03) and radius BMD had increased overall by 1.85% (n = 23; P = .008); both total hip and lumbar spine BMD decreased by 9.27% (n = 22; P < .001) and 4.53% (n = 31; P < .001), respectively. By the second postoperative year, BMD in the total forearm had decreased an additional 3.62% (n = 14; P<.001), whereas radius BMD remained unchanged. Although total hip and lumbar spine BMD significantly decreased at 1 year, by year 2 both total hip and lumbar spine BMD only slightly decreased and were not significantly different from before the operation. Serum calcium decreased from 9.8 mg/dL to 9.2 during the first year (not significant [NS]) and then to 8.8 (NS) by the second year. Parathyroid hormone increased from 59.7 pg/mL (nl 10-65 pg/mL) preoperatively to 63.1 during year 1 (NS) and continued to increase to 64.7 by year 2 (NS). No difference was noted among levels of 25-hydroxy vitamin D preoperatively (25.2 ng/mL; nl 10-65 ng/mL), at 1 year (34.4), and at 2 years (35.4). Our data indicate that bone loss is highest in the first year after gastric bypass with stabilization, and that, in some cases, there is an increase in bone density after the first year. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation).     

Commonalities in fly embryogenesis and mammalian pituitary patterning.

During embryonic development, morphogenetic gradients can specify the formation of gene expression territories. Here, we explore possible commonalities between pattern formation in the Drosophila blastoderm and murine pituitary. Shared principles include the need for positive feedback involving fate-determining genes to maintain a differentiated state, and the existence of intra- or extracellular inhibitory signals that improve spatial resolution of neighboring territories. The precision of spatial segregation is, however, limited by stochastic gene expression. Variability in gene expression at territory boundaries might give rise to a poorly differentiated pool of cells, which could harbor stem-like properties. The ideas outlined here deserve further theoretical and experimental exploration.