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Congenital choristoma (hairy polyp) of the eustachian tube: Surgical management of a rare clinical entity

January 22, 2016     Jonathan M. Melzer, MD, LT, MC, USN; Austin Morgan, MD, LT, MC, USN; David Darrow, MD

Macroscopically, choristomas can appear as soft, pedunculated masses that are hairy with a white or a violaceous hue. They can measure up to 6 cm in diameter.

Two cases of sublingual hematoma as a manifestation of child abuse

December 14, 2015     Muneesh Mehra, MD; Antonia E. Chiesa, MD; Andrew P. Sirotnak, MD


Common intraoral manifestations of child abuse include tears of the frenula, burns, and pharyngeal perforations. Sublingual hematomas can also occur as a result of trauma, but to the best of our knowledge, only 1 case has been previously described in the context of child abuse. We report 2 new cases of sublingual hematoma in infants that were the result of physical abuse. Cases of sublingual hematoma in infants and children without a clear and legitimate explanation of the cause should prompt consideration of child abuse.

Raeder syndrome: Paratrigeminal oculosympathetic syndrome presenting as a manifestation of chronic sinusitis

December 14, 2015     Cedric V. Pritchett, MD; Mark A. Zacharek, MD


Raeder syndrome (paratrigeminal oculosympathetic syndrome) is a rare clinical entity characterized by ipsilateral trigeminal sensory deficits, ptosis, and miosis, with an absence of anhidrosis secondary to interruption of the postganglionic oculosympathetic pathway. Going back to its original description, this constellation of physical examination findings has historically been associated with intracranial pathology involving the middle cranial fossa. Understanding this pathway is important in distinguishing Raeder syndrome from Horner syndrome, as the presentation of the former is now recognized to accompany a number of other disease entities in the head and neck region. We present an unusual case of Raeder syndrome associated with bacterial sinusitis, and we discuss its management and review the literature.

Physician liability issues and telemedicine: Part 2 of 3

December 14, 2015     Steven T. Kmucha, MD, JD, FACS

Written policies and procedures should be maintained at the same standard as traditional face-to-face encounters for documentation, maintenance, and transmission of the medical record of the telemedicine encounter.

Hemangioma of the soft palate

December 14, 2015     Yu-Hsuan Lin, MD; Yaoh-Shiang Lin, MD

Hemangioma is not commonly seen in the soft palate. A variety of symptoms may be present.

Endoscopic view of an osteoma of the maxillary sinus

December 14, 2015     Joseph P. Mirante, MD, FACS; Robert A. Merrell, MD; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS

Surgical removal of osteomas is generally indicated when they grow and cause symptoms or threaten structures.

Sensorineural hearing loss associated with a factitious disorder

December 14, 2015     Ayako Maruyama, MD; Yoshihiro Noguchi, MD; Taku Ito, MD; Kenji Narushima, MD; Ken Kitamura, MD


Factitious disorders are characterized by intentionally abnormal physical and/or psychological behavior, and affected patients often make up their symptoms and clinical histories. The most serious and chronic type of factitious disorder is Munchausen syndrome. We report the case of a 24-year-old woman with a 2-year history of sensorineural hearing loss (SNHL) who later confessed to feigning her hearing loss. She was eventually diagnosed with a factitious disorder. During those 2 years, she was able to induce her SNHL by exposing herself to excessive noise or high doses of aspirin. To the best of our knowledge, this is the first report describing an association between a factitious disorder and SNHL.

An unusual tongue base mass in an infant: Tongue base sialolipoma

December 14, 2015     Dawn T. Teo, MBBS; Romaine F. Johnson, MD, MPH; John E. McClay, MD


Sialolipoma is a rare tumor that occurs in the head and neck. We present a case arising from a minor salivary gland in an infant. The 6-month-old infant presented with difficulty swallowing, frequent reflux, and snoring that had been worsening several weeks before presentation. Physical examination showed a large mass arising from the tongue base. The patient was taken to the operating room for transoral removal of a presumed cyst. Histologic examination of the lesion showed a well-circumscribed lesion composed of lobules of mature adipose tissue and nodules of entrapped, non-neoplastic acini and ductules separated by thin, fibrous septae, consistent with a sialolipoma. To the best of our knowledge, this is the first reported case of a sialolipoma at the tongue base in a child. The patient has had no evidence of recurrence at 1 year of follow-up.

