Survival characteristics of injected human cartilage slurry in a nude mouse model: A preliminary study

July 13, 2014     Bounmany Kyle Keojampa, MD; Jacob Pieter Noordzij, MD; Bohdana Burke, MD; Joseph Alroy, DVM; Vartan Mardirossian, MD; Alphi Elackttu, MD; Zhi Wang, MD


We conducted a study to examine the viability, host response, and volume retention characteristics of drilled human septal cartilage slurry when injected into an athymic nude mouse model. We injected 0.2 ml of the slurry into the hind limbs of 6 mice. The mice were sequentially sacrificed over a period of 180 days. Histologic reviews of the hind limbs were performed to determine the viability of injected chondrocytes, host response, and volume retention. Specimens were obtained and histomorphologic analysis was performed at 1, 30, 90, and 180 days after injection. We identified viable cartilage throughout the study. Cartilage injection was well tolerated, and minimal inflammatory reaction occurred without significant adverse effects. The injected bolus of cartilage was found to have progressively dispersed throughout the muscle over time. Our findings warrant further investigation with a larger cohort of nude mice or possibly human subjects.

Angiolipoleiomyoma located in the earlobe

July 13, 2014     Sirin Yasar, MD; Zehra Asiran Serdar, MD; Fatih Goktay, MD; Burcu Barutcugil, MD; Selvinaz Ozkara, MD; Pelin Demirturk, MD


Angiolipoleiomyoma (ALLM) is a solid tumor that is mostly derived from muscle tissue. It is often located in the kidneys of patients with tuberous sclerosis; ALLMs located outside the kidneys are very rare. Among the rare presentations are cutaneous ALLMs, which manifest as 1- to 4-cm asymptomatic, acquired, solitary, subcutaneous nodules that have a strong predilection for males. To the best of our knowledge, only 22 cases of ALLM of the skin have been previously reported in the literature; in 5 of these cases, the tumor was located on the ear. Histologically, tumoral proliferation is observed with smooth muscle, fat tissue, and vascular channels surrounded by a fibrous capsule; cellular atypia is not observed. We report the case of a 67-year-old man who presented for evaluation of a purplish nodular lesion that had been present on his right earlobe for 10 years. Analysis of an excisional biopsy specimen revealed a nodular formation that consisted mostly of thick-walled veins within a fibromyxoid stroma; smooth-muscle tissue and fat globules were observed in places. The lesion was diagnosed as a cutaneous ALLM.

Otologic manifestation of Samter triad

July 13, 2014     Danielle M. Blake, BA; Alejandro Vazquez, MD; Senja Tomovic, MD; Robert W. Jyung, MD

It is important for otolaryngologists to be aware of the mucoid quality of these middle ear effusions, as they tend to be persistent and they do not respond well to myringotomy and tube placement, which usually results in tube obstruction.

Acute vocal fold hemorrhage after phonosurgery

July 13, 2014     Joel E. Portnoy, MD; Catherine Capo, BS; Robert T. Sataloff, MD, DMA, FACS

In this case, the KTP laser was used to vaporize the bilateral vocal fold varicosities.

Parathyroid adenoma

July 13, 2014     Lester D.R. Thompson, MD

Most of these lesions are identified in glands within their usual anatomic location instead of in an ectopic or supernumerary site.

Large osteoma of the maxillary sinus accompanied by an unerupted tooth

July 13, 2014     Jae-Hoon Lee, MD

CT of the maxillofacial region is required for patients with an osteoma to rule out Gardner syndrome, which should be considered when a patient has more than one osteoma.

Endoscopic view of a middle meatal cyst

July 13, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

Obstruction of the middle meatus and ethmoid infundibulum can occur as a result of swelling of the mucosal surfaces of the soft tissues, although most such obstructions are caused by polyps. Obstruction from a cystic mass is less common.

