Despite the presence of normal facial nerve function in the immediate postoperative period, patients may develop facial nerve dysfunction anywhere from several hours to several days after otologic surgery. This delayed facial paresis, following a broad range of otologic surgeries, has been well described in adults but not in pediatric patients. Viral reactivation is increasingly implicated as the underlying etiology of delayed facial paresis. We present a case of delayed facial paresis in a pediatric patient with a clinical course consistent with viral reactivation.
Issue: August 2010 Category: Original Articles Author: by Marc C. Thorne, MD, Brian P. Dunham, MD, and Lawrence W.C. Tom, MD
Plasmacytomas of the head and neck are rare tumors characterized by a monoclonal proliferation of plasma cells. Very few cases of plasmacytoma of the tongue base have been reported. We present a new case of extramedullary plasmacytoma of the tongue base, we discuss its diagnosis and management, and we review the literature on plasmacytomas of the head and neck.
Issue: August 2010 Category: Original Articles Author: by Haidar Alwan, BSc, MBChB, James W. Moor, MRCS, David Wright, MBChB;, Anastasios N. Kanatas, MRCS, PhD, and Helen E. Cruickshank, FRCS
Although foreign body ingestion and impaction in the pharynx or hypopharynx are quite commonly encountered at our institution, foreign body impaction in tongue tissue is rare. Six cases of foreign bodies embedded in the tongue were identified in a retrospective review spanning the years 1998 to 2007. All the foreign bodies were fish bones. Four of these patients required only tongue exploration to remove the bone; one required a partial glossectomy because of difficulties locating the bone; and one required incision and drainage of an intraglossal abscess that had developed, as well as a tracheostomy. All foreign bodies were successfully removed, with none of the patients experiencing altered sensation or problems with tongue mobility afterwards.
Issue: August 2010 Category: Original Articles Author: by Shirish Johari, BSc, MBBS, DLO, DOHNS(Edin.), MRCSEd; and Kevin Yaw-Khian Chong, MBBS, FRCS(Ed), M Med(ORL-Singapore), FAMS(ORL), FAAOHNS(USA), EAONO, AINO(Italy)
Laryngeal vascular leiomyomas are uncommon benign tumors that seldom recur following complete excision. The choice of excision procedure-via direct laryngoscopy or an open approach-is dictated by tumor size, the expected amount of blood loss, and any comorbidities the patient may have. We report an unusual case of a recurrent laryngeal vascular leiomyoma in a 64-year-old woman who also had a concurrent parathyroid adenoma and a history of breast carcinoma. A surgical resection via an external approach along with laser resection of a small glottic component was needed.
Issue: August 2010 Category: Original Articles Author: by Nir Hirshoren, MD, Jeffrey M. Weinberger, MD, FRCSC, Tzahi Neuman, MD, Ophir Ilan, MD, PhD, and Avraham Ben-Yaakov, MD
Coagulopathy is one of the relative contraindications to percutaneous dilational tracheostomy (PDT). We conducted a retrospective analysis of the records of 483 patients who had undergone PDT at Johns Hopkins Hospital from January 2000 through December 2007 to investigate the safety of PDT in those who were coagulopathic. The number of patients classified as coagulopathic varied greatly according to the particular diagnostic criteria used; 164 patients (33.95%) met one of the three diagnostic criteria (an abnormality in either prothrombin time, partial thromboplastin time, or platelet count), and 32 patients (6.63%) met two or three of these criteria. Complications occurred in 16 patients (3.31%), none of whom met two or more diagnostic criteria; bleeding accounted for 5 of these complications (1.04%). No statistically significant difference was seen in complication rates between the coagulopathic patients and the controls (noncoagulopathic patients). We conclude that in the hands of an experienced surgeon, PDT can be safely performed in patients with abnormal coagulation factors provided that the surgical team strictly adheres to a standardized protocol.
Issue: August 2010 Category: Original Articles Author: by Vinciya Pandian, MSN, CRNP, Ravi S. Vaswani, BS, Marek A. Mirski, MD, PhD, Elliott Haut, MD, Shivam Gupta, MBBS, MPH, and Nasir I. Bhatti, MD
Cases of primary colorectal signet-ring cell carcinoma metastatic to the tonsil are extremely rare. To the best of our knowledge, only 4 such cases have been previously reported in the literature. We report a new case in a 76-year-old white woman. She was treated with chemotherapy, but her disease continued to spread and she was eventually placed on comfort care and palliative radiation therapy. The manner in which tonsillar metastases evolve is still unknown, but some hypotheses have been proposed, and we briefly review these theories.
Issue: August 2010 Category: Original Articles Author: by Kelly K. Park, MD and Youn W. Park, MD, FACS
We conducted a retrospective study to measure laryngeal descent in human infants and to determine if there is any correlation between the associated anatomic changes and the timing of the peak incidence of sudden infant death syndrome (SIDS), which is 2 to 4 months of age. We performed a computerized search of hospital records at our institution to identify magnetic resonance imaging (MRI) scans of the head and neck and plain radiographs of the lateral neck in patients younger than 1 year of age (range: 1 to 357 days). After unusable images were excluded, 79 head and neck MRI scans and 111 lateral neck x-rays were suitable for study. Two measurements were taken from each image: one from the tip of the epiglottis to the uvula and one from the tip of the epiglottis to the center of the sella turcica. These measurements were then graphed against the subject's age. SPSS statistical software was used to determine growth curves of the various measurements. The first derivative of these curves was calculated to determine the rate of laryngeal descent at a given age. We found that most subjects did not have an overlapping epiglottis and uvula during the first few months of life. The rate of laryngeal descent, based on measurements of the distance between the epiglottis and uvula, gradually increased in a near-linear fashion from as low as 0.005726 mm/day at day 1 of life to as high as 0.028366 mm/day at 300 days of age. We found no sharp increase in the rate of descent at 2 to 4 months of age, and thus no support for our hypothesis that there might be a correlation between anatomic changes and the peak incidence of SIDS.
