Palatal Tonsils Research Articles

The clinical impact of p16 status in fine-needle aspirates of cervical lymph node metastasis of head and neck squamous cell carcinomas

Lymph node involvement is prognostically the most determinant clinical factor for patients with head and neck squamous cell carcinomas (HNSCCs). Ultrasound of the neck and fine-needle aspiration (FNA) cytology is one of the first diagnostic procedures and the most accurate diagnostic staging tool for the neck. Patients with HPV-positive oropharyngeal carcinomas (OPSCC) show a significantly better prognosis when compared with HPV-negative OPSCC. P16 overexpression is accepted as surrogate marker for HPV-positive in OPSCC. These HPV/p16-positive OPSCC are localized either in the palatal tonsils or the base of tongue and frequently present with lymph node metastases. We analyzed the correlation and reliability of p16 expression of the FNA of the lymph node metastasis with the immunohistochemical expression of p16 of the same lymph node metastasis and its corresponding primary tumor, as it could be of importance for determining the localization and different prognosis of the primary tumor. 54 HNSCC patients were evaluated, p16 expression of the primary tumors and their lymph node metastases correlated precisely. In 25 of the 54 HNSCC patients, a FNA of the lymph node metastases was taken before the treatment. The positive cytological and immunohistochemical p16 staining correlated exactly. Of the 17 histologically p16-negative lymph node metastases 15 FNA were p16-negative, whereas two samples were p16-positive. In our view, a cytological p16 analysis of cervical lymph node metastasis can facilitate the correct localization of the primary tumor and discriminate reliably HPV-positive OPSCC from HPV-negative HNSCC with their significantly diverse prognosis.

Giant tonsillolith - a rare cause of dysphagia.

Tonsilloliths are calcified concretions that originate within the palatal tonsil crypts. Moreover, development of these concretions into giant tonsilloliths is exceptionally uncommon. We present a 17-year-old female with a two-year history of increasing dysphagia, persistent oral cavity swelling and speech alteration. Clinical examination of the oral cavity revealed a large solid left tonsil with no obvious neck masses. Computer tomography demonstrated a well-defined, large calcified left tonsillar fossa mass of uncertain underlying cause. This patient subsequently underwent surgical excision for histology.

Peculiarities of clinical profile of snoring and mild to moderate obstructive sleep apnea–hypopnea syndrome patients

The purpose of this study is to perform comprehensive evaluation of the snoring and mild to moderate obstructive sleep apnea-hypopnea syndrome (OSAHS) patients for their anatomical, functional, and psychoemotional clinical properties. Seventy-four snoring patients, aged 24 to 64 (mean 41.83 ± 11.01) years underwent full-night polysomnography, nasopharyngoscopy, and Mueller maneuver. Clinical tests battery consisting of visual analogue scales (VAS) scales, Lithuanian version of Sleep Apnea Quality of Life Index (SAQLI-LT), Spielberg's State-Trait Anxiety Inventory (STAI), Beck Depression Inventory-Second Edition (BDI-II), and Epworth Sleepiness Scale (ESS) were applied to assess their distinctive clinical properties. The total group of snoring and mild to moderate OSAHS patients presented with considerably enlarged VAS snoring and daytime sleepiness scores (mean 66.32 ± 19.07 and 35.03 ± 27.83 points), mild BDI-II scores (mean 10.96 ± 9.42 points), and moderate trait anxiety scores (mean 41.51 ± 8.62 points). All the scores of daytime complaints measured with the VAS correlated statistically significantly with the mean scores of the ESS, SAQLI-LT, trait anxiety, and BDI-II. Both groups, of snoring and mild to moderate OSAHS patients, indicated similar intensity of the major complaints according to the VAS, same as similar BDI-II, STAI, and SAQLI-LT scores. A higher Friedman's score of palatal tonsils was found in the group of snoring patients, comparing to that of the group of mild to moderate OSAHS patients (p < 0.05). Snoring and mild to moderate OSAHS patients have resemblances in their distinctive anatomical and clinical properties. This group of the patients revealed mild depression and moderate trait anxiety scores when measured with the BDI-II and STAI, which correlated significantly with the severity of the patients' daytime complaints measured with the VAS.

