Laryngology

Traumatic tracheostomy and spent bullet aspiration after a gunshot injury: A case report

August 21, 2013     Jack Barasa, MD; Peter M. Nthumba, MD; and Peter Bird, FRACS
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Abstract

Penetrating tracheal injuries are rare. Even rarer is the finding of intrabronchial foreign bodies caused by penetrating objects. We report a patient who experienced a gunshot injury to the trachea and mandible. The tracheal wound was debrided and used as a tracheostomy; a spent bullet in the bronchial tree was missed on initial evaluation but later successfully retrieved bronchoscopically. Spent bullet aspiration is a very rare occurrence. A careful examination of radiographs is essential to aid with the diagnosis. Flexible bronchoscopy is the best means of bullet retrieval. Management of any associated injuries is made easier after the airway is secured.

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.

Iatrogenic epiglottic inversion during intubation

August 21, 2013     Adam Rourke, DO and Adam Rubin, MD
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The otolaryngologist must recognize when the epiglottis is inverted or risk inserting the laryngoscope too far and traumatizing the vocal folds.

Peripheral osteoma of the hard palate

August 21, 2013     Borlingegowda Viswanatha, MS, DLO, PhD
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Abstract

Peripheral osteomas of the hard palate are relatively rare. Two cases of osteoma of the hard palate are reported, along with a review of the literature.

Human papillomavirus and tobacco use in tongue base cancers

August 21, 2013     Daniel L. Stoler, PhD; Philip J. Smaldino, MS; Huferesh K. Darbary, PhD; Maureen A. Sullivan, DDS; Saurin R. Popat, MD, MBA; Wesley L. Hicks Jr., MD; Mihai Merzianu, MD; Daniel P. Gaile, PhD; Garth R. Anderson, PhD; and Thom R. Loree, MD, FACS
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Abstract

Human papillomavirus 16 (HPV-16) infection and tobacco use are associated with human oropharyngeal cancers. We conducted a study of the role of HPV and tobacco use in base of the tongue (BOT) cancers. DNA from 34 such cancers was subjected to HPV-16 and HPV-18-specific polymerase chain reaction analysis. Demographic and clinicopathologic data were obtained from each patient's medical record. HPV-16 was detected in 68% of tumors. Tobacco use was the only factor found to be significantly associated with HPV status. Tumors from 100% of patients who had never used tobacco tested positive for HPV, compared with only 56% of those who had ever used tobacco (Fisher exact test, p = 0.024). All tumors were associated with either tobacco use or HPV infection. These findings are consistent with the hypothesis that either tobacco use or HPV infection is necessary to the etiology of BOT tumors, and they suggest that tongue base carcinoma may be prevented by combining HPV vaccination with tobacco avoidance.

Transnasal esophagoscopy and the diagnosis of a mediastinal foregut duplication cyst

August 21, 2013     Amarbir S. Gill, BS and Jennifer L. Long, MD, PhD
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Foregut duplication cysts are true mucus-filled cysts lined with a thin epithelial layer, arising from either bronchogenic, esophageal, or neuroenteric precursor tissue.

Comparison of complication rates associated with stapling and traditional suture closure after total laryngectomy for advanced cancer

August 21, 2013     Brett A. Miles, DDS, MD; Deborah Larrison, MD; and Larry L. Myers, MD
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Abstract

We conducted a retrospective, matched-cohort, case-control study to compare complication rates associated with two wound closure procedures-stapling vs. traditional hand suturing-following total laryngectomy. Our study population was made up of 42 consecutively presenting patients-38 men and 4 women, aged 34 to 92 years (mean: 60.3) whose pharyngotomies were amenable to primary closure. Of this group, 37 patients had active endolaryngeal squamous cell carcinoma (SCC), 2 patients had inactive endolaryngeal SCC, 2 patients had thyroid cancer, and 1 patient had been treated for chronic aspiration. A total of 26 patients (61.9%) had undergone traditional suture closure of the neopharynx (suture group) and 16 patients (38.1%) had undergone closure with a linear stapling device (staple group). Other than the fact that the patients in the staple group were significantly older than those in the suture group (median: 71.0 vs. 56.5 yr, p = 0.002), there were no significant differences between the two groups in terms of comorbidities or cricopharyngeal myotomy, tracheoesophageal puncture, or neck dissection. There was a total of 8 postoperative infections-5 in the staple group (31.3%) and 3 in the suture group (11.5%)-not a statistically significant difference. Fistulas occurred in 4 staple patients (25.0%) and 6 suture patients (23.1%)-again, not statistically significant. We conclude that in appropriately selected patients, primary closure of the neopharynx can be safely and effectively achieved with a linear stapling device.

