Pharynx

Transoral removal of a large parapharyngeal space neurofibroma with the Harmonic Scalpel

July 13, 2014     Marcel Marjanovic Kavanagh, MD; Zlatko Sabol, MD, PhD, MSc; Sasa Janjanin, MD, PhD; Drago Prgomet, MD, PhD
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Abstract

We report the case of a 19-year-old man with neurofibromatosis type 1 who presented for evaluation of odynophagia, left-sided hemiparesis, multiple café au lait spots all over his body, and numerous subcutaneous and cutaneous neurofibromas. Imaging revealed the presence of two large neurofibromas-a 60 x 50 x 35-mm tumor in the left parapharyngeal space and an intradural tumor measuring 25 mm in diameter. We removed the larger tumor via a transoral route with the Harmonic Scalpel. The size of this tumor far exceeded the size of any other reported tumor removed in this manner. Various approaches to the parapharyngeal space have been described in the literature. To the best of our knowledge, this case represents the first report of a transoral removal of a huge parapharyngeal space neurofibroma with a Harmonic Scalpel.

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.

Descending necrotizing mediastinitis: A conservative approach

March 18, 2014     Sriram Iyer, MRCP; Joseph Collum, MRCP; Marta Babores, FRCP
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Abstract

Descending necrotizing mediastinitis (DNM) is a now-rare complication of dental and pharyngeal infections. Reports in the literature have emphasized the need for early, aggressive surgical intervention. We present a case of DNM with bilateral empyemas that arose secondary to a perforated pharyngeal abscess. The patient was successfully managed conservatively with intravenous antibiotics and intercostal drainage. We conclude that conservative management with antibiotics and image-guided percutaneous pleural drainage may be initially appropriate for the stable patient.

A systematic review of proton-pump inhibitor therapy for laryngopharyngeal reflux

August 21, 2013     Uchechukwu C. Megwalu, MD
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Abstract

The author performed a MEDLINE literature search to identify and evaluate all randomized, placebo-controlled trials of the treatment of laryngopharyngeal reflux (LPR) with an oral proton-pump inhibitor (PPI) that have been published since 1966. Eight such trials that included a total of 358 patients were identified. These eight studies contained seven different definitions of LPR. Validity scores (maximum: 9) ranged from 5 to 9 (mean: 7.5). One study investigated low-dose once-daily therapy, two studies investigated low-dose twice-daily therapy, and five studies investigated high-dose twice-daily therapy. Outcomes measures were not consistent among studies, and most studies used unvalidated outcomes measures. Only two studies found that a PPI was significantly better than placebo-one in the low-dose twice-daily group and one in the high-dose twice-daily group. The author concludes that the current body of literature is insufficient to draw reliable conclusions about the efficacy of PPI therapy for the treatment of LPR.

Multilevel treatment of moderate and severe obstructive sleep apnea with bone-anchored pharyngeal suspension sutures

August 21, 2013     Eric E. Berg, MD; Frederick Bunge, MD; and John M. DelGaudio, MD
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Abstract

Success rates for the surgical treatment of obstructive sleep apnea (OSA) vary, with phase I surgical success ranging from 40 to 75%. Pharyngeal suspension suture procedures are minimally invasive techniques with a reported efficacy of 20 to 78%. We conducted a study to evaluate the effectiveness of pharyngeal suspension suture procedures in conjunction with uvulopalatopharyngoplasty (UPPP) as a multilevel treatment for OSA. We retrospectively reviewed the charts of 30 adults-22 men and 8 women, with a mean age of 49 years and a mean BMI of 30.6-who were treated at a tertiary care academic medical center and a private otolaryngology practice. All patients had moderate or severe OSA, and all had failed continuous positive airway pressure therapy. Of this group, 20 patients underwent tongue base and hyoid suspension (TBHS) and 10 underwent tongue base suspension (TBS) alone; 23 patients had undergone concurrent or previous UPPP, 13 in the TBHS group and all 10 in the TBS group. Polysomnography was performed an average of 3.9 months postoperatively. Surgical success was defined as a reduction in respiratory distress index (RDI) of more than 50% and a postoperative RDI of 20 or less. The overall surgical success rate was 63% (19/30). In the surgical success group, the mean RDI fell from 44.6 to 9.4 (p < 0.0001); in the surgical failure group, the mean RDI rose from 41.3 to 48.9 (p = 0.58). There were 6 complications: 3 seromas, 2 suture breaks, and 1 dislodged screw. We conclude that pharyngeal suspension suture procedures as part of the multilevel treatment of moderate and severe OSA yields better outcomes than conventional surgical treatments with the added benefit of being minimally invasive.