Noma-like lesion in a patient with acute promyelocytic leukemia

The term noma is used to describe a spreading, invasive gangrene with edema of the face which starts as an ulcer of the mucous membrane and extends from in outwardly, rapidly perforating and destroying soft tissues and bone and almost always rapidly fatal.(1,2) The disease occurs mainly in children from deprived areas with low levels of hygiene. Cases of children are common and occur mainly in under-developed countries; adult cases are rare and are reported predominantly in developed countries. However, some adult cases can be attributed to malnutrition and to a predisposition to infectious disease. Leukemia is increasingly being recognized as an associated factor.(2) Patients with leukemia are at a high risk of developing nomas during chemotherapy, as this can induce agranulocytosis.(3) Regardless of the type of initial lesions, gangrene always develops rapidly, but remains well defined.(3) Most patients do not consult their doctor until the disease is at an advanced stage, its onset and progression remains a mystery.(1) The prognosis for childhood noma has improved dramatically since the discovery of antibiotics, prior to which there was only a 15% survival rate whereas now only 15% succumb to it.(2) Prompt and appropriate antibiotic therapy can ensure the patient's survival with an aesthetically acceptable outcome.(3) A 17-year-old Caucasian male, who had had throat pain and odynophagia for one week, was submitted for blood tests (Hemoglobin: 7.0 g/dL; Hematocrit: 21%; WBC: 33 x 109 cells/L and platelets: 38 x 109 cells/L). Acute promyelocytic leukemia (M3) was diagnosed and the patient was treated with daunorubicin plus vesanoid. A physical examination demonstrated an extensive necrotic lesion in the M. palatoglossus, soft palate, uvula and right tonsil, accompanied by an unpleasant odor (Figure 1). Samples were collected for biopsy and culture. The histopathologic findings showed nonspecific chronic diffuse inflammation infiltrated by necrotic areas and numerous bacteria. The culture identified Enterococcus spp, Staphylococcus aureus and Candida SP. In accordance with the histological and bacteriological findings it was concluded that this was a noma-like lesion. The patient then received antibiotic therapy using ceftazidime, amicacin, vancomycin, fluconazole and penicillin G. The patient developed pneumonia and sepsis and was treated in the intensive care unit. Total recovery albeit with extensive loss of soft palate tissue was attained in 45 days. Figure 1 Extensive necrotic lesion in the m. palatoglossus, soft palate, uvula and right tonsil with foul odor Cancrum oris (noma) occurs predominantly among deprived and poorly nourished children in developing countries, whohave poor oral hygiene. It is often associated with infections such as measles and rubella.(1,3) In 90% of cases, nomas develop before the age of 10 years old.(4) Other commonly associated diseases include: typhoid fever, whooping cough, typhus, syphilis, tuberculosis and leukemia in descending order of frequency.(1,3,4) To the best of our knowledge, there are only five cases reported concerning nomas or noma-like lesions in patients with oncohematological malignancies in PubMED (Table 1). Table 1 Case reports published in PubMED about Noma and Noma-like lesions in patients with oncohematological malignancies It is difficult to pinpoint any specific triggering agent in the complex microbiota of a noma.(1) Streptococcus, Fusobacterium and Bacterioides have been associated with cancrum oris.(3) This patient's lesion was diagnosed as a noma-like lesion because of the similarity of its clinical features: rapid progression to gangrenous necrosis of the hard and soft palate, uvula and right tonsil, leading to severe mutilation, as seen in noma lesions but of a different etiopathogenesis (Enterococcus spp, Staphylococcus aureus and Candida SP infection).(7) The differential diagnoses are: mucocutaneous leishmaniasis; lupus erythematosus; leprosy; agranulocytic ulcerations; physical trauma (including burns); syphilis; oral cancer and yaws.(1) Infections of the oral cavity can spread to other parts of the body.(1) The prognosis for nomas is largely dependent upon early and accurate diagnosis and treatment.

Differences between the ovine tonsils based on an immunohistochemical quantification of the lymphocyte subpopulations