Issue: July 2010 Category: Original Articles Author: by Robert E. Stephens, PhD, Austin Bancroft, DO, Alan G. Glaros, PhD, and Lisa H. Lowe, MD
Aneurysms of the petrous portion of the internal carotid artery (ICA) are rare. Their etiology is usually congenital, traumatic, or mycotic. Depending on the size and location of the aneurysm, the direction of its growth, and the specific adjacent structures involved, patients may or may not present with signs and symptoms. When signs and symptoms do manifest, they may include headaches, epistaxis, a vascular retrotympanic mass with hemotympanum and/or otorrhagia, pulsatile tinnitus, hearing loss, vertigo, and Horner syndrome or Raeder paratrigeminal neuralgia. We describe the imaging aspects of the case of a 27-year-old man who presented with a 5-day history of unilateral symptoms secondary to a lesion located in the area of the right foramen lacerum. The lesion proved to be an aneurysm of the petrous portion of the ICA. We discuss the anatomic, imaging, and otologic aspects of ICA aneurysms in this location.
Issue: July 2010 Category: Original Articles Author: by Enrique Palacios, MD, FACR, Juan Gómez, MD, Jorge E. Alvernia, MD, and Christian Jacob, MD
The hemoglobin (Hb) SC genotype is seen in persons who have inherited the gene for hemoglobin S from one parent and the gene for hemoglobin C from the other. Some people with this genotype develop Hb SC disease, a variant of sickle cell disease. Hb SC disease, a compound heterozygous condition, is the most common of the hemoglobinopathies and the least severe, although it is still serious. One of the documented complications of the presence of the Hb SC genotype is sensorineural hearing loss (SNHL). We conducted a prospective case-control study of 43 subjects, aged 15 to 65 years, who had the Hb SC genotype to determine the incidence of SNHL and to determine if the hearing loss in these subjects was correlated with sex or age. Our control group was made up of 100 generally healthy, sex- and age-matched subjects with the normal Hb AA genotype. SNHL was defined as a loss of more than 25 dB HL at two or more frequencies in the same ear or at one or more frequencies in both ears. We found that SNHL was present in 12 of the 43 subjects (27.9%) in the Hb SC group (17 of 86 ears [19.8%]) and in 17 of the 100 subjects (17.0%) in the Hb AA group (21 of 200 ears [10.5%]; the difference between the two groups was not statistically significant (χ2 = 1.589; p = 0.105). We found that in the Hb SC group, SNHL was more common among females than males (38.5 vs. 11.8%), although the difference was not quite significant statistically (χ2 = 2.435; p = 0.056); in the Hb AA group, the incidence was fairly equal-15.4 and 18.8%, respectively (χ2 = 0.033; p = 0.427). Therefore, we conclude that the hearing loss in the subjects of this study was not correlated with the presence of the Hb SC genotype in either sex. In terms of age, SNHL was significantly more common in subjects aged 41 to 65 years than in those aged 15 to 40 years in both genotype groups. In the Hb SC group, SNHL was present in 4 of the 33 younger subjects (12.1%) and in 8 of the 10 older subjects (80.0%) (χ2 = 14.354; p < 0.001). In the Hb AA group, the corresponding figures were 7 of 85 (8.2%) and 10 of 15 (66.7%) (χ2 = 26.840; p < 0.001). Therefore, we conclude that the hearing loss in the subjects of this study was a function of age and was not associated with the presence of the Hb SC genotype.
Issue: July 2010 Category: Original Articles Author: by Paul A. Onakoya, FWACS, Onyekwere G.B. Nwaorgu, FWACS, and Wuraola A. Shokunbi, FWACP
We describe a previously unreported phenomenon: positional dysphagia secondary to a Chiari I malformation. A 38-year-old woman presented with progressive dysphagia and cough. Flexible endoscopic evaluation of swallowing detected severe pharyngeal dysphagia and aspiration, as well as an intermittent cough reflex with all consistencies in the upright position. Various compensatory strategies were attempted to relieve the aspiration, but only assumption of the supine position was successful. Subsequent magnetic resonance imaging detected a herniation of the cerebellar tonsils to the level of C2 and the presence of a cervical syrinx-findings consistent with a Chiari I malformation. After surgical decompression of the malformation, the patient's symptoms completely resolved.
Issue: July 2010 Category: Original Articles Author: by David L. White, MD, Catherine J. Rees, MD, Susan G. Butler, PhD, Stephen B. Tatter, MD, PhD, Lisa W. Markley, MS, CCC-SLP, and Michael S. Cartwright, MD
Choanal polyps arise from inflamed, edematous mucosa in the paranasal sinuses. They extend into the choana and cause nasal obstruction and mouth breathing. In most cases, these polyps arise in the maxillary sinus, but rare cases of origin in the sphenoid sinus and other nasal structures have been reported. The presence of a choanal polyp in an atypical location can lead to diagnostic confusion and exploration of the wrong sinus at surgery. The author reports the case of a 15-year-old girl who was diagnosed with a sphenochoanal polyp. The patient was successfully treated via an endoscopic surgical approach.
