Globus sensation and laryngopharyngeal reflux

October 30, 2015     Michael J. Knabel, BS; Jonathan M. Bock, MD, FACS

Some study results have suggested that psychological factors such as depression and anxiety can influence the etiology of globus.

Laryngeal neuromas in a case of multiple endocrine neoplasia type 2B

October 30, 2015     Stanley W. McClurg, MD; Paul E. Wakely Jr., MD; Eugene G. Chio, MD


Mucosal neuromas of the larynx in the setting of multiple endocrine neoplasia type 2B (MEN-2B) are extremely rare; to the best of our knowledge, only 2 other cases have been previously reported in the world literature. We describe a new case, which occurred in a 30-year old woman who presented with dysphagia, dysphonia, and cough. On examination, she was found to have multiple laryngeal mucosal neuromas throughout the glottis and supraglottis. She underwent surgical resection of these lesions with resolution of her symptoms.

Letters to the Editor

October 30, 2015     Satvinder Singh Bakshi, MS, DNB; Raman Wadhera; Naushad Zafar; Sat Paul Gulati; Vijay Kalra; Anju Ghai

Physician liability issues and telemedicine: Part 1 of 3

October 30, 2015     Steven T. Kmucha, MD, JD, FACS

An unusual presentation of a lingual dermoid cyst

October 30, 2015     Megan L. Durr, MD; Annemieke van Zante, MD, PhD; Steven D. Pletcher, MD


Dermoid cysts are rare lesions of the head and neck that usually present in children as an asymptomatic, slowly growing mass. We report a case that demonstrates that dermoid cysts can present later in life as a recurrent acute infection. Our patient was a 48-year-old man with a 22-year history of recurrent abscesses of the tongue and floor of the mouth that had required a tracheotomy and multiple hospitalizations. Magnetic resonance imaging performed between acute episodes revealed the presence of a 1.8-cm lesion within the tongue musculature. The patient underwent resection, and pathology was consistent with a lingual dermoid cyst. At 2 years of follow-up, he experienced no recurrence of symptoms.

Endoscopic view of a total ethmoidectomy prior to the FESS era

October 30, 2015     Eiji Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS

Before the development of functional endoscopic sinus surgery (FESS), total intranasal ethmoidectomy was performed without the aid of telescopes.

Langerhans cell histiocytosis involving the external auditory canal: An unusual ear tumor

October 30, 2015     Kang-Wei Fan, MD; Cheng-Chien Yang, MD; Chia-I Chou, MD; Min-Tsan Shu, MD

Langerhans cell histiocytosis has an unpredictable natural history, which ranges from rapidly fatal progressive disease to spontaneous resolution.

Noninvasive intraoperative angiography for reconstruction of head and neck defects

October 30, 2015     Shiva P. Daram, MD; Justin M. Sacks, MD; Michael E. Kupferman, MD


Reconstruction of head and neck defects after cancer resection involves the use of local, pedicled musculocutaneous, and free flaps. Flap failure is often caused by vascular insufficiency, and it is associated with the presence of cardiovascular or peripheral vascular disease, a history of smoking, and previous radiation and/or surgery. Failure rates may be reduced by the use of indocyanine green near-infrared fluorescence laser angiography, which detects perfusion deficits intraoperatively. Although this technology has been validated in other fields, there is limited experience in the head and neck region. We present 3 cases in which different head and neck flaps were used along with this technology in patients at high risk for flap failure. All flaps were successfully implanted without perioperative or long-term complications. The increasing complexity, age, and comorbidities of the head and neck cancer population pose significant reconstructive challenges. This report demonstrates the feasibility of employing intraoperative angiography for local, pedicled, and free flaps. This noninvasive tool optimizes intraoperative planning and assesses viability, potentially lowering failure rates in high-risk patients. Identification of patients who most benefit from this technology warrants further investigation.

Unusual primary tumors presenting as papillary carcinomas metastatic to the neck

October 30, 2015     Agnes Dupret-Bories, MD, PhD; Marc Wilt, MD; Pierre Kennel, MD; Anne Charpiot, MD, PhD; Jean-Francois Rodier, MD, FACS


The presence of a metastatic papillary carcinoma in the neck is presumptive evidence of a primary thyroid neoplasm since neck metastases of other primary tumors are uncommon. Immunohistochemical studies may be required to diagnose these metastases. We report 2 cases in which an unrelated tumor mimicked a thyroid malignancy. Both patients had been referred for evaluation of enlarged lymph neck nodes without any other symptoms. In both cases, a lymph node biopsy identified a metastatic papillary adenocarcinoma that was believed to be consistent with a thyroid primary. Thyroidectomy was not performed in either case. Further investigations led to the diagnosis of other primary tumors that were unrelated to the thyroid; the unrelated primaries were an ovarian serous tumor in one patient and a papillary renal cell carcinoma in the other.

