June 11, 2013 Xie Su Jiang, MD, PhD; Jia Hong Bo, PhD; Xu Po, MS; and Zheng Ying Juan, BSC
Abstract
Spatial disorientation in airplane pilots is a leading factor in many fatal flying accidents. Spatial orientation is the product of integrative inputs from the proprioceptive, vestibular, and visual systems. One condition that can lead to sudden pilot incapacitation in flight is vestibular neuritis. Vestibular neuritis is commonly diagnosed by a finding of unilateral vestibular failure, such as a loss of caloric response. However, because caloric response testing reflects the function of only the superior part of the vestibular nerve, it cannot detect cases of neuritis in only the inferior part of the nerve. We describe the case of a Chinese naval command fighter pilot who exhibited symptoms suggestive of vestibular neuritis but whose caloric response test results were normal. Further testing showed a unilateral loss of vestibular evoked myogenic potentials (VEMPs). We believe that this pilot had pure inferior nerve vestibular neuritis. VEMP testing plays a major role in the diagnosis of inferior nerve vestibular neuritis in pilots. We also discuss this issue in terms of aeromedical concerns.
June 11, 2013 Richard J. Vivero, MD; Sandeep P. Dave, MD; Carmen R. Gomez, MD; and Donald T. Weed, MD
Abstract
We report what is to the best of our knowledge the first case of malignant transformation of a giant cell tumor of the larynx. The patient, a 34-year-old man, presented to our tertiary care university teaching hospital where he underwent hemilaryngopharyngectomy with radial forearm free flap reconstruction and 11 of 15 cycles of chemotherapy. He remained disease-free at approximately 6 years and 4 months of follow-up. The patient is decannulated and continues to have a good voice with excellent quality of life to this day. We discuss the patient's clinical course and subsequent treatment within the context of a review of the current literature regarding this disease entity. Our experience demonstrates that giant cell tumor of the larynx may present as a malignant neoplasm without adversely affecting the patient's prognosis when treated aggressively with surgical resection and adjunct chemotherapy.
Previous presentation: The information in this article has been updated from its original presentation as a poster at The Triologic Society's Combined Southern and Middle Sections Meeting; January 8-11, 2009; Bonita Springs, Fla.
June 11, 2013 Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; and Eiji Yanagisawa, MD, FACS
Ostial polys in the maxillary sinus can cause recurring maxillary sinus disease by obstructing the ethmoid infundibulum and natural ostium of the maxillary sinus.
June 11, 2013 Thomas K. Chung, MA; Keith Wilson, MD; and Yash J. Patil, MD
Abstract
The rectus abdominis flap offers a number of advantages over other flaps used in head and neck reconstruction. The flap can be harvested by a separate team and can be tailored to include skin, muscle, and fat. In addition, the available vascular pedicle is long and its large caliber provides an appropriate size match with recipient neck vessels. Central to reconstructive success is defining an arterial and venous pedicle that provides balanced perfusion to all components of the flap. Anomalous vascular anatomy presents principal challenges in reestablishing free flap perfusion. We present a case of double, right deep inferior epigastric arteries encountered during vertical rectus abdominis myocutaneous flap reconstruction of the tongue and floor of the mouth and discuss the clinical outcomes of this reconstruction.
June 11, 2013 Ryan F. Osborne, MD, FACS; Jason S. Hamilton, MD, FACS; and Reena Gupta, MD, FACS
Often asymptomatic initially, neurofibromas may cause pain, weakness, and numbness as they grow as a result of compression of the underlying nerve fascicles.
June 11, 2013 Nausheen Jamal, MD; Farhad Chowdhury, DO; Reena Gupta, MD; and Robert T. Sataloff, MD, DMA, FACS
Supraglottoplasty may be helpful in a patient with tracheotomy-dependent adult obstructive sleep apnea/hypopnea syndrome that is causally related to or aggravated by supraglottic obstruction.
