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Articles

A case of radiation-induced mucosal melanoma in an immunohistochemically S-100-negative patient

August 21, 2016     Michael Rodriguez, DO; Yash Patil, MD; Arun Gupta, DO, MPH

Abstract

We report a case of radiation-induced mucosal melanoma in a 41-year-old woman with a history of childhood rhabdomyosarcoma of the nasal cavity that had been treated with radiotherapy. During the workup for the melanoma, the patient was found to be negative for S-100 protein on immunostaining. While many melanotic markers for the histologic confirmation of melanoma exist, they can be negative in some cases, such as ours. To the best of our knowledge, only 1 case of radiation-induced melanoma has been previously reported in the English-language literature, and in that case the patient was S-100-positive. Although our case is rare, it suggests another possible long-term adverse effect of radiotherapy. We also describe the morphologies and histology associated with diagnosing melanoma in an S-100-negative patient.

Blastomycosis of the nose: A case report

August 21, 2016     Thomas M. Jetmore, MD; Jennifer Phan, MD; Abideen O. Yekinni, MD, FACS

Abstract

Blastomyces dermatitidis is a thermally dimorphic fungus endemic to the North American soil near the Mississippi, Ohio, and St. Lawrence river valleys, as well as the Great Lakes Basin. It is responsible for blastomycosis, a systemic pyogranulomatous disease. Blastomycosis of the head and neck is decidedly uncommon and often mistaken for cancer. There are only 3 previous case reports of blastomycosis presenting as an intranasal lesion. We report the unusual case of a 24-year-old man with blastomycosis presenting with a 4-week history of a progressively enlarging intranasal mass who had complete resolution of symptoms after treatment with itraconazole and surgical excision of the lesion.

Surgical management of a high jugular bulb

August 21, 2016     Daniel S. Roberts, MD, PhD; Brian Chen, MD; William Slattery, MD

Patient selection for surgical repair of a high dehiscent jugular bulb should include the presence of a codominant sigmoid sinus to avoid elevated postoperative intracranial pressure.

Idiopathic nasal bone osteitis: A preliminary report on a recently recognized entity

August 21, 2016     Yotam Shkedy, MD; Ohad Ronen, MD; Sarah Gips, MD; Avi Front†; Tal Marshak, MD; Nechama Uri, MD

Abstract

Osteitis of the nasal bones is a rare disease; when it occurs, it usually has a known etiology. To the best of our knowledge, idiopathic nasal bone osteitis (NBO) has not been described before. We conducted a study to analyze the behavior of idiopathic NBO and its outcome and to determine a cutoff level for diagnosis using technetium-99m-methylene-diphosphonate (Tc-MDP) bone scanning. This retrospective, controlled analysis involved 9 women (mean age: 44 yr) who had been admitted to an otolaryngology department in Israel with idiopathic NBO over a 5-year period. Clinical evaluation, isotopic evaluation, and computed tomography were done. A lesion-to-nonlesion ratio was calculated between an area of interest on the nasal bone and a reference point (L/R ratio). The same ratio was calculated for a control group of 20 subjects. All the Tc-MDP scans in the study group were suggestive of osteitis. Intravenous antibiotic treatment was effective in all cases. A high degree of accuracy was achieved with cutoff L/R ratios of 2.05 for planar views and 2.34 for single-photon emission computed tomography views.

Erratum

August 21, 2016    

Balloon dilation of the sphenoid sinus ostium for recurrent sphenoid sinusitis

August 21, 2016     Ken Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

The natural sphenoid sinus ostium is often amenable to balloon dilation, which can be performed in the office under local anesthesia or in the operating room under general anesthesia.

Epithelioid hemangioendothelioma of tongue presenting as a papilloangioma in a pregnant woman

August 21, 2016     Mainak Dutta, MS; Kuntal Roy, MD

Otolaryngologists dealing with proliferative, vessel-rich oral lesions should consider epithelioid hemangioendothelioma as one of the possibilities because it might recur or metastasize, requiring aggressive management.