Issue: July 2010 Category: Original Articles Author: by Mohannad Ahmad Al-Qudah, MD, FICS, FAAOHNS
Sarcoidosis rarely manifests by involving the cranial nerves exclusively. A 35-year-old woman presented with bilateral cavernous sinus masses and symptoms of trigeminal neuropathy. Computed tomography and magnetic resonance imaging suggested an intracranial tumor, favoring a meningioma. The patient underwent emergent surgical decompression and tumor excision. Histopathology of the resected tumor revealed classic features of sarcoidosis, and she received steroid treatment accordingly. Neurosarcoidosis must be considered in the differential diagnosis of idiopathic cranial neuropathies to avoid unnecessary surgery, since surgery has little, if any, role in the treatment of sarcoidosis. In the absence of primary organ involvement, radiologic diagnosis of cranial nerve sarcoidosis is unreliable; histopathology is required to reach a definitive diagnosis.
Issue: July 2010 Category: Original Articles Author: by Ali Amin, MD and Jasminka L. Balderacchi, MD
Ototoxicity secondary to the administration of the chemotherapeutic agent oxaliplatin is uncommon. We report a case of unilateral hearing loss that occurred immediately after the infusion of a single dose of oxaliplatin in a 70-year-old woman who was undergoing postoperative chemotherapy for rectal adenocarcinoma. To the best of our knowledge, no such case has been previously reported in the literature. The hearing loss in our patient was severe enough to limit her daily activities, and she experienced only minimal improvement during the next 2 years of follow-up.
Issue: June 2010 Category: Original Articles Author: by Narinder K. Malhotra, MD, Rizwan Aslam, DO, Sydney P. Lipman, MD, and Vicki J. Bilski, MS, CCC-A
Ecthyma gangrenosum is a rare necrotizing cutaneous infection usually caused by Pseudomonas aeruginosa. We report a case of ecthyma gangrenosum presenting as a sinonasal eschar and mimicking acute invasive fungal sinusitis in an immunocompromised 39-year-old man with a hematologic malignancy. To the best of our knowledge, this represents the first case of ecthyma gangrenosum affecting the sinonasal mucosa to be reported in the literature.
Issue: June 2010 Category: Original Articles Author: by Adrianna M. Hekiert, MD, Michael B. Cohen, MD, Kathleen T. Montone, MD, James N. Palmer, MD, and Satish Govindaraj, MD
A retrospective study was conducted to assess outcomes of reconstruction of the oral cavity with the platysma myocutaneous flap, in terms of flap survival, complications, and quality of life. Included were 10 patients with squamous cell carcinoma (stage T1 to T4; nodal status N0 to N2) of the oral cavity who were treated between 2002 and 2006. Each patient underwent tumor resection, modified radical neck dissection, and primary reconstruction with a platysma myocutaneous flap. Operating time, length of stay, time to swallow, and complications were assessed, and the University of Washington Quality of Life questionnaire was administered. Mean operating time was <4 hours, mean length of stay was 11 days, and mean time to swallow was 9 days. One patient had distal flap necrosis and one had wound dehiscence. No total flap failures or fistulas occurred. The authors conclude that the platysma myocutaneous flap provides thin, pliable, reliable tissue for use in the oral cavity. The additional operating room time is negligible, the surgical complications minimal, and the overall quality of life very good. This flap should be used more frequently in the reconstruction of oral cavity defects.
Issue: June 2010 Category: Original Articles Author: by Kevin H. Wang, MD, Ekai Kyle Hsu, MD, MBA, and Larry J. Shemen, MD
We describe a case of rhinoentomophthoromycosis, also known as rhinophycomycosis, in an Indian man hailing from the tropical northern region of the country. The patient presented with subcutaneous swelling in the midline of the forehead, dorsum of the nose, adjoining cheek area (more on the right side), philtrum, and upper lip. Biopsy taken from the right nostril area revealed nasofacial phycomycosis. The patient was treated successfully with itraconazole, 200 mg twice daily, and potasssium iodide, 5 drops in fruit juice three times daily.
Issue: June 2010 Category: Original Articles Author: by Naresh Bhatia, MS, Charu Singh, MS, Rahul Kawatra, MS, Seraj Alam, MS, and Ruchir Dhawan, MS
Synovial sarcoma is typically an aggressive malignant tumor of the soft tissues, usually in the extremities, that affects young adults. Tumors of the head and neck are rare. Reported head and neck sites have included the hypopharynx (the most common site), the oropharynx, the larynx, and the soft tissues of the neck; only 4 cases of orbital involvement have been previously reported. We describe a case of synovial sarcoma of the medial canthus, which we discovered during a review of a tumor registry. The patient, an 18-year-old woman, underwent conservative excision and postoperative radiation therapy. Long-term follow-up detected no evidence of recurrence. Because there is no established, consistent approach to the treatment of synovial sarcoma of the head and neck, we also present a consensus management plan based on our review of the literature.
Issue: June 2010 Category: Original Articles Author: by Shashidhar Kusuma, MD, David J. Skarupa, MD, Kim A. Ely, MD, Anthony J. Cmelak, MD, and Brian B. Burkey, MD
A 44-year-old man presented with squamous cell carcinoma (T1aN0M0) on the left vocal fold and was prepared for a combined laryngofissure cordectomy and type III thyroplasty. The author performed both procedures together-not only to lower the tension on the healthy vocal fold, but also to determine whether the thyroplasty would successfully close the glottic gap created by the cordectomy, resulting in relatively fast improvement in the patient's voice. Satisfactory glottic closure and a satisfactory voice result were achieved rather quickly. The patient was satisfied with his new voice, both in the early and late postoperative periods.
Issue: June 2010 Category: Original Articles Author: by Tolga Kandogan, MD
We present a case of bilateral otitis externa that did not respond to local treatment. Cutaneous biopsies revealed bilateral amyloid depositions secondary to multiple myeloma. Persistent, identical bilateral canal lesions may be the only manifestation of treatable systemic disease and should be biopsied, even though their bilaterality argues against malignancy.