In sheep, the pharyngeal first defence line against oral and inhaled antigens is organized in six tonsils. Since tonsils are regarded as secondary lymphoid tissue and part of the acquired immune system which is subjected to induction through contact with antigens, an evaluation of the different lymphocyte populations in tonsils is useful to determine a tendency of the specific tonsils to more inductive or more effective immunity. By means of immunohistochemistry, different lymphocyte populations were quantified and localized using a panel of eight antibodies, i.e. anti-CD45, anti-CD21, anti-CD2, anti-CD3, anti-CD4, anti-CD8, anti-WC1 and anti-Ki67. The CD21+ B lymphocytes were localized within the tonsillar lymphoid follicles. The CD2+/CD3+ T lymphocytes were numerous in the interfollicular regions and were aligned underneath and within the epithelium but were also observed at the CD21+ pole of the lymphoid follicles. Near the lingual and tubal tonsils, and the tonsil of the soft palate, the CD45+ cells around the seromucous glands and in the lamina propria were mainly CD3+ T cells. In all tonsils, the WC1+ gamma delta T cells formed a small lymphocyte population which harboured the lamina propria and the interfollicular region. The relative percentages of the different lymphocyte populations of the large palatine and pharyngeal tonsils, which are macroscopically the most developed, were comparable. In contrast, the lingual tonsil was significantly different from the other tonsils not only by its small size and lack of lymphoid follicles, but also by the lymphocyte populations. Based on the lymphocyte populations, the ovine tonsils can be divided in three groups with the tonsil of the soft palate, the tubal and paraepiglottic tonsil forming an intermediate between the palatine and pharyngeal tonsils as true tonsils on the one side, and the lingual tonsil as a scattered lymphocyte aggregation on the other side.

An analysis of clinical risk factors of deep neck infection

Objectives To clarify the clinical risk factors that aggravate deep neck infection. Patients and methods Sixty-five patients with deep neck infection (abscess or cellulitis), 42 males and 23 females, who were treated at the ear, nose, and throat department in Iwaki Kyoritsu General Hospital in the past 10 years, were retrospectively reviewed. Cases of inflammation of the upper airway including the oral cavity, laryngopharynx, palate tonsil and salivary gland, and cases of lymphadenitis were investigated. These patients were divided into five localized types and one wide range type according to the abscess locations as follows: oral cavity floor type, upper deep cervical type, submandibular type, submental type, retropharyngeal type, and wide range type. Results Seventeen of the 65 patients had diabetes, and significantly more diabetics had the wide range type than the localized type ( P < 0.05, Fisher's test). Diabetes complication was more often seen in the upper deep cervical type among patients aged 61 years or older, and in the wide range type among males aged 41 years or older and elderly women aged 61 years or older. No patients with odontogenic infection or sialolithiasis had associated diabetes mellitus. Two cases developed mediastinitis, and one was caused by retrotonsillar abscess and needed thoracic drainage. More than half of the wide range type cases and more than a quarter of each of the localized type cases except the upper deep cervical type also had laryngeal edema, and eight of them needed emergency tracheotomy. Thirteen of the 40 cases had bacteria belonging to the Streptococcus milleri group (SMG), and all were detected in patients who underwent surgical drainage. Four of the 13 cases where SMG was detected showed drug resistance to some sorts of antibiotics. Conclusion Oral disorders can develop deep neck infection independently of the presence of diabetes mellitus, compared with other causes. The presence of diabetes mellitus is associated with deep neck infection, aggravating parotitis and wide spread of inflammation. Retrotonsillar abscess often spreads to the retropharyngeal and parapharyngeal spaces, causing mediastinitis, so caution is necessary. Infection due to SMG tends to form abscess independently of diabetes mellitus. Since more than half of the wide range type and more than a quarter of each of the localized types except the upper deep cervical type were associated with laryngeal edema, airway management should be considered.

Bilateral multiple tonsilloliths

Tonsilloliths or tonsil stones are calcifications that form in the crypts of the palatal tonsils. These calculi are composed of calcium salts, alone or in combination with other mineral salts, and are usually small, although there have been occasional reports of large tonsilloliths or calculi in peritonsillar locations. Most often, these calculi are asymptomatic and small, often detected only by computed tomography (CT), although large calculi may be visible in routine panoramic radiographs. Although tonsilloliths normally do not require medical attention, they may become large enough to cause a variety of symptoms requiring treatment. Here, we report the case of a 45-year-old male with difficulty opening the mouth and previous treatment for carcinoma of the left buccal mucosa 6 years earlier. Routine orthopantomography revealed large, bilateral, radiopaque areas over the ramus of the mandible. A diagnosis of multiple tonsilloliths was made after confirming the exact location of the radiopacities on CT.

