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Infant with an unusual neck mass

April 30, 2016     Shiva Daram, MD; Ron B. Mitchell, MD

This case highlights the need to consider phlebectasias of the internal jugular vein when evaluating an infant with a compressible neck mass.

OK-432 injection therapy for cystadenocarcinoma of the parotid gland: A case report

April 30, 2016     Kiyoshi Makiyama, PhD, MD; Ryoji Hirai, PhD, MD; Fusako Iikuni, MD; Atsuo Ikeda, MD; Hirotaka Tomomatsu, MD


OK-432 is an immunomodulator that has been reported to be efficacious as an injection therapy for cervical lymphomas and ranulas. We performed OK-432 injection therapy to treat a cystadenocarcinoma of the parotid gland in a 72-year-old man. The 50 x 46-mm tumor was located in the deep lobe of the gland. The tumor had compressed the glossopharyngeal, vagus, and hypoglossal nerves, causing neurally mediated syncope, hoarseness, dysphagia, and dysarthria. A concentration of 5 KE/2 ml of OK-432 was injected. Within 2 months, the cyst had disappeared; no recurrence was apparent during 59 months of follow-up. To the best of our knowledge, no previous report has described injection of OK-432 for malignant cystic disease. We describe the injection method, injection dose, and postinjection course in the hope that this information will prove useful for future applications against malignant cystic disease.

The aging physician and surgeon

April 30, 2016     Robert T. Sataloff, MD, DMA, FACS; Mary Hawkshaw, RN, BSN, CORLN; Joshua Kutinsky, JD, PsyD; Edward A. Maitz, PhD


As the population of aging physicians increases, methods of assessing physicians' cognitive function and predicting clinically significant changes in clinical performance become increasingly important. Although several approaches have been suggested, no evaluation system is accepted or utilized widely. This article reviews literature using MEDLINE, PubMed, and other sources. Articles discussing the problems of geriatric physicians are summarized, stressing publications that proposed methods of evaluation. Selected literature on evaluating aging pilots also was reviewed, and potential applications for physician evaluation are proposed. Neuropsychological cognitive test protocols were summarized, and a reduced evaluation protocol is proposed for interdisciplinary longitudinal research. Although there are several articles evaluating cognitive function in aging physicians and aging pilots, and although a few institutions have instituted cognitive evaluation, there are no longitudinal data assessing cognitive function in physicians over time or correlating them with performance. Valid, reliable testing of cognitive function of physicians is needed. In order to understand its predictive value, physicians should be tested over time starting when they are young, and results should be correlated with physician performance. Early testing is needed to determine whether cognitive deficits are age-related or long-standing. A multi-institutional study over many years is proposed. Additional assessments of other factors such as manual dexterity (perhaps using simulators) and physician frailty are recommended.

Endoscopic identification and powered removal of the uncinate process

April 30, 2016     Dewey A. Christmas, MD; Joseph P. Mirante, MD, MBA, FACS; Eiji Yanagisawa, MD, FACS

The identification and complete removal of the uncinate process results in a widened middle meatus and access to the ethmoid bulla, the frontal recess, and the outflow tract of the maxillary sinus.

Long-term effects of intracochlear electrical stimulation with looped patterns on tinnitus: A case study

April 30, 2016     Remo A. Arts, PhD; Erwin L. George, PhD; Andreas Griessner, PhD; Clemens Zierhofer, PhD; Robert J. Stokroos, PhD


Electrical stimulation by cochlear implant (CI) has been proven to be a viable treatment option for tinnitus in many recent studies. In addition, intracochlear electrical stimulation independent of an acoustic input appears to suppress tinnitus, at least in the short term. We conducted a case study to investigate the long-term effects of both standard CI and intracochlear electrical stimulation independent of an acoustic input on tinnitus in a patient with single-sided deafness and tinnitus. We found no negative effects of intracochlear electrical stimulation independent of an acoustic input on speech perception in noise. Furthermore, the additional use of a standard CI was advantageous for speech discrimination in our patient. We conclude that long-term tinnitus suppression can be achieved via intracochlear electrical stimulation with looped patterns. Our findings in terms of speech discrimination in our patient were consistent with those reported in previous studies.

Gore-Tex extrusion following type I thyroplasty

April 30, 2016     Natalie A. Krane, MD; Amanda Hu, MD, FRCSC; Robert T. Sataloff, MD, DMA, FACS

Many different types of implants can be used for medialization thyroplasty, including Gore-Tex, Silastic, titanium, hydroxyapatite, and other materials.

Improved visualization of a dehiscent facial nerve with otoendoscopy

April 30, 2016     James G. Naples, MD; John W. House, MD; Benjamin J. Wycherly, MD

In middle ear surgery, endoscopy is a valuable instrument for second-look procedures in cholesteatoma.

