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Relationships among concha bullosa, nasal septal deviation, and sinusitis: Retrospective analysis of 296 cases

December 7, 2016  |  Hasan H. Balikci, MD; M. Mustafa Gurdal, MD; Saban Celebi, MD; Isa Ozbay, MD; Mustafa Karakas, MD


We aimed to investigate the relationships among concha bullosa (CB), nasal septal deviation (NSD), and sinus disease. We retrospectively reviewed paranasal sinus computed tomography scans obtained from 296 patients-132 men and 164 women, aged 17 to 76 years (median: 39)-who had been evaluated over a 19-month period. CBs were classified as lamellar, bulbous, and extensive. In cases of bilateral CB, the larger side was designated as dominant. In all, 132 patients (44.6%) exhibited pneumatization of at least one concha, 176 (59.5%) had NSD, and 187 (63.2%) had sinus disease. Some 89 of 106 patients with unilateral or one-side-dominant CB (84.0%) had NSD, 89 of 132 patients with CB (67.4%) had sinus disease, and 109 of the 176 patients with NSD (61.9%) had sinus disease. We found a statistically significant relationship between CB and contralateral NSD, but no significant relationship between CB and sinus disease or NSD and sinus disease. While CB is a common anatomic problem that may accompany NSD, a causal relationship between CB or NSD and sinus disease is dubious.

Nasopharyngeal airway to prevent tension pneumocephalus after open resection of anterior skull base tumors

December 7, 2016  |  Matthew E. Spector, MD; Jon-Paul Pepper, MD; Stephen Sullivan, MD; Lawrence Marentette, MD; Erin McKean, MD


We conducted a retrospective study to assess the efficacy of using a nasopharyngeal airway in lieu of a tracheotomy or prolonged intubation for the diversion of airflow to prevent tension pneumocephalus after an open resection of anterior skull base tumors. Our study population was made up of 120 patients-74 males and 46 females, aged 12 to 84 years (mean: 48.7)-who had undergone an anterior skull base resection with documented nasopharyngeal airway placement from 1996 through 2009. Our main outcome measure was the presence of tension pneumocephalus while controlling for the placement of a lumbar drain, the development of a cerebrospinal fluid (CSF) leak, and the type of reconstruction. All patients had been extubated on the day of surgery, and their nasopharyngeal airway had remained in place for 3 days. No documented complications of nasopharyngeal airway placement (e.g., nasal septum pressure necrosis or the displacement of tubes) had been documented. Tension pneumocephalus occurred in 3 patients (2.5%). A total of 33 patients (27.5%) received a lumbar drain, 14 (11.7%) experienced a CSF leak, and 5 (4.2%) had both. There was a statistically significant difference in the rate of tension pneumocephalus between patients who did and did not receive a lumbar drain placement (p = 0.02), between those who did and did not experience a CSF leak (p = 0.04), and between those who did and did not meet both criteria (p = 0.004). We conclude that resection of anterior skull base tumors does not necessitate a prophylactic tracheotomy or prolonged intubation and that the use of a nasopharyngeal airway to divert airflow is well tolerated and highly successful. Lumbar drainage, the development of a CSF leak, or both may increase the risk of tension pneumocephalus.

Fungus ball in an agger nasi cell

December 7, 2016  |  Jae-Hoon Lee, MD; Ha-Min Jeong, MD

Fungus balls, such as the one that presented in this case, are the most common form of fungal sinusitis.

Secretory carcinoma

December 7, 2016  |  Lester D. Thompson, MD

This tumor presents as a solitary, circumscribed but not encapsulated mass, although it may have invasive borders.

The "lake road sign": Another way to track the sulcus vocalis

December 7, 2016  |  Gauthier Desuter, MD, MSc; Delphine de Cock de Rameyen, MD; Donatienne Boucquey, MSc

Hypothetically, the lake road sign also could be applicable to mucosal bridges.

Risk of thyroid malignancy following an index head and neck squamous cell carcinoma: A population-based study

December 7, 2016  |  Jason Y. Chan, MBBS; Zhen Gooi, MBBS; Wojciech K. Mydlarz, MD; Nishant Agrawal, MD


To evaluate the incidence of a subsequent primary thyroid malignancy in patients with an index head and neck squamous cell carcinoma (HNSCC), we analyzed the National Cancer Institute's Surveillance, Epidemiology, and End Results database to identify a cohort of patients who had been diagnosed with a primary HNSCC from 1973 through 2004. The study population was made up of 60,323 patients of all ages, roughly three-quarters of whom were male. A total of 60 patients (0.1%) developed a subsequent thyroid malignancy-not a statistically significant finding. The overall standard incidence ratio (SIR) for a subsequent thyroid malignancy was 1.58 (p < 0.05). The highest SIRs were seen during in the first 5 years after diagnosis of the original primary (SIR: 3.05; p < 0.05), more specifically in 2 to 11 months after diagnosis (SIR: 7.11; p < 0.05). Further analyses demonstrated that SIRs were significantly higher in males (SIR: 1.71), in patients aged 60 through 79 years (SIR: 1.71), in whites (SIR: 1.55), in patients who had undergone external-beam radiotherapy for their index primary (SIR: 1.84), in those whose tumor was initially staged as regional (SIR: 1.96), and in patients whose index primary was in the oral cavity (SIR: 1.71) or larynx (SIR: 1.88) (p < 0.05 for all). We conclude that the incidence of a subsequent primary thyroid malignancy in patients with an HNSCC is highest during the first 5 years after diagnosis of the index primary, reflecting the benefit of continued surveillance.