June 11, 2013 Jason M. Samuelian, DO; Brandon J. Fisher, DO; Larry C. Daugherty, MD; and Usha A. Babaria, MD
Abstract
A 52-year old man was referred to our service for evaluation after being diagnosed with oropharyngeal squamous cell carcinoma. Contrast-enhanced computed tomography (CT) revealed a mass in the left tonsillar pillar, as well as submental lymphadenopathy. The extent of tumor infiltration was assessed by fluoro-2-deoxyglucose positron emission tomography scans, which showed increased uptake in the tumor bed and a suspicious-looking lymph node near the right hilum. No other signs or symptoms of distant metastasis were evident at that time, and the patient was treated with induction chemotherapy followed by chemoradiation. Several weeks after treatment completion, the patient returned, complaining of right medial foot edema. CT of the right lower extremity revealed multiple high-attenuation masses in the soft tissues of the right leg and foot, including a mass in the medial plantar region of the foot. Approximately 15 to 20% of patients with oropharyngeal squamous cell carcinoma develop distant metastasis throughout the course of the disease. Soft-tissue metastases from oropharyngeal cancers are rare, however, particularly when they present in the absence of widespread metastasis. A review of the current head and neck tumor literature describes soft-tissue metastases in less than 10% of patients with known distant metastases. Metastasis to distal regions such as the lower extremities has rarely been observed but should be included in the differential diagnosis for patients presenting with lower-extremity pain or edema.
June 11, 2013 Antonio D'Antonio, MD, PhD; Giampiero Mottola, MD; Alessia Caleo, MD; Maria Addesso, MD; and Amedeo Boscaino, MD
Abstract
Among the primary mesenchymal tumors of the hypopharynx and larynx, lipomas are rare. Macroscopically, they often resemble a retention cyst or laryngeal nodule. Spindle cell lipomas (SCLs) are an uncommon variant of lipoma. SCLs are extremely rare in the larynx; as far as we know, only 4 cases have been previously described in the literature. We present a new case of laryngeal SCL in a 65-year-old man who presented with a 1-year history of hoarseness, choking spells, stridor, and dyspnea. Examination revealed the presence of a large polyp on the left true vocal fold that had caused stenosis of the posterior glottis. The polyp was removed endoscopically, and the patient's stridor and dyspnea resolved. Histologically, the tumor was composed of bland, CD34-positive spindle cells with an abundant fibrous and myxoid stroma interspersed with mature fatty tissue. The patient was free of local recurrence at 2 years of follow-up.
June 11, 2013 Jay Goswamy, MRCS, DOHNS; Rohini Aggarwal, FRCS(ORL-HNS); Iain A. Bruce, MD, FRCS(ORL-HNS); and Michael P. Rothera, FRCS
Abstract
A hemangioma that rapidly increases in size has the potential to trap platelets and cause a consumptive coagulopathy. We describe the case of an 18-week-old boy who was brought to a local emergency department with ecchymosis on his nasal bridge and medial epicanthi, as well as a subconjunctival hemorrhage. He was noted to be anemic and thrombocytopenic. Packed red blood cells and platelets were transfused. However, despite hematologic correction, the ecchymosis and petechiae worsened, and a mass became evident in the right posterior triangle of the patient's neck. Computed tomography demonstrated a lobular soft-tissue-density mass in the right posterior triangle that extended to the level of the skull base. Histologic analysis of a biopsy specimen revealed that the lesion was a giant kaposiform hemangioma. The patient was diagnosed with Kasabach-Merritt syndrome, and prednisolone was commenced as a first-line treatment. However, the mass continued to grow, resulting in inspiratory stridor. Magnetic resonance imaging revealed encroachment into the thecal sac and compression of the spinal cord. The lesion was embolized, and vincristine therapy was commenced. Following a second embolization, the size of the lesion decreased and no further blood products were required. The hemangioma was deemed to be unresectable. The successful treatment in this case was dependent on the maintenance of hemostasis, the initial medical treatment with a corticosteroid, repeat embolization, and longer-term control with vincristine.
