Silastic injection for vocal fold medialization resulting in a false-positive finding on F18 FDG-PET/CT

September 20, 2015     Ayman Mahfouz, MBBS; Meeran Naji, MSc, MRCS, FRCR; Wing Yan Mok, BSc, MBBS, FRCR; Ali S. Taghi, MBBS, MD, FRCS(ORL-HNS); Zarni Win, MRCP, FRCR


A false-positive uptake of F18-fluorodeoxyglucose (FDG) on positron-emission tomography/computed tomography (PET/CT) can result in confusion and misinterpretation of scans. Such uptakes have been previously described after injection of polytetrafluoroethylene (Teflon) into the vocal folds. Similarly, vocal fold injection of silicone elastomer (Silastic) can result not only in a false-positive FDG uptake on PET/CT, but also in chronic inflammation. We report a case of increased FDG uptake in a vocal fold after Silastic injection that was misinterpreted as a malignancy in a 70-year-old woman who had metastatic carcinoma of the stomach.

Endoscopic resection of a mucocele of the crista galli

September 20, 2015     Mani Shidanshid, BSc, MBBS; Ali S. Taghi, MBBS, MD, FRCS(ORL-HNS); Romana Kuchai, FRCS; Hesham A. Saleh, FRCS


Mucoceles expand by the process of bone resorption and new bone formation, which leads to local destruction and displacement of adjacent structures. We present the case of a 47-year-old woman who presented with recurrent headaches, nausea, and vomiting, all of which were believed to have occurred secondary to a mucocele of the crista galli. To the best of our knowledge, only 1 similar case has been previously reported in the world literature; in that case, the crista galli was drained externally. In our patient, resolution of symptoms was achieved by endoscopic dacryocystorhinostomy, endoscopic frontal sinusotomy, and drainage of the mucocele under image guidance. We recommend that an endoscopic surgical approach be considered for the management of mucoceles of the crista galli.

Erosion of the incus by the chorda tympani nerve from a complex retraction pocket

September 20, 2015     Ramanan Daniel, MBBS; Fiona Hill, MBBS; Timothy Price, FRCS(OHNS)

Chronic eustachian tube dysfunction can lead to retraction of the tympanic membrane and bone erosion.

Endoscopy-assisted resection of a submandibular gland mass via a thyroidectomy incision

September 20, 2015     Jin Pyeong Kim, MD; Jung Je Park, MD; Hyun Woo Park, MD; Seung Hoon Woo, MD


Submandibular gland excision is traditionally performed via the transcervical approach. In an effort to avoid or reduce visible scarring and nerve injury, diverse innovative surgical trials have been conducted. We report the case of a submandibular gland mass that was endoscopically resected through a thyroidectomy incision. The patient was a 56-year-old woman with a long-standing right-sided submandibular gland mass and a smaller thyroid gland mass that was recently discovered on a routine checkup. The thyroid mass was managed with a total thyroidectomy. The submandibular mass was resected with endoscopic assistance through the thyroidectomy incision with an ultrasonic scalpel. The resection was successful, and the patient experienced no acute complications such as neural injury, hematoma, or seroma formation. Upon healing of the thyroidectomy scar, the cosmetic result was excellent. We conclude that endoscopic resection of a submandibular gland mass through a thyroidectomy incision is a feasible option that results in excellent surgical and cosmetic outcomes.

Facial nerve paralysis: Smile reconstruction using the masseteric nerve

September 20, 2015     Moustafa Mourad, MD; Christopher Linstrom, MD; Grigoriy Mashkevich, MD

Reanimation methods range from static slings and nerve transfers to dynamic muscle techniques, such as regional temporalis and free gracilis transfer.

A radiologic view of migration of a foreign body in the maxillary sinus by mucociliary movement

September 20, 2015     Jae Hoon Lee, MD

Displaced foreign objects should be removed from the antrum to prevent the development of maxillary sinusitis.

