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Lingual osseous choristoma

July 18, 2016     Daniel T. Ginat, MD, MS; Louis Portugal, MD

When they occur, symptoms of lingual osseous choristomas may include globus sensation, dysphagia, gagging, nausea, and irritation.

Laryngeal amyloidosis

July 18, 2016     Karthik S. Shastri, MD; Amy L. Rutt, DO; Robert T. Sataloff, MD, DMA, FACS

The diagnosis of laryngeal amyloidosis should trigger evaluation for systemic amyloidosis.

Phonatory symptoms and impact on quality of life in female patients with goiter

July 18, 2016     Abdul-latif Hamdan, MD, MPH, FACS; Alexander Dowli, MD; Jad Jabbour, BS; Alain Sabri, MD; Sami T. Azar, MD, FACP


Our objective is to report on the prevalence of phonatory symptoms and impact on quality of life in a group of female patients with goiter who had not been selected for surgery or who had not presented to the emergency room with respiratory distress. A total of 40 patients with goiter and 14 controls were enrolled in this study. Demographic data included age, sex, laryngopharyngeal reflux disease, allergy, smoking, duration of disease, presence or absence of compressive symptoms, presence or absence of thyroid gland nodules, vascular status, presence or absence of calcifications, and thyroid-stimulating hormone levels. Phonatory symptoms included hoarseness, vocal fatigue, vocal straining, lump sensation, and aphonia. The Voice Handicap Index 10 was used to assess the impact of phonatory symptoms on quality of life. The most common phonatory symptom in the patients with goiter was vocal fatigue followed by lump sensation. The only phonatory symptom that was significantly more present in patients with goiter was vocal straining. As for the impact of phonatory symptoms on quality of life, 15.8% of goiter patients had a Voice Handicap Index score >7 compared with 7.7% of controls. Phonatory symptoms are common in patients with goiter, with vocal straining occurring significantly more frequently than in controls. In 1 of 6 patients, the presence of phonatory symptoms had an impact on quality of life.

Management of obstructive sleep apnea in children: A practical approach

July 18, 2016     Kevin D. Pereira, MD; Cindy K. Jon, MD, MPH; Peter Szmuk, MD; Rande H. Lazar, MD; Ron B. Mitchell, MD


The management of sleep disordered breathing (SDB) in children differs between institutions, and there is a need for an updated review of current practice. Literature was reviewed using the PubMed database from 1995 to 2015 by four tertiary care providers experienced in the management of children with SDB. Articles were selected for clinical applicability, strength of evidence, and practicality for practicing clinicians. Fifty-five articles were identified by tertiary care providers in pediatric anesthesiology, pediatric pulmonology, sleep medicine, and pediatric otolaryngology. Each reviewed and analyzed literature independently based on their specialties, and a consensus document was created. The consensus was that the majority of children with SDB do not undergo polysomnography (PSG) before adenotonsillectomy (T&A). Indications for PSG are presented, with a practical approach recommended for the otolaryngologist. Clinical practice guidelines are available from leading national societies, but their recommendations differ. T&A is the first-line treatment and is highly effective in normal-weight but not in obese children. The perioperative management of children is challenging and needs to be individualized. Young children, those with severe obstructive sleep apnea, and those with significant comorbidities need to be observed overnight.

Nonsurgical options to treat giant-cell tumors of the head and neck: A case report and brief review of the literature

July 18, 2016     Allison N. Rasband-Lindquist, MD; Jonathan D. Lindquist, MD; Christopher G. Larsen, MD; Aaron Thiessen, MD; Douglas Girod, MD


Central giant-cell granulomas (CGCGs) are relatively uncommon. When they do occur, they typically arise in the mandible and maxilla. Some lesions are more destructive than others, and the destructive subtype has a tendency to recur. Unfortunately, there is no reproducible way to differentiate aggressive from nonaggressive subtypes. Treatment of CGCG has historically been based on surgical curettage or wide local excision. However, surgery has been associated with significant morbidity, disfigurement, and expense, as well as a high recurrence rate. Pharmacologic treatments-either as an alternative or an adjunct to surgery-have been shown to yield acceptable results. These agents include intralesional and/or systemic corticosteroids, bisphosphonates, calcitonin, and interferon alfa. These options are typically less expensive than surgery, and they are associated with few side effects, which makes them potentially more desirable. We report the case of a 36-year-old woman with a CGCG who was successfully treated with a combination of an intralesional steroid and an oral steroid over a period of 5 months. As evidenced by this case, medical management can be effective for tumor regression in treating CGCG of the head and neck, and it is ultimately associated with less morbidity and is less costly. To the best of our knowledge, no randomized controlled studies have been published on this topic. Such a study would be welcome, particularly considering the presence of both aggressive and nonaggressive subtypes of CGCG. We also briefly review the literature.

