Head and Neck

Endoscopic management of spontaneous CSF rhinorrhea with septal graft and middle turbinate rotational flap technique: A review of 31 cases

June 8, 2014     Shawky M. Elmorsy, MD; Yasser W. Khafagy, MD
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Abstract

Spontaneous cerebrospinal fluid (CSF) rhinorrhea poses a major challenge to rhinologists. Much controversy attends its cause, pathophysiology, management, and prognosis. It has been suggested that endoscopic placement of a septal graft with a middle turbinate rotational flap may represent the ideal approach to closing skull base defects. We conducted a retrospective chart review to compile the results of this approach in 31 patients with spontaneous CSF rhinorrhea-22 women and 9 men, aged 18 to 67 years (mean 38.5 ± 8.96) at diagnosis. After one surgery, success had been achieved in 27 of these patients (87.1%). The remaining 4 patients underwent a second surgery, and 2 of them experienced a successful closure. In the remaining 2 patients, a third surgery was still unsuccessful, and they were referred to the neurosurgical team for a shunt procedure. Thus, the overall success rate with the septal graft and a middle turbinate rotational flap was 93.5% (29/31). Septal grafts and middle turbinate flaps are easy to harvest and easy to place. Accurate localization of the defect, meticulous surgical technique, and cerebral dehydrating measures may improve outcomes. Further study of spontaneous CSF rhinorrhea to better evaluate its pathophysiology and prognostic factors is warranted.

Helical tomotherapy of the complete scalp and the ipsilateral lymph nodes in a case of scalp angiosarcoma

June 8, 2014     Sonja Katayama, MD; Markus Hantschke, MD; Steffen Lissner, PhD; Katja Lindel, MD; Dieter Oetzel, PhD; Klaus Herfarth, MD; Juergen Debus, MD, PhD; Florian Sterzing, MD
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Abstract

Scalp angiosarcoma represents a therapeutic challenge to all disciplines. This case report demonstrates the potential usefulness of helical tomotherapy (HT) as a new radiotherapeutic treatment option. A 71-year-old woman presented with a superficial angiosarcoma of the scalp, forehead, and left pre- and postauricular areas, with several nodular ulcerating and bleeding lesions. Irradiation of the gross tumor was performed with a total dose of 70 Gy in 2-Gy fractions and of the left cervical lymph nodes with 56 Gy in 1.6-Gy fractions. Good target coverage was achieved without compromising organs at risk, notably the brain. Treatment was very fast (661 seconds per fraction) and was administered with minimal acute toxicity (National Cancer Institute Common Toxicity Criteria: grade 2 erythema and grade 2 dysphagia). During treatment, tumor nodules dissolved into hyperkeratosis. We conclude that with HT, irradiation of the scalp and cervical lymph nodes can be conducted with minimal acute toxicity and without junction problems.

Bacteriology and antimicrobial susceptibility of ENT infections in a tropical hospital

June 8, 2014     Yok Kuan Chew, MBBS; Jack Pein Cheong, MBBS; Nambiar Ramesh, MBBS; Mohamad Din Noorafidah, MPath; Sushil Brito-Mutunayagam, MS; Abdullah Khir, MS; Narayanan Prepageran, FRCS
article

Abstract

We conducted a retrospective observational study to determine the spectrum and antibiotic sensitivity pattern of organisms isolated in otorhinolaryngologic (ORL) infections. We reviewed the laboratory culture and sensitivity records of 4,909 patients-2,773 males (56.5%) and 2,136 females (43.5%), aged 2 to 90 years (mean: 45.3 ± 12.6)-who had been seen at two government hospitals in Malaysia. Of this group, 4,332 patients had a respiratory tract infection (88.2%), 206 had an ear infection (4.2%), 188 had a deep neck infection (3.8%), and 183 had an oropharyngeal infection (3.7%). The most common isolated organisms were Klebsiella spp, Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, methicillin-susceptible S aureus, coagulase-negative S aureus, and Acinetobacter baumannii. We also identified the antimicrobial susceptibility of these organisms. We conclude that since the spectrum of causative pathogens in some infections differs between tropical and nontropical areas of the world, tropical hospitals should not completely adopt the antibiotic guidelines for ORL infections that have been recommended for hospitals in nontropical regions. We hope that our review and analysis of local data will help practitioners in Malaysia develop an appropriate prescribing policy with respect to ORL pathogens and antimicrobial susceptibility. The goal is to reduce the morbidity and mortality associated with these infections.

