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Laryngeal amyloidosis

July 18, 2016  |  Karthik S. Shastri, MD; Amy L. Rutt, DO; Robert T. Sataloff, MD, DMA, FACS

The diagnosis of laryngeal amyloidosis should trigger evaluation for systemic amyloidosis.

Phonatory symptoms and impact on quality of life in female patients with goiter

July 18, 2016  |  Abdul-latif Hamdan, MD, MPH, FACS; Alexander Dowli, MD; Jad Jabbour, BS; Alain Sabri, MD; Sami T. Azar, MD, FACP


Our objective is to report on the prevalence of phonatory symptoms and impact on quality of life in a group of female patients with goiter who had not been selected for surgery or who had not presented to the emergency room with respiratory distress. A total of 40 patients with goiter and 14 controls were enrolled in this study. Demographic data included age, sex, laryngopharyngeal reflux disease, allergy, smoking, duration of disease, presence or absence of compressive symptoms, presence or absence of thyroid gland nodules, vascular status, presence or absence of calcifications, and thyroid-stimulating hormone levels. Phonatory symptoms included hoarseness, vocal fatigue, vocal straining, lump sensation, and aphonia. The Voice Handicap Index 10 was used to assess the impact of phonatory symptoms on quality of life. The most common phonatory symptom in the patients with goiter was vocal fatigue followed by lump sensation. The only phonatory symptom that was significantly more present in patients with goiter was vocal straining. As for the impact of phonatory symptoms on quality of life, 15.8% of goiter patients had a Voice Handicap Index score >7 compared with 7.7% of controls. Phonatory symptoms are common in patients with goiter, with vocal straining occurring significantly more frequently than in controls. In 1 of 6 patients, the presence of phonatory symptoms had an impact on quality of life.

Management of obstructive sleep apnea in children: A practical approach

July 18, 2016  |  Kevin D. Pereira, MD; Cindy K. Jon, MD, MPH; Peter Szmuk, MD; Rande H. Lazar, MD; Ron B. Mitchell, MD


The management of sleep disordered breathing (SDB) in children differs between institutions, and there is a need for an updated review of current practice. Literature was reviewed using the PubMed database from 1995 to 2015 by four tertiary care providers experienced in the management of children with SDB. Articles were selected for clinical applicability, strength of evidence, and practicality for practicing clinicians. Fifty-five articles were identified by tertiary care providers in pediatric anesthesiology, pediatric pulmonology, sleep medicine, and pediatric otolaryngology. Each reviewed and analyzed literature independently based on their specialties, and a consensus document was created. The consensus was that the majority of children with SDB do not undergo polysomnography (PSG) before adenotonsillectomy (T&A). Indications for PSG are presented, with a practical approach recommended for the otolaryngologist. Clinical practice guidelines are available from leading national societies, but their recommendations differ. T&A is the first-line treatment and is highly effective in normal-weight but not in obese children. The perioperative management of children is challenging and needs to be individualized. Young children, those with severe obstructive sleep apnea, and those with significant comorbidities need to be observed overnight.

Nonsurgical options to treat giant-cell tumors of the head and neck: A case report and brief review of the literature

July 18, 2016  |  Allison N. Rasband-Lindquist, MD; Jonathan D. Lindquist, MD; Christopher G. Larsen, MD; Aaron Thiessen, MD; Douglas Girod, MD


Central giant-cell granulomas (CGCGs) are relatively uncommon. When they do occur, they typically arise in the mandible and maxilla. Some lesions are more destructive than others, and the destructive subtype has a tendency to recur. Unfortunately, there is no reproducible way to differentiate aggressive from nonaggressive subtypes. Treatment of CGCG has historically been based on surgical curettage or wide local excision. However, surgery has been associated with significant morbidity, disfigurement, and expense, as well as a high recurrence rate. Pharmacologic treatments-either as an alternative or an adjunct to surgery-have been shown to yield acceptable results. These agents include intralesional and/or systemic corticosteroids, bisphosphonates, calcitonin, and interferon alfa. These options are typically less expensive than surgery, and they are associated with few side effects, which makes them potentially more desirable. We report the case of a 36-year-old woman with a CGCG who was successfully treated with a combination of an intralesional steroid and an oral steroid over a period of 5 months. As evidenced by this case, medical management can be effective for tumor regression in treating CGCG of the head and neck, and it is ultimately associated with less morbidity and is less costly. To the best of our knowledge, no randomized controlled studies have been published on this topic. Such a study would be welcome, particularly considering the presence of both aggressive and nonaggressive subtypes of CGCG. We also briefly review the literature.

Neuroendocrine tumors of the larynx

July 18, 2016  |  Lester D. Thompson, MD

The most common laryngeal neuroendocrine tumor is the atypical carcinoid (moderately differentiated neuroendocrine carcinoma), which is a malignant epithelial tumor showing neuroendocrine histologic and immunohistochemical features.