Reconstruction after resection of a lower lip squamous cell carcinoma with a submental island flap

December 14, 2015     Jin Pyeong Kim, MD; Hyun Woo Park, MD; Jung Je Park, MD; Seung Hoon Woo, MD


Lip cancer is the most common malignancy of the oral cavity and the second most common cancer in the head and neck. Typically, squamous cell carcinoma of the lower lip is an ulcerated lesion with raised margins. Surgery is the best treatment for lower lip cancer. The lips are important aesthetically because of their prominent location on the face and functionally because of the essential mechanism of the sphincter in assisting mastication, swallowing, phonation, and expressing emotions. Depending on the location and size of a lip tumor, different types of reconstructive flaps are used. We describe our technique for reconstructing the lower lip with a submental island flap.

Pemphigus vulgaris: An underdiagnosed cause of oral ulcer

December 14, 2015     Avijit Choudhury, MBBS; Tamoghna Jana, MBBS, DLO; Saumik Das, MBBS, DLO, MS, DNB; Ramanuj Sinha, MBBS, DLO, MS, DNB

Diagnosis of pemphigus vulgaris requires a high degree of clinical suspicion, along with timely mucosal biopsy for histopathologic examination and a direct immunofluorescence study.

Button battery injuries in the pediatric aerodigestive tract

December 14, 2015     Abhinav R. Ettyreddy, BS; Matthew W. Georg, BS; David H. Chi, MD; Barbara A. Gaines, MD; Jeffrey P. Simons, MD


Children with a button battery impaction present with nonspecific symptoms that may account for a delay in medical care. We conducted a retrospective study of the clinical presentation, management, and complications associated with button battery ingestion in the pediatric aerodigestive tract and to evaluate the associated long-term morbidity. We reviewed the medical records of 23 patients who were treated for button battery impaction at our tertiary care children's hospital from Jan. 1, 2000, through July 31, 2013. This population was made up of 14 boys and 9 girls, aged 7 days to 12 years (mean: 4 yr). Patients were divided into three groups based on the site of impaction; there were 9 impactions in the esophagus and 7 each in the nasal cavity and stomach. We compiled information on the type and size of each battery, the duration of the impaction, presenting symptoms, treatment, and outcomes. The mean duration of battery impaction was 40.6, 30.7, and 21.0 hours in the esophagus, nasal cavity, and stomach, respectively. We were able to identify the specific type of battery in 13 cases; 11 of these cases (85%) involved a 3-V 20-mm lithium ion battery, including all cases of esophageal impaction in which the type of battery was identified. The most common presenting signs and symptoms were vomiting (n = 7 [30%]), difficulty feeding (n = 5 [22%]), cough (n = 5), and bloody nasal discharge (n = 5); none of the presenting signs and symptoms predicted the severity of the injury or the outcome. The median length of hospital stay was far greater in the esophageal group (12 days) than in the nasal and stomach groups (1 day each; p = 0.006). Battery impaction in the esophagus for more than 15 hours was associated with a significantly longer postoperative hospital stay than impaction for less than 15 hours (p = 0.04). Esophageal complications included strictures (n = 5), perforation (n = 3), and tracheoesophageal fistula formation (n = 2). Clinicians should consider battery impaction in the upper aerodigestive tract as an emergency that can lead to significant long-term morbidity, and therefore immediate surgical intervention is required.

Core biopsy as a simple and effective diagnostic tool in head and neck focal myositis

December 14, 2015     Chun Yee Tan, MBBS; Sheldon Chong, MBBS, MS; Chi-Kee Leslie Shaw, MBBS, MS, FRACS


Most unilateral head and neck masses are benign, although malignancy is a possibility in some cases. However, there are other rare causes of unilateral neck masses, such as focal myositis, which is a rare, benign condition belonging to the family of inflammatory pseudotumors of the skeletal muscles, with rare presentations in the head and neck region. Focal myositis presents as a rapidly enlarging neck mass that can be misdiagnosed by fine-needle aspiration biopsy and/or radiologic imaging as either an infective or a neoplastic process. To date, there are only 5 reported cases of adult focal myositis of the sternocleidomastoid muscle in the medical literature. In this article, the authors present 2 cases involving patients with focal myositis of the sternocleidomastoid muscle that were successfully diagnosed with core-needle biopsy and managed conservatively. The pros and cons of fine-needle aspiration biopsy and core-needle biopsy are discussed. Based on the authors' results, fine-needle aspiration biopsy universally fails to provide the diagnosis of focal myositis. In contrast, core-needle biopsy successfully diagnosed focal myositis in both of our patients. Both of them had complete resolution with conservative management.