Neuroendocrine tumors of the larynx

July 18, 2016     Lester D. Thompson, MD

The most common laryngeal neuroendocrine tumor is the atypical carcinoid (moderately differentiated neuroendocrine carcinoma), which is a malignant epithelial tumor showing neuroendocrine histologic and immunohistochemical features.

Clinical characteristics and follow-up of patients with external ear canal cholesteatoma treated conservatively

July 18, 2016     Erdal Sakalli, MD; Deniz Kaya, MD; Cengiz Celikyurt, MD; Selcuk Cem Erdurak, MD


We conducted a retrospective study to evaluate the clinical properties and follow-up of patients with external ear canal cholesteatoma (EECC) who were treated conservatively. Our study group was made up of 15 patients-6 men and 9 women, aged 21 to 82 years (mean: 48). In addition to demographic data, we compiled information on presenting signs and symptoms, the location of the lesion, treatment, and follow-up. All EECCs occurred spontaneously, and all were limited to the temporal bone. Lesions were left-sided in 7 patients, right-sided in 7, and bilateral in 1. For purposes of defining the location of the lesions, the ear canal was divided into four quadrants: anterior, posterior, superior, and inferior. Temporal bone computed tomography (CT) and otomicroscopic evaluation revealed that 7 of the 16 lesions (44%) were located in the anterior and inferior quadrants, 6 (38%) in the inferior quadrant only, 2 (13%) in the anterior, inferior, and posterior quadrants, and 1 (6%) in the anterior quadrant only. Otorrhea was present in 7 of the 15 patients (47%), otalgia in 6 (40%), itching in 4 (27%), fullness in 2 (13%), and occlusion in 1 (7%); 3 patients (20%) were asymptomatic. All patients were treated with local debridement and aspiration under otomicroscopy, and they were followed up with repeat aspirations approximately every 10 weeks under microscopy. The duration of follow-up ranged from 6 to 75 months (mean: 41). At study's end, cholesteatoma had not progressed in any patient during follow-up, indicating that repeat aspirations and regular follow-up of limited EECC prevent recurrence of signs and symptoms and progression of the disease.

Occult central venous stenosis leading to airway obstruction after subtotal parathyroidectomy

July 18, 2016     Duncan A. Meiklejohn, MD; Dylan K. Chan, MD, PhD; M. Lauren Lalakea, MD


Subtotal parathyroidectomy may be indicated in patients with chronic renal failure and tertiary hyperparathyroidism, a population at increased risk for central venous stenosis (CVS) due to repeated vascular access. Here we report a case of complete upper airway obstruction precipitated by subtotal parathyroidectomy with ligation of anterior jugular vein collaterals in a patient with occult CVS. This case demonstrates a previously unreported risk of anterior neck surgery in patients with chronic renal failure. We present a review of the literature and discuss elements of the history and physical examination suggestive of occult CVS, with additional workup proposed for appropriate cases. Recommendations are discussed for perioperative and postoperative care in patients at increased risk for CVS.

The inferior turbinate, an unusual site for a choanal polyp: Two case reports and a review of the literature

July 18, 2016     Maya Adhami, MD; Andre Coste, MD; Virginie Escabasse, MD; Frederique Chalumeau, MD


Choanal polyps are unilateral sinonasal lesions that are classified according to their site of origin. The aim of this report is to highlight an unusual form of choanal polyp and to present a thorough literature review. To the best of our knowledge, only 6 cases of a choanal polyp originating in the inferior turbinate have been previously reported in the literature. We describe 2 new cases. One patient was a 14-year-old boy who presented with nasal obstruction, facial headaches, and obstructive sleep apnea; the other patient was a 70-year-old man who presented with right mucopurulent rhinorrhea and right nasal obstruction. In both cases, nasal fibroscopy detected a polyp arising from the right inferior turbinate and extending toward the right choana. Endoscopic sinus surgery was performed in both cases to ensure a complete excision. Cases of choanal polyp arising from the inferior, middle, and superior turbinates and the septum are rare, although some appear to be more common than is generally believed, especially in the pediatric population. We therefore recommend that unusual forms of choanal polyp be included in the differential diagnosis of a unilateral sinonasal mass.