A case of pediatric parapharyngeal space ganglioneuroma

April 30, 2016     Natalie Garzorz, MD; Gillian R. Diercks, MD; Harrison W. Lin, MD; William C. Faquin, MD, PhD; Laura V. Romo, MD; Christopher J. Hartnick, MD, MS


Ganglioneuromas are rare, benign neoplasms derived from sympathetic neural crest progenitor cells. In the pediatric population, ganglioneuromas usually develop in the mediastinum or retroperitoneum. We report the case of a 3-year-old boy who presented with a painless enlarging neck mass, which was found to be a parapharyngeal space ganglioneuroma that extended to the skull base. We summarize the current principles regarding the diagnostic workup and treatment of these neoplasms, and we briefly review the literature.

Sympathetic hearing loss: A review of current understanding and report of 2 cases

April 30, 2016     Patrick F. Morgan, MD; Peter G. Volsky, MD; Barry Strasnick, MD, FACS


Sympathetic hearing loss (SHL) is a rare complication that appears to occur when the immune system is primed against sequestered inner ear antigens. SHL has been implicated in delayed hearing loss after acoustic tumor removal, revision stapedectomy, and temporal bone fractures. We present 2 cases of suspected SHL after excision of skull base tumors during which the surgical approach had violated the otic capsule. Both patients experienced delayed contralateral sensorineural hearing loss. In comparing our cases with those previously reported, we hope to inspire others to do likewise and to develop an understanding of this clinical entity.

An extended toboggan technique for resection of substernal thyroid goiters

April 30, 2016     Catherine F. Sinclair, MD; Glenn E. Peters, MD; William R. Carroll, MD


We describe our technique for the safe resection of substernal thyroid goiters. Early mobilization of the thyroid gland from tracheal attachments anteriorly and laterally facilitates extraction of the goiter from the mediastinum. Retrograde dissection through the ligament of Berry on the ipsilateral side can also facilitate identification of the recurrent laryngeal nerve and delivery of the substernal portion of the gland. We describe 2 representative cases in which we successfully used this technique.

If cytology of Warthin tumor is accurate, can management be conservative?

April 30, 2016     Alexander C. Vlantis, FCS(SA)ORL; Siu Kwan Ng, FRCSEd; Chi Keung Mak, MRCS(Ed); Jackie M. Cheung, MBChB; Amy B. Chan, FHKC Path; C. Andrew van Hasselt, MMed(Otol)


We conducted a retrospective study to assess the accuracy of fine-needle aspiration cytology (FNAC) in the diagnosis of Warthin tumor and to evaluate the subsequent risk of conservative nonsurgical management. We reviewed the records of 75 patients (76 tumors) with a parotid mass that had been diagnosed as a Warthin tumor by FNAC. This patient population was made up of 64 men and 11 women, aged 46 to 93 years (mean: 67). Of the 76 tumors, 40 were treated with surgical excision and 36 with conservative measures. Histology of the 40 excised parotid masses revealed that 38 (95%) were indeed Warthin tumors, 1 (2.5%) was a low-grade adenocarcinoma, and 1 was benign-not otherwise specified. None of the 36 tumors underwent malignant transformation either clinically or on repeat FNAC (if performed) during a follow-up of 4 to 120 months (mean: 55.5 ± 32.2). We conclude that conservative management of Warthin tumors confidently diagnosed on FNAC may be an option for patients who are unwilling or unable to undergo surgical excision.

Lichen nitidus on the dorsal tongue

April 30, 2016     Pedro Costa de Araujo, MD; Jerome R. Lechien, MD

This relatively uncommon, asymptomatic, idiopathic inflammatory eruption is usually found on the abdomen, pelvic area, or extremities, but rarely on the tongue.

Cervical disc herniation causing difficulty swallowing

April 30, 2016     Sheng-Yao Cheng, MD; Jih-Chin Lee, MD

Anterior cervical disc herniation is relatively rare and is usually asymptomatic until a certain degree of hypopharyngeal and esophageal compression leads to dysphagia.

Pneumocephalus after insertion of an inflatable nasal tampon for the management of epistaxis

April 30, 2016     Adam J. Kimple, MD, PhD; Michael O. Ferguson, MD


While the fundamental principles of epistaxis management have not changed over the decades, the methods by which tamponade is achieved have been evolving. Inflatable nasal tampons are being used and seen with increasing frequency in our ENT clinic. They are usually placed by emergency department personnel, who then refer patients to our clinic for removal. The classically described complications of nasal packs are induction of the nasopulmonary reflex, toxic shock syndrome, and discomfort. In this article, we describe a case of pneumocephalus following placement of an inflatable nasal tampon. To the best of our knowledge, this is the first report of pneumocephalus after placement of an inflatable nasal tampon.