Metastatic cervical carcinoma from an unknown primary: Literature review

May 7, 2014     Rodrigo Arrangoiz, MS, MD; Tom J. Galloway, MD; Pavlos Papavasiliou, MD; John A. Ridge, MD, PhD; Miriam N. Lango, MD
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Abstract

Carcinoma of an unknown primary (CUP) encompasses a heterogeneous group of tumors for which no primary site can be detected following a thorough history, physical examination, and noninvasive and invasive testing. CUP presenting with metastasis to the neck (metastatic cervical carcinoma from an unknown primary [MCCUP]) has been an enigma since von Volkmann first described it in 1882 as a cancer arising in a branchial cleft cyst. Genetic studies have shed some light on this unusual entity. In most cases, clinical features, imaging studies, and a meticulous assessment of the upper aerodigestive tract should assist in identifying the source of disease. Molecular testing of cytologic specimens for Epstein-Barr virus and human papillomavirus (HPV) can facilitate identification of the primary site in the nasopharynx and oropharynx. At least 25% of MCCUPs are directly attributable to HPV-related malignancies, and this number can be expected to increase. Minimally invasive transoral mucosal sampling can identify an otherwise clinically and radiologically occult cancer. We performed a literature review with the objective of discussing the history, epidemiology, clinical presentation, diagnostic workup, and management of MCCUP.

Parathyroid adenoma in a woman with secondary hyperparathyroidism

May 7, 2014     Darrin V. Bann, PhD; Neerav Goyal, MD, MPH; David Goldenberg, MD, FACS
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For surgical treatment of secondary hyperparathyroidism, a common approach is the removal of three and one-half glands (subtotal parathyroidectomy), leaving the remaining half gland in place with an intact vascular pedicle. Alternatively, a total parathyroidectomy may be performed, and one-half of one gland may be minced and reimplanted into shallow pockets created in the sternocleidomastoid or brachioradialis muscles.

Endoscopic transnasal transsphenoidal approach for craniopharyngioma: Report of 6 cases

May 7, 2014     Chan-Soon Park, MD; Byung-Guk Kim, MD; Ji-Hyeon Shin, MD; Jin-Hee Cho, MD
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Abstract

We conducted a retrospective study to evaluate outcomes in patients with a craniopharyngioma who were managed via a transnasal transsphenoidal approach. Craniopharyngiomas exhibit histologically benign but “clinically malignant” features. Our study group was made up of 5 patients who underwent a total of 6 operations. The study population included 1 female and 5 males, aged 14 to 50 years (mean: 29.2). The overall rate of near-total tumor removal was 67%, but all patients eventually experienced a recurrence. Revision surgery to correct any severe postoperative complications was not required in any case. We found that the endoscopic transnasal transsphenoidal approach could be a safe and less invasive surgical option for the removal of craniopharyngiomas, although we were unable to remove all tumor or prevent recurrences.

Chronic lymphocytic thyroiditis (Hashimoto thyroiditis)

May 7, 2014     Lester D.R. Thompson, MD
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Appropriate management requires lifelong thyroid hormone replacement therapy, resulting in decreased thyroid antibody levels, although complications of therapy may be seen.

