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Medial orbital wall reconstruction with a porous polyethylene titan barrier implant

March 16, 2016  |  Alexander Ovchinsky, MD; Jeffrey P. Cranford, MD

When selecting an alloplastic implant for orbital reconstruction, it is important to consider the material properties of the implant.

Is the emergency department management of ENT foreign bodies successful? A tertiary care hospital experience in Australia

March 16, 2016  |  Ritesh Gupta, MBBS, MS(ENT); Rugare Percy Nyakunu, MBBS, BMedSci; Jorian Russell Kippax, MBChB, FACEM


We evaluated the role of the emergency department (ED) in the management of ear, nose, and throat foreign bodies in an Australian tertiary care hospital. We retrospectively reviewed all cases of ENT foreign-body presentations in the ED over a 2-year period. We identified 168 such cases, a large proportion of which involved pediatric patients. In addition to demographic factors, we also collected data on the nature of the foreign bodies, the specific sites involved, the rate of successful treatment by the ED staff, the seniority/rank of the treating clinician, and complications. Foreign bodies in the ear accounted for 49% of all cases, the nose for 43%, and the throat for 8%. The ED staff attempted to remove the foreign body in 89% of cases, while the rest were referred to the ENT team. The rate of successful removal of all foreign bodies attempted by the ED team was fairly high-78%; success rates were 86% for nasal foreign bodies, 72% for aural objects, and 67% for those lodged in the throat. No major complications occurred; minor bleeding episodes after removal occurred in 8% of cases. Most ENT foreign-body presentations were managed safely and entirely by the ED team; most of the ENT referrals were to outpatient clinics.

Stapediovestibular ankylosis in an HIV/HCV-copositive patient

March 16, 2016  |  Stephan Radoslavov Lolov, MD, PhD, DSc


To the best of the author's knowledge, no case of a patient with stapediovestibular ankylosis who was also coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) has been previously described in the literature. This report describes the case of a 36-year-old woman who was diagnosed with all three conditions. The clinical diagnosis of stapes fixation was based on otoscopic, audiometric, tympanometric, and surgical findings. Stapedectomy was performed, and perilymph and serum samples were obtained and tested for anti-HIV and anti-HCV antibodies. While the titers of anti-HCV antibodies in the serum and perilymph were of similar magnitude, there were almost 16 times more anti-HIV antibodies in the serum than in the perilymph. This case offered a unique opportunity to study the titers of anti-HIV/HCV antibodies in both the blood serum and perilymph. Data relating to these titers may provide new insights into the mechanisms of stapediovestibular ankylosis and inner ear immunology.

Helicobacter pylori in lacrimal secretions

March 16, 2016  |  Aysegul Batioglu-Karaaltin, MD; Ozlem Saatci, MD; Meltem Akpinar, MD; Melih Ozgur Celik, PhD; Omer Develioglu, MD; Ozgur Yigit, MD; Mehmet Kulekci, MD; Alper Tunga Akarsubasi, PhD


The aim of this study was to investigate the presence of Helicobacter pylori in human lacrimal and nasal secretions. Eighty patients with complaints of dyspepsia who had undergone endoscopies and gastric antrum biopsies were included in the study. A total of five specimens, including 2 lacrimal secretion samples, 2 nasal mucosal swab samples, and 1 gastric antrum biopsy, were collected from each patient and investigated with polymerase chain reaction (PCR) methods consisting of the urease enzyme coding gene GlmM (UreC) and the H pylori-specific 16S rRNA coding gene. The Reflux Symptom Index and ophthalmologic complaints of the patients were recorded. The detected positivity rates of the H pylori 16S rRNA coding gene in gastric biopsies and nasal mucous and lacrimal secretions were 55, 11.2, and 20%, respectively. The patients were grouped as gastric-antrum-biopsy-negative (Group I [n = 36]) and -positive (Group II [n = 44). In Group II, H pylori positivity in the lacrimal and nasal mucous secretions was 36.3 and 18%, respectively. A comparison between the groups in terms of H pylori presence in nasal mucous and lacrimal secretions yielded statistically significant differences (p = 0.0001, p = 0.003). The simultaneous presence of H pylori in nasal mucous and lacrimal secretions was 13.6% in Group II. H pylori positivity in nasal mucous and lacrimal secretions had a positive moderate correlation (r = 0.40; p = 0.0003). The present study is the first report on the presence of H pylori in lacrimal secretions through nested PCR, which suggested the presence of a number of mechanisms for H pylori transmission to lacrimal secretions.

