Unexpected cholesteatoma in a very young child with a congenital aural duplication anomaly

April 27, 2015     Moo Kyun Park, MD

Cholesteatoma can develop in very young children with congenital aural stenosis and a duplication anomaly, and physicians should consider this condition in affected children with otalgia and otorrhea.

Guidelines for squamous cell carcinoma of the head and neck: A systematic assessment of quality

April 27, 2015     Yanming Jiang, MD; Xiao-Dong Zhu, PhD; Song Qu, PhD; Ling Li, MD; Zhirui Zhou, MD


We conducted a study to evaluate the quality of guidelines for squamous cell carcinoma of the head and neck (SCCHN) with the exception of nasopharyngeal cancer. Electronic searches were conducted of the U.S. National Guideline Clearinghouse, the Canadian Medical Association Infobase, the Guidelines International Network, the Scottish Intercollegiate Guidelines Network, the China Biology Medicine disc, PubMed, and Embase. Two independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. The degree of agreement among these sources was evaluated by using the intraclass correlation coefficient (ICC). A total of 514 articles were found to be clinical-guideline-related, and 49 guidelines were included in our analysis. Scores were assigned for each of the AGREE II domains: scope and purpose (mean: 71.63% ± 2.80; median: 75%; ICC: 0.76), stakeholder involvement (mean: 43.37% ± 2.96; median: 50%; ICC: 0.93), rigor of development (mean: 45.63% ± 3.84; median: 42%; ICC: 0.83), clarity of presentation (mean: 68.08% ± 2.53; median: 72%; ICC: 0.85), applicability (mean: 32.41% ± 3.03; median: 29%; ICC: 0.92), and editorial independence (mean: 42.55% ± 4.57; median: 42%; ICC: 0.95). We considered a domain score of greater than 60% to represent an acceptable level of quality. We conclude that, overall, the quality of SCCHN guidelines is moderate in relation to international averages. Greater efforts are needed to provide high-quality guidelines that serve as a useful and reliable tool for clinical decision making in this field.

Large Haller cell mucocele leading to maxillary sinusitis

April 27, 2015     Jae-Hoon Lee, MD

Paranasal sinus mucoceles are epithelial-lined cystic lesions containing mucus or mucopurulent fluid. Symptoms vary depending on the location of the mucocele.

The myth of learning styles: What medical educators need to know

April 27, 2015     Kenneth D. Royal, PhD, MSEd; Myrah R. Stockdale, MS

While it is true that individuals may have a preferred means of receiving information, there is no evidence that learners actually learn better when information is presented to them via their preferred method.

Acinic cell carcinoma of the posterior wall of the pharynx

April 27, 2015     Gökhan Erpek, MD; Ceren Günel, MD; Ibrahim Meteoğlu, MD


Acinic cell carcinoma accounts for approximately 2 to 6% of all salivary gland tumors. It usually originates in the parotid gland; the minor salivary glands and the upper respiratory tract are involved only infrequently. We describe a case of acinic cell carcinoma of the posterior wall of the pharynx in a 21-year-old woman. To the best of our knowledge, this is the first case of this type of carcinoma at this location to be published in the literature. The mass was excised, and the patient was referred for postoperative radiation therapy to reduce the risk of local recurrence, but she did not keep her appointment and was lost to follow-up.

Frontal recess polyp extending to the posterior choana-a frontal recess-choanal polyp

April 27, 2015     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

Frontal recess-choanal polyps, as found in the case described in this report, are rare.

Malignant otitis externa

April 27, 2015     Christina H. Fang, BS; James Sun, BS; Robert W. Jyung, MD

The advent of anti-pseudomonal antibiotics has significantly reduced the mortality of malignant otitis externa.

Conidiobolus coronatus granuloma of the right inferior turbinate: A rare presentation

April 27, 2015     Saurabh Varshney, MBBS, MS; Pratima Gupta, MBBS, MD; Sampan Singh Bist, MBBS, MS; Sanjeev Bhagat, MBBS, MS


Fungal infections are common in tropical countries such as India. Very few clinical cases caused by the Entomophthorales Zygomycetes have been reported. Rhinofacial infection is a rare form of zygomycosis in humans, and only limited information regarding optimal treatment is available. We report here a rare case of rhinofacial Conidiobolus coronatus infection in a previously healthy 18-year-old man who presented with a fungal granuloma of the right inferior turbinate and face. Diagnosis was confirmed by microbiologic culture from a tissue biopsy. The infection was successfully treated with surgery and itraconazole therapy for 12 months. The clinical presentation and treatment of this rare, chronic, indolent form of fungal infection are highlighted in this article.