Posthemorrhagic polyp: Risk of misdiagnosis of the cause of glottic insufficiency

September 20, 2015     Massi Romanelli-Gobbi, MD; Julia Ellerston, MA; Rima A. DeFatta, MD; Joel Portnoy, MD; Robert T. Sataloff, MD, DMA, FACS

Patients with vocal fold hemorrhage often present with sudden dysphonia and may not be able to recall an inciting event.

Primary sinonasal meningioma in a child

September 20, 2015     Dodul Mondal, MBBS; Manisha Jana, MD; Prabir Kumar Sur, MD; Ebnam Murshed Khan, MD


Meningiomas are common intracranial extra-axial masses. They are rarely encountered in extracranial locations; when they are, the most common head and neck locations are the paranasal sinuses and the temporal bone. Meningiomas in children are very rare, especially in the neonatal period. The clinical presentation and clinical findings are often nonspecific. The diagnosis can be established by imaging and histopathologic examination with immunohistochemistry. We describe a case of primary sinonasal meningioma in a 2-year-old boy whose onset of symptoms had begun during the neonatal period. We discuss the clinical features, imaging results, and histopathologic and immunohistochemical findings in this case.

Spontaneous true aneurysm of the superficial temporal artery presenting as an asymptomatic forehead mass

September 20, 2015     Nenad Zivkovic, MD, PhD; Milan B. Jovanovic, MD, PhD; Marko Markovic, MD, PhD; Sanja Milenkovic, MD, PhD


Superficial temporal artery aneurysms are rare; when they do occur, they are usually associated with head trauma. Spontaneous true aneurysms of the superficial temporal artery are extremely rare. They are classified as true aneurysms when all three layers of the vessel are found to be involved on histologic examination. Therapeutic options include conservative management, image-guided embolization, and surgical excision. We report a case of an extracranial spontaneous aneurysm of the frontal branch of the superficial temporal artery. A 20-year-old man presented with an asymptomatic, pulsatile, 1-cm forehead mass that had gradually increased in size. The aneurysm was evaluated by clinical examination and three-dimensional computed tomographic angiography. Complete resection was performed with local anesthesia. Histologic examination revealed that the aneurysm involved all three layers of the blood vessel: the tunica intima, tunica media, and tunica adventitia. No atherosclerotic changes or inflammatory cells were found. To the best of our knowledge, this is only the third reported case of a histologically verified spontaneous aneurysm of the frontal branch of the superficial temporal artery. Awareness of this rare pathology in the differential diagnosis of a forehead mass may facilitate diagnosis and prevent complications.

Endoscopic transnasal transsphenoidal transtuberculum sellae extradural approach to suprasellar pituitary lesions: A case report

September 20, 2015     Tapan Nagpal, MS


Pituitary adenomas are benign tumors that arise within the anterior lobe (the adenohypophysis) of the pituitary gland in the sella turcica. As they grow, they can extend through the pituitary stalk and into the suprasellar compartment. The surgical management of these adenomas via a conventional intradural approach is fraught with a high risk of causing a large cerebrospinal fluid leak. We report a case of pituitary adenoma in a 60-year-old woman whose surgery was performed via a minimally invasive endoscopic transnasal transsphenoidal transtuberculum sellae extradural approach.

Pleomorphic sarcoma of the neck

September 20, 2015     Lester D. Thompson, MD

Pleomorphic sarcoma is an uncommon neoplasm in the head and neck now that refinements in diagnostic techniques have more accurately classified tumors that used to be placed in this category.

Protection from blood aerosol contamination when managing epistaxis: A study of the effectiveness of a patient mouth mask

September 20, 2015     Salman Baig, FRCSI; Tahir Rashid, FCPS, FEB(ORL-HNS); Muhammad Saleem, FRCS


