How to refer to patients

April 2, 2014     Linda Zinn, Managing Editor, Ear, Nose & Throat Journal

Endoscopic modified Lothrop approach for the excision of bilateral frontal sinus tumors

March 18, 2014     Jiun Fong Thong, MRCS; Deyali Chatterjee, MD; Siew Yoong Hwang, FRCS


We describe the use of an endoscopic modified Lothrop approach for clearance of an extensive sinonasal-type hemangiopericytoma of the nasal cavity and paranasal sinuses with bilateral frontal sinus involvement in a 44-year-old woman. The modified Lothrop approach is conventionally used to treat sinusitis, but with some slight modifications to the technique, it can also be used for tumor excision.

Cervical sympathetic chain paraganglioma: A report of 2 cases and a literature review

March 18, 2014     Rahul Seth, MD; Manzoor Ahmed, MD; Aaron P. Hoschar, MD; Benjamin G. Wood, MD; Joseph Scharpf, MD


We review 2 cases of surgically and pathologically confirmed paraganglioma of the cervical sympathetic chain. Both patients-a 46-year-old man and a 33-year-old woman-were treated surgically. Intraoperatively, both tumors were found to be hypervascular and arising from the cervical sympathetic chain. Histopathologic analysis confirmed both as paragangliomas. Paragangliomas arising from the cervical sympathetic chain are exceptionally rare, but they must be considered in the differential diagnosis of parapharyngeal masses. They often present with ipsilateral Horner syndrome and oropharyngeal fullness, and they may be associated with a higher rate of catecholamine secretion. Typical imaging characteristics include anterolateral or lateral displacement of both the carotid and jugular vessels.

Bilateral external auditory canal cholesteatomas

March 18, 2014     Danielle M. Blake, BA; Alejandro Vazquez, MD; Robert W. Jyung, MD

External auditory canal cholesteatomas may be classified as idiopathic or secondarily acquired, most commonly occurring in postoperative or post-traumatic settings.

Laryngeal schwannoma presenting as a pedunculated mass in the glottis

March 18, 2014     Hideki Nakagawa, MD; Naoyuki Kohno, MD; Toshiyuki Kusuyama, MD; Hiroyuki Fukuda, MD

This is the first case of laryngeal schwannoma that presented as a pedunculated tumor arising from the true vocal fold.

Y-V alar base reduction

March 18, 2014     Grant S. Hamilton III

For alar modification, removing tissue from inside the nostril to decrease width or from the lateral aspect of the ala to decrease flare works well in many patients, but these techniques may produce an unnatural result.

Madelung disease: Multiple symmetric lipomatosis

March 18, 2014     Enrique Palacios, MD, FACR; Harold R. Neitzschman, MD, FACR; Jeremy Nguyen, MD

Patients with multiple symmetric lipomatosis commonly also suffer from various neuropathies, especially paresthesias and autonomic neuropathy.

Endoscopic view of an inferior meatal polyp

March 18, 2014     Jae Hoon Lee, MD

Most polyps in the nasal cavity develop from the mucosa of the anterior ethmoid sinus, the contact areas of the uncinate process, and the middle turbinate so that they are observed in the middle meatus.

Schwannoma of the nasal septum: An unusual finding

March 18, 2014     Shruti Dhingra, MS, DNB; Jaimanti Bakshi, MS, DNB; Satyawati Mohindra, MS, DNB


Schwannomas of the nasal cavity are rare benign tumors, and those that arise from the nasal septum are even rarer. When they do occur, they usually become symptomatic early because of the close confines of the nasal cavity. We describe a case of nasal septal schwannoma that was noteworthy in that the patient-a 28-year-old woman-waited 8 months after the onset of symptoms to seek medical care. Her symptoms included complete right-sided nasal obstruction, occasional epistaxis, and hemifacial pain. The tumor was completely removed via an endoscopic approach. We discuss the clinical presentation, differential diagnosis, and treatment of this rarely encountered neoplasm.

Descending necrotizing mediastinitis: A conservative approach

March 18, 2014     Sriram Iyer, MRCP; Joseph Collum, MRCP; Marta Babores, FRCP


Descending necrotizing mediastinitis (DNM) is a now-rare complication of dental and pharyngeal infections. Reports in the literature have emphasized the need for early, aggressive surgical intervention. We present a case of DNM with bilateral empyemas that arose secondary to a perforated pharyngeal abscess. The patient was successfully managed conservatively with intravenous antibiotics and intercostal drainage. We conclude that conservative management with antibiotics and image-guided percutaneous pleural drainage may be initially appropriate for the stable patient.