Primary laryngeal actinomycosis in an immunosuppressed woman: A case report

July 21, 2013     Tarik Abed, MBBS; Jay Ahmed, MBBS; Niamh O'Shea, MBBS; Simon Payne, FRCPath; Gavin W. Watters, FRCS
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Abstract

We report a rare case of primary laryngeal actinomycosis, which occurred in a 35-year-old woman with end-stage renal failure secondary to systemic lupus erythematosus with membranous glomerulonephritis. The patient, who had been on long-term immunosuppression therapy, presented with hoarseness. Flexible laryngoscopy detected the presence of a granular glottic mass at the anterior commissure of the larynx. Histology revealed actinomycotic organisms associated with an abscess. The patient was treated with a prolonged course of oral penicillin V and speech therapy, and her dysphonia resolved almost completely. Although actinomycotic infection of the larynx is rare, it should be considered in the differential diagnosis of hoarseness in an immunocompromised patient.

Laryngotracheal rhinosporidiosis

July 21, 2013     J. Madana, MS; Deeke Yolmo, MS; S. Gopalakrishnan, MS; Sunil K. Saxena, MS
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Abstract

Rhinosporidiosis is a chronic granulomatous disease caused by Rhinosporidium seeberi. It usually affects mucous membranes of the nose, nasopharynx, and ocular conjunctiva. Cutaneous, laryngeal, tracheal, genital, and bony dissemination is rare. Laryngotracheal involvement poses many diagnostic and therapeutic challenges. A 45-year-old South Indian man presented with complaints of a mass in both nostrils for 2 years, associated with progressive hoarseness of voice and difficulty in breathing for 6 months. Rhinosporidial lesions were seen bilaterally in the nasal cavity. Telescopic and fiberoptic laryngoscopic examinations showed reddish, strawberry-like masses with whitish spots on their surface involving the larynx and trachea. Computed tomography of the head and neck revealed soft-tissue mass lesions involving the bilateral nasal cavities and nasopharynx, extending to the oropharynx and involving the larynx and trachea. A preliminary tracheostomy was performed, followed by direct laryngoscopic excision of the laryngeal lesions and rigid-bronchoscopy-guided excision of the tracheal lesions. The patient was prescribed dapsone and advised to take it for 2 years. At 2 years of follow-up, there was no recurrence.

Unusual pseudomyiasis with Musca domestica (housefly) larvae in a tracheostomy wound: A case report and literature review

July 21, 2013     Mohammad Shakeel, MS; Iram Khan, MD; Imteyaz Ahmad, MD; Zafar Iqbal, MS; Syed Abrar Hasan, MS
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Abstract

We report a case of pseudomyiasis (accidental myiasis) in a 52-year-old man who had previously undergone surgery and placement of a tracheostomy tube for laryngeal cancer. The patient presented to our outpatient department with a foul-smelling, blood-stained discharge and frequent and severe episodic pain at the site of the tracheostomy. He also reported the discharge of many whitish larvae from the site. On clinical examination, 3 of these larvae were removed from the tracheostomy wound and later identified as Musca domestica (housefly) larvae. The patient underwent further mechanical removal twice daily for 3 days, during which time 23 more larvae, or maggots, were removed. His condition improved, and he returned for regular follow-up with no recurrence or complications. Myiasis is an infestation of humans and vertebrate animals by insect larvae that feed on both dead and living tissue. Myiasis is most common in hot and humid climates in tropical and subtropical regions, such as the underdeveloped areas of India, Africa, and Southeast Asia, which provide favorable breeding grounds for flies. Myiasis is classified as specific, semispecific, or accidental, depending on whether the fly larvae require a host in order to develop. We review the literature on myiasis and its entomologic aspects in general. We also discuss the need for the proper care of tracheostomy wound myiasis because the site of such an infestation is close to vital organs in the neck. To the best of our knowledge, only 3 cases of tracheostomy wound myiasis have been previously reported in the English-language literature; 2 of them involved infestation with Chrysomyia bezziana larvae and 1 with Lucilia caesar larvae. We believe our case is the first case of tracheostomy wound pseudomyiasis attributable to M domestica larvae.

Posterior cordectomy: How much is enough?

July 21, 2013     Reena Gupta, MD; Belinda Mantle, MD; Ryan F. Osborne, MD
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Bilateral vocal fold paralysis has traditionally been treated with tracheotomy, which bypasses the source of obstruction and exerts a lesser impact on swallow function compared with other interventions, but fewer patients are willing to tolerate this option.

Tonsillar Kaposi sarcoma in a patient with membranous glomerulonephritis on immunosuppressive therapy

July 21, 2013     Nabeel Al-Brahim, FRCPC; Ashraf H. Zaki, MD; Khaled El-Merhi, MD; Mahmoud S. Ahmad, MD
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Abstract

Kaposi sarcoma is a malignant vascular neoplasm uncommonly seen in immunosuppressed patients. Herein we report an unusual case of tonsillar Kaposi sarcoma in a patient with membranous glomerulonephritis treated with prednisolone and cyclosporine. The patient presented after 10 months of starting the treatment with a tonsillar mass. Histological examination was typical of monomorphic spindle cell proliferation with slit-like vascular channels. The tumor cells expressed CD34, D2-40 and positive nuclear stain for HHV-8. Kaposi sarcoma is associated with immunosuppression and rarely occurs in the tonsil. Clinicians should be aware of this rare presentation of Kaposi sarcoma.

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