Using ultrasonic preoperative thyroid volume to determine incision length for minimally invasive thyroid surgery

August 26, 2015     Austin P. Daly, MD; Massi Romanelli-Gobbi, MD; Jeffrey L. Miller, MD; David Rosen, MD; David M. Cognetti, MD; Edmund A. Pribitkin, MD
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Abstract

The determination of the volume of a diseased thyroid lobe or an entire gland by preoperative ultrasonography may enable surgeons to select candidates for a minimally invasive approach to thyroid lobectomy or total thyroidectomy. We retrospectively reviewed the charts of 71 adults who had undergone minimally invasive nonendoscopic thyroid surgery at our hospital from January 2007 through May 2009. We compiled data on ultrasonic preoperative thyroid volumes and operative incision lengths. Of the 71 patients, 40 had undergone lobectomy and 31 had undergone total thyroidectomy. The lobectomy group was evenly subdivided into two groups based on the median volume of the affected lobe; 20 patients had a volume of <28.32 ml and 20 had a volume of >28.32 ml. The incision length ranged from 2.0 to 3.8 cm (mean: 3.1 ± 0.53) in the smaller-volume lobectomy group and from 2.5 to 5.0 cm (mean: 3.7 cm ± 0.71) in the larger-volume lobectomy group; the difference was statistically significant (p < 0.01). The 31 patients in the total thyroidectomy group were subdivided on the basis of the median volume of the entire thyroid gland; 16 patients had a volume of <49.24 ml and 15 had a total volume of >49.24 ml. The incision length in those two groups ranged from 2.5 to 4.0 cm (mean: 3.4 ± 0.53) and 3.6 to 6.0 (mean: 5.1 ± 0.99), respectively; again, the difference was statistically significant (p < 0.001). The findings of our study suggest that preoperative ultrasonographic thyroid lobe volume or total thyroid gland volume can be used to determine the appropriate minimum length for the surgical incision.

Can vinegar be used in treating Pseudomonas ear infections in a patient with a perforated eardrum?

August 26, 2015     Muhamed Aslam Khan, MS, MRCSEd; Nazneen Khan, MBBS, DGO, DRCOG
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Abstract

Chronic Pseudomonas ear infections are difficult to treat, particularly in immunodeficient patients. Vinegar therapy is a time-tested measure for the treatment of these infections. It is inexpensive, simple, easy to administer, and very effective. However, some physicians are reluctant to use it in immunocompromised patients or in the setting of a perforated tympanic membrane. We describe our successful use of vinegar therapy in a 32-year-old man with both of these conditions. His Pseudomonas ear infection had persisted for more than 5 years despite conventional drug treatment. Eventually, we treated him with instillations of topical vinegar, and his infection cleared in 3 weeks.

Introduction Chronic Pseudomonas infection of the ear in humans is difficult to treat, especially in immunodeficient patients. This infection has remained resistant to many modalities of treatment, leading to frustration for patients and physicians alike. Pseudomonas organisms can be killed in an acidic environment, which can be created with...

Supraglottoplasty in a 39-year-old woman

August 26, 2015     Hilary M. Caruso Sales, DO; Amanda Hu, MD, FRCSC; Robert T. Sataloff, MD, DMA, FACS
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In this case, the patient's larynx was diffusely erythematous and edematous, with thick secretions and severe posterior “cobblestoning.”

A 39-year-old woman presented with hoarseness of 3 months' duration. The hoarseness had started after an upper respiratory infection. She developed associated symptoms of odynophagia, postnasal drip, dyspnea, and the sensation that her throat was closing. Treatment with antibiotics, cough medications, and nebulizers had not improved her...

Base of tongue schwannoma

August 26, 2015     Gautam Bir Singh, MS; Rubeena Arora, MS; Sunil Garg, MS, DNB; Kiran Aggarwal, MD
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On T1-weighted MRI, these lesions appear hypointense or isointense relative to the tongue muscle.