A case of minocycline-induced black thyroid associated with papillary carcinoma

March 16, 2016  |  Kohei Nishimoto, MD, PhD; Yoshihiko Kumai, MD, PhD; Daizo Murakami, MD, PhD; Eiji Yumoto, MD, PhD


We report a rare case of black thyroid accompanied by papillary carcinoma in a patient with an extended history of minocycline treatment. A 78-year-old man was referred to our outpatient clinic with swelling in his neck. He had been taking minocycline for the previous 2 years and 7 months to treat chronic perianal pyoderma. Neck ultrasonography and computed tomography demonstrated a 3.5 x 3.7 x 5.0-cm nodule in the left thyroid lobe, and fine-needle aspiration cytology identified it as a papillary carcinoma. The patient underwent a total thyroidectomy and neck dissection. During the procedure, a distinct black discoloration of the thyroid parenchyma was observed. Histopathology confirmed both the black thyroid and the papillary carcinoma. Based on the thyroid gland's discoloration and the history of minocycline use, the patient was diagnosed with minocycline-induced black thyroid. He was symptom-free 20 months after surgery.

Surgical treatment of superior laryngeal neuralgia: A case report and review of the literature

March 16, 2016  |  Richard Salzman, MD, PhD; Tomáš Gabrhelík, MD, PhD; Ivo Stárek, MD, PhD


Superior laryngeal (SL) neuralgia is paroxysmal pain above the thyrohyoid membrane. We present a case of SL neuralgia that was resistant to conservative treatment and eventually required surgical intervention. The patient was a 39-year-old woman with a 5-year history of debilitating pain above the thyroid cartilage. After having undergone different imaging scans with negative results, she tried various treatments (e.g., antibiotics, analgesics, stellate ganglion block, radiofrequency SL neurotomy, and stereotactic radiosurgery), all of which were ineffective. Finally, she underwent bilateral surgical SL neurotomy. Postoperatively, she immediately noticed a significant alleviation of her pain. Her postoperative course was completely uneventful, as she experienced no dysphagia or dysphonia, even transiently. One month later, she no longer required regular painkillers, and at 14 months, she remained essentially pain-free. While medical management remains the treatment of choice for SL neuralgia, we recommend that refractory cases be treated initially with a neural block with local anesthesia. Patients who do not respond are candidates for surgery. We consider selective peripheral SL neurotomy to be safe and effective when performed by experienced hands. We also discuss the difficulties of managing SL neuralgia.

The economic impact of revision otologic surgery

March 16, 2016  |  Sahar Nadimi, MD; John P. Leonetti, MD; George Pontikis, MD


Revision otologic surgery places a significant economic burden on patients and the healthcare system. We conducted a retrospective chart analysis to estimate the economic impact of revision canal-wall-down (CWD) mastoidectomy. We reviewed the medical records of all 189 adults who had undergone CWD mastoidectomy performed by the senior author between June 2006 and August 2011 at Loyola University Medical Center in Maywood, Ill. Institutional charges and collections for all patients were extrapolated to estimate the overall healthcare cost of revision surgery in Illinois and at the national level. Of the 189 CWD mastoidectomies, 89 were primary and 100 were revision procedures. The total charge for the revision cases was $2,783,700, and the net reimbursement (collections) was $846,289 (30.4%). Using Illinois Hospital Association data, we estimated that reimbursement for 387 revision CWD mastoidectomies that had been performed in fiscal year 2011 was nearly $3.3 million. By extrapolating our data to the national level, we estimated that 9,214 patients underwent revision CWD mastoidectomy in the United States during 2011, which cost the national healthcare system roughly $76 million, not including lost wages and productivity. Known causes of failed CWD mastoidectomies that often result in revision surgery include an inadequate meatoplasty, a facial ridge that is too high, residual diseased air cells, and recurrent cholesteatoma. A better understanding of these factors can reduce the need for revision surgery, which could have a positive impact on the economic strain related to this procedure at the local, state, and national levels.