S295 – Palate Length, Tonsil Size, and Sleep Apnea Severity

Objectives Determine the relationships between soft tissue oropharyngeal measurements and obstructive sleep apnea severity. Methods A prospective series of adult patients undergoing surgical theraphy for obstructive sleep apnea (OSA) was studied. Tonsil size (graded 0 to 4+) and median (palatal spineuvula tip) and lateral (posterior hard palate-free edge soft palate) dimensions of the soft palate were directly measured transorally at the time of surgery. From the preoperative polysomnographic and the medical record, respiratory disturbance index (RDI), lowest oxygen saturation (LSat) and body mass index (BMI) were determined. The relationships between both RDI and LSat and tonsil size and palatal dimensions was determined with multivariate linear regression adjusted for BMI. Results 88 patients were enrolled. The mean (±)95% confidence interval values for the median and lateral soft palate lengths were 4.71 (±) 0.14 cm and 3.73 (±) 0.12 cm, respectively; the mean tonsil size was 1.8 (±) 0.3. The mean RDI and LSat were 44.0 (±) 5.6 events/hour and 84.7 (±) 2.4%, respectively. On multivariate regression, only BMI significantly predicted RDI (p=0.003); median (p=0.210) and lateral (p=0.507) palate lengths and tonsil size (p=0.860) did not. For the LSat, both BMI and tonsil size were significant predictors (p&lt;0.001 and p=0.017, respectively); median and lateral lengths were not (p=0.251 and p=.376, respectively). Conclusions Adjusted for BMI, soft palate length does not consistently predict sleep apnea severity. Adjusted for BMI, tonsil size predicts the LSat but not the RDI. These results highlight difficulties associated with correlating soft tissue anatomy with sleep apnea severity.

Airway Obstruction in a Young Adult With Infectious Mononucleosis by Epstein-Barr Virus

To the Editor: Infectious mononucleosis (IM) denotes a clinical syndrome characterized by systemic somatic complaints with prominent fever, fatigue and malaise, lymphadenopathy, and sore throat. The principal cause of IM is primary infection with Epstein-Barr virus (EBV). Approximately 10% of cases are more appropriately termed IM-like illness and may result from primary infection with cytomegalovirus, Toxoplasma gondii, human immunodeficiency virus, adenovirus, viral hepatitis, and possibly rubella virus.1 Infectious mononucleosis caused by EBV usually resolves over a period of weeks or months without sequelae but may occasionally be complicated by a wide variety of neurological, hematologic, hepatic, respiratory, and psychological complications.1,2 The rarest but most deadly complication of IM is respiratory obstruction. These patients have massive tonsillar enlargement, pharyngeal edema, or both, sufficient to cause upper airway obstruction and death. It may be caused by swelling of the tonsils and adenoids; edema of the uvula, epiglottis, or arytenoids; or the formation of a pseudomembrane similar to that seen in diphtheria. Corticosteroids may have a role in hastening resolution of some complications, especially upper airway obstruction and possibly immune-mediated anemia and thrombocytopenia, but should be used judiciously.1,2 A 20-year-old man presented to our hospital complaining of 3-day fever, sore throat, dysphagia, fluxion, and severe cervical lymphadenopathy. He had no known allergies. On physical examination, his temperature was 37.5°C, blood pressure was 130/80 mm Hg, pulse was 90 beats/min, and respirations were 20 breaths/min. The patient's tonsils were markedly enlarged, with confluent exudates. The cervical lymph nodes were enlarged and tender. The white blood cell count was 13,100 cells/μL (lymphocytes, 43.5%; neutrophils, 42.5%), hemoglobin was 13 g/dL, hematocrit was 38.9%, and platelet count was 171,000/μL. The peripheral blood smear microscopy revealed 7% atypical lymphocytes. On admission, elevated serum levels of aspartate aminotransferase (120 U/L [reference range, 5-40 U/L]), alanine aminotransferase (267 U/L [reference range, 7-56 U/L]), and lactate dehydrogenase (1034 U/L [reference range, 313-618 U/L]) were observed. Monotest was negative. Clinical manifestation was compatible with IM syndrome. Specific antibodies for EBV, cytomegalovirus, Toxoplasma, and human immunodeficiency virus 1/2 were measured. Because of patient's tonsillar enlargement and severe cervical lymphadenopathy, intravenous methylprednisolone was initiated on the first hospital day. Intravenous hydration and clindamycin were also administered, because anaerobic microorganisms may be associated with this condition. 3,4. On the second hospital day, despite corticosteroids administration, the tonsillar enlargement and cervical lymphadenopathy worsened, and obstructive dyspnea developed. The patient was intubated, because of near-complete airway obstruction. Five hours later, after patient's stabilization, he was transferred to another hospital's intensive care unit. One month later, he was discharged in good condition. The next day, specific IgM EBV antibodies were positive (>160 U/mL). Diagnosis of EBV IM was established.5 Significant upper airway obstruction results from palatal and nasopharyngeal tonsil hypertrophy and inflammatory edema of surrounding soft tissues. Airway obstruction with progressive symptoms occurs in less than 5% of all patients and is one of the most common indications for hospitalization for IM. This complication mainly concerns younger children rather than adults, unlike our case.1,2,6,7 The benefit of corticosteroids for complications of IM has been advocated based on anecdotal experience but has not been critically evaluated. Corticosteroids are unnecessary in mild, uncomplicated cases and should not be routinely administered to all persons with IM. In addition, there are theoretical concerns about immunomodulation of a virus with transforming potential that has been causally linked to a variety of malignancies. Indications include incipient upper airway obstruction, autoimmune hemolytic anemia or neutropenia, thrombocytopenia with hemorrhage, meningoencephalitis, and other neurological complications. Intravenous or oral corticosteroids given for 1 to 3 days have been used with similar results of dramatic subjective improvement within 24 hours and objective improvement within 72 hours.1,6,7 Nevertheless, in our case, corticosteroids failed to prevent airway obstruction. Therefore, corticosteroid therapy may hasten resolution of complications in some but not all cases of IM. Nikolaos Papadopoulos, MD* Anastasios Liverezas, MD* Nikolaos Antonakopoulos, MD* Apostolos Karathanasis, MD† Georgios Apostolopoulos, MD* *Internal Medicine Department †Microbiology Department 411 General Army Hospital Tripoli, Greece [email protected]

