Head and Neck

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.

Rhabdomyosarcoma of the supraglottis in an adult

June 8, 2014     Alex Fernandez, MS; Reena Gupta, MD; Hootan Zandifar, MD
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Primary laryngeal rhabdomyosarcoma is an extremely uncommon malignant neoplasm in adults, accounting for relatively few documented cases compared with squamous cell carcinoma.

Metastatic ovarian sex-cord stromal tumor with annular tubules in a patient without Peutz-Jeghers syndrome

June 8, 2014     Kimi Dart, DO; Ted Schwartzenfeld, DO; Warren Brandes, DO; Anthony D'Errico, DO; Michael Stender, MD
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Abstract

Sex-cord stromal tumors (SCSTs) with annular tubules (SCTATs) are a small class of ovarian lesions that possess histologic features of both Sertoli and granulosa cells. Approximately one-third of patients with SCTAT also have Peutz-Jaghers syndreome, which makes these cases especially rare. Patients with non-PJS-associated SCTAT make up the remaining two-thirds; 20% of these cases have a metastatic presentation. Metastasis of these tumors to the head and neck region has only been reported in a few instances. In this article we report a case of a 25-year-old woman who presented with “a lump in her throat” and was ultimately diagnosed with SCTAT. We also discuss the current protocols in the diagnosis and treatment of this entity.

Condyloma acuminatum of the buccal mucosa

June 8, 2014     Rashmi Jaiswal, PhD; Manoj Pandey, MS; Mridula Shukla, DipNB; Mohan Kumar, MD
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Abstract

Condyloma acuminatum is a human papillomavirus (HPV)-induced disease. It is usually transmitted sexually, and it frequently occurs in the anogenital area. A finding of condyloma acuminatum in the oral cavity is rare. Besides HPV, other risk factors for oral condyloma include chewing betel quid and smoking. We report the case of a 52-year-old man who presented with a 2 x 2-cm verrucous white patch on his buccal mucosa. He was habituated to both betel quid and cigarette smoking. A biopsy of the lesion identified it as a verrucous hyperplasia of the squamous epithelium with HPV-related koilocytic changes. The lesion was excised, and further histopathology identified it as condyloma acuminatum. The patient was disease-free 9 months postoperatively. The possibility of condyloma acuminatum should be considered in the differential diagnosis of an oral white lesion. The most common treatments are surgical excision, cryosurgery, electrocautery, and laser excision. There is no known role for antiviral therapy.

Sebaceous carcinoma of the parotid gland: A case report and review of the literature

June 8, 2014     Alexander Manteghi, DO; Seth Zwillenberg, MD; Vivian Arguello-Guerra, MD
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Abstract

Sebaceous carcinoma is a rare malignancy primarily affecting the periocular sebaceous glands. Sebaceous carcinoma of the parotid gland is exceedingly rare, with only 30 cases reported in the literature. Our case brings this total to 31. We present a case involving a 57-year-old man with a slowly enlarging, right tail-of-parotid mass abutting the ear lobule with overlying skin discoloration. Excision of the mass with superficial parotidectomy was performed, and microscopic examination demonstrated sebaceous carcinoma with positive margins. Subsequently, the patient underwent a completion parotidectomy and inferior auriculectomy with no evidence of residual tumor. Six months after postoperative adjuvant radiotherapy, the patient remains tumor-free. The clinical and morphologic features of this tumor are discussed.

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.

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
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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.

Extensive basal cell carcinoma of the face: An extreme case of denial

June 8, 2014     Soroush Zaghi, MD; Pedram Ghasri, MD; Paul Busse, MD, PhD; John Clark, MD; Kevin Emerick, MD
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Abstract

Patients with head and neck cancer are particularly susceptible to using denial as a coping mechanism. While some forms of denial may help patients achieve better levels of physical functioning, persistent denial can serve as a major barrier to treatment. We report a case of extreme denial by a 60-year-old woman with an extensive basal cell carcinoma of the face that had been neglected for more than 20 years. We present this case to raise awareness of the potential danger of denial, and we discuss strategies that physicians can undertake to properly manage patients who engage in it. Since the diagnosis and treatment of head and neck cancer can result in profound psychological trauma, gaining an appreciation for how patients cope with it is an important part of the comprehensive care of head and neck oncology patients.

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.

Ossifying fibromyxoid tumor metastatic to the thyroid: A case report and review of the literature

June 8, 2014     Ricardo R. Lastra, MD; Jason G. Newman, MD; John S. Brooks, MD; Jui-Han Huang, MD, PhD
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Abstract

Ossifying fibromyxoid tumors are rare soft-tissue neoplasms, usually with an indolent course. However, atypical/malignant variants have been described, showing either local recurrence after complete excision or metastasis to the lungs, mediastinum, adrenals, or soft tissue. We report the case of an ossifying fibromyxoid tumor of the left ankle that metastasized to the lung and thyroid gland 12 years after the initial diagnosis and surgical treatment. To our knowledge, this is the first reported case of this neoplasm metastasizing to the thyroid gland.

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.

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.

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