Clinical characteristics and follow-up of patients with external ear canal cholesteatoma treated conservatively

July 18, 2016  |  Erdal Sakalli, MD; Deniz Kaya, MD; Cengiz Celikyurt, MD; Selcuk Cem Erdurak, MD


We conducted a retrospective study to evaluate the clinical properties and follow-up of patients with external ear canal cholesteatoma (EECC) who were treated conservatively. Our study group was made up of 15 patients-6 men and 9 women, aged 21 to 82 years (mean: 48). In addition to demographic data, we compiled information on presenting signs and symptoms, the location of the lesion, treatment, and follow-up. All EECCs occurred spontaneously, and all were limited to the temporal bone. Lesions were left-sided in 7 patients, right-sided in 7, and bilateral in 1. For purposes of defining the location of the lesions, the ear canal was divided into four quadrants: anterior, posterior, superior, and inferior. Temporal bone computed tomography (CT) and otomicroscopic evaluation revealed that 7 of the 16 lesions (44%) were located in the anterior and inferior quadrants, 6 (38%) in the inferior quadrant only, 2 (13%) in the anterior, inferior, and posterior quadrants, and 1 (6%) in the anterior quadrant only. Otorrhea was present in 7 of the 15 patients (47%), otalgia in 6 (40%), itching in 4 (27%), fullness in 2 (13%), and occlusion in 1 (7%); 3 patients (20%) were asymptomatic. All patients were treated with local debridement and aspiration under otomicroscopy, and they were followed up with repeat aspirations approximately every 10 weeks under microscopy. The duration of follow-up ranged from 6 to 75 months (mean: 41). At study's end, cholesteatoma had not progressed in any patient during follow-up, indicating that repeat aspirations and regular follow-up of limited EECC prevent recurrence of signs and symptoms and progression of the disease.

Occult central venous stenosis leading to airway obstruction after subtotal parathyroidectomy

July 18, 2016  |  Duncan A. Meiklejohn, MD; Dylan K. Chan, MD, PhD; M. Lauren Lalakea, MD


Subtotal parathyroidectomy may be indicated in patients with chronic renal failure and tertiary hyperparathyroidism, a population at increased risk for central venous stenosis (CVS) due to repeated vascular access. Here we report a case of complete upper airway obstruction precipitated by subtotal parathyroidectomy with ligation of anterior jugular vein collaterals in a patient with occult CVS. This case demonstrates a previously unreported risk of anterior neck surgery in patients with chronic renal failure. We present a review of the literature and discuss elements of the history and physical examination suggestive of occult CVS, with additional workup proposed for appropriate cases. Recommendations are discussed for perioperative and postoperative care in patients at increased risk for CVS.

The inferior turbinate, an unusual site for a choanal polyp: Two case reports and a review of the literature

July 18, 2016  |  Maya Adhami, MD; Andre Coste, MD; Virginie Escabasse, MD; Frederique Chalumeau, MD


Choanal polyps are unilateral sinonasal lesions that are classified according to their site of origin. The aim of this report is to highlight an unusual form of choanal polyp and to present a thorough literature review. To the best of our knowledge, only 6 cases of a choanal polyp originating in the inferior turbinate have been previously reported in the literature. We describe 2 new cases. One patient was a 14-year-old boy who presented with nasal obstruction, facial headaches, and obstructive sleep apnea; the other patient was a 70-year-old man who presented with right mucopurulent rhinorrhea and right nasal obstruction. In both cases, nasal fibroscopy detected a polyp arising from the right inferior turbinate and extending toward the right choana. Endoscopic sinus surgery was performed in both cases to ensure a complete excision. Cases of choanal polyp arising from the inferior, middle, and superior turbinates and the septum are rare, although some appear to be more common than is generally believed, especially in the pediatric population. We therefore recommend that unusual forms of choanal polyp be included in the differential diagnosis of a unilateral sinonasal mass.

Virtual reality in rhinology--a new dimension of clinical experience

July 18, 2016  |  Ivica Klapan, PhD, MD; Pero Raos, PhD, MEng; Tomislav Galeta, PhD, MEng; Goranka Kubat, MD


There is often a need to more precisely identify the extent of pathology and the fine elements of intracranial anatomic features during the diagnostic process and during many operations in the nose, sinus, orbit, and skull base region. In two case reports, we describe the methods used in the diagnostic workup and surgical therapy in the nose and paranasal sinus region. Besides baseline x-ray, multislice computed tomography, and magnetic resonance imaging, operative field imaging was performed via a rapid prototyping model, virtual endoscopy, and 3-D imaging. Different head tissues were visualized in different colors, showing their anatomic interrelations and the extent of pathologic tissue within the operative field. This approach has not yet been used as a standard preoperative or intraoperative procedure in otorhinolaryngology. In this way, we tried to understand the new, visualized “world of anatomic relations within the patient's head” by creating an impression of perception (virtual perception) of the given position of all elements in a particular anatomic region of the head, which does not exist in the real world (virtual world). This approach was aimed at upgrading the diagnostic workup and surgical therapy by ensuring a faster, safer and, above all, simpler operative procedure. In conclusion, any ENT specialist can provide virtual reality support in implementing surgical procedures, with additional control of risks and within the limits of normal tissue, without additional trauma to the surrounding tissue in the anatomic region. At the same time, the virtual reality support provides an impression of the virtual world as the specialist navigates through it and manipulates virtual objects.

Patient preferences in early glottic cancer treatment

July 18, 2016  |  Michael L. McNeil, MD; Derek R. Wilke, MD, FRCP(C); S. Mark Taylor, MD, FRCS(C), FACS


Patients with early-stage glottic cancer are primarily treated with one of three options: endoscopic laser excision, external-beam radiation, or open conservation surgery. We sought to determine patient preferences for treatment when presented with a choice between CO2 laser resection and radiation (open conservation surgery was not offered because the endoscopic approach is preferred at our institution). This prospective cohort study was conducted at the Dalhousie University Faculty of Medicine in Halifax, Canada. Our patient population was made up of 54 men and 10 women, aged 30 to 84 years (mean: 65.0 ± 11.2). Their disease were staged as follows: carcinoma in situ, n = 11; T1a = 21; T1b = 6; and T2 = 26. Patients were quoted identical cure rates for the two treatment modalities. The controversial issue of voice outcomes was discussed, but no leading information was given to the study cohort. All 64 patients chose CO2 laser resection as opposed to radiation therapy for definitive treatment.