Leiomyosarcoma of the parapharyngeal space: A very rare entity

July 13, 2014     Haim Gavriel, MD; Eyal Yeheskeli, MD; Gratiana Hermann, MD; Ephraim Eviatar, MD


Leiomyosarcoma of the head and neck is very rare, as only about 100 cases have been reported; of these, only 3 cases have been previously reported in the parapharyngeal space. We report the fourth such case, and we review the features of this entity. The patient was an 84-year-old woman who presented to the emergency department for treatment of an 18-month history of right-sided headache, a 6-month history of right-sided hearing loss and nasal obstruction, and a 2-month history of dysphagia. Physical examination revealed a bulge in the right side of the soft palate and the right lateral nasopharyngeal wall and complete obstruction of the right eustachian tube. Indirect laryngoscopy detected a bulge in the right lateral hypopharyngeal wall. Otoscopy revealed otitis media with effusion in the right ear. Imaging demonstrated a space-occupying lesion in the right parapharyngeal space that extended from the base of the skull to the level of the hypopharynx. Biopsy and histology identified the mass as a leiomyosarcoma. Metastasis to the brain was discovered shortly thereafter, and the patient died 10 months later. The unusual presentation of head and neck leiomyosarcoma requires a high index of suspicion and appropriate diagnostic imaging. Surgical excision is the recommended treatment when feasible; chemoradiotherapy does not appear to affect disease progression.

Transoral removal of a large parapharyngeal space neurofibroma with the Harmonic Scalpel

July 13, 2014     Marcel Marjanovic Kavanagh, MD; Zlatko Sabol, MD, PhD, MSc; Sasa Janjanin, MD, PhD; Drago Prgomet, MD, PhD


We report the case of a 19-year-old man with neurofibromatosis type 1 who presented for evaluation of odynophagia, left-sided hemiparesis, multiple café au lait spots all over his body, and numerous subcutaneous and cutaneous neurofibromas. Imaging revealed the presence of two large neurofibromas-a 60 x 50 x 35-mm tumor in the left parapharyngeal space and an intradural tumor measuring 25 mm in diameter. We removed the larger tumor via a transoral route with the Harmonic Scalpel. The size of this tumor far exceeded the size of any other reported tumor removed in this manner. Various approaches to the parapharyngeal space have been described in the literature. To the best of our knowledge, this case represents the first report of a transoral removal of a huge parapharyngeal space neurofibroma with a Harmonic Scalpel.

Rhinosporidiosis: An unusual presentation

July 13, 2014     Borlingegowda Viswanatha, MS, DLO, PhD


Rhinosporidiosis is a chronic granulomatous disease that primarily affects the mucous membranes of the nose and nasopharynx. It is caused by Rhinosporidium seeberi. Clinically it presents as a reddish, bleeding, polypoid mass with a characteristic strawberry-like appearance on its surface, which is caused by the presence of mature sporangia. In the case described here, a 35-year-old man presented with a 6-month history of a slowly growing polypoid mass in his left nasal cavity. The surface of the mass was smooth, pale, and covered with nasal mucosa. It was attached to the nasal septum. Fine-needle aspiration cytology was suggestive of a parasitic cyst. The mass was excised with the use of local anesthesia. Histopathologic examination of the resected specimen revealed rhinosporidiosis. Prior to this diagnosis, the patient had not exhibited most of the typical clinical features that are suggestive of rhinosporidiosis. In the case of a nasal mass, a diagnosis of rhinosporidiosis is important to establish prior to any surgery because bleeding during and after surgery is usually profuse and can be life-threatening. The site of the excised mass should be cauterized to prevent recurrence.

Pediatric rhabdomyosarcoma

July 13, 2014     Rosemary Ojo, MD; Si Chen, MD; Liset Pelaez, MD; Ramzi Younis, MD

All children with rhabdomyosarcoma require multimodality therapy to maximize local tumor control. This can involve different combinations of chemotherapy, surgery, and radiation therapy.

Invasive primary aspergillosis of the larynx presenting as hoarseness and a chronic nonhealing laryngeal ulcer in an immunocompetent host: A rare entity

July 13, 2014     Mimi Gangopadhyay, MD; Kaushik Majumdar, MD; Arghya Bandyopadhyay, MD; and Anup Ghosh, MS(ENT)


