Surgery

Two cases of pyogenic granuloma in pregnancy

August 27, 2014     Alex Fernandez, MS; Jason Hamilton, MD, FACS; Raphael Nach, MD
article

Management and treatment of rhinologic issues in pregnant patients can be complex because of the limited availability of safety data.

Modified radical mastoidectomy and its complications-12 years' experience

May 7, 2014     Sardar U. Khan, DLO, FCPS, FRCS(Ire); Rajesh K. Tewary, MS, FRCS(Ed); Timothy J. O'Sullivan, FRCS(Canada)
article

Abstract

To find the incidence of complications of modified radical mastoidectomy and to evaluate different parameters that play a role in their causation, we conducted a retrospective study spanning a period of 12 years. Included were 210 patients who underwent primary modified radical mastoidectomies performed by one senior surgeon; of these patients, 163 fulfilled the inclusion criteria. The charts were evaluated for patients' age and sex, laterality, intraoperative pathology, and complications. The complications were grouped into nine categories for analysis of their etiology. The results in this study were compared with those from other published reports. Complications were documented in 46 of 163 (28.2%) operated ears; 21 (45.7%) of them were noted in children <15 years of age, and 25 (54.3%) were found in adults. Sex and laterality were of no significance. The most common complication recorded was residual/recurrent cholesteatoma (20 [12.3%]), followed by meatal stenosis (11 [6.7%]). A moist cavity with discharging ear was noted in only 4 (2.5%) patients. No facial nerve palsies or dead ears were observed. Eleven (6.7%) patients had more than one complication. The parameters evaluated were size of the meatus, tympanic membrane appearance, status of the mastoid cavity, height of the facial ridge, and extent of the disease process. Complications can be caused by a number of factors, such as congenital anomalies, disease process, and the surgeon's skill. Each complication must be thoroughly evaluated for immediate management and to learn how to avoid it in the future.

Nasal valve surgery: Assessment of quality of life with the Glasgow Benefit Inventory

May 7, 2014     Jaiganesh Manickavasagam, MRCS(Edin), DOHNS(Lond); Smeeta Wong, MRCS; Veronika Varabei, MBBS; Ullas Raghavan, FRCS(ORL)
article

Abstract

We used the 18-question Glasgow Benefit Inventory (GBI) to conduct a retrospective assessment of quality of life following nasal valve surgery. We telephoned 53 patients who had undergone open rhinoplasty for the treatment of nasal valve collapse over a 2-year period. A total of 39 patients-24 men and 15 women, aged 20 to 50 years (mean: 38)-agreed to participate and answer the questions. Follow-up ranged from 3 to 12 months (mean: 8). The spectrum of possible GBI scores ranges from -100 (maximum negative outcome) to 0 (no change) to +100 (maximum benefit); in our group, the median total score was +56 (interquartile range: +32 to +90.5) and the overall total score was +58. The three subscale components of the GBI-general benefit, physical benefit, and social benefit-were analyzed individually; the respective median scores were +46 (+21 to +71), +67 (+25 to +91.5), and +50 (+17 to +100), and the respective overall scores were +60, +59, and +50. Based on these findings, we conclude that nasal valve surgery significantly improves quality of life.

Retropharyngeal pseudoabscess manifesting in nephrotic syndrome

May 7, 2014     Shirish Johari, DLO, MRCSEd, DOHNS(Edin); Pankaj Handa, MD, MRCP(Ire), FAMS; Jin Keat Siow, MD, MBBS, FRCSEd
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Abstract

We describe a case of nephrotic syndrome that manifested as a retropharyngeal pseudoabscess. The patient was a 32-year-old man who presented with a short history of throat discomfort and a choking sensation. Laryngoscopy identified bulging of the posterior pharyngeal wall that partially occluded the laryngeal inlet. A lateral neck x-ray revealed that the prevertebral space was widened, and computed tomography detected fluid in the retropharyngeal and parapharyngeal spaces. Neck exploration revealed that the edema had been caused by nonsuppurative fluid. Biochemical analyses revealed marked hypoalbuminemia and heavy proteinuria suggestive of nephrotic syndrome. Following surgery, the patient's symptoms resolved. Aseptic effusion into the retropharyngeal space is rare; reported etiologies include internal jugular vein thrombosis, neoplasia, radiation therapy, trauma, acute calcific tendinitis, hereditary angioedema, and myxedema of hypothyroidism. To the best of our knowledge, this is the first case of nephrotic syndrome initially manifesting as retropharyngeal pseudoabscess to be reported in the literature. Thrombotic occlusion of the pharyngeal venous plexus secondary to hypercoagulability is a plausible explanation for such isolated retropharyngeal effusion.

