Other ENT Topics

Dizziness in the elderly: Diagnosing its causes in a multidisciplinary dizziness unit

May 7, 2014     Roeland B. van Leeuwen, MD, PhD; Tjasse D. Bruintjes, MD, PhD
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Abstract

We conducted a study to determine the causes of dizziness in patients aged 70 years and older who had been referred to our multidisciplinary dizziness clinic between Nov. 1, 2000, and Dec. 31, 2008. This population was made up of 731 patients-254 men (34.7%) and 477 women (65.3%). During their consultations, all of these patients were evaluated simultaneously by an ENT surgeon and a neurologist. We were able to identify the cause of dizziness in 620 of these patients (84.8%). The two most common causes were benign paroxysmal positional vertigo (BPPV), which was found in 202 patients (27.6%), and hyperventilation/anxiety, which was diagnosed in 112 patients (15.3%). Based on our findings, we conclude that the cause of dizziness can be established in the vast majority of elderly patients. We also compare our findings in these older patients with those of a group of 2,556 younger patients who were seen at our hospital and with the findings reported in other studies.

Saddle-nose deformities in the rheumatology clinic

May 7, 2014     Benjamin E. Schreiber, MA, MD, MRCP; Sarah Twigg, MRCP; Joe Marais, FRCS(ORL); Andrew C.S. Keat, MD, FRCP
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Abstract

Saddle-nose deformity can occur as a result of trauma to the nose, but it has also been well described in the setting of infections such as leprosy and syphilis and idiopathic inflammatory conditions such as granulomatosis with polyangiitis (formerly known as Wegener granulomatosis) and relapsing polychondritis. Since these deformities may also arise without an evident precipitating cause, they can pose a diagnostic conundrum. We review 2 cases of saddle-nose deformity that were treated at Northwick Park Hospital in Middlesex, England. The first patient was a 53-year-old woman who presented with epistaxis and deviation of the nasal septum. She subsequently developed a saddle-nose deformity and a septal ulcer. An autoimmune screen was negative, and histologic findings were nonspecific. She underwent successful reconstruction with a polyethylene implant. The second patient was a 21-year-old woman who presented with nasal obstruction and a nasal septal deviation. Two years later, she was diagnosed with Crohn disease and treatment with azathioprine was commenced. Eventually, the cartilaginous dorsum of her nose collapsed. A biopsy of the area revealed nonspecific, active, chronic inflammation. A polyethylene implant was placed to correct the deformity, but part of the implant became dislodged, and revision surgery was not successful. A subsequent revision was performed, and the early results were encouraging. Saddle-nose deformity may be a manifestation of underlying connective tissue disease, so it is important to detect and treat any such condition before embarking on surgical repair of the deformity. Our 2 cases indicate that this very deforming condition is poorly understood and treatment can be unsatisfactory.

Evaluating the role of single-photon emission computed tomography in the assessment of neurotologic complaints

May 7, 2014     Shruti S. Joglekar, MD; Jason R. Bell, MD; Malka Caroline, MD; Paul J. Chase, DO, FAOCR; James Domesek, MD; Pinal S. Patel, ARRT, CNMT; Robert T. Sataloff, MD, DMA, FACS
article

Abstract

We conducted a retrospective study to reexamine the value of single-photon emission computed tomography (SPECT) in the evaluation of patients with neurotologic complaints, and to assess the intra- and inter-radiologist variability of SPECT readings. Our study population was made up of 63 patients-23 men and 40 women, aged 34 to 91 years (mean: 59)-who had presented to a tertiary care otolaryngology practice and university hospital for evaluation of head trauma, sensorineural hearing loss, tinnitus, and/or vertigo. All patients had undergone brain scanning with SPECT during their evaluation, and almost all had also undergone magnetic resonance imaging (MRI) and standard computed tomography (CT). We compared the findings of all three imaging modalities in terms of their ability to detect neurotologic abnormalities. We found that detection rates were very similar among the three modalities; abnormalities were found in 24% of SPECT scans, 26% of MRIs, and 23% of CTs. Nevertheless, we did find that among 60 patients who underwent all three types of imaging, 13 (22%) exhibited areas of cerebral hypoperfusion on SPECT while their MRIs and CTs were read as either normal or nonspecific. In all, 18 of these 60 patients (30%) exhibited normal or nonspecific findings on all three types of imaging. In addition, when SPECT scans were read by the same radiologist at different times, different results were reported for 17 of the 63 scans (27%). Likewise, when SPECT scans were read by different radiologists, different results were reported for 21 of 63 scans (33%). We conclude that SPECT may be a valuable complementary diagnostic modality for making a comprehensive neurotologic evaluation and that it may detect abnormalities in some patients whose other imaging is read as normal. However, we did not find that SPECT was the most sensitive of the three modalities in neurotologic evaluation, as we had previously found in a preliminary study that the senior author (R.T.S.) published in 1996. In addition, with respect to our radiologists, both their intra- and inter-reader reliability was low, and we recommend additional study on this matter.

