Minimally invasive resection of olfactory neuroblastoma by transnasal endoscopy

August 26, 2015     Chin-Fang Chang, MD; Sheng-Chang Chiu, MD; Shiou-Yu Yeh, MD, MPH; Mu-Kuan Chen, MD, PhD; Yung-Sung Wen, MD, MS
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Abstract

Olfactory neuroblastoma is rare. We conducted a retrospective study to review our experience with minimally invasive resection of olfactory neuroblastomas via a transnasal endoscopic technique, including an analysis of surgical outcomes. Our series included 5 patients-3 men and 2 women, aged 29 to 75 years (mean: 48). Surgical outcomes were evaluated on the basis of each patient's preoperative Dulguerov classification and postoperative evaluation on computed tomography and magnetic resonance imaging. One patient was treated with surgery alone, 3 with surgery plus radiotherapy, and 1 with surgery, radiotherapy, and chemotherapy. During follow-up of 18 to 115 months, all 5 patients remained alive and disease-free. We found that endoscopic resection of olfactory neuroblastoma is a feasible and effective procedure, even in patients with more aggressive stages of disease. We also believe that the Dulguerov classification is more useful than other classifications for clinical management and surgical planning. Long-term follow-up is necessary to look for late recurrence.

Introduction Olfactory neuroblastoma is a rare malignant neuroectodermal tumor that occurs in the nasal cavity; some of these tumors extend to the paranasal sinuses, anterior skull base, and orbit. The first reported case was described by Berger and Luc in 1924.1

Otic capsule dehiscence syndrome: Superior semicircular canal dehiscence syndrome with no radiographically visible dehiscence

August 26, 2015     P. Ashley Wackym, MD, FACS; Scott J. Wood, PhD; David A. Siker, MD; Dale M. Carter, MD
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Abstract

We conducted a prospective longitudinal study of two cohorts of patients who had superior semicircular canal dehiscence syndrome (SSCDS); one group had radiographically confirmed superior canal dehiscence (SCD), and the other exhibited no identified otic capsule dehiscence on imaging (no-iOCD). We compiled data obtained from prospective structured symptomatology interviews; diagnostic studies; three-dimensional, high-resolution, temporal bone computed tomography; and a retrospective case review from our tertiary care referral center. Eleven adults and 1 child with SSCDS were identified, surgically managed, and followed. Six of these patients-1 man and 5 women, aged 29 to 54 years at first surgery (mean: 41.8)-had radiologically confirmed SCD. The other 6 patients-1 man, 4 women, and 1 girl, aged 1 to 51 years (mean: 32.2)-had no-iOCD. The 6 adults with SCD underwent surgery via a middle cranial fossa approach with plugging procedures. The 5 adults and 1 child with no-iOCD underwent round window reinforcement (RWR) surgery. One SCD patient developed no-iOCD 1.5 years after SCD surgery, and she subsequently underwent RWR surgery. Our main outcome measures were patient symptomatology (with video documentation) and the results of diagnostic studies. Other than the character of migraine headaches, there was no difference in preoperative symptomatology between the two groups. Postoperatively, resolution of SSCDS symptoms ultimately occurred in all patients. Both the SCD and the no-iOCD groups experienced a highly significant improvement in postural control following treatment (Wilcoxon signed rank test, p < 0.001). We conclude that the term otic capsule dehiscence syndrome more accurately reflects the clinical syndrome of SSCDS since it includes both superior semicircular canal dehiscence and no-iOCD, as well as posterior and lateral semicircular canal dehiscence, all of which can manifest as SSCDS. We have also included links to videos in which 4 of the SSCDS patients with no-iOCD in this study discussed their symptoms and the results of their surgery; these links are found in the “References” section in citations 12-15. Links to three other videos of interest are contained in citations 10, 11, and 24.

Unusual sites of metastasis of papillary thyroid cancer: Case series and review of the literature

August 26, 2015     Rafael Antonio Portela, MD; Garret W. Choby, MD; Andrea Manni, MD; David Campbell, MD; Henry Crist, MD; David Goldenberg, MD
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Abstract

Papillary thyroid cancer (PTC) is the most common malignancy of the thyroid gland. It typically spreads via lymphatic extension. The rate of regional PTC metastasis to the neck is relatively high, while metastases outside the deep cervical chain are rare. Distant metastases are found in only 1% of patients with PTC at the time of surgery; the two most common sites are the lung and bone. We report 4 cases of PTC metastasis to unusual sites: (1) the occipital skull and internal jugular vein, (2) the parapharyngeal space, (3) the sternocleidomastoid muscle, and (4) the right atrium of the heart. It has been well documented that aggressive distant metastasis is a characteristic of PTC, and it is known to be an indicator of a poor prognosis. Some of our patients' sites of metastatic disease have not been previously reported. Patients in this series exhibited aggressive histologic findings, including columnar cell and follicular variants of papillary disease. In addition, all 4 patients demonstrated “PET-avid” disease with decreased iodine avidity.