A 29-year-old man presented to the ENT outpatient department of our tertiary care teaching hospital with the chief complaint of swelling of the tongue for the previous 3 years. The swelling had increased over time, and now the patient had an intense foreign body sensation in the tongue, as well as an obvious cosmetic deformity. Interestingly, the...

Hybrid frontal sinus surgery with balloon dilation and microdebrider resection

August 26, 2015     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS
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In cases with polyps obstructing the sinus ostia, if a hybrid procedure employing both microdebrider resection and balloon dilation is performed, a satisfactory sinus outflow tract can be obtained.

A 47-year-old man was referred because of a 2-year history of recurring frontal pain with intermittent frontal sinusitis treated medically on numerous occasions. Computed tomography (CT) of the sinuses showed bilateral frontal sinusitis (figure 1, A). Nasal telescopic evaluation revealed middle meatal and frontal recess polyps with thick...

Airway characteristics of infants with Pierre Robin sequence who undergo mandibular distraction osteogenesis

August 26, 2015     Paul Hong, MD, FRCSC; Donald Kearns, MD, FAAP
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Abstract

Newborn upper airway obstruction secondary to micrognathia and Pierre Robin sequence can be managed with conservative and surgical interventions. Mandibular distraction osteogenesis has been used to relieve micrognathia associated with severe airway obstruction. We conducted a retrospective chart review to identify patients with Pierre Robin sequence who underwent mandibular distraction osteogenesis during a 2-year period. Our study group was made up of 16 infants-11 boys and 5 girls, aged 21 to 112 days (mean: 55.9). In addition to demographic data, we compiled data on their baseline characteristics, airway characteristics, pre- and perioperative findings, and postoperative airway outcomes. Although most patients experienced documented improvements in Cormack-Lehane laryngoscopy grades postoperatively, the severity of micrognathia and airway obstruction did not always correlate with the higher grades. As well, the degree of improvement on laryngoscopic findings was not always evident, even though patients experienced a clinical benefit. All patients who had undergone a preoperative tracheostomy were decannulated successfully. We found that mandibular distraction osteogenesis was a safe and effective intervention for newborns with severe micrognathia and airway obstruction in our study population. It is interesting that the degree of micrognathia was not always correlated with the degree of airway compromise and laryngoscopy grades.

Introduction Upper airway obstruction secondary to micrognathia was first widely reported by Pierre Robin in 1934.1 He described a constellation of findings, which included micrognathia, glossoptosis and, in some patients, cleft palate. This syndrome is now commonly referred to as the Pierre Robin sequence (PRS).

Missed skull base injury during sinonasal surgery: A dangerous scenario still existing

August 26, 2015     Mohamed H. Hassab, MD; Ahmed Z. Eweiss, MD, FRCS(ORL-HNS); Ahmed A. Ibrahim, MD
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Abstract

Skull base injury is a known complication of sinonasal surgery. Cerebrospinal fluid (CSF) rhinorrhea has been reported to occur in 0 to 2.5% of these procedures. More extensive skull base injury may result in more serious complications. In this retrospective case series, we report on 7 cases of iatrogenic skull base injury due to sinonasal surgery that was missed by the operating surgeons. Included were 5 male and 2 female patients. Six patients sustained the skull base injury during endoscopic sinus surgery, and 1 patient was injured during septoplasty. Two patients presented with CSF rhinorrhea alone, 2 patients had repeated episodes of meningitis, 2 patients had other neurologic sequelae, and 1 patient had exotropia due to associated orbital injury. We conclude that skull base injury due to sinonasal surgery is still being missed; this oversight may lead to potentially fatal results. The true incidence of this complication is probably still unknown.