Intrapharyngeal schwannoma in a pediatric patient

June 11, 2013     Nader Nassif, MD; Mariaelisabetta Cottelli, MD; Davide Farina, MD; and Marco Berlucchi, MD
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Abstract

Schwannomas are benign peripheral nerve neoplasms that arise from Schwann cells. They usually occur in the adult population. The most common site in the head and neck region is the parapharyngeal space. Intrapharyngeal schwannomas are extremely rare, and those that have been reported all occurred in adults. We report what to the best of our knowledge is the first case of an intrapharyngeal schwannoma in a pediatric patient. The patient, a 15-year-old boy, was treated successfully with surgical excision.

The effect of chronic obstructive pulmonary disease on laryngopharyngeal sensitivity

September 7, 2012     Nicola A. Clayton, MScMed, BAppSc; Giselle D. Carnaby-Mann, MPH, PhD; Matthew J. Peters, MD; Alvin J. Ing, MBBS, MD
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Abstract

Patients with chronic obstructive pulmonary disease (COPD) may be at increased risk of aspiration secondary to impaired swallow function. One possible cause of this impairment is a reduction in laryngopharyngeal sensitivity. The relationship between COPD and laryngopharyngeal sensitivity has not been previously determined. We conducted a study to investigate the effect of COPD on laryngopharyngeal sensitivity by using laryngopharyngeal sensory discrimination testing (LPSDT). Our study population was made up of 20 adults (mean age: 71.7 yr) with clinically proven COPD and 11 healthy, age-matched controls. All 31 subjects underwent LPSDT with the use of an air-pulse stimulator via a nasendoscope. The threshold of laryngopharyngeal sensation was evaluated by measuring the amount of air pressure required to elicit the laryngeal adductor reflex (LAR). We found that the patients with COPD had a significantly higher LAR threshold than did the controls (p< 0.001). We conclude that patients with COPD have significantly less mechanosensitivity in the laryngopharynx. This sensory change may place patients with COPD at increased risk for aspiration.

Acute candidal pharyngolaryngitis

July 5, 2012     Andrew Mallon, DO; Rima A. DeFatta, MD; Robert T. Sataloff, MD, DMA, FACS
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Use of inhaled steroids has been identified as a risk factor for the development of laryngeal candidiasis. Therefore, if dysphonia, cough, and general laryngeal irritation occur in a patient using inhaled steroids, the possibility of laryngeal candidiasis should be considered.

Percutaneous injection pharyngoplasty for the treatment of a pharyngocele

February 18, 2012     Amanda Hu, MD, FRCSC and Albert L. Merati, MD, FACS
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Unusual parapharyngeal acinic cell carcinoma

January 25, 2012     Jeremy Nguyen, MD, Enrique Palacios, MD, FACR, Elorice Horam, MD, and Harold Neitzschman, MD, FACR
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Hypopharyngeal perforation: An unusual complication of transesophageal echocardiography

November 22, 2011     David Bakhos, MD, Jean-Phillippe Cottier, MD, PhD, Patrice Beutter, MD, and Sylvain Morinière, MD, PhD
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Abstract

Physicians frequently use transesophageal echocardiography (TEE) for clinical cardiology and during surgery. It is considered a safe procedure, and only a few cases of complications have been reported in the literature. We present the case of a 78-year-old man who experienced a perforation of the hypopharynx following TEE. The perforation went unrecognized for 10 days. Computed tomography identified a cervical abscess, which was drained. The patient recovered and was doing well at the 1-year follow-up. Hypopharyngeal perforation is a rare but potentially life-threatening complication. Surgeons should know and recognize its clinical signs to prevent its occurrence.

An unusual case of a ballpoint pen migrating into the parapharyngeal space and middle mediastinum

November 22, 2011     Grace H. Kim, MD, Eugene P. Snissarenko, MD, and Paul D. Kim, MD
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Abstract

Foreign bodies that penetrate the esophagus and migrate extraluminally are unusual. If they are left untreated, serious complications arise from mediastinitis, and damage to the major structures in the neck can occur. We report a case of a patient who presented with chest pain on inspiration that was found to be caused by a foreign body in the parapharyngeal space and middle mediastinum. Preoperative imaging is critical in obtaining landmarks for safe surgical exploration and is essential to the successful management of penetrating and migrating foreign bodies. This case highlights the importance of localizing the foreign body preoperatively to aid in its surgical removal via a transcervical approach.

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