Mulberry hypertrophy and accompanying sinonasal pathologies: A review of 68 cases

August 21, 2016     Davut Akduman, MD; Mehmet Haksever, MD; Muhammed Yanilmaz, MD; Fevzi Solmaz, MD

Abstract

Mulberry hypertrophy occasionally coexists with sinonasal pathologies. There are very few reports in the literature on this clinical entity. We conducted a retrospective study to draw attention to this condition in the context of accompanying sinonasal pathologies. Our study group was made up of 68 patients-51 males and 17 females, aged 13 to 57 years (mean: 34.9)-who had been diagnosed with mulberry hypertrophy and at least one accompanying sinonasal pathology. All patients had a long-standing chronic discharge. Forty-nine of these patients (72.1%) had unilateral mulberry hypertrophy. The most common concomitant pathologies were chronic rhinosinusitis and ostiomeatal complex disease; others included septal deviation, nasal polyposis, allergic rhinitis, and concha bullosa. Thirty-six patients (52.9%) with varying degrees of choanal/nasal obstruction were operated on with endoscopic excision to treat the mulberry hypertrophy. In all, most patients underwent some sort of surgery to treat either the mulberry hypertrophy or the accompanying sinonasal pathology. Based on our findings, we suggest a clinical staging system to serve as a way to standardize management and guide future basic and clinical research.

Audiologic changes after pinna augmentation

August 21, 2016     Kavit Amin, MBBS, BSc(Hons), MRCS(Eng); Robert Hone, MBBS, MRCS; Rahul Kanegaonkar, BSc, DLO, FRCS(ORL-HNS)

Abstract

No studies to date have objectively assessed whether pinna morphology affects sound intensity detected within the external auditory canal (EAC). Commonly performed procedures on the EAC are carried out for acquired and congenital pathology, together with correction of ear deformities. Our aim was to use an experimental model to identify whether a relationship exists between pinna shape and its subsequent effect on the hearing subject. An anatomically accurate and life-size model made of rubber composite was used for this study. Serial sections (small wedge, defect open; small wedge, defect closed; large wedge, defect open; large wedge, defect closed [equivalent to a protruding ear]; and pinnectomy) were undertaken, and the sound intensity changes assessed at the junction between the EAC and middle ear (tympanic membrane position) using an AURICAL Plus (Otometrics; Taastrup, Denmark) sound processor. A statistically significant loss was demonstrated for wedge-excised models, which was greatest at 180° azimuth. This loss was significantly reduced when the wedge defects were closed. A statistically significant improvement was demonstrated in the protruding (“bat”) ear model compared with the normal ear at 0° azimuth. In this model, gain in sound intensity is adversely affected by pinna wedge resection. Because this change may be increased in those with protruding ears, this factor is important to consider for all cosmetic and noncosmetic operations to the pinna, and it supports the notion that the pinna is not a simple funnel.

Postoperative hypofunctioning of the thyroid gland after total laryngectomy

August 21, 2016     Sirshak Dutta, MS, DLO; Kaustuv Das Biswas, MS, DLO; Soumya Ghatak, MS; Dibakar Haldar, MD; Indranil Sen, MS; Ramanuj Sinha, MS, DNB

Abstract

Primary laryngeal carcinoma is a common cancer, predominantly affecting males. Hypothyroidism is an undesirable sequela of both surgery and radiotherapy, the two most commonly used modalities of treatment. For advanced cases, standard treatment protocol includes total laryngectomy and neck dissection along with pre- or postoperative radiotherapy. Hemithyroidectomy is also routinely performed as an integral part of total laryngectomy. In the present study, assessment of the function of the remaining half of the thyroid gland has been done in cases of total laryngectomies in combination with uni- or bilateral neck dissection and pre- or postoperative radiotherapy. This prospective, observational study was carried out for a period of 5 years in the Otolaryngology Department of R.G. Kar Medical College and Hospital, Kolkata, India, involving a dynamic cohort of patients with advanced laryngeal carcinoma (stage T3 or T4a) who underwent total laryngectomy (including hemithyroidectomy) and bilateral or unilateral neck dissection for primary laryngeal cancer along with preoperative and postoperative radiotherapy. Assessment of the thyroid function was based on the measurement of serum thyroid-stimulating hormone and free thyroxine levels. The results revealed that 23.8%, 45.2%, and 73.8% patients developed either clinical or subclinical hypothyroid state at 6, 12, and 24 weeks, respectively, after the surgery. The estimation of relative risk (RR) was found to be most prominent among the group belonging to the “preoperative radiation with bilateral neck dissection” group at all levels of assessments, but all of the RRs were found to be insignificant per their 95% confidence intervals. Superiority of any method could not be established or refuted firmly due to the small sample size of the study. We presume that in the future, a study with a larger sample size, involving a meta-analysis of multicentric data, would be the most suitable method to throw some light on this issue.

