A 54-year-old man presented with a solitary, erythematous, rapidly growing 1-cm nodule on his scalp that had arisen over the previous 3 months. He had no history of skin cancer. An excisional biopsy of the lesion showed a fairly well-circumscribed but focally invasive tumor consisting of areas of typical-appearing clear cell hidradenoma as well as areas with mucinous goblet-type cells and cells with eosinophilic cytoplasm and decapitation-type secretion. There was marked cellular atypia, numerous atypical mitotic figures and focal necrosis. The tumor cells focally involved the overlying epidermis (Paget's disease). Large areas of mucin were identified throughout the lesion. The tumor cells stained with markers for cytokeratin 7 and focally for EMA and CEA, confirming ductal differentiation. The goblet cells and mucinous areas stained with mucicarmine and PASD. The patient was diagnosed with hidradenocarcinoma with mucinous differentiation. Associated Paget's disease has only rarely been reported, and mucinous metaplasia is a previously unreported feature in hidradenocarcinoma.

Merkel cell carcinoma of the lower lip is a rare clinical entity. It is generally thought to be more aggressive than the more common skin cancers of the lips and oral cavity. The literature reveals that delayed diagnoses and poor survival are common among patients with these malignancies. Recommended treatment is surgical excision with wide margins and treatment of cervical metastases with either surgery or radiotherapy or both. Unlike other malignant neoplasms, the occurrence of Merkel cell carcinoma in a relatively older population makes comorbid conditions a key factor in treatment planning.

Estimates reveal there are approximately 50,000 thunderstorms and 8 million lightning flashes daily worldwide. In the United States, lightning strikes are responsible for 300 to 600 deaths annually, with thousands more people injured.' Otolaryngologists are often involved in caring for lightning strike survivors.Numerous articles have addressed the otologic manifestations of lightning strike, including burns to the auricle and external auditory canal, tympanic membrane rupture, middle ear injury, and sensorineural hearing loss. An article from our institution also reported temporal bone findings on autopsy after lightning strike.' Youngs et aL3 reported similar postmortem results. A recent article reported an unusual otolaryngologic manifestation of transient dysphagia after lightning trike.^ We report a case of lightning strike in which, in addition to the expected otologic manifestations, the patient also exhibited prolonged dysphagia. Characteristics of lightning strike with associated audiologic, otologic, and swallowing findings are reviewed and patient evaluation, treatment, and outcome are discussed. CASE REPORTL.M. is a previously healthy 64-year-old woman from Florida who was struck by lightning while horseback riding with friends in the mountains near Vail, Colorado. The lightning bolt reportedly struck the paFrom the Department of Otolaryngology-Head and Neck Surgery, The Colorado University Health Sciences Center.

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