Issue: May 2010 Category: Original Articles Author: by James J. Klemens, MD, Wendy Recant, MD, Joseph M. Baron, MD, and Miriam I. Saadia-Redleaf, MD
The presentation of ectopic cervical thymic tissue as an anterior neck mass is rare. We report 3 similar cases in 3 boys-2 who had a thymic cyst and 1 who had an ectopic cervical thymus. We discuss the radiographic presentation on ultrasound and magnetic resonance imaging in these cases. We also review the typical histologic picture; histology is the only way of diagnosing this condition.
Issue: May 2010 Category: Original Articles Author: by Estie Meyer, MBChB, FCORL(SA), Wakisa Mulwafu, MBChB, FCORL(SA), Johannes J. Fagan, MBChB, FCS(SA), MMed(Otol), Robin A. Brown, MBChB, DCH(SA), FRCS(Edin), and Kathryn Taylor, MBChB, DCH(SA), MMed(Anat Path)
Osteomas of the turbinates are extremely rare. In this report, a case of inferior turbinate osteoma in a 24-year-old woman is described. The patient presented with a 6-month history of unilateral nasal obstruction. Computed tomography showed a bony dense mass in the anterior part of the left inferior turbinate. The lesion was removed endoscopically, and the patient recovered uneventfully. To the best of the author's knowledge, this is only the fifth case of a turbinate osteoma to be reported in the world literature, and only the second case that involved the inferior turbinate.
Issue: May 2010 Category: Original Articles Author: by Borlingegowda Viswanatha, MS, DLO
We report a case of a neurilemmoma presenting as a midline nasal mass in a 13-year-old girl. To the best of our knowledge, this is the first report of a nasal neurilemmoma in a pediatric patient. Although this neoplasm is benign in nature, surgical resection is warranted to prevent recurrence, and it is the sole means of treatment. The overall prognosis is excellent, as was the case for our patient. We discuss the diagnosis and management of neurilemmomas and urge physicians not to exclude nasal neurilemmoma from the differential diagnosis in a pediatric patient who presents with a nasal mass.
Issue: May 2010 Category: Original Articles Author: by Gary D. Josephson, MD, Sapna A. Patel, MD, Laurie Duckworth, PhD, Melissa Kress, DO, and Jeffrey Goldstein, MD
Pleomorphic adenomas of the nasal cavity are rare. We describe the case of a middle-aged white man who presented to our clinic with a long history of unilateral nasal obstruction. Preoperative imaging was performed, and the patient was taken to the operating room for endoscopic excision of the lesion. Surgical margins were negative. The patient's nasal obstruction resolved, and he was doing well at his first postoperative visit. The pathologic diagnosis was a pleomorphic adenoma. We discuss the features and management of this entity.
Issue: May 2010 Category: Original Articles Author: by Jason L. Acevedo, MD, Jennifer Nolan, MD, J. Kevin Markwell, MD, JD, and David Thompson, MD, FACS
Head movement should create a transient pressure imbalance across the membranous inner ear. We used basic concepts of fluid dynamics to develop a theoretical model of the inner ear. According to this model, two contiguous fluidic systems-the perilymphatic system and the endolymphatic system-are in hydrostatic equilibrium across a compliant membrane. Our model demonstrates that changes in resistance or compliance in one system results in a transient distortion of the membranous inner ear until equilibrium between the two systems is restored. The concept of hydrodynamic pressure changes in the inner ear has received little attention, but it may represent a new approach to understanding the inner ear and treating inner ear diseases.
Issue: April 2010 Category: Original Articles Author: by Vivian M. Yu, MD, Paul J. Strykowski, PhD, and Rick M. Odland, MD, PhD
Phonosurgery is an effective treatment for some vocal fold pathologies, and the Voice Handicap Index (VHI) survey has been shown to be a useful instrument for evaluating treatment effectiveness. We conducted a nonrandomized, prospective study of 21 patients who underwent phonosurgery for the treatment of non-neoplastic vocal fold lesions at our academic tertiary-care referral center. Our goals were to compare pre- and postoperative VHI scores (subjective assessments) and pre- and postoperative results of acoustic and aerodynamic tests (objective assessments). We sought to determine if there was any correlation between the subjective and objective findings. We looked for differences between professional voice users (n = 10) and nonprofessional voice users (n = 11) in both subjective and objective measures. We found statistically significant differences between pre- and postoperative values in three of four VHI parameters, but in only one of 13 objective measures. There was no correlation between preoperative VHI scores and preoperative acoustic and aerodynamic test results. The professional voice users expressed greater postoperative improvement as reflected by lower VHI scores than did the nonprofessional voice users, confirming that the former are more negatively affected by a voice disability.
Issue: April 2010 Category: Original Articles Author: by Jeffrey Cheng, MD and Peak Woo, MD, FACS
We describe what is, to the best of our knowledge, the first use of a double bilobed radial forearm free flap in reconstructive surgery of the tongue and floor of the mouth following bilateral tumor resection. Our patient was a 78-year-old man who had experienced tumor recurrence in the anterior floor of the mouth after previous resection and radiotherapy. Eleven weeks postoperatively, the patient could extend his tongue to his hard palate and past his mandibular alveolus anteriorly. Within 6 months, he was able to tolerate an oral diet of soft food and exhibited understandable speech quality. Although the use of a single bilobed radial forearm flap is widely used after hemiglossectomy, our double bilobed modification extends this technique to anterior tongue and floor-of-mouth defects. This technique provides adequate bulk while allowing for depth of a ventral sulcus that will minimize tethering of the tongue and reduce oral incompetence. We recommend that this technique be included in the armamentarium of any reconstructive head and neck cancer surgeon.