Thrombophlebitis of the temporal vein as an extracranial complication of acute bacterial rhinosinusitis

August 26, 2015     Markus E. Huth, MD; Marco D. Caversaccio, MD, PhD
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Abstract

A 39-year-old white man presented with a swollen left upper eyelid secondary to progressive acute bacterial rhinosinusitis (ABRS). Physical examination found a 40% reduction in vision in the left eye and right-sided erythematous temporal swelling with tenderness to palpation. Computed tomography revealed the presence of an inflammatory lesion in the left orbit. Duplex ultrasonography demonstrated a thrombotic occlusion in the right superficial temporal vein (STV). For treatment of the complicated ARBS, the patient received intravenous antibiotics and underwent surgery. The STV thrombophlebitis was treated with low-molecular-weight heparin. Postoperatively, the patient recovered completely and his vision normalized; 10 days later, duplex ultrasonography showed a patent STV. The development of contralateral STV thrombophlebitis is conceivably facilitated by venous anastomoses of the scalp in the front of the head. As a result, embolic spread would be a possible complication of infectious ABRS foci communicating with intraorbital and pericranial veins. To the best of our knowledge, this is the first reported case of such a complication of ARBS in the literature.

Introduction A common cold regularly involves the mucosa of the paranasal sinuses, and thus it can be referred to as viral rhinosinusitis. By compromising paranasal sinus drainage and ventilation, bacterial superinfection ultimately results in acute bacterial rhinosinusitis (ABRS).1 The cardinal symptoms of ABRS are purulent rhinorrhea, facial...

Giant Zenker diverticulum

August 26, 2015     Vini Balakrishnan, MS; Jason Handwerker, MD; Sunil P. Verma, MD
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Open procedures are typically preserved for larger sacs and cases in which transoral access is limited.

A 79-year-old woman presented with a 10-year history of progressive dysphagia to solid foods and a gradual weight loss. Physical examination demonstrated a mass on the left side of her neck that tripled in size during a Valsalva maneuver. Computed tomography (CT) and a barium swallow showed an air-fluid level in a left-sided Zenker diverticulum (...

A study of neck and shoulder morbidity following neck dissection: The benefits of cervical plexus preservation

August 26, 2015     Massimiliano Garzaro, MD; Giuseppe Riva, MD; Luca Raimondo, MD; Laura Aghemo, MD; Carlo Giordano, MD; Giancarlo Pecorari, MD
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Abstract

We conducted a study to evaluate the hypothesis that the preservation of cervical root branches of the cervical plexus is associated with greater shoulder mobility, less loss of face and neck sensation, and better quality of life (QoL) following functional neck dissection in which the spinal accessory nerve is spared. We also investigated the impact of postoperative physiotherapy on these three outcomes. Our study population was made up of 54 patients-47 men and 7 women, aged 34 to 78 years (mean: 53.4)-who had undergone functional neck dissection as a treatment for head and neck cancer over a 3-year period at our institution. Patients were divided into two groups: 23 patients whose cervical root branches were preserved during surgery (preservation group) and 31 whose branches were removed (removal group). Shoulder mobility was measured by the Arm Abduction Test (AAT), face and neck sensation was assessed by fingertip touch in eight areas of the head and neck, and QoL was determined by the University of Washington-Quality of Life questionnaire (UW-QoL4). The AAT revealed that the preservation group had significantly better shoulder mobility. The fingertip touch evaluation revealed significantly less loss of sensation in Saffold regions A and D. Analysis of the UW-QoL4 results revealed that the preservation group experienced significantly less pain, significantly fewer shoulder complaints, and significantly fewer limitations on activities and recreation, as well as significantly better health-related and overall QoL. The preservation group also had a significantly better composite score, global score, social function score, and mood and anxiety score on the UW-QoL4 assessment. Finally, we found that physiotherapy improved both QoL and shoulder mobility, although these improvements were not statistically significant. We conclude that preservation of the cervical root branches significantly improves outcomes in patients who undergo functional neck dissection.

Introduction Shoulder complaints after radical neck dissection were described by Ewing and Martin in 1952 as “the shoulder syndrome.”1 This syndrome consists of shoulder pain, a loss of sensation, a reduced range of motion, and anatomic deformities such as scapular flaring and shoulder droop.2-5 It has been demonstrated that the more...