A "nail-biting" case of an airway foreign body

May 7, 2014     Parker A. Velargo, MD; Jennifer D. McLevy, MD
article

While cases of large, completely obstructing foreign bodies in the subglottis would lead to sudden respiratory distress, the initial presentation of smaller foreign bodies in the subglottis can be quite similar to croup, presenting with biphasic stridor, cough, and/or the steeple sign.

The cosmetic Z-plasty: Restoring and refining an old technique for neck rejuvenation

May 7, 2014     Nicholas Vendemia, MD; David E. Rosow, MD; Anthony N. LaBruna, MD
article

Abstract

Direct excision of the “turkey neck” skin fold with Z-plasty closure was introduced in the 1970s, but it has fallen out of favor in an era in which much emphasis is placed on minimizing visible scars. Although the newer techniques may effectively improve the aesthetic contour of the neck without leaving visible scars, they may not be optimal for selected patients who want a quick, “no-hassle” correction of their neck contour without changing the overall appearance of their face. We conducted a retrospective study of 50 patients-47 men and 3 women, aged 59 to 80 years (mean: 70)-who had undergone cosmetic Z-plasty performed by the senior author (A.N.L.) over a 9-year period. These patients either did not want or were not candidates for a face-lift or other procedure. Patients' charts were examined for demographic data, complications, and overall satisfaction with the procedure. In 46 of the 50 cases, the initial cosmetic result was acceptable to both the patient and the surgeon. The only complications were recurrent or residual areas of skin redundancy or dissatisfaction with the scar, but these were easily corrected with a second procedure using local anesthesia in the office setting. We conclude that cosmetic Z-plasty is a safe and effective means of correcting turkey neck deformity in patients who desire a procedure with a short operating time, a brief recovery period, a low complication rate, and a minimal effect on the overall appearance of their face. Although cosmetic Z-plasty is frequently considered to be antiquated, we believe refined versions of this procedure can still be of value to the plastic surgeon. In addition to describing our study results, we also describe in detail our surgical technique, including several contemporary refinements.

Y-V alar base reduction

March 18, 2014     Grant S. Hamilton III
article

For alar modification, removing tissue from inside the nostril to decrease width or from the lateral aspect of the ala to decrease flare works well in many patients, but these techniques may produce an unnatural result.

Pediatric cervical sympathetic chain schwannoma with Horner syndrome: A rare case presentation

March 18, 2014     Sanjeev Bhagat, MS; Saurabh Varshney, MS; Sampan S. Bist, MS; and Nitin Gupta, MS
article

Abstract

Schwannomas are rare, benign, slowly growing neurogenic tumors that originate in peripheral, spinal, or cranial nerves other than the optic and olfactory nerves. In the head and neck, these tumors usually arise from the vagus nerve and the cervical sympathetic chain in the parapharyngeal space. Cervical sympathetic chain schwannomas represent a rare subgroup of schwannomas; fewer than 60 cases have been reported in the literature. These tumors are rarely seen in children and adolescents. Because patients typically present with an asymptomatic neck mass and vague complaints, clinical suspicion is important in making the diagnosis. Neural deficits at presentation are uncommon. The presence of features of Horner syndrome before excision is very rare, having been previously reported in only 10 cases of cervical sympathetic chain schwannoma. We report an extremely rare case of a cervical sympathetic chain schwannoma in a child who presented with Horner syndrome. The lesion was successfully excised.