Fungal necrotizing fasciitis of the head and neck in 3 patients with uncontrolled diabetes

March 18, 2014     Saravanam Prasanna Kumar, DNB; Arunachalam Ravikumar, MS; Lakshmanan Somu, MS


Necrotizing fasciitis is an uncommon, rapidly progressive soft-tissue infection that is associated with a high incidence of morbidity and mortality. It is usually caused by bacteria and rarely caused by or complicated by a fungus. We report 3 cases of necrotizing fasciitis of the head and neck in patients with uncontrolled diabetes. Fungi were isolated in all 3 cases. In 1 fatal case, the invasive zygomycete Apophysomyces elegans was isolated. Keys to the management of this condition are (1) early isolation of the causative organism by fungal smear and culture, (2) adequate control of diabetes, (3) maintenance of electrolyte balance, and (4) controlled aggressive surgical debridement at an early stage. We emphasize the importance of fungal smears and cultures in the management of this rapidly spreading infection.

Merkel cell carcinoma

March 18, 2014     Jeffrey D. Shiffer, MD; Lester D.R. Thompson, MD

The expected 5-year survival rate for patients with Merkel cell carcinoma is more than 80% if the tumor is less than 2 cm and has not metastasized. Once a tumor has metastasized regionally, the 5-year survival rate drops to about 50%.

Early detection of nasopharyngeal carcinoma using IgA anti-EBNA1 + VCA-p18 serology assay

March 18, 2014     Achmad C. Romdhoni, MD, PhD; Nurul Wiqoyah, MS; Widodo Ario Kentjono, MD, PhD

Nasopharyngeal carcinoma (NPC) is the most common head and neck malignancy in Indonesia. Overall, it ranks fourth in males and sixth in females as the most prevalent type of cancer in that country. The data show that in the year 2011, NPC incidence was considered to be intermediate (6.2/100,000 population per year). Through histopathologic examination, about 70 to 80% of these cases were found to be type III according to the WHO classificaton. NPC carries an excellent prognosis if treated early, but most patients presented with stage III to IV disease, which negatively affected the cure rate and increased the mortality rate. Epstein-Barr virus (EBV) IgA serology has been established as an effective marker for NPC. Therefore, biologic markers, DNA, and/or antibody-based diagnosis is needed to decrease NPC cases. A screening program needs to be developed that will identify people at high risk of NPC and those who are in the early stage of the disease. In this study, 20 samples were collected from posttherapy patients. An otolaryngologic examination, histopathology of nasopharyngeal tissue, and blood testing for serologic markers were performed. IgA anti-EBNA1 + VCA-p18 enzyme-linked immunosorbent assay showed positive impact as a tool for confirming the diagnosis of NPC, but it still has to be combined with other specific diagnostic tools for post-therapy monitoring and for determining prognosis.

Necrotizing fasciitis of the ear: An unusual case

March 18, 2014     Jessica L. Gullung, MD; Jacob E. Smith, MD; April D. Hendryx, DO; Krishna G. Patel, MD, PhD


We describe a rare case of necrotizing fasciitis of the ear in an otherwise generally healthy 39-year-old man. The ear is rarely involved in this often-fatal disease. The diagnosis was suspected on the basis of clinical examination and confirmed by computed tomography and pathology of a biopsy specimen, which revealed subcutaneous gas formation and dermal infiltration of inflammatory cells, respectively. The patient was promptly treated with surgical debridement, intravenous antibiotics, and hyperbaric oxygen. He recovered well and subsequently underwent otoplastic reconstruction with very satisfactory results. By documenting this case, we aim to heighten awareness of necrotizing fasciitis of the head and neck in an effort to improve survival rates.

Pediatric cervical sympathetic chain schwannoma with Horner syndrome: A rare case presentation

March 18, 2014     Sanjeev Bhagat, MS; Saurabh Varshney, MS; Sampan S. Bist, MS; and Nitin Gupta, MS


Schwannomas are rare, benign, slowly growing neurogenic tumors that originate in peripheral, spinal, or cranial nerves other than the optic and olfactory nerves. In the head and neck, these tumors usually arise from the vagus nerve and the cervical sympathetic chain in the parapharyngeal space. Cervical sympathetic chain schwannomas represent a rare subgroup of schwannomas; fewer than 60 cases have been reported in the literature. These tumors are rarely seen in children and adolescents. Because patients typically present with an asymptomatic neck mass and vague complaints, clinical suspicion is important in making the diagnosis. Neural deficits at presentation are uncommon. The presence of features of Horner syndrome before excision is very rare, having been previously reported in only 10 cases of cervical sympathetic chain schwannoma. We report an extremely rare case of a cervical sympathetic chain schwannoma in a child who presented with Horner syndrome. The lesion was successfully excised.