The danger to healthcare personnel of acquiring a blood-borne infection accidentally transmitted by a patient is well known. Such an infection can have serious and career-altering implications. Epistaxis, which is the most common emergency seen in ENT practice, poses a great risk of contaminated blood being spattered on the face of the attending medical provider. Areas of possible contamination include the mucosa of the nasal passages, oral cavity, and conjunctiva. Various strategies to prevent contamination have been described in the literature, most of which involve the wearing of protective equipment by the healthcare provider. We conducted a prospective, randomized study of 60 epistaxis patients to determine if a simple surgical mask warn by the patient over his or her mouth would protect the treating physician from aerosolized blood contamination. We found evidence of significant blood splashes on the physician in 8 of the 30 cases (26.7%) in which the patient did not wear a mask, compared with only 4 cases (13.3%) when the mouth mask was worn. We therefore conclude that a patient mouth mask is a simple, inexpensive, and effective way to minimize the risk of aerosolized blood contamination during the treatment of epistaxis.

Schwannoma of the cervical esophagus: Report of 2 cases and a review of the literature

September 20, 2015     Yu-Long Wang, MD; Jian-Guang Sun, MD; Jian Wang, MD; Wen-Jun Wei, MD; Yong-Xue Zhu, MD; Yu Wang, MD; Guo-Hua Sun, MD; Kuan Xu, MD; Hui Li, MD; Ling Zhang, MD; Qing-Hai Ji, MD


Schwannomas of the cervical esophagus are extremely rare, as fewer than a dozen reports have been published in the literature. Therefore, their clinical characteristics and management have not been definitively elucidated. We report 2 cases of cervical esophageal schwannoma (CES) in which the patients-a 52-year-old woman and a 53-year-old woman-were initially misdiagnosed clinically. The correct diagnosis was later established on the basis of contrast-enhanced computed tomography (CT) and intraoperative frozen-section analysis. In both cases, the tumor was enucleated, and the esophagus was closed by primary intention. Both patients resumed an oral diet 2 weeks postoperatively. Follow-up detected no evidence of recurrence. Our review of the literature revealed that CES is a benign mesenchymal tumor that can be misdiagnosed both clinically and pathologically. Preoperative contrast-enhanced CT and intraoperative frozen-section analysis help in the planning for conservative enucleation, which precludes the need for esophageal resection and its associated morbidity.

Otolaryngologic manifestations of Noonan syndrome

September 20, 2015     Katie Geelan-Hansen, MD; Samantha Anne, MD, MS


Noonan syndrome is an autosomal dominant disorder with associated anomalies that include short stature, congenital heart defects, developmental delay, and characteristic facial features among other abnormalities. Articulation deficiency and language delay are often present and require speech therapy. Otitis media and hearing loss have been reported to be common in these patients. We performed a retrospective chart review of pediatric patients who were diagnosed with Noonan syndrome at our tertiary care center from January 1979 through December 2009. We found 19 such patients. Of these, 8 had received single-specialty care at our hospital; it is not known if they had received otolaryngologic care from an outside provider. These 8 patients were not included in our study. The remaining 11 patients-6 boys and 5 girls, aged 1 to 19 years (mean: 9.2)-had all received multidisciplinary care at our institution; 9 of them had received care from an otolaryngologist at our center. Of this group, 7 had history of feeding difficulty, 6 had experienced speech delay that required speech therapy, 6 had undergone placement of a pressure equalization tube, 4 had undergone adenoidectomy with or without tonsillectomy, and 1 had been treated with endoscopic sinus surgery. Although this study is limited by our small number of patients, our results suggest that early otolaryngologist involvement must be considered in the care of children with Noonan syndrome because many have evidence of eustachian tube dysfunction, hearing loss, and speech delay.

A year in the office of a rural otolaryngologist

September 20, 2015     Donald Robert Lewis, MD, FACS, FAAO-HNS

IgG4-related plasma cell granuloma of the maxillary sinus: A report of 2 cases

September 20, 2015     Masaru Kojima, MD, PhD; Yoshimasa Nakazato, MD, PhD; Kaoru Hirabayashi, MD, PhD; Nobuhide Masawa, MD, PhD; Naoya Nakamura, MD, PhD


We report 2 rare cases of IgG4-related plasma cell granuloma of the maxillary sinus. Histologically, both lesions were characterized by severe lymphoplasmacytic infiltration. In 1 case, fibrous sclerosis and obliterative arteritis were observed. Immunohistochemical study demonstrated that IgG4-positive cells comprised more than 40% of the IgG-positive plasma cells. Moreover, the serum IgG4 level was elevated in both cases. A good responsiveness to steroid therapy has been seen in IgG4-related disease. From a therapeutic perspective, it is important to recognize IgG4-related plasma cell granuloma.