Issue: April 2010 Category: Original Articles Author: by Alvin B. Ko, MD, Pierre Lavertu, MD, FRCS, FACS, and Rod P. Rezaee, MD
Laryngeal cancer in patients younger than 30 years is uncommon. We present data on this population obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) Program. We identified 99 patients in this age group from the SEER 17 registry, which includes data submitted from 1973 through 2003. This population was made up of 52 females and 47 males; most were white, and most were aged 25 to 29 years. Malignancies of the glottis were the most common cancers, followed by supraglottic lesions. The 5-year relative survival rate was lowest among those aged 15 to 19 years-60.1%; 5-year relative survival among those aged 20 to 24 and 25 to 29 years was 87.7 and 87.4%, respectively. The etiology of squamous cell carcinoma (SCC) in children and adolescents remains uncertain, but in the adult population, a history of smoking, drinking, and poor oral hygiene cannot be ignored. Carcinoma of the larynx in young people has been related to malignant degeneration of papillomas and to complications of radiotherapy for papillomas. Infection with the human immunodeficiency virus possibly accelerates the development of SCC in patients with significant risk factors, presumably by impairing normal immune surveillance mechanisms.
Issue: April 2010 Category: Original Articles Author: by Amy L. Rutt, DO, Mary J. Hawkshaw, BSN, RN, CORLN, and Robert T. Sataloff, MD, DMA, FACS
Acute pharyngitis in adults is primarily a viral infection; only about 10% of cases are of bacterial etiology. Most cases of bacterial pharyngitis are caused by group A beta-hemolytic streptococci (GABHS). One laboratory method for the diagnosis of GABHS is rapid antigen diagnostic testing (RADT), which can be processed during an emergency department visit and which has become a popular alternative to throat swab cultures. We conducted a study to define the sensitivity and specificity of RADT, using throat culture results as the gold standard, in 100 emergency department patients who presented with symptoms consistent with streptococcal pharyngitis. We found that RADT had a sensitivity of 68.2% (15 of 22), a specificity of 89.7% (70 of 78), a positive predictive value of 65.2% (15 of 23), and a negative predictive value of 90.9% (70 of 77). We conclude that RADT is useful in the emergency department when the clinical suspicion is GABHS, but results should be confirmed with a throat culture in patients whose RADT results are negative.
Issue: April 2010 Category: Original Articles Author: by Sezgin Sarikaya, MD, Can Aktaş, MD, Didem Ay, MD, Asli Çetin, MD, and Ferudun Celikmen, MD
Vestibular evoked myogenic potential (VEMP) testing has gained popularity as a diagnostic modality in otolaryngology and audiology. To maximize the utility of this test, examiners need the availability of ideal test settings and reliable norms. We conducted a prospective study of 8 subjects with no history of neurotologic symptoms to examine the test-retest consistency of VEMP testing and to analyze the impact of stimulus type and muscle tension monitoring. All subjects underwent VEMP testing with two stimuli: a 500-Hz tone and a click. With each stimulus, testing was completed with and without monitoring of sternocleidomastoid muscle tension. All subjects participated in an initial testing session and then returned for a repeat testing session 2 to 4 weeks later. We measured the amplitude of primary waveforms P13 (first positive peak) and N23 (first negative peak) and analyzed the reliability and reproducibility of the mean amplitude asymmetry of these VEMP peaks. The P13 component of the VEMP (specificity: 86.25%) demonstrated a more stable amplitude than did the N23 component (specificity: 70.50%). Therefore, our statistical analysis of the effect of stimulus type and muscle tension monitoring on test-retest reliability was limited to the P13 waveform. We found that neither the type of stimulus nor the presence or absence of muscle tension monitoring had any statistically significant effect on amplitude asymmetry. We concluded that in VEMP testing, the P13 component was more specific than the N23 component in identifying normal subjects and that the P13 component provided consistent results across test sessions, regardless of the type of stimulus or the presence or absence of muscle tension monitoring.
Issue: April 2010 Category: Original Articles Author: by Matthew L. Bush, MD, Raleigh O. Jones, MD, and Jennifer B. Shinn, PhD
Cerebellopontine angle (CPA) ganglionic hamartomas are rare. We present a case of a 49-year-old woman who presented with left-sided hearing loss of more than 4 years' duration and vertigo since childhood. Magnetic resonance imaging revealed a mass on the intracanalicular segment of cranial nerve VIII on the left side, consistent with acoustic schwannoma. She opted for observation of the tumor. The patient returned 21 months after the initial evaluation with new-onset left facial weakness. At this time, a working diagnosis of facial nerve neuroma was made. The lesion was excised, and pathology confirmed a diagnosis of left-sided CPA ganglionic hamartoma. Otolaryngologists should be familiar with this uncommon tumor and include it in the differential diagnosis of CPA lesions.
Issue: March 2010 Category: Original Articles Author: by Sidrah M. Ahmad, BS, Fernando Garcia, MD, and Robert T. Sataloff, MD, DMA, FACS
Extramedullary plasmacytomas most commonly occur in the nasal cavity, nasopharynx, paranasal sinuses, and larynx. Thyroid involvement is rare, as fewer than 75 cases have been previously reported in the literature. We report a new case of disseminated plasmacytoma of the thyroid, which occurred in a 68-year-old woman. The diagnosis was made with an incisional biopsy. The patient initially experienced a complete response to radiotherapy (46.8 Gy in 26 fractions), but she developed multiple metastases at distant sites, including the breast, abdominal wall, and buttock despite various chemotherapy regimens. Ultimately, she was placed on palliative radiotherapy. We also briefly review the diagnostic and treatment options for patients with extramedullary plasmacytoma.