An imaging study of the facial nerve canal in congenital aural atresia

October 30, 2015     Shouqin Zhao, PhD; Demin Han, PhD; Zhenchang Wang, PhD; Jie Li, MD; Yanni Qian, MD; Yuanyuan Ren, MD; Jiyong Dong, MD


We conducted a prospective study to investigate the abnormalities of the facial nerve canal in patients with congenital aural atresia by computed tomography (CT). Our study population was made up of 99 patients-68 males and 31 females, aged 6 to 22 years (mean: 13.5)-who had unilateral congenital aural atresia without any inner ear malformations. We compared our findings in these patients with those in 50 controls-33 males and 17 females, aged 5 to 22 years (mean: 15.0)-who had normal ears. We classified the congenital aural atresia patients into three groups (A, B, and C) according to their Jahrsdoerfer grading scale score (≥8; 6 or 7; and ≤5, respectively). The course of the facial nerve canal in both the controls and the study patients was determined by temporal bone CT with multiplanar reconstruction. The distances from different parts of the facial nerve canal to surrounding structures were also measured. The course of the facial nerve canal in the normal ears did not vary much, and there were no statistically significant differences according to head side and sex. In groups B and C, the tympanic segment, mastoid segment, and angle of the second genu of the facial nerve canal were all significantly smaller than those of the controls (p < 0.01 in all cases). Statistically, the tympanic segment of the facial nerve canal in patients with congenital aural atresia was downwardly displaced. The mastoid segment of the facial nerve canal in these patients was more anterior than that of the controls. We conclude that congenital aural atresia is often accompanied by abnormalities of the facial nerve canal, especially in the tympanic segment, the mastoid segment, and the second genu. We found that the lower the Jahrsdoerfer score was, the shorter the tympanic segment was and the more forward the mastoid segment was.

A hyperpneumatized frontal sinus with middle meatal obstruction

October 30, 2015     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

In this case, the narrowing of the middle meatus by the hypertrophic polypoid middle turbinate resulted in intermittent frontal sinusitis and headaches.

Laryngofissure for resection of a recurrent saccular cyst

October 30, 2015     Reed C. Gilbow, BS; J. Mark Reed, MD; Jeffrey D. Carron, MD

Congenital saccular cysts represent a rare cause of airway obstruction and inspiratory stridor in infants.

Masseter flap for reconstruction of defects after excision of buccal mucosa cancers with intact mandible

October 30, 2015     Pankaj Chaturvedi, MS; Sandeep Lerra, MS(ENT); Farheen Ustad, MS; Prathamesh S. Pai, MS(ENT); Devendra A. Chaukar, MS; Anil K. D'Cruz, MS


Among the reconstructive options available for buccal mucosa defects with an intact mandible, free flap with microvascular anastomosis is the best option. However, in the developing world, with poor resources, limited infrastructure, and high patient load, this cannot be offered to all patients. We report on the success of the masseter flap for reconstruction of such defects in carefully selected patients. Despite some known limitations, this flap is easy to learn and carries acceptable complications. The results of this flap may not be comparable to those of microvascular reconstructions, but they are better than those from other options such as skin graft, nasolabial flap, submental flap, etc., in terms of surgical time required, no donor site morbidity, and minimal aesthetic deformity.

Laryngeal neurofibroma

October 30, 2015     Andreas Anagiotos, MD; Dirk Beutner, MD

Neurofibromas are rarely seen in the larynx. Common symptoms are stridor, hoarseness, dysphagia, dysphonia, and globus sensation.

Angiolymphoid hyperplasia with eosinophilia

October 30, 2015     Lester D. Thompson, MD

Angiolymphoid hyperplasia with eosinophilia (ALHE) is a benign vascular tumor that features immature blood vessels lined by epithelioid endothelial cells with a prominent inflammatory infiltrate, frequently showing a conspicuous eosinophil component.