Pseudo third cranial nerve palsy secondary to orbital ectopic lacrimal gland cyst: Management with functional endoscopic sinus surgery

February 12, 2014     Puneet S. Braich, BSc; Jonathan E. Silbert, MD; Andrew J. Levada, MD; and Neil R. Schiff, MD
article

Abstract

An otherwise healthy 13-month-old girl was noted by her pediatrician to have developed a left head turn. The patient was referred to a pediatric ophthalmologist, who noticed signs of incomplete third cranial nerve palsy. Magnetic resonance imaging revealed the presence of an abnormal lesion in the inferonasal orbit that was abutting the ethmoid sinus. After consultation with an ENT specialist, the decision was made to remove the lesion via functional endoscopic sinus surgery because this approach was deemed to provide adequate access while limiting morbidity. Histology of the excised lesion identified it as true ectopic lacrimal gland tissue with cysts. We recognize and comment on the fact that in many reported cases of ectopic lacrimal gland cyst, the tissue was not ectopic at all but instead represented an extension of normal lacrimal gland tissue.

Cervical accessory tragus: An unusual pediatric neck mass

January 21, 2014     Thomas R. Lowry, MD
article

An accessory tragus occurs as the result of a developmental anomaly of the first branchial arch, and it may be associated with other branchial cleft abnormalities.

Recurrent chondro-osseous respiratory epithelial adenomatoid hamartoma of the nasal cavity in a child

January 21, 2014     Kazuhiro Nomura, MD, PhD; Takeshi Oshima, MD, PhD; Atsuko Maki, MD, PhD; Takahiro Suzuki, MD, PhD; Kenjiro Higashi, MD; Mika Watanabe, MD, PhD; Toshimitsu Kobayashi, MD, PhD
article

Abstract

Chondro-osseous respiratory epithelial adenomatoid hamartoma (COREAH) is an extremely rare type of hamartoma. To the best of our knowledge, only 1 case has been previously reported. A 7-year-old girl presented with a case of COREAH of the bilateral nasal cavities. Polypous masses in both nasal cavities were resected endoscopically, and they were histologically diagnosed as COREAH. A large polypous mass recurred 1 year postsurgically on the right side only. A second endoscopic surgery was performed, and the lesion was confirmed to be recurrent COREAH. Hamartoma of the nasal cavity is rare and is generally considered to be self-limiting. This case suggests that nasal hamartomas may have neoplastic characteristics, and therefore require complete resection.

A rare cause of submandibular swelling in a 12-year-old child: Pleomorphic adenoma

January 21, 2014     Puneet S. Braich, MD, MPH; Shohan Shetty, MD; Archana Lingampally, MBBS; Michael S. Ajemian, MD, FACS; Mahesh H. Bhaya, MBBS, FACS
article

Abstract

Pleomorphic adenoma is rare in pediatric populations, where viral and congenital problems are the usual culprits responsible for submandibular masses. We report the case of a 12-year-old child who presented with a painless right submandibular mass that had developed over the course of 4 months. The patient denied fever, erythema, and edema. The mass was diagnosed as a branchial cleft cyst before complete excision was performed. The pattern and etiology of a pleomorphic adenoma in children differs from those in adults. In children, it requires prompt and correct diagnosis to keep morbidity and mortality at a minimum.

Bilateral dacryocystoceles as a rare cause of neonatal respiratory distress: Report of 2 cases

January 21, 2014     Mélanie Lecavalier, MD; Lily H.P. Nguyen, MD, MSc, FRCSC
article

Abstract

Although obstruction of the nasolacrimal duct is a fairly common finding in newborns, development of a dacryocystocele (nasolacrimal duct cyst) is uncommon. Bilateral dacryocystoceles that expand intranasally and cause respiratory distress in the newborn are rarer still. We present 2 cases of bilateral dacryocystoceles that caused neonatal respiratory compromise. Our first patient, a newborn girl, was managed successfully with probing of the nasolacrimal ducts and endoscopic marsupialization of the cysts. Our second patient, a newborn boy, responded well to conservative treatment with a nasal decongestant, lacrimal sac massage, and warm compresses. While bilateral dacryocystoceles are rare, they should be considered in cases of neonatal respiratory distress and concomitant nasal obstruction.

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