Anatomic measurements of the anterior and posterior ethmoid arteries in cadaveric heads using endoscopic sinus instrumentation

May 7, 2014     Zeeshan S. Aziz, MD; Ninef E. Zaya, MD; Richard M. Bass, MD
article

Abstract

The challenges of endoscopic sinus surgery lie in the complexity of the anatomy of the nasal vault and side walls and the proximity to critical structures. Additionally, operating in a three-dimensional space while relying on a two-dimensional image for surgical navigation can be a disorienting task. Successful sinus surgery relies on the surgeon having a clear understanding of the anatomy and relationships within the operative field. We performed a study of 8 adult cadaveric heads to better elucidate the location of the ethmoid arteries in relation to an accessible external landmark, the nasal sill. Sinus endoscopy was performed on the heads to identify and measure the distance from the nasal sill to the anterior and posterior ethmoid arteries. We found that the distance from the nasal sill to the anterior ethmoid artery was approximately 6.0 cm, and the distance to the posterior ethmoid artery was approximately 6.7 cm. The interarterial distance was approximately 1.2 cm. With a better understanding of these vessels, surgeons will be better able to avoid them during surgery and thereby minimize the risk of excessive intraoperative bleeding and perioperative orbital hematoma.

Endoscopic modified Lothrop approach for the excision of bilateral frontal sinus tumors

March 18, 2014     Jiun Fong Thong, MRCS; Deyali Chatterjee, MD; Siew Yoong Hwang, FRCS
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Abstract

We describe the use of an endoscopic modified Lothrop approach for clearance of an extensive sinonasal-type hemangiopericytoma of the nasal cavity and paranasal sinuses with bilateral frontal sinus involvement in a 44-year-old woman. The modified Lothrop approach is conventionally used to treat sinusitis, but with some slight modifications to the technique, it can also be used for tumor excision.

Schwannoma of the nasal septum: An unusual finding

March 18, 2014     Shruti Dhingra, MS, DNB; Jaimanti Bakshi, MS, DNB; Satyawati Mohindra, MS, DNB
article

Abstract

Schwannomas of the nasal cavity are rare benign tumors, and those that arise from the nasal septum are even rarer. When they do occur, they usually become symptomatic early because of the close confines of the nasal cavity. We describe a case of nasal septal schwannoma that was noteworthy in that the patient-a 28-year-old woman-waited 8 months after the onset of symptoms to seek medical care. Her symptoms included complete right-sided nasal obstruction, occasional epistaxis, and hemifacial pain. The tumor was completely removed via an endoscopic approach. We discuss the clinical presentation, differential diagnosis, and treatment of this rarely encountered neoplasm.

Accessory parotid malignancy requiring ductal transection

February 12, 2014     Avery Kaplan; Alex Fernandez, MS; and Ryan Osborne, MD, FACS
article

While malignancies of the accessory parotid gland are rare, when they do occur they jeopardize ductal integrity.

Endoscopic view of sphenoid sinus illumination and transillumination

February 12, 2014     Ken Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; and Eiji Yanagisawa, MD, FACS
article

The sphenoid sinus has been considered a more challenging sinus to view with the lighted guide wire; unlike the other three paranasal sinuses, the sphenoid sinus is “hidden” from view because of its more posterior location.

Severe symptomatic hypocalcemia following total thyroidectomy in a patient with a history of Roux-en-Y gastric bypass surgery

January 21, 2014     Justin A. Gross, MD; Steven M. Olsen, MD; Cody A. Koch, MD, PhD; Eric J. Moore, MD
article

Abstract

Patients who undergo a Roux-en-Y gastric bypass (RYGB) procedure are at moderate risk for calcium and vitamin D deficiency. Those who subsequently undergo thyroid or parathyroid surgery are at high risk for developing severe symptomatic hypocalcemia if they are not monitored and adequately treated prophylactically. We describe the case of a morbidly obese 40-year-old man who had undergone RYGB surgery 6 months prior to the discovery of metastatic papillary thyroid carcinoma. He subsequently underwent total thyroidectomy with central and bilateral neck dissection. Following surgery, he developed severe symptomatic hypocalcemia, as his calcium level fell to a nadir of 6.0 mg/dl. He required aggressive oral and intravenous repletion therapy with calcium, vitamin D, and magnesium for 10 days before hospital discharge. Providers should institute careful preoperative screening, patient counseling, and prophylactic calcium and vitamin D therapy for all thyroid surgery patients who have previously undergone RYGB surgery to prevent the development of severe and life-threatening hypocalcemia. Only a few reports of patients have been published on the dangers of thyroid and parathyroid surgery in patients who have undergone bariatric surgery. We report a new case to add to the body of literature on this patient population. We also review calcium homeostasis and supplementation as they relate to this situation.

Endoscopic view of a biodegradable middle meatal spacer

January 21, 2014     Joseph P. Mirante, MD, FACS; Dewey A. Christmas, MD; Eiji Yanagisawa, MD, FACS
article

Middle meatal spacers have included simple packing of the middle meatus for several days in the postoperative period, as well as insertion of various preformed splints.

Angioleiomyoma on the dorsum of the nose excised via an open rhinoplasty approach

December 20, 2013     Philip W. Stather, MBChB; Zuhair O. Kirresh, FRCS; Paul N. Jervis, FRCS
article

Abstract

We describe what we believe is the first reported case of an angioleiomyoma on the dorsum of the nose. The patient was a 65-year-old woman who presented with a year-long history of an intermittently recurrent lump on the right side of the dorsum. The lesion was removed via an open rhinoplasty approach. Histologic examination identified it as an angioleiomyoma.

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