Issue: March 2010 Category: Original Articles Author: by Brian J. Park, MD, MPH, Randy J. Kalish, MD, and Arthur P. Vercillo, MD
We describe 2 cases of bilateral Ménière disease with features resembling autoimmune inner ear disease in patients who were found to be carriers of human leukocyte antigen (HLA) B27. For immunohistochemical analysis, mouse inner ear sections were used as the tissue substrate for reaction with serum. Both patients demonstrated an increased immunofluorescence reaction compared with a normal control. We suggest that an antibody-mediated mechanism may be responsible for HLA-B27-associated Ménière disease.
Issue: March 2010 Category: Original Articles Author: by Shamila G. Rawal, MD, Kunal H. Thakkar, MD, Kasra Ziai, BS, Peter A. Santi, MD, and Hamid R. Djalilian, MD
Lingual tonsil hypertrophy is an uncommon cause of upper aerodigestive tract pathology. We present the case of a 17-year-old boy who developed severe dysphagia and subsequent weight loss as a result of lingual tonsil hypertrophy. He was successfully treated with plasma-mediated radiofrequency-based ablation (Coblation). In the past, traditional surgical procedures for lingual tonsil hypertrophy were difficult to perform and recovery was difficult, but the introduction of Coblation has made lingual tonsillectomy much easier.
Issue: March 2010 Category: Original Articles Author: by Sarah E. Mowry, MD, Marvin Ament, MD, and Nina L. Shapiro, MD
Epiphora has traditionally fallen under the purview of ophthalmologists. However, owing to the development of endoscopic dacryocystorhinostomy, this condition has been increasingly observed in otolaryngologic practice. We report the case of a woman with a 4-month history of right epiphora and dacryocystitis. Nasal endoscopy revealed the presence of a tumor at the inferior meatus. Histopathologic examination of a biopsy specimen identified the tumor as an oncocytoma. Surgical excision via a lateral rhinotomy approach was performed. At 3 years postoperatively, the patient was disease-free. Lacrimal sac and nasolacrimal duct tumors are rare, but they should be considered as a possible etiology in patients with acquired epiphora because most of these tumors are malignant.
Issue: March 2010 Category: Original Articles Author: by Benoît Delas, MD, Marine Bertrand, MD, Emmanuel Babin, MD, PhD, Arnaud François, MD, Jean-Paul Marie, MD, PhD, Danièle Dehesdin, MD, PhD, and Olivier Choussy, MD
Neonatal suppurative parotitis is very rare. One review of the English-language literature spanning 35 years found only 32 cases. Most cases are managed conservatively with antibiotic therapy; early antibiotic treatment reduces the need for surgery. The predominant organism is Staphylococcus aureus. We report a new case of neonatal suppurative parotitis in a 3-week-old boy. The patient was diagnosed on the basis of parotid swelling, a purulent exudate from a Stensen duct, and the growth of pathogenic bacteria in culture. He responded well to 9 days of intravenous antibiotic therapy. We also discuss the microbiologic and clinical patterns of this disease.
Issue: February 2010 Category: Original Articles Author: by Sardar U. Khan, DLO, FCPS, Peter G. O'Sullivan, BSc, MPhil, and John McKiernan, FRCPI
Ameloblastomas are locally aggressive gnathic tumors with a high propensity for recurrence. Presentation of an ameloblastoma exclusively in the sinonasal tract is extremely rare, with few reported cases in the literature. Management involves surgical excision and close follow-up. We report a case in which the patient had complete unilateral nasal obstruction caused by an ameloblastoma. The tumor was completely excised endoscopically, and at the 12-month follow-up, there was no evidence of recurrence.
Issue: February 2010 Category: Original Articles Author: by Samuel C. Leong, MRCSEd, DO-HNS, Petros D. Karkos, AFRCSI, MPhil, Jasna Krajacevic, MSc, MD, Rafizul Islam, MBBS, and Stephen E. Kent, FRCS
Lymphangioma is an uncommon benign pathology, usually reported in children and rarely in adults. In the past, the definitive diagnosis was made intraoperatively and was usually an unexpected finding. However, with today's modern imaging technologies, such as computed tomography and magnetic resonance imaging, the diagnosis can be assumed before intervention, even though the final diagnosis still can be reached only via histopathologic examination. Imaging techniques also can aid in the precise mapping of the lesion and in defining its boundaries with the surrounding vital structures, improving therapeutic success. Various therapeutic options are reported in literature, but complete surgical excision is still considered the best approach. We report a case of cervical lymphangioma of unknown etiology in an 18-year-old man and discuss the presentation, diagnosis, and management of this lesion.
Issue: February 2010 Category: Original Articles Author: by Sampan Singh Bist, MS, Saurabh Varshney, MS, Manisha Bisht, MD, and Rajesh Kumar, MS
We conducted a retrospective review of 11 cases of adult cervical necrotizing fasciitis that were treated at our institution over a period of 5-plus years. The most common etiology was a dental infection, which was seen in 7 of the 11 patients (64%). Most cultures were sterile because all of these patients had been referred to us after they had already been treated elsewhere with intravenous antibiotics and without surgical intervention. Under our management, patients spent an average of 21.6 days in the hospital, and they underwent an average of 1.6 debridements under general anesthesia. Aggressive wound care, broad-spectrum antibiotic therapy, and timely surgical intervention resulted in an overall survival rate of 91% (10/11), including a 75% survival (3/4) for patients with thoracic extension.
Issue: February 2010 Category: Original Articles Author: by Jaimanti Bakshi, MBBS, MS, DNB, Ramandeep S. Virk, MBBS, MS, FIMSA, Ajay Jain, MBBS, MS, and Mayuresh Verma, MBBS, MS
Kimura disease is an uncommon chronic, benign, inflammatory condition of unknown etiology. It occurs endemically in Asia and sporadically in the West. Because it often imitates neoplastic or inflammatory processes of the head and neck, otolaryngologists and head and neck surgeons should be aware of its clinical presentations. In this article, the author reports 2 cases of Kimura disease-1 that was characterized by an unusual bilateral presentation and 1 that was managed conservatively-and he briefly reviews the literature on this entity.