Protocol for research on obstructive sleep apnea syndrome (OSAS) among epilepsy patients in University Science Malaysia Hospital

Sleep dysfunction and sleep disorders are among the most common and the most underdiagnosed conditions in all of medicine, contributing to significant impairment in countless individuals, sometimes on a daily basis. Sleep-related dysfunction is particularly common in many types of neurologic dysfunction, including movement disorders such as Parkinson's disease, degenerative disorders such as Alzheimer's disease, and stroke. Perhaps no area, however, involves the number and diversity of interactions as exist between sleep and epilepsy.1 Sleep disorders are common in the general population, so it is not surprising that they are also common in epilepsy patients. When patients with epilepsy were compared with control patients using the Epworth Sleepiness Scale, epilepsy patients were drowsier. A difference was not seen, however, when a sleep apnea scale was included, emphasizing the importance of this condition. The study demonstrates that excessive daytime sleepiness is common in both epilepsy subjects and control subjects, and that much of this may be due to treatable conditions (particularly sleep apnea).2 Obstructive sleep apnea syndrome (OSAS) is a disorder of abnormal respiration during sleep that results in a combination of hypoxemia and hypercapnia. The syndrome can be caused by obstruction of the upper airway during sleep, by abnormality in regulation of breathing by the central nervous system, or by a combination of obstructive and central problems.3 The apneic episodes lead to hypoxemia and to chronic sleep deprivation because multiple arousals during the apneic episodes cause sleep fragmentation. Sleep deprivation and hypoxia can decrease the seizure threshold in epilepsy patients. In many epilepsy patients without sleep apnea, seizures may occur on arousal. 4 Under the University Science Malaysia research university grant (RU Grant) epilepsy study project , we have developed a research protocol to study the prevalence of obstructive sleep apnea syndrome in epilepsy patients. The research protocol has been approved by the University Science Malaysia Research Ethics Committee (Human) Health Campus. All epilepsy patients, both male and female who attended the neurology clinic in University Science Malaysia Hospital (HUSM) and who agree to participate in this study will be included. This protocol involved the assessment of sleepiness in epilepsy patients by using the Berlin and Epworth questionaires. The second step is the careful and meticulous examination of patients by otorhinolaryngologists to identify any obvious obstructive cause from the nose down to the upper airway. The possible causes are long, bulky uvula, large hypertrophied palatal tonsils, large tongue and narrow pharynx, nasal septal deviation, nasal polyps, or collapse of the nasal valve on inspiration. Less common are a retrognathic mandible, vocal cord disorders, laryngeal or tracheal abnormalities. All of the subjects will then undergo an overnight polysomnography test in HUSM sleep laboratory. The obstructive apnea is defined as absence of airflow detected by the end tidal nasal cannula with presence of chest wall movement. The number and duration of obstructive apneas of any length will be quantified. The apnea index (AI) is defined as the number of obstructive apneas of any length per hour of sleep, is calculated for each Protocol for research on obstructive sleep apnea syndrome (OSAS) among epilepsy patients in University Science Malaysia Hospital 2 of 3 subject. Central apnea is defined as the absence of airflow detection with absence of chest wall movement. Mixed apnea is defined as apneas having both central and obstructive component. The lowest and highest oxygen saturation (SaO2) and the number of desaturation of more than four percent will be quantified. The total sleep time for each subject will also be quantified. The OSAS will be divided into mild, moderate and severe. Mild OSAS is defined as AI more than 1 but less than 15, moderate OSAS AI between 15 to 30 and severe OSAS when AI more than 30. Patients diagnosed as OSAS will be treated accordingly and the outcome measurement study will be carried out. By having this research protocol, it is our hope that both epilepsy and previously undiagnosed OSAS will be treated properly and accordingly. CORRESPONDENCE TO Dr Baharudin Abdullah Dept ORL-HNS, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia. Tel: +609-7664110 Fax: +609-7653370 Email: baharudin@kb.usm.my