Prophylactic antibiotic therapy for fractures of the maxillary sinus

April 27, 2015     Robert S. Schmidt, MD; Kelley M. Dodson, MD; Richard A. Goldman, MD


We conducted a study to examine the incidence of acute sinusitis following maxillary sinus fractures, as well as the impact of antibiotics in the postinjury period. Fifty patients who presented to our institution with a fracture of the maxillary sinus were prospectively randomized to receive either a nasal saline spray and a 3-day course of antibiotics (either amoxicillin/clavulanate or levofloxacin) or nasal saline alone; there were 25 patients in each group. After a minimum of 3 days, all patients were assessed for acute sinusitis. Follow-up data were available on 17 patients (a total of 21 fractured sinuses) in the antibiotic group (68%) and 14 patients (17 fractured sinuses) in the control group (56%). The groups were balanced in terms of demographics, location of fractures, mechanism of fracture, and time to follow-up. After 3 days, 95.23% of the fractured sinuses in the antibiotic group and 88.23% of the fractured sinuses in the control group exhibited signs or symptoms consistent with or suggestive of acute sinusitis. Very few sinuses in either group showed no evidence of sinusitis: only 1 in the antibiotic group (4.76%) and 2 in the control group (11.76%); this difference was not significant (p = 0.5768). We conclude that while the clinical rate of acute sinusitis after maxillary sinus fractures is high, a 3-day course of antibiotics is not effective in preventing its symptoms in the postinjury period.

Potentially lethal pharyngolaryngeal edema with dyspnea in adult patients with mumps: A series of 5 cases

April 27, 2015     Masafumi Ohki, MD; Yuka Baba, MD; Shigeru Kikuchi, PhD; Atsushi Ohata, PhD; Takeshi Tsutsumi, PhD; Sunao Tanaka, MD; Atsushi Tahara, MD; Shinji Urata, MD; Junichi Ishikawa, MD


In this article we describe 5 rare cases of mumps-associated pharyngolaryngeal edema. To the best of our knowledge, this report includes the first case of mumps-associated pharyngolaryngeal edema in a patient who had previously received mumps vaccination, and these cases represent the sixth report of mumps-associated pharyngolaryngeal edema in the English literature. All 5 of our patients with mumps infection were adults and manifested airway stenosis due to pharyngolaryngeal edema. This edema responded favorably to steroid treatment without tracheotomy. We conclude that a pharyngolaryngeal examination is recommended for patients with mumps infection. Steroid treatment is usually effective against pharyngolaryngeal edema; however, in certain cases tracheotomy may be inevitable.

The role of MMP-2, MMP-9, and TIMP-1 in the pathogenesis of nasal polyps: Immunohistochemical assessment at eight different levels in the epithelial, subepithelial, and deep layers of the mucosa

April 27, 2015     Nuray Bayar Muluk, MD; Osman Kürşat Arikan, MD; Pınar Atasoy, MD; Rahmi Kiliç, MD; Eda Tuna Yalçinozan, MD


We conducted a prospective study to investigate the role of matrix metalloproteinase-2 (MMP-2), matrix metalloproteinase-9 (MMP-9), and tissue inhibitor of metalloproteinase-1 (TIMP-1) in the pathogenesis of nasal polyps. Our study group consisted of 24 patients-21 men and 3 women, aged 23 to 70 years (mean: 45.97 ± 11.60)-with nasal polyposis who underwent functional endoscopic sinus surgery. For comparison purposes, we assembled a control group of 11 patients-6 men and 5 women, aged 18 to 56 years (mean: 29.90 ± 14.22)-without nasal polyps who underwent septoplasty and/or rhinoplasty. We analyzed 36 polyp specimens obtained from the study group (10 from the nasal cavity, 10 from the maxillary sinus, and 16 from the ethmoid sinus) and 11 tissue specimens from the control group (each control provided 1 specimen from the inferior turbinate). We then calculated the mean number of these cells in the epithelium, subepithelial layer of the lamina propria, and the deep paraglandular layer of the mucosa. In general, we found that MMP-2, MMP-9, and TIMP-1 values were higher in the nasal polyp group. These differences became less so as patients' ages and the duration of polyps increased. We conclude that the most important role that MMP-2 plays in polyp growth may be in terms of perivascular localization and an increase in vascular permeability, which causes inflammatory cell migration and edema in the extracellular matrix. An increase in MMP-2 in glandular tissue may lead to hydrolysis of tissue matrix components. The degraded extracellular matrix may result in fibrosis of the polyps. An increase of MMP-9 in the apical part of the epithelium in the polypoid tissue of the nasal cavity, maxillary sinus, and ethmoid sinus may facilitate the epithelial and endothelial cell migration that is observed during polyp development and growth.