Efficacy of allograft fascia lata in tympanic membrane repair

April 30, 2016     Ashley O'Connell Forster, MD; Joel Jones, MD; John Davis, AuD; Brittany Weber, MD; Mary Hawkshaw, RN, BSN, CORLN; Robert T. Sataloff, MD, DMA, FACS


We conducted a retrospective study to determine the efficacy of allograft fascia lata in both primary and revision tympanic membrane surgery (myringoplasty). Our patient population included 64 patients-31 men and 33 women, aged 19 to 98 years (mean: 49.5)-who had undergone tympanic membrane surgery with allograft fascia lata. Patients were grouped according to whether they had undergone primary surgery (n = 47) or revision surgery (n = 17). Data were compiled at preoperative and immediate postoperative visits, as well as at 3, 6, 9, and 12 months postoperatively. Residual perforations were defined as those present for less than 6 weeks postoperatively, and recurrent perforations were defined as those that occurred more than 6 weeks postoperatively. A residual perforation was found in only 1 patient (1.6%), a primary surgery patient. Recurrent perforations were found in 8 of the 64 patients (12.5%), including 5 in the primary group (10.6%) and 3 in the revision group (17.6%). We conclude that allograft fascia lata is a comparable alternative to other graft materials for performing myringoplasty.

Commentary on "The aging physician and surgeon" by Sataloff et al

April 30, 2016     Richard V. Homan, MD

Is unenhanced 18F-FDG-PET/CT better than enhanced CT in the detection of retropharyngeal lymph node metastasis in nasopharyngeal carcinoma?

April 30, 2016     Iuan-Sheng Wu, MD; Guang-Uei Hung, MD; Bo-Ling Chang, MD; Chi-Kuang Liu, MD; Tung-Hao Chang, MD; Hong-Shen Lee, PhD; Mu-Kuan Chen, MD, MS, PhD


Positron-emission tomography/computed tomography (PET/CT) has been proposed as a means to enhance the pretreatment evaluation of cervical lymph node status in patients with nasopharyngeal carcinoma (NPC). We conducted a prospective study to compare PET/CT and enhanced CT for the detection of retropharyngeal lymph node (RLN) metastasis in NPC, and to ascertain the factors that affect its diagnostic performance. Our study population was made up of 33 patients-24 men and 9 women, aged 30 to 81 years (mean: 52)-with newly diagnosed NPC who had been treated over a 2-year period. All patients underwent enhanced CT first, followed by unenhanced 18F-fluorodeoxyglucose (FDG) PET/CT. The detection rate of RLN metastasis on PET/CT was significantly lower than that on enhanced CT (36.4 vs. 75.8%; p < 0.001). A total of 25 of 26 nodes with a discordant finding were negative on PET/CT; they included 13 metastatic lymph nodes with low FDG uptake, 9 that were located close to the primary tumor, 2 that were confluent RLNs, and 1 that was adjacent to the physiologic FDG-avid prevertebral muscle. The maximum standardized uptake value (SUVmax) of RLNs was positively correlated with the minimum axial diameter (r = 0.803, p < 0.001). The PET/CT detection rate was 0% for lymph nodes smaller than 5 mm, 9% for those 5 to 10 mm, and 73% for those 1 cm or larger. The detection rate of PET/CT at level C1 was significantly lower than that at C2 (22 vs. 67%; p = 0.035). We conclude that unenhanced PET/CT is markedly inferior to enhanced CT for detecting RLN metastasis in NPC, especially in lymph nodes with a minimum axial diameter of less than 1 cm and those in proximity to the primary tumor. Using enhanced CT in PET/CT is justified to improve the recognition of RLN metastasis in patients with NPC.

Effectiveness of steroid injections for bamboo nodules: A case report

April 30, 2016     Mitsuyoshi Imaizumi, MD, PhD; Yasuhiro Tada, MD; Wataru Okano, MD; Akiko Tani, MD; Koichi Omori, MD


Vocal nodules are generally caused by vocal abuse, and conservative treatments such as voice therapy have been advocated as a first-choice treatment for vocal nodules. Reports of vocal fold lesions related to autoimmune diseases, such as bamboo nodules, are rare in the literature. Here we report a very rare case of bamboo nodules in a 30-year-old woman treated by steroid injection into the vocal folds by videoendoscopic laryngeal surgery in an outpatient setting. She was successfully treated without further recurrence. This report indicates that a steroid injection into bamboo nodules might be a useful treatment option, especially in patients who have not shown any improvement after conservative treatments.

The rare fourth branchial cleft anomaly

April 30, 2016     Jonathan A. Harounian, MD; David Goldenberg, MD; Jason G. May, MD

The treatment for fourth branchial anomalies is complete surgical excision because of the risk of infection and life-threatening abscesses.

Nasal polyp with osseous metaplasia

April 30, 2016     Jacky Wai-Kei Lam, MBBS(HK), FHKCORL, FHKAM(ORL); Leah Lai Lau, MBBS(HK)

The differential diagnosis of sinonasal pathologies with highly radiodense materials includes rhinolith, mycetoma, inverted papilloma with calcifications, chondrosarcoma, osteosarcoma, and fibro-osseous lesions.