Flora bakteryjna występująca na powierzchni i w miąższu migdałków w przewlekłym zapaleniu migdałków podniebiennych

The purpose of the work was to present the frequency of isolation of particular bacterial species from smear samples obtained from the surface of the palatal tonsils and from aspirates of tonsillar core. The material involved 100 patients, 49 women and 51 men among them, who were qualified to tonsillectomy based on their history, otolaryngological examination and selected laboratory parameters and in whom bacteriological examination of smears taken from the right and left palatal tonsil were performed. The material obtained from superficial tonsillar smears and from tonsillar core aspirates was subject to bacteriological analysis. Frequency of isolation of particular bacterial species was performed. Higher detectability of beta-haemolytic streptococci was found in tonsillar core aspirates, as compared to superficial smears. Bacteriological analysis of palatal tonsil core aspirate was shown to be a good method of isolation of pathogenic microbial strains.

Rapid PrPSc Detection in Lymphoid Tissue and Application to Scrapie Surveillance of Fallen Stock in Japan: Variable PrPSc Accumulation in Palatal Tonsil in Natural Scrapie

Rapid western blot (WB) procedure for an abnormal isoform of prion protein (PrP(Sc) ) detection in lymphoid tissues was established and has been applied to the surveillance of fallen stock. In this program, brain and palatal tonsil were examined by WB and three cases of sheep scrapie were detected. While one clinically scrapie-infected sheep harbored PrP(Sc) in the brain and palatal tonsil, the two sheep in the pre-clinical stage harbored PrP(Sc) in the brain, but not in the palatal tonsil. This study shows that PrP(Sc) accumulation in palatal tonsil is variable in natural scrapie, even among genetically susceptible sheep.

Normal FDG Distribution Patterns in the Head and Neck: PET/CT Evaluation

To retrospectively evaluate the distribution of fluorine 18 fluorodeoxyglucose (FDG) in the head and neck region with combined positron emission tomography-computed tomography (PET/CT) in patients with no known abnormality in this region. The institutional review board allowed a retrospective review of PET/CT images obtained in 78 patients with non-head and neck cancer and waived the requirement for informed consent. The accumulation of FDG in 11 normal head and neck structures was visually and quantitatively assessed retrospectively. Positive rate percentage (PRP) was defined as the sum of the percentages of patients with grade 2 and grade 3 tracer uptake intensity. Standardized uptake values (SUVs) were calculated for quantitative analysis. Mean SUVs were compared between the male and female patients by using the unpaired t test, and the correlation between FDG uptake and patient age was assessed by using the Pearson correlation coefficient test. Intense tracer uptake was usually seen in the palatine tonsils (PRP, 98%; mean SUV, 3.48), soft palate (PRP, 96%; mean SUV, 3.13), and lingual tonsils (PRP, 96%; mean SUV, 3.11). In the inferior concha (PRP, 4%; mean SUV, 1.56), thyroid gland (PRP, 3%; mean SUV, 1.31), and tongue (PRP, 1%; mean SUV, 1.39), uptake was typically minimal. FDG accumulation was variable in the sublingual glands (PRP, 72%; mean SUV, 2.93), spinal cord (PRP, 64%; mean SUV, 2.12), submandibular glands (PRP, 53%; mean SUV, 2.11), parotid glands (PRP, 51%; mean SUV, 1.90), and vocal cords (PRP, 19%; mean SUV, 1.77). The mean normal-tissue SUV in the soft palate was higher in male than in female patients (P <.01). A negative correlation between age and physiologic FDG uptake was seen in the palatine tonsils (r=-0.51, P <.001) and sublingual glands (r=-0.70, P <.001). Intense FDG uptake was usually observed in the palatine tonsils, lingual tonsils, and soft palate, whereas uptake in the major salivary glands was variable.

