In 1998 the UK government published its white paper The New NHS: Modern and Dependable, in which it first suggested that patients being referred with a suspicion of cancer should have a maximum wait of two weeks to see a specialist. The rationale for this was that outcomes for late-stage disease are significantly worse when compared with outcomes for early-stage disease (Table 1). It was assumed that reducing the wait to see a specialist would reduce the stage of disease at presentation.
Conclusion Although the initial impression was of malignant otitis externa, Professor Michaels agreed that the histopathology was not conclusive, and a specialist review was recommended to exclude a rare form of lymphoma. An interesting presentation of multiple cranial nerve palsies in an elderly diabetic
From the Countess of Chester Hospital, ChesterIntroduction Neuro-endocrine tumours of the middle ear are rare and often present with nonspecific symptoms.
Case reportA 36-year-old woman presented with an 18-month history of hearing loss and right otalgia. Her past medical history consisted of a left mastectomy (in 2006) and an appendicectomy for carcinoid tumour (in 1990). Otoscopy revealed a retracted right tympanic membrane, and audiometry confirmed a moderate conductive hearing loss (60 dB). Initial management involved the insertion of a grommet.
Radiological findingsA high resolution computed tomography (CT) scan of the right temporal bone revealed soft tissue debris associated with the ossicular chain, and lack of pneumatisation of the mastoid air cells.
ManagementAn exploratory cortical mastoidectomy and middle-ear exploration were performed. A yellowish mass extending from the mesotympanum to the mastoid antrum was found and excised.
Histological findingsThe lesion appeared to have features of middle-ear adenoma showing neuro-endocrine differentiation. A staging CT scan did not show any distant neuro-endocrine tissue. Screening hormonal tests were negative. Metaidobenzylguanidine and octreotide scanning was normal. An annual chromogranin-A scan was organised as follow up.Discussion and lessons learnt Dr Connor and Dr Sandison held the opinion that this lesion was most likely a primary middle-ear adenoma rather than a primary carcinoid tumour. Dr Sandison felt that metastasis from the previous appendix carcinoid tumour was highly unlikely. Endocrine and ENT follow up is required to exclude the presence of other neuro-endocrine tissue and to detect any early recurrences.
Case reportOn examination, the patient had a left-sided vagal palsy and no palpable neck mass. Magnetic resonance imaging showed a left cervical tumour. Intra-operatively, a pigmented, parapharyngeal tumour was found deep to the common carotid artery, with multiple speckled, soft-tissue metastases. The tumour appeared to be arising from the cervical sympathetic chain and extending into the skull base. The tumour could not be excised completely.
Radiological findingsMagnetic resonance imaging demonstrated a lesion centred at the level of the first cervical vertebra, lying medial to the internal carotid artery and partly encasing it, and extending inferiorly into the carotid bifurcation. It had a low signal on T2-weighted images, with small internal signal voids. Some left-sided cervical nodes were also visible.
Histological findingsExpert review of the previous and current histology indicated that the lesion removed in 2006 was a paraganglioma while the lesion removed in 2011 was a malignant melanocytic schwannoma. The two were not interlinked.
ManagementThe patient was referred to a specialist melanoma oncologist.
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