A limited thoracocervical approach for accessing the anterior mediastinum in retrosternal goiters: Surgical technique and implications for the management of head and neck emergencies

March 16, 2016  |  Petros V. Vlastarakos, MD, MSc, PhD, IDO-HNS(Eng); Aaron Trinidade, MD, PGDip, MRCS, DO-HNS; Marie-Claire Jaberoo, MD, FRCS(ORL-HNS), DO-HNS; George Mochloulis, MD, CCST(ORL-HNS)


In this article we describe the surgical management of retrosternal goiters via a limited thoracocervical approach, and we explore how the respective surgical know-how can be used in the management of the carotid blowout syndrome. Four cases involving patients who had undergone thyroidectomy via a limited thoracocervical approach are retrospectively reviewed. An acute blowout of the innominate artery managed with the same principal surgical technique is also reviewed. Three patients had a total thyroidectomy and one had a hemithyroidectomy. No malignancy was found. There was no mortality or unexpected morbidity from the limited thoracocervical approach. The median length of the inpatient stay was 3 days. The blowout survivor lived for 9 months, with no rebleeding and with an acceptable quality of life. We conclude that a limited thoracocervical approach can be safely performed by head and neck surgeons for accessing the anterior mediastinum in retrosternal goiters, and the respective surgical know-how can be used in the immediate management of an acute carotid blowout syndrome with satisfying long-term results and provision of quality end-of-life care.

Otogenic lateral sinus thrombosis in children: A review of 7 cases

March 16, 2016  |  Jesse T. Ryan, MD; Maria Pena, MD; George H. Zalzal, MD; Diego A. Preciado, MD, PhD


Otogenic lateral sinus thrombosis (LST) is a rare but serious intracranial complication of acute or chronic otitis media. Reported mortality rates have ranged from 8 to 25%; the pediatric mortality rate might be as low as 5%. Controversy still exists over the medical and surgical management of this condition. We conducted a retrospective chart review of 7 cases of pediatric otogenic LST that were treated at our institution over a period of 8 years. We hypothesized that good outcomes in very sick patients can be achieved by aggressively managing the mastoid cavity and without the need for a thrombectomy. Our study group was made up of 4 boys and 3 girls, aged 6 to 15 years (mean: 11.1). All patients received intravenous antibiotics and underwent mastoidectomy with unroofing of the sigmoid sinus and placement of a tympanostomy tube. Sinus exploration with thrombectomy was not performed in any patient. Anticoagulation was used perioperatively in 5 patients (71%) without complication. All patients recovered well without major sequelae, which supports our hypothesis. We also describe the case of a patient with multiple concomitant intracranial comorbidities associated with this rare condition.

Ultrasonography-guided minimally invasive removal of parotid calculi: A prudent approach

February 24, 2016  |  Uma Patnaik, MS, DNB; Sreejith Nair, MS; Atul Mishra, MD


The trend in modern salivary calculi surgery is toward minimally invasive procedures because these benign conditions do not warrant open salivary gland surgery. Since ultrasonography is readily available, highly specific, noninvasive, and cost-effective, we have used an ultrasonography-guided technique for patients with parotid gland calculi, as both a diagnostic and a therapeutic tool for calculi removal, thus avoiding the morbidity of open surgery. We describe a case in which we used this novel technique for the peroral removal of multiple parotid calculi in a 29-year-old man. The use of ultrasonography in parotid calculi removal has been reported in the literature, but only infrequently. Our extensive search of the peer-reviewed English-language literature found no article reporting the technique that we describe here.