Issue: February 2010 Category: Original Articles Author: by Borlingegowda Viswanatha, MS, DLO
A prospective, multicenter research study is under way to demonstrate long-term improvement in chronic rhinosinusitis symptoms after transantral balloon dilation of the ethmoid infundibulum. Trial results from an interim analysis of symptomatic status using the Sino-Nasal Outcome Test 20 survey demonstrate significant and sustained improvement through post-procedure 1-year follow-up. Additionally, these data provide evidence that the symptomatic improvements following balloon expansion within the ostiomeatal unit to treat medically refractory inflammation of the maxillary sinuses, either alone or with concomitant anterior ethmoid disease, are similar.
Issue: February 2010 Category: Original Articles Author: by James Stankiewicz, MD, FACS, Theodore Truitt, MD, and James Atkins Jr., MD
We report an unusual case of hypocalcemia and respiratory distress related to acid-suppressive therapy. The patient was a 50-year-old woman with bilateral laryngeal paralysis and hypoparythyroidism resulting from a thyroidectomy performed more than 30 years previously. She required large doses of calcium supplementation to maintain a normal calcium level. Her airway had been marginally adequate. A few weeks prior to presentation, she began to experience increasing dyspnea. Examination was suggestive of laryngopharyngeal reflux, and she was started on a therapeutic trial of esomeprazole 40 mg twice daily. Three days later, she presented to the emergency room with airway distress. Laboratory studies indicated that the patient had hypocalcemia. The esomeprazole was discontinued, and she was treated with intravenous calcium; her symptoms resolved. We attribute the airway distress to tetany in synkinetically reinnervated laryngeal adductor muscles. We recommend that acid-suppressive therapy should be used with caution in patients with hypoparathyroidism or hypocalcemia.
Issue: February 2010 Category: Original Articles Author: by Ninef E. Zaya, MD and Gayle Woodson, MD
Unilateral sinus disease has a wide differential diagnosis. When a patient has a history of maxillary dental work on the same side as the sinusitis, a foreign entity introduced during or subsequent to the dental manipulation must be considered. We present a case of calcified maxillary cyst that was discovered at the site of a remote tooth extraction. Pathologic analysis revealed the presence of vegetable matter within the cyst. To the best of our knowledge, no case of a maxillary cyst secondary to vegetable matter has been previously reported in the literature.
Issue: January 2010 Category: Original Articles Author: by Alexander Langerman, MD, Farhad Sigari, MS, MD, and Robert Naclerio, MD
Cerebrospinal fluid (CSF) rhinorrhea after a septoplasty procedure is very rare and potentially life-threatening. We present a case of iatrogenic postseptoplasty CSF rhinorrhea. To the best of our knowledge, only 2 other cases of CSF rhinorrhea complicating septoplasty have previously been reported. However, neither resolved in the manner that our case did, when spontaneous cessation of CSF rhinorrhea unexpectedly occurred upon removal of intranasal splints. We discuss the clinical importance of anatomic variations and potential causative mechanisms of CSF rhinorrhea during septoplasty. Our experience with this case suggests a mechanism of injury to the cribiform plate during septoplasty that has not been described previously.
Issue: January 2010 Category: Original Articles Author: by Annabelle C. Leong, MRCS, Toral Patel, MBBS, Faizal Rehman, MS, Manuel Oyarzabal, FRCS (ORL), and Paul Gluckman, FRCS (ORL)
We propose the use of a microelectromechanical system (MEMS) accelerometer as a middle ear microphone for future totally implantable cochlear prostheses. The MEMS accelerometer would be attached to the umbo to detect and convert the natural bone vibration that occurs in response to external sounds into an electrical signal that represents the acoustic information. The signal could be further processed to stimulate cochlear implant electrodes. To determine the feasibility of our proposal, we conducted a study to investigate whether the characteristics of umbo vibration along two orthogonal axes-one axis being perpendicular to the tympanic membrane and the other axis being parallel to the tympanic membrane plane but orthogonal to the long process of the malleus-differ significantly enough to compromise the sensing performance of the proposed accelerometer should a position misalignment occur during the implant procedure. We used laser Doppler vibrometry to measure the displacement of the umbo along the two orthogonal axes in 4 cadaveric temporal bones at multiple frequencies within the audible spectrum. We found that the peak-to-peak displacement frequency response along both axes was nearly flat from 250 Hz to 1 kHz, and it gradually rolled off with a slope of approximately -20 dB and -40 dB per decade above 1 kHz and 4 kHz, respectively. At each frequency, the displacement exhibited a linear function of the input sound level with a slope of 20 dB per decade. A comparison of measurements along the two axes indicated a similar frequency response, with an average amplitude difference of 20%. The characterization data suggest that the performance of a miniature ossicular vibration-sensing device attached on the umbo would not be degraded in the event of a position misalignment. The data also indicate that a MEMS accelerometer needs to achieve a resolution of
to detect normal conversation. Issue: January 2010 Category: Original Articles Author: by Darrin J. Young, PhD, Mark A. Zurcher, MS, Tung Trang, MD, Cliff A. Megerian, MD, and Wen H. Ko, PhD
Lipomas are benign mesenchymal tumors that are often found in the head and neck. Intrinsic lipomas of the larynx and supraglottic area are rare, as fewer than 115 cases have been reported in the literature; almost all of these occurred in isolation. We report a case of a laryngeal lipoma that was associated with diffuse systemic lipomatosis. The tumor was successfully removed via an endoscopic laser resection. To the best of our knowledge, this is only the second case of laryngeal lipoma associated with lipomatosis to be reported in the English-language literature. We also review the literature on head and neck lipomas.