Vocal fold granulomas

August 21, 2016     Helen Lesser, BS; Amy Rutt, DO; Robert T. Sataloff, MD, DMA, FACS

Occasionally, even after excellent reflux control, surgical removal and steroid injection into the base of the granulomas, application of mitomycin C, and voice therapy, patients develop recurrent granulomas.

Functional and psychological impact of nasal bone fractures sustained during sports activities: A survey of 87 patients

August 21, 2016     Paul Lennon, FRCS(ORL-HNS); Sam Jaber, MRCS; John E. Fenton, FRCSI, FRCS(ORL)

Abstract

Nasal bone fractures that require reduction are a common sequela of sports injuries. We conducted a survey to ascertain the outcomes of patients who had experienced a nasal bone fracture and who subsequently underwent manipulation under anesthesia. We reviewed data on 217 nasal bone fractures that had been seen at our institution over a 3-year period. Of these, 133 (61.3%) had occurred as a result of a sports activity. Thirty of the 133 patients (22.6%) had been managed conservatively, while the other 103 (77.4%) had undergone manipulation under anesthesia. We were able to contact 87 of the 103 patients (84.5%) by telephone, who served as the study population. The most common sports associated with these 87 injuries were hurling (n = 26; 29.9%), rugby (n = 22; 25.3%), Gaelic football (n = 20; 23.0%), and soccer (n = 13; 14.9%). Patients who had undergone treatment within 2 weeks were significantly more satisfied with their outcome than were those who had been treated later (p < 0.01). Twenty-six patients (29.9%) reported that their injury had had a detrimental impact on their subsequent performance in their sport; 12 (13.8%) described a fear of reinjury when they returned to play, 7 (8.0%) experienced functional problems, 3 (3.4%) complained of diminished performance, and 4 others (4.6%) quit playing contact sports altogether. To the best of our knowledge, our study is the first to demonstrate that a fracture of the nasal bones may have a notable psychological impact on an athlete and that it can lead to diminished performance or a complete withdrawal from contact sports.

Subjective and objective parameters in the evaluation of radiofrequency ablation of the inferior turbinate do not correlate: A pilot study

August 21, 2016     Peter Valentin Tomazic, MD; Claus Gerstenberger, MSc; Bettina Rant, MD; Ulrike Nemetz, MD; Christiana Brezjak-Kahlert, MD; Axel Wolf, MD; Kurt Freudenschuss, MD; Gerald Wolf, MD

Abstract

Inferior turbinate hypertrophy is a common cause of nasal obstruction. We conducted a prospective study to correlate subjective and objective parameters in assessing the effectiveness of radiofrequency ablation (RFA). Our initial study population was made up of 10 patients who presented with nasal obstruction; 1 patient was lost to follow-up, leaving us with 7 women and 2 men, aged 26 to 65 years (mean: 37.9 ± 12.8), and 16 turbinates (7 bilateral, 1 right, and 1 left). Visual analogue scale (VAS) scores, Nasal Obstruction and Symptom Evaluation (NOSE) questionnaire scores, rhinomanometry results, and CT- and MRI-based volumetry were obtained before RFA and 6 months afterward. For the subjective parameters, the mean pre- and postoperative VAS scores for the 16 turbinates were 6.6 ± 1.6 and 2.8 ± 2.0 (p < 0.001), respectively, and the mean pre- and postoperative NOSE scores in the 9 patients were 15.3 ± 3.1 and 5.8 ± 5.4 (p = 0.003). For the objective parameters, the mean pre- and postoperative rhinomanometry values at 150 Pa were 241.0 ± 141.3 and 265.4 ± 157.3 ml/sec (p = 0.403), and the mean pre- and postoperative volumetry values were 5.3 ± 2.5 and 5.0 ± 2.1 cm3 (p = 0.551). Note that only the differences in the subjective parameters reached statistical significance. RFA of the inferior turbinates as a treatment for nasal obstruction is safe and easy. However, our study found a discrepancy between the subjective and objective outcomes parameters, as the former showed highly significant improvement and the latter showed only a slight improvement that did not reach statistical significance.