Facial reanimation according to the postresection defect during lateral skull base surgery

December 7, 2016  |  John P. Leonetti, MD; Sahar Nadimi, MD; Sam J. Marzo, MD; Douglas Anderson, MD; Darl Vandevender, MD


The vast majority of benign tumors of the cerebellopontine angle, temporal bone, and parotid gland can be successfully resected without permanent injury to the facial nerve. Malignant tumors or recurrent disease may require facial nerve sacrifice, especially if preoperative facial paresis is present. This article will present case examples of the various methods to reconstruct facial animation after lateral skull base resections that require sacrifice of cranial nerve VII, and the associated mimetic facial musculature. Facial mimetic outcome after reanimation was graded using the House-Brackmann scale. Primary neurorrhaphy or interposition grafting may be performed when both the proximal and distal portions of the facial nerve are available and viable facial musculature is present. If only the distal facial nerve and viable facial musculature are available, a split hypoglossal to facial nerve anastomosis is used. A proximal facial nerve to microvascular free flap is performed when the proximal facial nerve is available without distal nerve or viable musculature. A cross-facial to microvascular free flap is performed when the proximal and distal facial nerve and facial musculature are unavailable. The above methods resulted in a House-Brackmann score of III/VI in all case examples postoperatively. The method of facial reanimation used depends on the availability of viable proximal facial nerve, the location of healthy, tumor-free distal facial nerve, and the presence of functioning facial mimetic musculature.

Rare primary mucosal melanoma of the larynx

December 7, 2016  |  Adam Blanchard, MD; Jeremy B. Nguyen, MD; Philip Daroca, MD; Paul Friedlander, MD; Eleanor Lewin, MD; James Vu, MD, MBA; Enrique Palacios, MD, FACR


Few cases of primary mucosal melanoma of the larynx have been documented in the literature, so only a limited amount of data exists regarding its diagnosis and treatment. The prognosis is poor, as patients often present at a late stage with regional or distant metastases. We describe the case of a 66-year-old man who presented with hoarseness and dysphagia. Laryngoscopy identified a dark discoloration of the supraglottic larynx and incomplete mobility of the right vocal fold; an excisional biopsy confirmed the diagnosis. We discuss the epidemiology, clinical features, diagnosis, interpretation of imaging findings, and management of this rare malignant melanoma.

Primary solitary intralabyrinthine schwannoma: A report of 7 cases and a review of the literature

December 7, 2016  |  Avi Shupak, MD; Yehuda Holdstein, MD; Margalit Kaminer, MSc; Itzhak Braverman, MD


Intralabyrinthine schwannomas (ILSs) are uncommon benign tumors that originate in the Schwann cell sheath of the intralabyrinthine distal branches of the vestibulocochlear nerve. They have no initial involvement in the internal auditory canal, although that might develop later. These lesions can arise inside the cochlea, originate in the vestibule or, in rare cases, develop in the semicircular canals. From these sites, spread might take place via the anatomic connections between the perilymphatic spaces in the scala vestibuli and the anterior vestibule. Thus, ILSs centered in the cochlea might involve the vestibule, and those originating in the vestibular end organs would reach the cochlea. Presenting signs and symptoms include a progressive or sudden sensorineural hearing loss (which occurs in more than 95% of patients), as well as tinnitus and vertigo. Magnetic resonance imaging characteristics include sharp circumscription and hypointensity on thin, heavily T2-weighted 3D images and strong enhancement after gadolinium administration on T1-weighted images. We describe a series of 7 cases of primary ILS that were managed at two of our institutions. We also discuss the need for a comprehensive otoneurologic evaluation that encompasses the functional derangement and the tumor location as delineated by MRI, and we describe the treatment options.

Undifferentiated pleomorphic sarcoma of the vocal fold

December 7, 2016  |  Chang-Yeong Jeong, MD; Choung-Soo Kim, MD


Undifferentiated pleomorphic sarcoma, previously called malignant fibrous histiocytoma, usually arises in the extremities and retroperitoneum. Primary laryngeal undifferentiated pleomorphic sarcoma is very rare, with only 63 cases having been reported in the literature as of 2015. The disease has a poor prognosis because of problems with local recurrence and metastasis. Wide resection has been recommended as a treatment modality in previous reports. We report a case of undifferentiated pleomorphic sarcoma of the vocal fold in a 64-year-old man presenting with rapid growth. The lesion was treated with type III microlaryngeal surgery followed by radiation therapy. The patient's voice was good enough for social communication, and there was no evidence of recurrence on regular examination.