Laryngeal tuberculosis: A public health concern

October 30, 2015     Matthew B. Zavod, MD, FACS

Physical examination findings in patients with laryngeal tuberculosis vary, but they can include edema, hyperemia, nodularity, ulcerations, exophytic mass, and obliteration of anatomic landmarks.

Vascular malformation with phleboliths involving the parotid gland: A case report with a review of the literature

October 30, 2015     Caleb Ho, MD; Benjamin L. Judson, MD; Manju L. Prasad, MD


Phleboliths within the parotid gland are exceedingly rare. We report a case of a venous malformation with multiple phleboliths that involved the left parotid gland and extended into the extraparotid tissue in a 43-year-old woman. We also review 13 similar cases that have been reported since 1948, and we highlight the significance of distinguishing phleboliths from sialoliths because management of the two can be entirely different. Phleboliths in and around the salivary glands primarily affect the parotid and submandibular glands in adult women. Patients can present with recurrent, intermittent swelling that may be associated with food intake and hyposalivation. Any sialolithiasis located outside of its most common location in the submandibular glands must be investigated thoroughly before surgery.

Comparison of SPECT/CT and planar MIBI in terms of operating time and cost in the surgical management of primary hyperparathyroidism

October 30, 2015     Dhave Setabutr, MD; Kavita Vakharia, MD; Stephen J. Nogan, MD; George N. Kamel, MD; Thomas Allen, MD; Brian D. Saunders, MD; David Goldenberg, MD


We conducted a retrospective study to compare operating times and costs in patients who underwent guided parathyroidectomies with either (1) technetium-99m (99mTc) multiplex ion-beam imaging (MIBI) parathyroid scintigraphy with single-photon emission computed tomography/computed tomography (SPECT/CT) fusion images or (2) sestamibi dual-phase 99mTc MIBI planar parathyroid scintigraphy alone preoperatively. Our study population was made up of the first 24 patients at our facility who had undergone SPECT/CT parathyroid imaging with technetium-99m (99mTc) MIBI and a group of 24 patients who had undergone MIBI planar imaging alone. Patient demographics, preoperative laboratory test results, operating times, and hospital charges were analyzed. We found that less operating time was required for the planar MIBI group than in the SPECT/CT group (mean: 135 vs. 158 min), although the difference was not statistically significant. Likewise, the total cost of treatment was lower in the planar MIBI group (mean: $10,035 vs. $11,592); the difference was statistically significant by one measure (p x 0.02, Wilcoxon rank sum test) but not by another (p x 0.06, Student t test). Although SPECT/CT is efficient for patients with small and difficult-to-localize adenomas, it has yet to demonstrate greater efficacy or cost-effectiveness than planar MIBI for routine parathyroidectomy in patients with primary hyperparathyroidism when an easily identifiable parathyroid adenoma is localized.

Inferior turbinate augmentation with auricular cartilage for the treatment of empty nose syndrome

October 30, 2015     Angela A. Chang, MD; Deborah Watson, MD


Empty nose syndrome (ENS) is a potential complication of excessive resection of turbinate tissue. Patients with ENS complain of nasal obstruction despite a widely patent nasal cavity. Various implants, including autologous bone and biomaterials, have been used to reduce the width of the nasal cavity. Implantation of these grafts, however, has been limited by extrusion, infection, and resorption. We introduce a novel surgical technique that uses autologous auricular cartilage to augment the turbinate and to restore the natural airflow patterns of the nasal cavity. We present a representative case of ENS caused by excessive inferior turbinate reduction that was improved by turbinate augmentation with autologous auricular cartilage.

Pitfalls in imaging the submandibular glands with PET/CT

October 30, 2015     Enrique Palacios, MD, FACR; Michael Ellis, MD, FACS; Edward C. Lam, MD; Harold Neitzschman, MD, FACR, FACNM; Morgan Haile, MD


Imaging of the submandibular glands can provide vital information about malignant neoplastic processes. One of these modalities, fluorine-18 fluorodeoxyglucose-positron-emission tomography/computed tomography (FDG-PET/CT), has become very important in the detection of malignancies because it provides functional and metabolic information as well as anatomic localization. However, there are several pitfalls associated with FDG-PET/CT in terms of salivary gland imaging. For example, a normal increase in the uptake of radiotracer might be mistaken for a neoplastic process. Other routine findings may include normal physiologic uptake in some structures, benign tumors and medical conditions, and iatrogenic abnormalities. We review a case in which compensatory hypertrophy of a submandibular gland was suspected to be a possible malignancy.

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