Bilateral true vocal fold atrophy

April 27, 2015     Jason Bell, MD; Rima A. DeFatta, MD; Robert T. Sataloff, MD, DMA, FACS

The most common cause of vocal fold atrophy is aging, but other causes include paresis, menopause, and thyroiditis, as well as neuromuscular junction disorders such as myasthenia gravis.

Perineural spread of cutaneous squamous cell carcinoma along the great auricular nerve

April 27, 2015     Daniel Thomas Ginat, MD, MS; Diana Bolotin, MD, PhD; Alexander J. Langerman, MD

Although perineural tumor spread in the head and neck most commonly involves the cranial nerves, particularly the trigeminal and facial nerves, the spinal nerve branches can also be affected.

Parathyroid localization using 4D-computed tomography

April 27, 2015     Darrin V. Bann, PhD; Thomas Zacharia, MD; David Goldenberg, MD, FACS; Neerav Goyal, MD, MPH

To decrease the risk of iatrogenic cancers associated with 4D-CT, several groups have used one- or two-phase imaging protocols to identify parathyroid adenomas.

Sinonasal undifferentiated carcinoma as a third primary neoplasm: A case report and review of the literature

April 27, 2015     John J. Chi, MD; Michael D. Feldman, MD; James N. Palmer, MD


A 71-year-old man with a history of a pituitary prolactinoma and metastatic pancreatic carcinoma presented with epistaxis, visual changes, bilateral ophthalmoplegia, involuntary closure of the left eye, and ptosis of the right eye. The patient was found to have a soft-tissue mass in the posterior nasal cavity with extension through the floor of the sella turcica, the sphenoid sinuses, cavernous sinuses, and suprasellar region. The patient was subsequently taken to the operating room. Intraoperative frozen section of the sinonasal mass demonstrated carcinoma. The final pathology of the mass revealed sinonasal undifferentiated carcinoma (SNUC)-the patient's second skull base lesion and third primary neoplasm. SNUC is a rare neoplasm of the sinonasal cavities that rapidly progresses from symptom onset to mortality in the presence of aggressive multidimensional therapies. Given its poor prognosis and possibly devastating treatments, an open discussion of treatment options between physicians and the patient is of the utmost importance. Although SNUC is rare, it is important that practicing otolaryngologists, neurosurgeons, and skull base surgeons be familiar with this disease process-especially when caring for patients with a history of a benign skull base neoplasm and concern for possible recurrence, as was the case in this report.

Is there a relationship between myeloperoxidase activity and conductive hearing loss in chronic otitis media complicated by cholesteatoma?

April 27, 2015     Ozlem Celebi Erdivanli, MD; Arif Sanli, MD


We conducted a prospective, controlled study of patients with chronic otitis media and cholesteatoma (1) to examine the expression of myeloperoxidase (MPO) using immunohistochemical staining techniques and (2) to investigate the relationship between MPO activity and the degree of conductive hearing loss in these patients. Our study population included 51 adults-26 men and 25 women, aged 18 to 58 years (mean: 37.5)-who had been diagnosed with chronic otitis media and cholesteatoma by physical examination and computed tomography (study group). Another 30 patients-13 men and 17 women, aged 18 to 52 years (mean: 32.7)-who had chronic otitis media without cholesteatoma served as the control group. Following audiometric evaluations, all patients underwent appropriate surgery. Postoperatively, cholesteatoma samples were analyzed by immunostaining for MPO positivity as a marker for acute inflammation. We found that MPO activity was present in all 51 study patients (100%) but in only 10 controls (33.3%); the difference was statistically significant (p< 0.01). In the study group, the degree of MPO activity was slight in 6 patients (11.8%), moderate in 24 patients (47.1%), and intense in 21 patients (41.2%), while in the control group, all 10 MPO-positive cases showed only a slight degree of activity. We also found a statistically significant association in the study group between the degree of MPO activity and the degree of conductive hearing loss (χ2 = 13.518; p < 0.001). We encourage further study of all steps in the process of cholesteatoma formation.