Surgical resection of cervical schwannoma and paraganglioma: Speech and swallowing outcomes

August 26, 2015     Noah P. Parker, MD; Noel Jabbour, MD; Amy Anne Lassig, MD; Bevan Yueh, MD, MPH; Samir S. Khariwala, MD
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Abstract

We conducted a retrospective study (1999 to 2009) at our tertiary care institution to evaluate speech and swallowing outcomes after the resection of cervical schwannoma or paraganglioma. Of 6 patients treated for schwannoma, 5 (83.3%) had immediate dysphonia and dysphagia. All patients with deficits received primary reinnervation (n = 2) or subsequent medialization laryngoplasty (n = 3). At 6 months, 4 patients (66.6%) still had dysphonia and dysphagia. At final follow-up (median: 10 months; range: 8 to 12 months), 4 patients (66.7%) had dysphonia and 2 (33.3%) had dysphagia. Of 10 patients treated for paraganglioma, 6 (60.0%) had immediate dysphonia and dysphagia. Four patients received subsequent medialization laryngoplasty; none had primary reinnervation. At 6 months, 3 (30%) still had dysphonia and dysphagia. At final follow-up (median: 15.5 months; range: 1.25 to 48 months), 2 (20.0%) had dysphonia and dysphagia. All patients with deficits received speech and swallowing therapy. We conclude that cervical schwannoma and paraganglioma resection was associated with high rates of immediate postoperative dysphonia and dysphagia. Schwannoma had higher initial rates and poorer recovery. Primary and/or subsequent laryngeal procedures combined with therapy led to symptom resolution in some patients.

Introduction Extracranial neurogenic tumors of the head and neck are rare and are frequently intimately involved with critical neurovascular structures, especially when located within the parapharyngeal space. Cervical schwannoma and paraganglioma are two such tumors. Their often intimate involvement with nerves that are either exiting the...

Analysis of predisposing factors for complications of percutaneous tracheostomy

August 26, 2015     Ivan Dom&egrave;nech, MD, PhD; Paula Cruz Toro, MD; Jordi Tornero, MD; Ana Giordano, MD; &Agrave;ngela Callejo, MD
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Abstract

Since the turn of the century, percutaneous tracheostomy (PT) has become an alternative to the classic open technique and is an elective procedure in intensive care units at most centers. We conducted a prospective study to identify and quantify the complication rate with PT and to analyze this procedure's association with potential risk factors. Our study population was made up of 114 patients-83 men (72.8%) and 31 women (27.2%), aged 18 to 81 years (mean: 57 ± 15)-who underwent PT at our center over an 18-month period. We sought to determine if there were any associations between PT complications and sex, previous fibroscopy, cervical length, cervical risk factors, and general risk factors. Generally minor complications were noted in 15 patients (13.2%); 13 patients experienced hemorrhage, 1 exhibited subcutaneous emphysema, and 1 had a vagal reaction that resolved with medical treatment. Only 3 of these cases (2.6%) were considered to be clinically relevant: 1 hemorrhage (which was treated with ligation), the emphysema (which resolved spontaneously), and the vagal reaction (which resolved with medical treatment). Statistically, we found that PT complications were significantly correlated with two factors: coagulopathy (p = 0.015) and hemodynamic instability (p = 0.017). Even so, these complications were not clinically significant, and they resolved with conservative treatment measures. Given the low incidence and mild degree of these complications, we consider PT to be a safe procedure, even in patients with a high risk of hemorrhage or cervical anatomic difficulties.

Temporomandibular joint herniation into external auditory canal

August 26, 2015     Jui-Hsien Hsu, MD; Cheng-Chien Yang, MD; Min-Tsan Shu, MD
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Herniation of the TMJ into the EAC is a rare condition that mostly occurs in patients with bony wall defects in the anterior EAC.

A 28-year-old woman was referred to our clinic with the chief complaints of right-sided otorrhea and otalgia for 3 months. She also mentioned an abnormal click sound in her right ear when opening her mouth during this period.