Implants in otology

March 18, 2014     Barry E. Hirsch, MD

Progress in technology facilitates progress in patient care.

Two cases of granular cell tumors of the head and neck at different sites

March 18, 2014     Mustafa Paksoy, MD; Mehmet Eken, MD; Emin Ayduran, MD; Gokhan Altin, MD


Granular cell tumor (GCT) is an uncommon, primarily benign lesion. We describe 2 cases of GCT. Patient 1 was a 38-year-old man who presented with a reddish, vegetative lesion that involved the posterior third of the left true vocal fold. Patient 2 was an 18-year-old girl who presented with a firm, slightly extruded submucosal mass in the posterior lateral third of the tongue. Both lesions were identified as GCTs on biopsy. Both tumors were removed surgically, and both patients exhibited no signs of recurrence during follow-up. It is important that otolaryngologists be familiar with GCT and its management. Although the length of follow-up has varied substantially in the literature, we recommend long-term surveillance, including regular clinical examinations and periodic imaging with contrast-enhanced magnetic resonance imaging, at least until additional studies have clarified the natural history and recurrence patterns of GCT with greater certainty.

Facial nerve palsy associated with a cystic lesion of the temporal bone

March 18, 2014     Na Hyun Kim, MD; Seung-Ho Shin, MD


Facial nerve palsy results in the loss of facial expression and is most commonly caused by a benign, self-limiting inflammatory condition known as Bell palsy. However, there are other conditions that may cause facial paralysis, such as neoplastic conditions of the facial nerve, traumatic nerve injury, and temporal bone leions. We present a case of facial nerve palsy concurrent with a benign cystic lesion of the temporal bone, adjacent to the tympanic segment of the facial nerve. The patient's symptoms subsided after facial nerve decompression via a transmastoid approach.

Multiple plasma cell granulomas of the larynx in a young man

March 18, 2014     Courtney Shires, MD; Sandeep Samant, MD, FACS


Plasma cell granuloma of the larynx is a rare benign lesion of unknown etiology, with only 21 cases reported previously. We report an additional case of plasma cell granuloma in which a 26-year-old man experienced a 1.5 x 3.4-cm, completely obstructing subglottic lesion. Because of the patient's young age, history of hemoptysis, bleeding from his tracheostomy, and the rarity of plasma cell granulomas, the patient was assumed to have hemangioma until proven otherwise. He presented with a partially obstructing glottic lesion 4 months later. Both the subglottic and glottic lesions were excised endoscopically. Multiple modalities have been used to treat plasma cell granulomas, including radiation, endoscopic CO2 laser ablation, high-dose prednisone, and open excision. In our case, steroids were given in the interim between the 2 excisions. This is the first report of a patient with two laryngeal plasma cell granulomas and the 22nd reported case of laryngeal plasma cell granuloma.

Aggressive inflammatory pseudotumor of the maxillary sinus and orbit

March 18, 2014     Sheldon Chong, MBBS, MS(ORL-HNS); Carren S.L. Teh, MBBS, MS(ORL-HNS); Shashinder Singh, MBBS, FRACS; Mun Kein Seong, MBBS, MPath; Subrayan Viswaraja, MBBS, FRCS(Edin), FRCOphth(UK)


Inflammatory pseudotumor (IPT) is a rare, locally aggressive, benign neoplasm of unknown etiology. It is uncommon in the head and neck region, particularly in the paranasal sinuses. We present an unusual case of IPT of the maxillary sinus and orbit in a 27-year-old woman who presented with cheek swelling, right orbital swelling, double vision, and associated fever and trismus. Computed tomography identified a mass with radiologic features suggestive of a malignancy of the maxillary sinus and orbit; the mass extended into the infratemporal fossa, parapharyngeal space, anterior antral wall, and surrounding soft tissue. A diagnosis of IPT was established on the basis of histologic and immunohistochemical analysis, which identified a proliferation of bland spindle cells and a mixed inflammatory cell infiltrate. Despite its aggressive appearance, IPT is associated with a good prognosis. Our patient was treated successfully with a combination of surgery, steroid therapy, and methotrexate. Chemotherapeutic agents are generally reserved for recalcitrant cases.

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