June 11, 2013 Amanda B. Sosulski, MD and James D. Hayes, MD
Abstract
We present a case of recurrent cicatricial stenosis of the external ear canals caused by ectodermal dysplasia, specifically Rapp-Hodgkin syndrome, in a 45-year-old woman. No form of medical or surgical management has produced durable patency of the patient's ear canals, and her hearing loss is being managed with hearing aids. Topical management of the recurring external otitis slows the process but has been unsuccessful in preventing restenosis of both external auditory canals.
June 11, 2013 Yoav Hahn, MD; and Dennis I. Bojrab, MD
Abstract
We conducted a retrospective study to compare the results of ossicular chain reconstruction (OCR) with two types of composite prosthesis: a hydroxyapatite-polyethylene (HAPEX) implant and a hydroxyapatite-titanium (HATi) prosthesis. We reviewed the records of 222 patients-104 males and 118 females, aged 8 to 79 years (mean: 39.7)-who had undergone OCR for ossicular chain dysfunction and who met our eligibility criteria. In addition to demographic data and the type of prosthesis, we compiled information on pre- and postoperative audiometric findings, the underlying diagnosis, the timing of surgery (primary, planned, or revision), the type of surgery (tympanoplasty alone, tympanoplasty with antrotomy, intact-canal-wall tympanomastoidectomy, or canal-wall-down tympanomastoidectomy), the extent of reconstruction (partial or total), the use of the malleus, the use of a tragal cartilage graft, and evidence of extrusion. Of the 222 patients, 46 had undergone insertion of either a partial (n = 36) or total (n = 10) ossicular replacement prosthesis (PORP and TORP, respectively) made with HAPEX, and 176 had received a PORP (n = 101) or TORP (n = 75) made with HATi. Postoperatively, the mean air-bone gap (ABG) was 14.0 dB in the HAPEX group and 14.7 dB in the HATi group, which was not a significant difference (p = 0.61). Postoperative success (ABG ≤20 dB) with PORP was obtained in 30 of the 36 patients in the HAPEX group (83.3%) and in 87 of the 101 patients in the HATi group (86.1%), while success with TORP was achieved in 7 of 10 HAPEX patients (70.0%) and 56 of 75 HATi patients (74.7%); there was no significant difference in either PORP or TORP success rates between the HAPEX and HATi groups (p = 0.32). A significantly better hearing result was obtained when the malleus was used in reconstruction (p = 0.035), but the use of tragal cartilage led to a significantly worse outcome (p = 0.026). Revision surgery was associated with a significantly worse postoperative result (p = 0.034). Prosthesis extrusion was observed in 9.0% of all cases. The two types of composite assessed in this study yielded similar results in terms of functional hearing and stability, but the HATi prosthesis had some significant advantages. For example, it was associated with more cases in which the ABG closed to less than 10 dB. In addition, because of its thinner stem and lower profile, it can be used in situations that are not possible with the HAPEX implant.
June 11, 2013 Sean T. Donovan, MD; Grant T. Rohman, MD; John P. Selph, MD; Roy Rajan, MD; Rosemary M. Stocks, MD; and Jerome W. Thompson, MD, MBA
Abstract
Suppurative parotitis is an uncommon entity identified in newborns. While Staphylococcus aureus has been frequently identified as the causative pathogen among the few patients diagnosed with neonatal suppurative parotitis (NSP), there has only been one prior case described in the literature that was due to methicillin-resistant Staphylococcus aureus (MRSA). Because of its virulence, MRSA presents new and substantial challenges for the surgeon; we describe two cases of NSP caused by MRSA and the subsequent surgical intervention necessitated for cure. We also include a review of all cases of NSP described in the English-language literature.
June 11, 2013 Mainak Dutta, MS; Soumya Ghatak, MS; and Ramanuj Sinha, DLO, MS, DNB
Pressure ulcers over the pinna usually develop as a result of local compression from oxygen mask tubing.
