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The role of surgery in necrotizing otitis externa

January 25, 2017  |  Maayan Gruber, MD; Eyal Sela, MD; Ilana Doweck, MD; Ariel Roitman, MD; Nechama Uri, MD; Samer Srouji, MD; Raanan Cohen-Kerem, MD


This retrospective case review describes a subset of 5 patients with necrotizing otitis externa (NOE) with a refractory disease course who underwent surgery as part of their management plan between 2008 and 2013. Surgery promoted the cure of 4 of the 5 patients, and a fungal pathogen was recovered in 4 of 5 surgical samples. We conclude that surgery may be a necessary diagnostic and treatment adjunct in selective cases of NOE, especially in patients with a refractory disease course or with a suspected fungal etiology.

Effect of renal failure on voice

January 25, 2017  |  Walid A. Mudawwar, MD; Elie S. Alam, MD; Doja S. Sarieddine, BS; Zaahir A. Turfe, MD; Abdul-Latif H. Hamdan, MD, EMBA, FACS


The objective of this case-control study was to assess the impact of dysphonia on quality of life and to report the perceptual and acoustic findings in patients with chronic renal failure. A total of 22 patients with chronic renal failure and 18 healthy controls were recruited. Patients were asked to complete the Voice Handicap Index (VHI)-10 to assess the impact of dysphonia on quality of life. Perceptual evaluation of patients' voice recordings using the GRBAS classification was performed. Acoustic analysis was also conducted. Fundamental frequency, habitual pitch, shimmer, relative average perturbation, harmonic-to-noise ratio, voice turbulence index, and the maximum phonation time were reported. The mean scores of the VHI-10 were within normative values, with no significant difference between groups. There was also no significant difference in any of the acoustic parameters or in the mean score of any of the perceptual parameters between patients and controls. We conclude that patients with renal failure do not have dysphonia with a significant impact on quality of life, as evident by the normative values of the VHI-10. There were neither perceptual nor acoustic differences between patients and controls.

Severe neck stiffness in a child with an undiagnosed Chiari malformation

January 25, 2017  |  Cameron E. Kliner, MS; Eric E. Berg, MD; Ron B. Mitchell, MD

Otologic symptoms, rather than headaches, may be the earliest manifestation of type I Chiari malformation.

Invasive fungal laryngopharyngitis resulting in laryngeal destruction with complete laryngotracheal separation: Report of a case

January 25, 2017  |  Tyler Swiss, BS; Sergio Santino Cervantes, MD; Michael Hinni, MD; David G. Lott, MD


As the treatment of hematopoietic cancers evolves, otolaryngologists will see a higher incidence of opportunistic infections. We discuss a case of invasive fungal disease that invaded the larynx, pharynx, trachea, and pulmonary parenchyma after chemotherapy. The patient, a 46-year-old woman, presented 1 week after undergoing induction chemotherapy. Her initial symptoms were odynophagia and dysphagia. Despite encouraging findings on physical examination, her health rapidly declined and she required an urgent tracheotomy and multiple operations to address spreading necrosis. Because of her inability to heal, she was not a candidate for laryngectomy, so she was treated with conservative management. The patient was then lost to follow-up, but she returned 5 months later with laryngeal destruction and a complete laryngotracheal separation. While noninvasive fungal laryngitis is routinely encountered, its invasive counterpart is rare. The literature demonstrates that some cases completely resolve with medical therapy alone but that surgery is necessary in others. We recommend surgical debridement of all necrotic tissue.

Acute bacterial meningitis caused by acute otitis media in adults: A series of 12 patients

January 25, 2017  |  Daniel M. Kaplan, MD; Ofer Gluck, MD; Mordechai Kraus, MD; Youval Slovik, MD; Hindy Juwad, Bsc


We conducted a retrospective chart review to characterize the outcomes of 12 patients-9 men and 3 women, aged 21 to 79 years (mean: 49)-who had been treated at our tertiary care center for acute bacterial meningitis caused by acute otitis media (ABMAO). Fever was the most common presenting sign/symptom, observed in 8 patients, followed by otalgia, neck stiffness, headache, and confusion. An opaque and bulging tympanic membrane was observed in 8 patients. Cultures were positive for Streptococcus pneumoniae in the cerebrospinal fluid, ear, and blood in 7, 5, and 3 patients, respectively. Immediate treatment included tympanocentesis, with aspirates sent for bacteriologic cultures. Seven patients (58.3%) underwent surgery; 5 were operated on early, and 2 underwent surgery at a later stage because of a suspected defect in the mastoid bone. A cortical mastoidectomy was performed in 6 of the 7 surgical patients; the remaining patient underwent a canal-wall-down procedure. Ten patients experienced a full recovery, 1 died, and 1 had a poor neurologic outcome (vegetative state); both of the latter 2 patients were older than 60 years. We conclude that early diagnosis, administration of antibiotics, and myringotomy are crucial for control of ABMAO. A cortical mastoidectomy with ventilation tube insertion can be reserved for patients who do not respond, which is common.

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.