Rational resident research requirements: Reevaluating goals for research in otolaryngology-head and neck surgery residency programs

July 18, 2016     Quintin M. Cappelle, MD; Tara E. Brennan, MD; Miriam I. Redleaf, MD

Virtual reality in rhinology--a new dimension of clinical experience

July 18, 2016     Ivica Klapan, PhD, MD; Pero Raos, PhD, MEng; Tomislav Galeta, PhD, MEng; Goranka Kubat, MD


There is often a need to more precisely identify the extent of pathology and the fine elements of intracranial anatomic features during the diagnostic process and during many operations in the nose, sinus, orbit, and skull base region. In two case reports, we describe the methods used in the diagnostic workup and surgical therapy in the nose and paranasal sinus region. Besides baseline x-ray, multislice computed tomography, and magnetic resonance imaging, operative field imaging was performed via a rapid prototyping model, virtual endoscopy, and 3-D imaging. Different head tissues were visualized in different colors, showing their anatomic interrelations and the extent of pathologic tissue within the operative field. This approach has not yet been used as a standard preoperative or intraoperative procedure in otorhinolaryngology. In this way, we tried to understand the new, visualized “world of anatomic relations within the patient's head” by creating an impression of perception (virtual perception) of the given position of all elements in a particular anatomic region of the head, which does not exist in the real world (virtual world). This approach was aimed at upgrading the diagnostic workup and surgical therapy by ensuring a faster, safer and, above all, simpler operative procedure. In conclusion, any ENT specialist can provide virtual reality support in implementing surgical procedures, with additional control of risks and within the limits of normal tissue, without additional trauma to the surrounding tissue in the anatomic region. At the same time, the virtual reality support provides an impression of the virtual world as the specialist navigates through it and manipulates virtual objects.

Patient preferences in early glottic cancer treatment

July 18, 2016     Michael L. McNeil, MD; Derek R. Wilke, MD, FRCP(C); S. Mark Taylor, MD, FRCS(C), FACS


Patients with early-stage glottic cancer are primarily treated with one of three options: endoscopic laser excision, external-beam radiation, or open conservation surgery. We sought to determine patient preferences for treatment when presented with a choice between CO2 laser resection and radiation (open conservation surgery was not offered because the endoscopic approach is preferred at our institution). This prospective cohort study was conducted at the Dalhousie University Faculty of Medicine in Halifax, Canada. Our patient population was made up of 54 men and 10 women, aged 30 to 84 years (mean: 65.0 ± 11.2). Their disease were staged as follows: carcinoma in situ, n = 11; T1a = 21; T1b = 6; and T2 = 26. Patients were quoted identical cure rates for the two treatment modalities. The controversial issue of voice outcomes was discussed, but no leading information was given to the study cohort. All 64 patients chose CO2 laser resection as opposed to radiation therapy for definitive treatment.

Congenital granular cell tumor in a child with tetralogy of Fallot

July 18, 2016     Felicity Lenes-Voit, MD; Anthony Sheyn, MD; Debra Weinberger, MD

Although congenital granular cell tumors are always benign, they can cause feeding difficulties and airway obstruction.

Epitympanic meningoencephalocele presenting as a growing middle ear mass

July 18, 2016     James G. Naples, MD; John W. House, MD; Benjamin J. Wycherly, MD

This patient had a subtle middle ear mass without an obvious effusion at the initial presentation; on repeat examination, it became more obvious that this was a meningoencephalocele

Spontaneous bleeding from a thyroid adenoma

July 18, 2016     Tsung-Jung Liang, MD; Shiuh-Inn Liu, MD, PhD

Massive thyroid hemorrhage with airway obstruction warrants urgent management, and the importance of definite airway establishment for ventilation and oxygenation cannot be overemphasized.

