We have shown that cyclooxygenase-2 is expressed in thyroid carcinoma and thyroid epithelium from patients with Hashimoto's thyroiditis but not in normal thyroid. The expression of COX-2 in both of these thyroid pathologies may provide a basis for the relationship between carcinogenesis and autoimmunity.

Since its introduction, functional endoscopic sinus surgery (FESS) has demonstrated success rates of 76% to 98%. A small group of the patients in whom initial FESS and optimal medical therapy fail require revision endoscopic sinus surgery (RESS). This group has recently been studied by several authors, and we have evaluated a group of 90 RESS patients selected from 753 consecutive primary FESS patients. Patients were followed for a mean of 22.8 months. Extent of disease, history of polyps, allergy, previous traditional endonasal sinus surgery, male gender, chronic steroid use, and the presence of a deviated septum all appeared to adversely affect RESS outcome. The surgeon's knowledge of the sinus anatomy is critical, especially in revision sinus cases in which landmarks are distorted or absent. In our review, RESS was associated with a 1% major complication rate and was successful in 67% of patients. Computer-assisted endoscopic sinus surgery integrates preoperative imaging with realtime endoscopic visualization, augments the surgeon's knowledge of anatomy, and helps to minimize patient risk.

Thyroid surgeons are becoming increasingly more aware of a histologically distinct subset of thyroid carcinoma whose classificationfall s between well-differentiated and anaplastic carcinomas with respect to both cell differentiation and clinical behavior. This subtype oftumors has been categorized as poorly differen tiated or insular carcinoma, based on its characteristic cell groupings. Although the differentiation of insular carcinoma from other thyroid carcinomas has important prognostic and therapeutic significance, relatively little about insular carcinoma has been published in the otolaryngology literature. In this article, we describe a new case of insular carcinoma and we discuss the fin dings of our review of the literature. We conclude that insular thyroid carcinoma warrants aggressive management with total thyroidectomy foll owed by radioactive iodine ablation of any remaining thyroid tissue.

Penetrating middle ear injury can result in hearing loss, vertigo, andfacial nerve injury. We describe the cases of 2 children with penetrating trauma to the right ear that resulted in ossicular chain disrupt ion; one injury was caused by cotton-tipped swabs and the other by a wooden matchstick. Symptoms in both children included hearing loss and otalgia ; in addition, one child experienced ataxia and the other vertigo. Physical examination in both cases revealed a pelf oration in the posterosuperior quadrant of the ty mpanic membrane and visible ossicles. Audiometry identified a moderate conductive hearing loss in one child and a mild sensorineural hearing loss in the other: Both children underwent middle ear exp loration and reduction ofa subluxed stapes. We discuss the diagnosis, causes, and management ofp enetrating middle ear trauma. To reduce the morbidity associated with these traumas, otologic surgeo ns should act promptly and be versatile in choosing methods ofrepairin g ossicular chain injuri es. Introdu ction Penetrating middl e ear and tympanic membrane inj uries in children can be se lf-i nflicted or ca used by caregivers or medical personn el. Damage can include tympanic membrane perforation, hemotympanum, inj ury to the ossicu lar chain or facia l ner ve, verti go, perilymphatic fistula, and conductive and/or sensorineural hearing loss."! Some injuries can be managed expec tantly or with elective surgical intervention while others require urgent surgical Fro m the Division of Pedi atric Otolaryngo logy, Department of Surge ry, A lfred I. duP ont Hosp ital for Childre n, Ne mo urs Children's Clinic, Wilmi ngton, De l., and the Department of Otolaryngology-H ead and Neck Surgery, Th omas Jefferson Un iversi ty Hospita l, Philadelphi a.

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