Effects on auditory function of chronic exposure to electromagnetic fields from mobile phones

August 21, 2016     Sanjeev Bhagat, MS(ENT); Saurabh Varshney, MS(ENT); Sampan Singh Bist, MS(ENT); Deepak Goel, DM(Neurology); Sarita Mishra, MS(ENT); Vivek Kumar Jha, MSLAP

Abstract

The widespread use of mobile phones has given rise to apprehension regarding the possible hazardous health effects of high-frequency electromagnetic fields (EMFs) on auditory function. We conducted a study to investigate the effects of long-term (>4 yr) exposure to EMFs emitted by mobile phones on auditory function. Our study population was made up of 40 healthy medical students-31 men and 9 women, aged 20 to 30 years (mean 22.7). Of this group, 31 subjects typically held their phone to the right ear and 9 to the left ear; the non-phone-using ear served as each subject's control ear. The phone-using subjects were also split into two groups of 20 based on the duration of their daily phone use (≤60 min vs. >60 min). All subjects underwent pure-tone audiometry, speech audiometry, impedance audiometry, and brainstem evoked response audiometry (BERA), and comparisons were made between the phone-using ear and the control ear and between the shorter and longer duration of daily use. We found no statistically significant differences in high-frequency pure-tone average between the phone-using ears and the control ears (p = 0.69) or between the shorter- and longer-duration phone-using ears (p = 0.85). Moreover, statistical analysis of BERA findings revealed no significant differences between the phone-using ears and the control ears in terms of wave I-III, III-V, and I-V interpeak latencies (p = 0.59, 0.74 and 0.44, respectively). None of the subjects reported any subjective symptoms, such as headache, tinnitus, or sensations of burning or warmth behind, around, or on the phone-using ear. We conclude that the long-term exposure to EMFs from mobile phones does not affect auditory function.

Hypopharyngeal strictures and webs

August 21, 2016     Mark A. Fritz, MD; Gregory N. Postma, MD

These thin, web-like narrowings can often be missed or underappreciated on contrast swallows yet can be markedly symptomatic.

Are routine preoperative CT scans necessary in adult cochlear implantation? Implications for the allocation of resources in cochlear implant programs

August 21, 2016     Bruno Kenway, MRCS, DO-HNS; Petros V. Vlastarakos, MD, MSc, PhD; Anand V. Kasbekar, MRCS, DO-HNS; Patrick R. Axon, MD, FRCS(ORL-HNS); Neil Donnelly, MSc, FRCS(ORL-HNS)

Abstract

Our aim was to critically assess the influence of preoperative computed tomography (CT) scans on implantation decisions for adult cochlear implant candidates. The working hypothesis was that these routine scans might not provide critical additional information in most adult cochlear implant candidates. The charts of 175 adults with unilateral cochlear implantation were reviewed. Preoperative CT scan reports were audited, and scans with reported pathology were examined by an Otologist/ENT Surgeon. Clinic notes and multidisciplinary team meeting summaries were also analyzed to assess whether the results of the radiology report had influenced the decision to implant or the laterality of implantation. Twenty-five of the 175 scans (14.3%) showed an abnormality. Five of those 25 scans showed evidence of previous surgeries already known to the clinicians. Of the remaining 20 scans, 17 showed abnormalities, including wide vestibular aqueducts, Mondini deformities, and varying degrees of otospongiosis, the identification of which can be considered preoperatively helpful. Of the 175 scans, 3 (1.7%) demonstrated abnormalities that influenced the side of implantation or the decision to implant and, therefore, had an impact on treatment. We conclude that a preoperative CT scan seems to have an impact on treatment in only a small percentage of adult cochlear implantees. Hence, it may only need to be performed in patients with a history or clinical suspicion of meningitis or otosclerosis, if the individual was born deaf or became deaf before the age of 16, or if there are other clinical reasons to scan (e.g., otoscopic appearance). The related resources can be allocated to other facets of cochlear implant programs.

Clinical, functional, and surgical findings in chronic bilateral otitis media with effusion in childhood

August 21, 2016     Svetlana Diacova, MD; Thomas J. McDonald, MD; Ion Ababii, MD, PhD