Primary aspergillosis usually affects the paranasal sinuses, orbit, ear, and lower respiratory tract. Laryngeal aspergillosis usually occurs as a result of secondary invasion from the tracheobronchial tree, more commonly in immunocompromised hosts. Primary laryngeal localization of Aspergillus infection is seldom encountered. We report the case of an immunocompetent 42-year-old man who presented with hoarseness and a laryngeal ulcer of fairly long duration. A malignancy was initially suspected clinically, but a laryngoscopic biopsy led to a diagnosis of invasive primary laryngeal aspergillosis. No other focus of aspergillosis was found on x-ray and computed tomography. After identification of Aspergillus niger on culture, inquiries revealed no exposure to steroids, cytotoxic drugs, or irradiation, and workups for malignancy, human immunodeficiency virus infection, tuberculosis, and diabetes were negative. Although isolated laryngeal involvement is rare, aspergillosis may be considered in the differential diagnosis of a chronic nonhealing laryngeal ulcer that is clinically suggestive of a malignancy, even in an immunocompetent host.

Reinnervation of facial muscles with only a cross-facial nerve graft in a 25-year-old patient with congenital facial palsy

July 13, 2014     Kamal Seyed-Forootan, MD; Hamid Karimi, MD; Esmaiil Hasani, MD


The standard method for managing chronic facial palsy is the two-stage free-muscle flap. We report a case involving a 25-year-old patient who had facial palsy from her birth. Twelve months after the first stage of a cross-facial nerve graft, we found that the voluntary movements of her facial muscles had returned. Within the following 12 months, she gained complete recovery of her movements on the affected side, as confirmed by electromyography studies. This case demonstrates that neurotization of facial muscles in chronic facial palsy is possible. However, further studies are needed to define the trophic effects or trophic mediators that can restore function to atrophied facial muscles and to determine which patients might benefit from the cross-facial nerve graft procedure without the free-muscle graft procedure.

Meningeal carcinomatosis in undifferentiated nasopharyngeal carcinoma: A case report

July 13, 2014     Daniel M. Cushman, MD; German Giese, MD; Panta Rouhani, MD, PhD, MPH


Meningeal carcinomatosis is the tumoral invasion of the leptomeninges. It is caused by the spread of malignant cells throughout the subarachnoid space, which produces signs and symptoms due to multifocal involvement. Cranial nerve symptoms are the most common focal findings. The diagnosis is usually made by imaging and/or cytology. Head and neck cancers are the cause of approximately 2% of all cases of meningeal carcinomatosis; in very rare cases, they are caused by a nasopharyngeal carcinoma. We report a case of meningeal carcinomatosis that was caused by a recurrence of undifferentiated nasopharyngeal carcinoma. The patient, a 60-year-old woman, experienced no focal neurologic symptoms and exhibited no radiologic evidence of meningeal involvement. We also review the literature on meningeal carcinomatosis secondary to nasopharyngeal carcinoma.

Evidence-based update on tympanostomy tube placement for otitis media in children

July 13, 2014     Jeffrey Cheng, MD; Lisa Elden, MD

Controversy has grown over the indications, timing, and efficacy of tympanostomy tube placement compared with watchful waiting.

Primary cervical thoracic duct cyst: A case report and review of the literature

July 13, 2014     Ameet Kumar, MS; T.S. Ramakrishnan, MS; Samaresh Sahu, MD, DNB


Thoracic duct cysts are uncommon entities that are usually found in the thoracic segments of the thoracic duct. The presence of a thoracic duct cyst in the cervical area has been rarely reported. Etiologically, these cysts can arise either as a primary growth or secondary to trauma, obstruction, or inflammation. This entity was first described in 1964, and only 33 cases have been previously reported in literature. Of these, 16 cases involved a primary cyst. We report a new case of a primary thoracic duct cyst, and we discuss its presentation, diagnosis, and management, with an emphasis on meticulous surgical technique. We also review the relevant literature.

Papillary thyroid cancer in a gravid woman

July 13, 2014     Darrin V. Bann, PhD; Neerav Goyal, MD, MPH; David Goldenberg, MD, FACS

All attempts should be made to preserve the recurrent laryngeal nerve with resection of all gross tumor, particularly in cases of known contralateral RLN dysfunction.