신이식 후 연구개와 구개 편도에 발생한 Epstein-Barr Virus 양성인 말초성 T 세포 림프종 1예

Posttransplant lymphoproliferative disorder (PTLD) is a heterogenous group of lymphoid proliferative disorders ranging from non-specific reactive hyperplasia to malignant lymphoma occurring in transplant patients. The origins of PTLD are mostly B lymphocytes and linked to Epstein-Barr virus (EBV) infection, but T lymphocyte PTLDs are uncommon and not associated with EBV infection. We report a case of EBV-associated peripheral T-cell lymphoma involving soft palate and left palatine tonsil occurring in a 35 year old female patient 14 years after renal allograft transplantation. Positivity for CD3 demonstrated in the tumor cells, while CD56 was not expressed. We detected positive reaction for EBV-encoded RNAs (EBERs) in the neoplastic cells by in situ hybridization. She is being treated by chemotherapy at present after surgical removal of lesion and reduction of immunosuppression. (J Clinical Otolaryngol 2004;15:286-289)

Staging of obstructive sleep apnea/hypopnea syndrome: a guide to appropriate treatment.

Early studies by Friedman et al. have demonstrated the value of staging obstructive sleep apnea/hypopnea syndrome (OSAHS) patients for the prediction of success for uvulopalatopharyngoplasty (UPPP) on the basis of short-term follow up. The goal of this study is to test the value of this staging system in a prospective study. This is a prospective study of two cohorts of patients: one was treated with the benefit of a clinical staging system and the other without. Patients with symptoms of OSAHS were assessed by polysomnography and were staged according to a previously described staging system. The staging system is based on palate position, tonsil size, and body mass index (BMI). The control group was treated without the benefit of staging. All patients in the control group were treated with UPPP only. Patients in the experimental group were treated based on their clinical stage. Patients with stage I disease, regardless of the severity of disease, were treated with UPPP only. Selected patients with stage II and stage III disease were treated with UPPP in addition to a staged tongue-base reduction using a radiofrequency technique (TBRF). Follow-up at 6 months showed significant improvement compared with a group of patients treated without the benefit of a staging system. Successful treatment of patients with stage II disease improved from 37.9% to 74.0%. The overall success rate improved from 40% to 59.1%. Clearly, patients with stage I disease had the best success rate, but a selective protocol based on clinical staging improves the overall success rate. In addition, it can eliminate as surgical candidates those patients with whom the procedure is likely to fail.

Clinical staging for sleep-disordered breathing.

The purpose of this study was to identify prognostic indicators that would lead to stratification of patients likely to have successful surgery for sleep-disordered breathing (SDB) versus those destined to fail. We retrospectively reviewed 134 patients to correlate palate position and tonsil size to the success of the UPPP as based on postoperative polysomnography results. Similar to our previously published data on the Friedman Score as a predictor of the presence and severity of SDB, the palate position was determined on physical examination of the oral cavity and was graded for each patient. This grade combined with tonsil size was used to stage the patients. Stage I was defined as having palate position 1 or 2 combined with tonsil size 3 or 4. Stage II was defined as having palate position 3 or 4 and tonsil size 3 or 4. Stage III patients had palate position 3 or 4 and tonsil size 0, 1, or 2. Any patient with body mass index of greater than 40 was placed in the stage III group. The results of uvulopalatopharyngoplasty (UPPP) were then graded as success or failure and success rates were compared by stage. Academically affiliated tertiary care referral center. Stage I patients who underwent UPPP had a success rate of 80.6%, stage II patients had a success rate of 37.9%, and stage III patients had a success rate of 8.1%. A clinical staging system for SDB based on palate position, tonsil size, and body mass index is presented. It appears to be a valuable predictor of the success of UPPP. Additional studies and wider use of the staging system will ultimately define its role in the treatment of SDB.

Intraoral distribution of Actinobacillus actinomycetemcomitans in young adults with minimal periodontal disease