June 11, 2013 Evan M. Graboyes, MD; Clint T. Allen, MD; Rebecca D. Chernock, MD; and Jason A. Diaz, MD
Abstract
We report the case of a 31-year-old woman with systemic lupus erythematosus who was found to have oral hairy leukoplakia (OHL). She was on immunosuppressive therapy but was human immunodeficiency virus (HIV)-negative. OHL has been previously reported in HIV-negative patients who were immunosuppressed for other reasons, such as solid organ or hematopoietic stem cell transplantation, hematologic malignancies, or systemic diseases. To the best of our knowledge, this is the first case of OHL in an HIV-negative patient reported in the otolaryngology literature. It adds to the growing list of cases of OHL in HIV-negative patients and serves as a reminder to physicians to include OHL in the differential diagnosis for oral cavity lesions in all immunosuppressed patients. The article also summarizes the current state of knowledge about the pathogenesis of OHL, its relation to the Epstein-Barr virus, and the treatment options.
June 11, 2013 Nader Nassif, MD; Mariaelisabetta Cottelli, MD; Davide Farina, MD; and Marco Berlucchi, MD
Abstract
Schwannomas are benign peripheral nerve neoplasms that arise from Schwann cells. They usually occur in the adult population. The most common site in the head and neck region is the parapharyngeal space. Intrapharyngeal schwannomas are extremely rare, and those that have been reported all occurred in adults. We report what to the best of our knowledge is the first case of an intrapharyngeal schwannoma in a pediatric patient. The patient, a 15-year-old boy, was treated successfully with surgical excision.
June 11, 2013 Andrew G. Shuman, MD
June 11, 2013 Manish Gupta, MS(ENT); Sunder Singh, MS(ENT); and Monica Gupta, MD(Med)
Abstract
We report a rare case of incus dislocation into the external auditory canal following a head injury. The patient was a 35-year-old man who presented to the surgical emergency unit with a head injury that he had sustained during a traffic accident. An x-ray of the skull detected a longitudinal fracture of the right temporal bone. The ENT examination revealed the presence of a bony structure and a blood clot in the right external auditory canal. Computed tomography identified a disruption of the ossicular chain, with an incus-like bony shadow in the external canal. The wide opening of the fracture line and the impact of the accident were believed to have pushed the incus through the fracture and into the external canal. The patient was successfully treated with exploratory tympanotomy and ossiculoplasty.
June 11, 2013 Hilmi Alper Senkal, MD; Taner Yilmaz, MD; and Ahmet Bulent Sozeri, MD
Abstract
Testicular carcinoma metastatic to the neck is rare. Even more rare is a finding of choriocarcinoma as a neck mass without any sign of a primary testicular tumor, as only a few cases have been reported in the literature. We describe a new case that occurred in a 29-year-old man who presented with a neck mass. Fine-needle aspiration biopsy identified the tumor as a malignant epithelial neoplasm. Radiologic findings indicated the presence of a systemic metastasis of a tumor to the chest and abdomen, as well as the neck. Findings on an incisional biopsy of the neck mass were consistent with a choriocarcinoma. The testicles were normal on palpation and ultrasonography. The patient was diagnosed with metastatic choriocarcinoma with an unknown primary, and he was started on chemotherapy. On the second day of treatment, which was 25 days after his referral to our clinic, he died of respiratory insufficiency.
June 11, 2013 Soliman El-Shakhs, MD; Yaser Khalil, MD; and Asmaa Gaber Abdou, MD
Abstract
We conducted a study to evaluate the success of facial nerve preservation in 27 adults with a parotid tumor who underwent total parotidectomy. Of this group, 11 patients had a malignant tumor, 10 had a recurrent benign tumor, and 6 had a primary benign tumor. Preoperatively, 7 patients had facial nerve paresis. Postoperatively, facial nerve preservation was achieved in all but 1 case; in the exception, the nerve was sacrificed and grafting was necessary. In conclusion, facial nerve preservation can be achieved in almost all cases of total parotidectomy.