Petrosquamosal sinus discovered during mastoidectomy, and its radiologic appearance on temporal bone CT: Case report and brief review

July 13, 2014     Hyun Joon Shim, MD; Seong Jun Song, MD; Ki Woong Chung, MD; Sang Won Yoon, MD


We report the case of a 47-year-old woman who underwent a mastoidectomy. Preoperative computed tomography demonstrated an unusually distended bony canal that passed through the superolateral portion of the right petrous bone. Intraoperatively, we identified the anomaly as a petrosquamosal sinus (PSS). This unusually dilated venous channel had arisen from the adjacent sigmoid sinus. A PSS is an emissary vein of the posterior fossa that courses along the petrosquamosal junction, connecting the sigmoid or transverse sinus with the extracranial venous system. While it usually regresses during fetal life, a dilated PSS occasionally persists into adulthood. Its anatomic course may lead to problematic bleeding during mastoidectomy.

Ototoxicity in Nigeria: Why it persists

July 13, 2014     Daniel D. Kokong, MBBS, FWACS; Aminu Bakari, MBBS, FWACS, FICS; Babagana M. Ahmad, MBBS, FWACS, FICS


No therapy is currently available to reverse the serious damage that can be caused by ototoxic drugs, such as permanent hearing loss and balance disorders. Otolaryngologists in various regions of the world have developed strategies aimed at curtailing drug-induced ototoxicity, but similar efforts in most developing nations have yet to be well established. We conducted a study to document our experience in Nigeria. Our study population was made up of 156 patients-66 males and 90 females, aged 5 to 85 years (mean: 32.1 ± 30.7)-who were diagnosed with drug-induced ototoxicity over a 3-year period. Tinnitus was the first and the predominant symptom in 140 patients (89.7%). The most common cause of drug-induced ototoxicity among the 156 patients was injection of an unknown agent (n = 55 [35.3%]); among the known agents, the most common were chloramphenicol (n = 25 [16.0%]), chloroquine (n = 22 [14.1%]), and gentamicin (n = 20 [12.8%]). One pregnant woman experienced a miscarriage at 4 months after receiving intramuscular chloroquine, and another woman fell into a coma after receiving intramuscular streptomycin. Two agents that have not been linked to ototoxicity-oxytocin and thiopentone sodium-were found to be ototoxic in our study (1 case each). Of the 312 ears, 31 (9.9%) showed normal audiometric patterns; on the other end of the spectrum, 155 ears (49.7%) had profound sensorineural hearing loss (SNHL). Mixed hearing loss was seen in 90 ears (28.8%). Hearing loss was bilaterally symmetrical in 127 patients (81.4%), bilaterally asymmetrical in 15 patients (9.6%), and unilateral in 14 patients (9.0%). Treatment was primarily medical; hearing aids were fitted for 7 patients (4.5%). Only 41 patients (26.3%) kept as many as 3 scheduled follow-up appointments. Ototoxicity remains prevalent in the developing countries of Africa. Numerous drugs and other agents are responsible, and management outcomes are difficult to ascertain. Thus, our emphasis must be placed on prevention if we are to minimize the potentially devastating effects of ototoxicity.

Nasal vestibule schwannoma: Report of a rare case

June 8, 2014     Ismail Fadzilah, MSurg(ORL-HNS); Husain Salina, MSurg(ORL-HNS); Baharudin Khairuzzana, MSurg(ORL-HNS); Omar Rahmat, MSurg(ORL-HNS); SHA Primuharsa Putra, MSurg(ORL-HNS)


Schwannomas of the nasal cavity and paranasal sinuses are quite rare, especially in the nasal vestibule. We report the case of a 61-year-old woman who presented with a 2-month history of progressively worsening right-sided epistaxis and nasal blockage. Rigid nasoendoscopy showed a mobile, smooth, globular mass occupying the right nasal vestibule. The mass arose from the lateral nasal wall and impinged on the anterior part of the middle turbinate posteriorly. Computed tomography of the paranasal sinuses showed a 3.8 x 1.7-cm enhancing mass in the right nostril. The mass obliterated the nasal cavity and caused mild deviation of the septum. The preoperative histopathologic examination showed positivity for vimentin and S-100 protein, suggesting a diagnosis of schwannoma. The patient underwent an intranasal laser-assisted excision biopsy. The histopathologic examination confirmed the diagnosis of schwannoma. Postoperative recovery was uneventful, and no recurrence was seen in the follow-up period.

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