Pleomorphic adenoma of the frontal sinus masquerading as a mucocele

December 14, 2015     Yok Kuan Chew, MBBS; Sushil Brito-Mutunayagam, MS; Aun Wee Chong, MS; Narayanan Prepageran, FRCS; Patricia Ann Chandran, MPath; Baharudin Khairuzzana, MS; Omkara Rubini Lingham, MS


Pleomorphic adenoma is the most common type of benign salivary gland tumor. It can also be found in the larynx, ear, neck, and nasal septum. It is rarely found in the maxillary sinus, and it has never been reported in the frontal sinus. We report a case of pleomorphic adenoma of the frontal sinus that masqueraded as a mucocele. We discuss the clinical presentation, diagnosis, and treatment of this patient, and we review the literature.

Nasal obstruction and recurrent sinusitis caused by bilateral pneumatized ethmoid bullae

December 14, 2015     Meir Warman, MD; Seth Willen, MD; Peter J. Catalano, MD, FACS, FARS


The presentation of an enlarged pneumatized bulla ethmoidalis (BE) that obstructs the ethmoid infundibulum has not been previously reported. We report such a case in a 23-year-old woman who presented with recurrent acute rhinosinusitis and chronic rhinosinusitis. The obstruction had been caused by inferior and anterior pneumatization of the BE. Surgery was successful in alleviating all symptoms, and the patient remained symptom-free at 10 months of follow-up. We describe the radiologic and endoscopic findings in this case, and we discuss the possible mechanisms by which BE is involved in the pathogenesis of recurrent acute and chronic rhinosinusitis.

Bone-anchored hearing aid implantation in a patient with Goldenhar syndrome

December 14, 2015     Griffin Santarelli, MD; Roberta E. Redfern, PhD; Aaron G. Benson, MD


Patients with Goldenhar syndrome exhibit a number of characteristic symptoms, including middle and internal ear malformations that may cause profound hearing loss. Bone-anchored hearing aids have been used to treat these patients in the past, although complications may arise due to the nature of the disease. Herein we present the case of a pediatric patient with Goldenhar syndrome whose hearing aid abutment extruded spontaneously because of poor bone quality, despite adequate thickness. We provide a brief review of the literature and suggest a flexible surgical plan for any syndromic pediatric patient.

The Potter technique for cleft lip rhinoplasty

December 14, 2015     Joseph J. Rousso, MD, FACS

The Potter technique is a simpler method than the Dibbell technique to achieve nasal symmetry when the alar base width is harmonious.

Facial nerve neurofibroma presenting with external auditory canal tumor and facial palsy

December 14, 2015     Yao-Ying Tseng, MD; Cheng-Chien Yang, MD; Chen-Chuan Li, MD; Min-Tsan Shu, MD

Facial nerve neurofibromas are benign and rare, and they generally present with facial palsy; however, hearing loss, tinnitus, and vertigo are also observed occasionally.

Sensorineural hearing loss in beta-thalassemia patients treated with iron chelation

December 14, 2015     Ustun Osma, MD; Erdal Kurtoglu, MD; Hulya Eyigor, MD; Mustafa Deniz Yilmaz, MD; Nurdan Aygener


The predictive value of pure-tone audiometry (PTA) in the early detection of ototoxicity has been questioned, particularly in the higher frequencies. Otoacoustic emissions testing appears to be more sensitive to cochlear insult than conventional PTA. We conducted a cross-sectional descriptive study to compare the efficacy of distortion-product otoacoustic emissions (DPOAE) testing with that of PTA as a method of audiologic monitoring. Our study group was made up of 159 patients (318 ears)-69 males (43.4%) and 90 females (56.6%), aged 5 to 61 years (mean: 23.59 ± 12.55). All patients had been diagnosed with either β-thalassemia major (BTM) or β-thalassemia intermedia (BTI), and all had received at least 1 year of treatment within the previous year with an iron chelator-either deferasirox, desferrioxamine (deferoxamine in the United States), deferiprone, or a combination of desferrioxamine and deferiprone. PTA and DPOAE evaluations were performed by the same audiologist using the same audiometer for all patients. In the right ears, the overall incidence of ototoxicity as manifested by sensorineural hearing loss was 39.0% on PTA and 22.0% on DPOAE testing; in the left ears, the corresponding figures were 27.7 and 19.5%, respectively. There were no statistically significant differences in the incidence of ototoxicity between the BTM and BTI groups with any of the four different drug regimens on PTA (p = 0.765, p = 0.378, p = 0.265, and p = 0.579, respectively) or on DPOAE testing (p = 0.890, p = 0.263, p = 0.390, and p = 0.340, respectively). Based on these data, we found no significant difference between PTA and DPOAE testing in their ability to detect ototoxicity. We conclude that periodic testing with both PTA and DPOAE is necessary for patients with suspected β-thalassemia in order arrive at a prompt diagnosis and initiate timely management.

Globus sensation and laryngopharyngeal reflux

October 31, 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 31, 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.