The aim of the present study was to investigate the intraoral distribution of Actinobacillus actinomycetemcomitans in young adults with minor signs of periodontal disease but harboring the organisms in the oral cavity. 17 healthy volunteers, 20 to 27 years of age, participated. Samples from mucosal surfaces of the oro-pharyngeal cavity and saliva (n = 221) as well as subgingival plaque from every tooth (n =477) were selectively cultivated for A. actinomycetemcomitans. Species identity and presence of the leukotoxin encoding gene, ltxA, were checked by multiplex polymerase chain reaction. Moreover, the leukotoxin promoter region was analyzed. No isolate harbored a 530 bp deletion in the promoter region of the leukotoxin gene, signaling minimally toxic strains. 42.1 +/- 30.4% extracrevicular and 34.4 +/- 29.5% subgingival samples were culture-positive. In extracrevicular samples, the organism could easily be recovered from cheek mucosa (62%), saliva (59%) and the palatal tonsils (41%). Mean log-transformed numbers of A. actinomycetecomitans colony forming units (CFU/ml) in culture-positive material ranged between 1.8 from the hard palate and 2.3 from 10 microl saliva. The highest prevalence in subgingival plaque was observed at maxillary 3rd molars (55%) followed by maxillary lateral incisors (50%) and mandibular 3rd molars (41%). Mean log-transformed counts of CFU/ml ranged between 2.2 at maxillary 3rd molars and 3.4 at upper central incisors. When adjusted for jaw, site and tooth type, the odds of isolating higher numbers of the organism were increased with every mm probing depth by a factor of 1.35 (p <0.05). The odds ratio for bleeding on probing was 1.38. Thus, in this young adult population with minor periodontal disease, A. actinomyetemcomitans was mainly associated with some deviation from gingival health. Of concern might be a minority of subjects (29%) with an extremely wide distribution of the organism in the oral cavity.

口腔症状を主症状とした第２期梅毒の１例

We report a case of secondary syphilis with various oral manifestations. A 26-year-old woman visited our hospital because of lingual pain. The patient had a red and soft verruca at the left angle of the mouth as well as three oval papules on the right side of the tongue. In addition, oral examination revealed marked swelling and redness of bilateral palatal tonsils along with opaline plaque over the palatoglossal arch and inferior surface of tongue. Moreover, multiple cervical lymphadenopathy, alopecia, and psoriasic exanthema on the planta were observed. There were no particular lesions of the vulva or inguinal lymphadenopathy. Serological examination showed the RPR test was×128, the TPHA test>2560, and the FTA-ABS test×1280. Since the Jarisch-Herxheimer reaction was induced after treatment with 1000mg/day of amoxicillin for 2 weeks, the patient was treated with 2000mg/day of erythromycin for 6 weeks. Oral lesions improved after 2 weeks of treatment, and the RPR test was×64 after 3 weeks of treatment. After 4 weeks of treatment, the oral lesions almost completely resolved.

Precise Cannulation of the Foramen Ovale in Trigeminal Neuralgia Complicating Osteogenesis Imperfecta with Basilar Invagination: Technical Case Report

Trigeminal neuralgia is a rare feature of basilar invagination, which is itself a complication of osteochondrodysplastic disorders. Microvascular decompression is an unattractive option in medically refractory cases. The conventional percutaneous approach to the trigeminal ganglion is anatomically impossible because the foramen ovale points inferiorly and posteromedially. We report a new technique for image-guided trigeminal injection in a patient with basilar invagination complicating osteogenesis imperfecta. A 26-year-old woman with osteogenesis imperfecta presented with a 3-year history of typical left maxillary division trigeminal neuralgia, which was poorly controlled by carbamazepine at the maximum tolerated dose. She had obvious cranial deformities, left optic atrophy, delayed left eye closure, tongue atrophy, but normal facial sensation and corneal reflexes. A computed tomographic scan and magnetic resonance imaging confirmed severe basilar invagination. Frameless stereotactic glycerol injection of the left trigeminal ganglion was performed under general anesthesia using the infrared-based EasyGuide Neuro system (Philips Medical Systems, Best, The Netherlands) with magnetic resonance imaging and computed tomographic registration. The displaced and distorted left foramen ovale was cannulated via a true frameless stereotactic method with the trajectory determined by virtual pointer elongation. The needle placement was confirmed with injection of contrast medium into the trigeminal cistern. The path needed to enter the foramen traversed the right cheek, soft palate, and left tonsil. The patient went home pain-free with a preserved corneal reflex and no complications. Frameless stereotaxy allows customization to individual patient anatomy and may be adapted to a variety of percutaneous procedures used in areas where the anatomy is complex.

Immunohistochemical detection of rinderpest virus: effects of autolysis and period of fixation

Samples of eyelid, tongue, soft palate and palatine tonsil were collected from calves infected experimentally with rinderpest virus. The tissues were fixed in 10 per cent neutral buffered formalin immediately, 24 or 48 hours post mortem. Then, after three days, 10 days, 28 days or three months in formalin, they were processed into paraffin blocks and examined innnunohistochemically for rinderpest viral antigen. The tonsil was the best of the four tissues in providing a consistently positive immunohistochemical signal for the presence of virus, despite autolytic changes and/or prolonged fixation.