Rhinolith from a long-ago insertion of a bead into the nasal cavity

September 20, 2015     Hung-Che Lin, MD; Chih-Hung Wang, MD, PhD; Hsin-Chien Chen, MD, PhD

CT may be used to assess the calcification deposits and the number and size of rhinoliths.

Adult-onset familial vocal fold paralysis

September 20, 2015     Ida Amir, MRCS, DOHNS; Yanick J. Crow, MBBS, PhD, MRCP; Pradeep Morar, MD, FRCS(ORL-HNS)


We describe the cases of 2 brothers in their early 50s, born to consanguineous parents, who presented with acute stridor as a result of adult-onset bilateral abductor vocal fold paralysis. Both patients had a history of adult-onset asthma. No other associated symptoms were evident, and findings on neurologic examination and all other investigations were normal. Both patients required emergency surgical tracheostomy. Another brother with a similar history had died of an airway problem when he was 53 years of age; 2 other younger brothers and 3 younger sisters were currently unaffected. To the best of our knowledge, this is the first report of adult-onset familial bilateral vocal fold paralysis in the absence of associated features. The parents' consanguinity suggested an autosomal recessive basis to this disorder. In addition to describing the features of this case, we review the literature relating to adult-onset familial vocal fold paralysis.

Sensorineural hearing loss after ossicular manipulation and drill- generated acoustic trauma in type I tympanoplasty with and without mastoidectomy: A series of 51 cases

September 20, 2015     K. Cagdas Kazikdas, MD; Kazim Onal, MD; Nadir Yildirim, MD


Recognized causes of high-frequency sensorineural hearing loss (SNHL) after tympanoplasty with and without mastoidectomy include acoustic trauma from manipulation of the ossicles, the noise generated by suctioning and, in the case of mastoidectomy, the noise generated by temporal bone drilling. We conducted a retrospective study to identify the effects of ossicular manipulation and mastoid drilling on high-frequency SNHL. Our study population was made up of 51 patients-20 males and 31 females, aged 10 to 59 years (mean: 28.5). Of this group, 26 patients had undergone a unilateral over-under tympanoplasty only (tympanoplasty group) and 25 had undergone a unilateral tympanoplasty plus additional mastoid surgery (mastoidectomy group). Bone-conduction audiograms were obtained pre- and postoperatively; the latter were obtained within 24 hours after surgery and again at 6 months of follow-up. In the tympanoplasty group, a significant SNHL, primarily at 2 kHz, was seen in 6 patients (23%) at 24 hours, but at 6 months there was no depression of bone-conduction thresholds. In the mastoidectomy group, a significant SNHL, primarily at 2 and 4 kHz, occurred in 12 patients (48%) at 24 hours, and bone-conduction deterioration was still present in 4 patients (16%) 6 months after surgery. The difference between the preoperative audiograms and the 6-month audiograms in both groups was statistically significant (p = 0.034). We conclude that (1) over-under tympanoplasty, which requires significant manipulation of the ossicles, can cause temporary SNHL after surgery, and (2) prolonged exposure to the noise generated by mastoid drilling can result in permanent SNHL.

A large laryngeal pleomorphic leiomyosarcoma arising from a small pedicle without mucosal invasion: Case report

September 20, 2015     Napadon Tangjaturonrasme, MD


Laryngeal leiomyosarcoma is a rare mesenchymal malignancy of the head and neck region. The author presents a case of an atypical laryngeal leiomyosarcoma that featured a large pedunculated lesion without mucosal invasion. This feature has not been previously described in the English-language literature. The diagnosis, treatment, and outcome are also discussed.

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