Postoperative shoulder function after different types of neck dissection in head and neck cancer

May 7, 2014     Adil Sheikh, MBBS; Hussain Shallwani, MBBS; Shehzad Ghaffar, FCPS, FRCS
article

Abstract

Reported complications of neck dissection surgery have included decreases in shoulder muscle power and range of motion, drooping shoulder, and shoulder pain. We conducted a cross-sectional study to assess postoperative shoulder function following three different types of neck dissection surgery that were performed at Aga Khan University Hospital and to determine how various treatment factors and patient characteristics affected postoperative shoulder function. Our study population included 70 patients-51 men and 19 women, aged 18 to 70 years (mean: 48.6 ± 11.6)-who had undergone a total of 92 neck dissections (22 patients underwent bilateral procedures). Patients were assessed by physical examination and questionnaire responses. The physical examination included objective assessments of shoulder muscle power against resistance, active range of motion, maximum possible forward flexion, the length of time needed to repeat active shoulder flexion 5 times, and shoulder abduction. The questionnaire covered shoulder mobility during activities of daily living, the results of physiotherapy (and exercise), postoperative radiation status, and shoulder pain. Of the 92 neck dissections, 17 were selective (18.5%), 64 were modified radical (69.6%), and 11 were radical (12.0%). We found that patients who had undergone a nerve-sparing procedure (i.e., selective neck dissection or a modified radical neck dissection) exhibited significantly better shoulder function than did patients who had undergone radical neck dissections (p < 0.01). In addition, increasing age (p < 0.001) and a history of diabetes (p = 0.003) were associated with worse shoulder function, and postoperative physiotherapy was associated with better shoulder function (p = 0.002). Neither sex, weight, the side of the neck operated on (left or right), the administration of postoperative radiation, the length of time between surgery and shoulder function assessment, comorbidities such as hypertension and ischemic heart disease, nor the status of the level V lymph nodes had any statistically significant association with shoulder function.

Massive pleomorphic adenoma of the parotid gland: Surgical considerations

May 7, 2014     Alex Fernandez, MS; Ryan F. Osborne, MD, FACS; Jason S. Hamilton, MD, FACS
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Preservation of the facial nerve and its branches requires special consideration when dealing with a large parotid mass. The traditional approach of anterograde dissection of the facial nerve proves ineffective in patients with large lesions that effectively obstruct the field of view and origin of the nerve trunk

Cervical sympathetic chain paraganglioma: A report of 2 cases and a literature review

March 18, 2014     Rahul Seth, MD; Manzoor Ahmed, MD; Aaron P. Hoschar, MD; Benjamin G. Wood, MD; Joseph Scharpf, MD
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Abstract

We review 2 cases of surgically and pathologically confirmed paraganglioma of the cervical sympathetic chain. Both patients-a 46-year-old man and a 33-year-old woman-were treated surgically. Intraoperatively, both tumors were found to be hypervascular and arising from the cervical sympathetic chain. Histopathologic analysis confirmed both as paragangliomas. Paragangliomas arising from the cervical sympathetic chain are exceptionally rare, but they must be considered in the differential diagnosis of parapharyngeal masses. They often present with ipsilateral Horner syndrome and oropharyngeal fullness, and they may be associated with a higher rate of catecholamine secretion. Typical imaging characteristics include anterolateral or lateral displacement of both the carotid and jugular vessels.

Madelung disease: Multiple symmetric lipomatosis

March 18, 2014     Enrique Palacios, MD, FACR; Harold R. Neitzschman, MD, FACR; Jeremy Nguyen, MD
article

Patients with multiple symmetric lipomatosis commonly also suffer from various neuropathies, especially paresthesias and autonomic neuropathy.

Fungal necrotizing fasciitis of the head and neck in 3 patients with uncontrolled diabetes

March 18, 2014     Saravanam Prasanna Kumar, DNB; Arunachalam Ravikumar, MS; Lakshmanan Somu, MS
article

Abstract

Necrotizing fasciitis is an uncommon, rapidly progressive soft-tissue infection that is associated with a high incidence of morbidity and mortality. It is usually caused by bacteria and rarely caused by or complicated by a fungus. We report 3 cases of necrotizing fasciitis of the head and neck in patients with uncontrolled diabetes. Fungi were isolated in all 3 cases. In 1 fatal case, the invasive zygomycete Apophysomyces elegans was isolated. Keys to the management of this condition are (1) early isolation of the causative organism by fungal smear and culture, (2) adequate control of diabetes, (3) maintenance of electrolyte balance, and (4) controlled aggressive surgical debridement at an early stage. We emphasize the importance of fungal smears and cultures in the management of this rapidly spreading infection.

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