Advanced airway management teaching in otolaryngology residency programs in Canada: A survey of residents

April 27, 2015     Val&eacute;rie C&ocirc;t&eacute;, MD; Lukas H. Kus, MD, MSc; Xun Zhang, PhD; Keith Richardson, MD; Lily H.P. Nguyen, MD, MSc, FRCS(C)


We conducted a study to assess residents' levels of comfort with advanced airway management in Canadian otolaryngology residency programs. In October 2008, an electronic questionnaire was sent to all otolaryngology residents in Canada. Responses were voluntary and anonymous. The response rate was 64.8% (94 of 145 residents). Residents were asked about the amount of teaching they received and the amount they would like to receive each year in four areas: emergency surgical airway, pediatric airway, airway trauma, and management of complications during laryngoscopy/bronchoscopy. They were also asked how comfortable they were with their current level of knowledge in these areas. Overall, residents were not comfortable with difficult airway situations, scoring a mean of 3.08 on a 5-point Likert scale. Residents were most comfortable with the emergency airway and least comfortable with the pediatric airway. Overall, residents indicated that they had not received adequate teaching on advanced airway management, and they consistently desired more. With respect to the type of instruction, most residents requested more teaching via simulations, mannequins, and cadaver or animal models. Linear regression models revealed a positive relationship between their overall comfort with airway management and the number of airway teaching hours they received. Their consensus was that formal airway training should occur during postgraduate year (PGY) 2, with refresher courses offered every 2 years. This is the first wide-scale assessment of the status of airway teaching in otolaryngology residency programs in Canada. Overall, our findings suggest that otolaryngology residents in these programs are not comfortable with advanced airway management early in their training and feel they would benefit from a significant increase in airway teaching time. Comfort levels improved with increasing levels of training such that PGY5 residents indicated they were indeed comfortable with advanced airway management.

Biphasic synovial sarcoma of the hypopharynx

April 27, 2015     Ustun Osma, MD; H&uuml;lya Eyigor, MD; Dinc Suren, MD; Cem Sezer, MD; Mustafa Deniz Yilmaz, MD


Synovial sarcoma is a malignant mesenchymal neoplasm usually involving the extremities of young adults. Localization in the head and neck region is rare. Histologically, these lesions have biphasic and monophasic variants, the latter being more rare and difficult to identify. Immunohistochemistry plays a crucial role in the diagnosis. We report a case of a biphasic synovial sarcoma arising in the hypopharynx with a review of the literature concerning this rare neoplasm.

Distortion-product otoacoustic emissions testing in neonates treated with an aminoglycoside in a neonatal intensive care unit

April 27, 2015     Iosif Vital, MD; George Psillas, MD; Nikolaos Nikolaides, MD; George Kekes, MD; Stavros Hatzopoulos, MD; John Constantinidis, MD


We evaluated the ototoxic effect of aminoglycosides on the outer hair cells of newborns in a neonatal intensive care unit (NICU) by means of distortion-product otoacoustic emissions (DPOAE) testing. Our study population was made up of 164 newborns who were divided into three groups: group A consisted of 105 infants who were given aminoglycoside therapy (either gentamicin or amikacin, or a combination of the two) as treatment for suspected or proven bacterial infection and septic states; group B included 30 newborns who were not given an antibiotic or who were given an antibiotic other than an aminoglycoside; group C, a control group, was made up of 29 healthy neonates who were hospitalized in the well-baby nursery. All the neonates underwent DPOAE testing in both ears (the f2 primary tone was presented at 2.0, 2.5, 3.2, and 4.0 kHz). We found that 41 patients in group A (39.0%) and 13 in group B (43.3%) failed the DPOAE test in one or both ears; the difference between these two groups was not statistically significant (p = 0.673). In group C, the DPOAE fail rate was 13.8% (4 newborns). In group A, there was no statistically significant association between the pass/fail rate and the specific aminoglycoside that was administered, or in the duration of antibiotic treatment, the number of doses, and the size of the mean daily dose and the mean total dose. In clinical practice, DPOAE testing is a sensitive method of evaluating the integrity of the outer hair cells in the basal turn of the cochlea after exposure to ototoxic drugs such as aminoglycosides. However, our study did not demonstrate that the aminoglycosides had any ototoxic effect on the hearing of neonates in the NICU.

Giant Stensen duct calculus

April 27, 2015     Wen-Sen Lai, MD; Jih-Chin Lee, MD; Yueng-Hsiang Chu, PhD; Ying-Nan Chang, MD

A sialolith in the anterior third of a Stensen duct usually can be extracted in a minimally invasive manner via trans-oral sialolithotomy to avoid the morbidity associated with a sialadenectomy.

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