Malignant transformation of a high-grade osteoblastoma of the petrous apex with subcutaneous metastasis

June 14, 2016     Casey T. Kraft, BS; Robert J. Morrison, MD; H. Alexander Arts, MD, FACS


We describe the clinical presentation, management, and pathologic findings in a case of osteosarcoma of the petrous apex with an atypical metastasis to the lower abdominal wall. We retrospectively reviewed the record of a 49-year-old man who was diagnosed with a right petrous apex lesion, which biopsy identified as a high-grade osteoblastoma. After two attempts at en bloc resection were not curative, radiation and chemotherapy were recommended. The patient subsequently developed a cutaneous lower abdominal mass that was diagnosed as an osteosarcoma. Meanwhile, the petrous apex tumor continued to grow despite treatment until the patient died from the burden of disease. Temporal bone osteoblastomas and osteosarcomas are both extremely rare, and they can be difficult to differentiate histologically. Our case illustrates this difficulty and demonstrates the possibility of a high-grade osteoblastoma's malignant conversion to an osteosarcoma.

Aberrant position of nonrecurrent inferior laryngeal nerve: Report of 3 cases and a review of the literature

June 14, 2016     Thomas J. Willson, MD; Jayne Stevens, MD; Nathan Salinas, MD; Joseph A. Brennan, MD


The presence of a nonrecurrent inferior laryngeal nerve (NRILN) is a significant risk factor for nerve injury during thyroid, parathyroid, and vascular surgeries involving the paratracheal area of the head and neck. The objective of this report is to review the association between an aberrant right subclavian artery (SCA) identified on preoperative imaging and an NRILN identified intraoperatively during thyroid and parathyroid surgery. We reviewed 3 selected cases in which we preoperatively identified an aberrant right SCA and determined the intraoperative position of the inferior laryngeal nerve on the right. It is important to note that 1 of these cases demonstrated that the inferior laryngeal nerve may be found in its normal anatomic position, coursing inferiorly through the tracheoesophageal groove. This anatomic finding is unexpected in a patient with a preoperatively identified aberrant right SCA. We also performed a literature review of more than 250 cases to investigate the association between an intraoperative finding of NRILN and vascular anomalies on imaging. We found 5 reported cases that involved an aberrant right SCA, predictive of NRILN, with the nerve identified in the tracheoesophageal groove.

Twenty-four years of powered endoscopic nasal polypectomy

June 14, 2016     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

Powered endoscopic nasal polypectomy with a microdebrider can be performed with either local or general anesthesia.

Investigation of diagnosis and surgical treatment of mucosal contact point headache

June 14, 2016     Jia Wang, MD; Jin-Shu Yin, MD; Hong Peng, MD


We aimed to investigate the differences in incidence of nasal anatomic abnormalities between patients with and without headache and the outcome of surgical treatment for the headache patients with mucosal contact points. We conducted the observational study and recruited 107 subjects without headache (nonheadache group) and 78 patients with recurrent headache for more than 2 years (headache group). Study participants underwent high-resolution sinus computed tomography scans, and the incidence of nasal anatomic abnormalities was calculated in both groups. An additional 25 patients with recurrent headache underwent endoscopic surgical treatment. Mucosal contact points were observed in 85.9% of patients with recurrent headache and also in 80.4% of participants without headache. The most common mucosal contact point was between a deviated nasal septum and lateral nasal wall (41.1%). The incidence of deviated nasal septum contacting with lateral nasal wall was significantly different between the headache group (55.1%) and the nonheadache group (40.2%) (p < 0.05). The postoperative pain scores of the additional 25 headache patients with recurrent headache and mucosal contact point who were treated with endoscopic surgery decreased significantly compared with their preoperative measurements (p < 0.001), but only 44% of patients had recovered from headache 7 days postoperatively. We conclude that some patients with recurrent headache may not have a mucosal contact point, and some patients with mucosal contact points may not meet the diagnostic criteria of mucosal contact point headache since pain was not resolved within 7 days after surgical treatment. The diagnostic criteria of mucosal contact point headache before surgery should be reevaluated.

Unconventional fix for an orocutaneous fistula

June 14, 2016     Laura Garcia-Rodriguez, MD; Rahil Dharia, BS; Cameron Heilbronn, MD; Tamer Ghanem, MD, PhD

Local risk factors for OCF and PCF secondary to total laryngectomy include infections, exposure of salivary fluids, and radiation.