Abstract

We conducted a prospective, observational study over a 3-year period to compare the clinical, functional, and surgical findings in children with chronic bilateral otitis media with effusion who underwent one of three different types of treatment. Our study population was made up of 150 patients-79 boys and 71 girls aged 24 to 84 months-who were randomly assigned to one of the three treatment groups of 50 patients each. One group was treated with myringotomy, tympanostomy tube insertion, and adenoidectomy (T+A group); another with a combination of physical conservative treatment and adenoidectomy (P+A group); and the third with physical conservative treatment alone (P-only group). Hearing levels and tympanogram trends were evaluated during a follow-up of 12 months. In the T+A group, we noted a stable normalization of hearing in 95 of the 100 ears. Treatment with the P+A combination resulted in an improvement of hearing in 79 ears, but the improvement was maintained in only 27 ears during 12 months of follow-up. In the group with the P-only regimen, an amelioration of hearing was registered in 76 ears, but it was unstable in all cases. A type A tympanogram was maintained during the follow-up period for 2 ears in the P+A group and for 4 ears in the P-only group. Myringotomy with a detailed examination of the tympanic cavity in all ears with prolonged abnormal audiologic results revealed that types C and B tympanograms, which were found in most ears in the P+A and P-only groups, corresponded to middle ear chronic inflammatory changes (retraction pockets, granulations, adhesions, etc.) Based on our findings, we conclude that the use of a physical conservative treatment with or without an adenoidectomy does not prevent the development of chronic adhesive and purulent otitis media.

Comparison of a microsliced modified chondroperichondrium shield graft and a temporalis fascia graft in primary type I tympanoplasty: A prospective randomized controlled trial

July 18, 2016     Shambhu Nath Bhattacharya, MS; Sudipta Pal, MS; Somnath Saha, MS; Prasanta Kumar Gure, MS; Anupam Roy, MS

Abstract

We conducted a prospective, randomized, controlled trial to compare outcomes in type I tympanoplasty patients who received an autologous microsliced modified cartilage perichondrium shield graft (cartilage group) and those who received an autologous temporalis muscle fascia graft (fascia group). Our three outcomes measures were (1) anatomic success rates at 3 months, (2) hearing results at 6 months, and (3) rates of morphologic success (i.e., the absence of reperforation, retraction, and graft displacement) at 2 years among those in each group who had an intact graft at 3 months. Of 56 patients who were initially enrolled and who underwent one of these type I tympanoplasty procedures, 51 completed the study-28 in the cartilage group and 23 in the fascia group. The former was made up of 11 males and 17 females, aged 15 to 48 years (mean: 27.4), and the latter included 9 males and 14 females, aged 15 to 52 years (mean: 31.7). The overall graft take rate at 3 months with respect to perforation closure (anatomic success) was 93.3% in the cartilage group and 91.7% in the fascia group, which was not a statistically significant difference. The mean hearing gain at 6 months was 11.7 ± 7.6 dB in the cartilage group and 12.6 ± 6.0 dB in the fascia group-again, not statistically significant. At 2 years, morphologic success rates were 92.3 and 81.0%, respectively-again, not statistically significant. We conclude that autologous microsliced modified cartilage perichondrium shield graft tympanoplasty is as effective as conventional temporalis fascia tympanoplasty in terms of graft take rates and functional results. Indeed, medium-term outcomes (2-yr follow-up) revealed that sustainable morphologic success was actually better with the cartilage technique than with the fascia technique because it was associated with fewer revision surgeries.

Accessory parotid gland tumors: A series of 4 cases

July 18, 2016     Takuya Kakuki, MD; Kenichi Takano, MD; Makoto Kurose, MD; Atsushi Kondo, MD; Tsuyoshi Okuni, MD; Noriko Ogasawara, MD; Tetsuo Himi, MD

Abstract

Accessory parotid gland tumors are clinically rare, and their management remains unclear. In this article, we describe our experience with 4 patients-2 males and 2 females, aged 13 to 66 years-who were diagnosed with an accessory parotid gland tumor. All patients presented with an asymptomatic midcheek swelling, and all underwent fine-needle aspiration biopsy, ultrasonography, computed tomography, and magnetic resonance imaging. A standard parotidectomy was performed on all patients. Postoperatively, 2 patients were found to have a malignant tumor, while the other 2 had a pleomorphic adenoma. No patient experienced any obvious facial nerve injuries postoperatively, and no recurrences were observed. We discuss the preoperative evaluation, treatment, and prognosis of these tumors, and we briefly describe the literature. The first choice of treatment for accessory parotid gland tumors is surgical resection. In our experience, a standard parotidectomy approach is safe and cosmetically appealing.

Ketamine-snorting-induced nasal septum perforation

July 18, 2016     Keng-Kuang Tsai, MD; Chih-Hung Wang, MD, PhD

Ketamine causes vasoconstriction, and long-term abuse leads to mucosal ischemia, atrophy and, ultimately, necrosis, followed by underlying cartilage or bone destruction.

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