The incidence of postoperative aspiration among children undergoing supraglottoplasty for laryngomalacia

August 26, 2015     Lauren C. Anderson de Moreno, MD; Sarah J. Burgin, MD; Bruce H. Matt, MD, MS
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Abstract

We conducted a retrospective study to determine the incidence of aspiration after supraglottoplasty at Riley Hospital for Children in Indianapolis. We reviewed the charts of 468 patients-281 males and 187 females, aged 2 days to 20 years-who had undergone supraglottoplasty for the treatment of laryngomalacia; most patients (69.9%) were aged 28 days to 2 years. A total of 47 patients (10.0%) experienced aspiration after supraglottoplasty; the overall association between supraglottoplasty and aspiration was not statistically significant (p = 0.25). Aspiration was positively correlated with age younger than 18 months, the performance of a revision procedure, the presence of an underlying neuromuscular disorder (n = 20), and the need for a postoperative gastrostomy tube (p < 0.001 for all). When the 20 patients with a neuromuscular disorder were excluded from our data analysis, the incidence of aspiration after supraglottoplasty fell to only 5.8% (27/468). We conclude that supraglottoplasty is a safe and effective procedure for the treatment of laryngomalacia. It does not significantly increase the overall incidence of aspiration in children, and thus the risk of aspiration should not be considered a deterrent to surgery, even in children with neuromuscular problems.

Post-thyroidectomy hypocalcemia: Impact on length of stay

July 20, 2015     Joe Grainger, FRCS; Mohammed Ahmed, MRCP; Rousseau Gama, FRCPath; Leonard Liew, FRCS; Harit Buch, FRCP; Ronald J. Cullen, FRCS
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Abstract

Hypocalcemia is a recognized complication following thyroid surgery. Variability in the definition of hypocalcemia and different opinions on its management can lead to unnecessary patient morbidity and longer hospital stays as a result of inappropriate or untimely treatment. Therefore, we developed a management guideline for the recognition and treatment of post-thyroidectomy hypocalcemia, and we conducted a retrospective study to assess its impact on length of stay (LOS). Between April 1, 2007, and March 31, 2009, 29 adults had undergone a total or completion thyroidectomy at our large district general hospital. Of this group, postoperative hypocalcemia (defined as a serum calcium level of <2.00 mmol/L) developed in 13 patients (44.8%) during the first 3 postoperative days. Our guideline went into effect on July 1, 2009, and from that date through June 30, 2010, 18 more adults had undergone a total or completion thyroidectomy. Of that group, hypocalcemia developed in 7 patients (38.9%); the guideline was actually followed in 5 of these 7 cases (71.4%). In the preguideline group, the development of hypocalcemia increased the mean LOS from 2.0 days to 7.0 days (p < 0.001). The management of postoperative hypocalcemia in these cases was highly variable and was dictated by variations in practice rather than patient needs. In the postguideline group, postoperative hypocalcemia increased the mean LOS from 2.7 days to only 3.7 days (p = 0.07). While the difference between LOS in the two hypocalcemic groups did not reach statistical significance, we believe it merely reflects the relatively small number of patients rather than any lack of guideline efficacy. The implementation of a simple flowchart guideline for the management of postoperative hypocalcemia in our hospital has resulted in more uniform management and a reduced LOS.

Nasal myiasis: A case report

July 20, 2015     Zrria L. White, MD; Michael W. Chu, MD; Richard J. Hood, MD
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Abstract

Nasal myiasis is a rare condition, with only a few reported cases and no treatment consensus. We propose a conservative treatment approach with saline irrigation and debridement. Two patients in the ICU of Norfolk General Hospital, a tertiary academic referral center, presented simultaneously with nasal myiasis. Both patients were negative for necrotic masses or tumors, and neither patient had any contributory medical comorbidities. Both patients were treated conservatively with a single dose of pyrantel pamoate, daily sinus irrigation with saline, and daily bedside endoscopic debridement. After 2 days, the nasal myiasis resolved, and both patients recovered without sequelae. We conclude that this conservative, nonsurgical approach to management is both safe and effective.

Introduction Human myiasis is often seen in the tropics and subtropics but is extremely rare in the Northern Hemisphere.1 Myiasis is a parasitic infestation of live human or vertebrate animal tissues by dipterous larvae of nonbiting flies, which feed on host tissues or fluids.1

Upper aerodigestive amyloidosis

July 20, 2015     Jaime Eaglin Moore, MD; Amanda Hu, MD; Al Hillel, MD
article

As the patient was asymptomatic, close observation and only laser excision were recommended if the patient's condition progressed.

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