Issue: January 2010 Category: Original Articles Author: by Megan L. Durr, MD, Nishant Agrawal, MD, John R. Saunders, MD, and Patrick K. Ha, MD
Behçet disease is a multisystem vasculitis characterized by mucosal aphthosis, primarily in the oral and genital mucosa. Only a few cases of involvement of the nasal mucosa have been reported in the literature, and its true prevalence is not known. We conducted a cross-sectional study of 400 consecutively presenting patients with confirmed Behçet disease (according to classification-tree criteria) to determine the incidence of nasal mucosal involvement, to identify its particular characteristics, and to determine if there are any statistically significant differences in clinical and paraclinical parameters between Behçet disease patients with nasal involvement and those without. To the best of our knowledge, this is the first systematic evaluation of nasal involvement in patients with Behçet disease to be published in the literature. Data analysis was performed with Statistical Package for the Social Sciences software (SPSS), and a confidence interval (CI) at 95% was calculated for each finding. Involvement of the nasal mucosa was seen in 31 of the 400 patients (7.8%; CI: 5.1 to 10.5). Among those 31 patients, the most common nasal symptom was dysosmia, which was seen in 15 patients (3.8% of the total population; CI: 1.9 to 5.7); other nasal symptoms included obstruction in 10 patients (unilateral in 9), ulcers in 2, pain in 2, and a burning sensation and discharge in 1 each. No patient reported a history of epistaxis or nasal itching. Abnormal signs were present in only 16 patients (4.0%; CI: 2.1 to 5.9); they included nasal cartilage deformity in 6, unilateral nasal obstruction in 4, postnasal discharge in 3, nonaphthous ulcer in 3, and crusted ulcer in 2 (2 patients each had 2 abnormal signs). No case of aphthous ulcer, nasal discharge, nasal scar or deformity, septal perforation, or nodular or granulomatous cartilage lesion was found. There were no statistically significant differences in clinical and paraclinical disease manifestations between those patients who had nasal mucosal involvement and those who did not.
Issue: January 2010 Category: Original Articles Author: by Farhad Shahram, MD, Masoud Motasaddi Zarandy, MD, Aqeela Ibrahim, MD, Naghmeh Ziaie, MD, Masumeh Saidi, MD, Behrooz Nabaei, MD, MPH, and Fereydoun Davatchi, MD
Nonoperative management is generally accepted as a treatment strategy for nasopharyngeal cancer characterized by destruction of the skull base. Chemoradiotherapy is considered the standard of care in these cases. We report a case in which imaging studies documented the successful treatment of the patient's locally extensive nasopharyngeal carcinoma with this nonsurgical approach.
Issue: January 2010 Category: Original Articles Author: by Federico Ampil, MD, Guillermo Sangster, MD, Glenn Mills, MD, Cherie Ann Nathan, MD, Timothy Lian, MD, and Andrew Hall, BS
Schwannomas of the nasal septum are extremely rare, and therefore their diagnosis and treatment can pose certain challenges. We describe the case of an incidentally discovered schwannoma of the nasal septum that was unique in that the lesion was completely asymptomatic. In view of our finding, we believe that routine examinations of both nasal fossae should be considered during routine diagnostic laryngeal flexible endoscopy.
Issue: December 2009 Category: Original Articles Author: by Fabio Pagella, MD, Georgios Giourgos, MD, Elina Matti, MD, and Andrea Colombo, MD
Necrotizing otitis externa (OE) is traditionally seen in elderly diabetics and immunocompromised patients. During a 7-year period at our institution, we treated 6 patients with necrotizing OE who were not diabetic, who were not immunocompromised, and who were relatively young (age range: 27 to 65 yr; mean: 42.8). The necrotizing OE in these patients was less aggressive but just as severe as its usual presentation in older diabetic or immunocompromised patients. All 6 patients had evidence of bony erosion on computed tomography of the temporal bones, although 4 had negative findings on technetium-99m scintigraphy. Four of the 6 patients required mastoid exploration and fascia lata grafting, and the other 2 chose to undergo extensive daily microdebridements and intravenous antibiotics followed by 6 weeks of oral antibiotics. We recommend that a diagnosis of necrotizing OE be kept in mind when evaluating any patient who presents with severe otalgia, particularly in the presence of Pseudomonas aeruginosa infection of the external auditory canal, edema, granulation tissue, and bony erosion.
Issue: December 2009 Category: Original Articles Author: by Fergal Glynn, MRCSI and Rory McConn Walsh, MD, FRCS (ORL-HNS)
We conducted a prospective analysis to independently observe the initial opinion of: (1) consulting pediatric residents (postgraduate year 2 [PGY-2]), (2) corresponding consulting attending physicians (general pediatric or pediatric emergency medicine), and (3) consulting otolaryngology PGY-2 residents when assessing patients for “noisy breathing.” Each was asked to define the type of noisy breathing present and to formulate a diagnosis based on a limited set of choices. The final diagnosis was determined by a single attending pediatric otolaryngologist (S.E.S.) at the completion of the diagnostic workup. The accuracy for characterization of breath sounds for the pediatric residents, attending pediatricians, and otolaryngology residents were 26.1%, 23.5%, and 98.6%, respectively. The positive predictive values for the determination of diagnosis were 71.6%, 69.4%, and 76.6%, respectively. These findings indicate that pediatric residents and attending pediatricians may be deficient in their ability to characterize the breath sounds commonly seen in patients with noisy breathing. Further education of pediatricians may lead to a more accurate diagnostic evaluation of a child with noisy breathing.
Issue: December 2009 Category: Original Articles Author: by Iman Naseri, MD, Frederick L. Durden, MD, and Steven E. Sobol, MD, MSc
