Anatomic measurements of the anterior and posterior ethmoid arteries in cadaveric heads using endoscopic sinus instrumentation

May 7, 2014     Zeeshan S. Aziz, MD; Ninef E. Zaya, MD; Richard M. Bass, MD


The challenges of endoscopic sinus surgery lie in the complexity of the anatomy of the nasal vault and side walls and the proximity to critical structures. Additionally, operating in a three-dimensional space while relying on a two-dimensional image for surgical navigation can be a disorienting task. Successful sinus surgery relies on the surgeon having a clear understanding of the anatomy and relationships within the operative field. We performed a study of 8 adult cadaveric heads to better elucidate the location of the ethmoid arteries in relation to an accessible external landmark, the nasal sill. Sinus endoscopy was performed on the heads to identify and measure the distance from the nasal sill to the anterior and posterior ethmoid arteries. We found that the distance from the nasal sill to the anterior ethmoid artery was approximately 6.0 cm, and the distance to the posterior ethmoid artery was approximately 6.7 cm. The interarterial distance was approximately 1.2 cm. With a better understanding of these vessels, surgeons will be better able to avoid them during surgery and thereby minimize the risk of excessive intraoperative bleeding and perioperative orbital hematoma.

The cosmetic Z-plasty: Restoring and refining an old technique for neck rejuvenation

May 7, 2014     Nicholas Vendemia, MD; David E. Rosow, MD; Anthony N. LaBruna, MD


Direct excision of the “turkey neck” skin fold with Z-plasty closure was introduced in the 1970s, but it has fallen out of favor in an era in which much emphasis is placed on minimizing visible scars. Although the newer techniques may effectively improve the aesthetic contour of the neck without leaving visible scars, they may not be optimal for selected patients who want a quick, “no-hassle” correction of their neck contour without changing the overall appearance of their face. We conducted a retrospective study of 50 patients-47 men and 3 women, aged 59 to 80 years (mean: 70)-who had undergone cosmetic Z-plasty performed by the senior author (A.N.L.) over a 9-year period. These patients either did not want or were not candidates for a face-lift or other procedure. Patients' charts were examined for demographic data, complications, and overall satisfaction with the procedure. In 46 of the 50 cases, the initial cosmetic result was acceptable to both the patient and the surgeon. The only complications were recurrent or residual areas of skin redundancy or dissatisfaction with the scar, but these were easily corrected with a second procedure using local anesthesia in the office setting. We conclude that cosmetic Z-plasty is a safe and effective means of correcting turkey neck deformity in patients who desire a procedure with a short operating time, a brief recovery period, a low complication rate, and a minimal effect on the overall appearance of their face. Although cosmetic Z-plasty is frequently considered to be antiquated, we believe refined versions of this procedure can still be of value to the plastic surgeon. In addition to describing our study results, we also describe in detail our surgical technique, including several contemporary refinements.

Introduction Redundant midline neck skin, sometimes known as a “turkey neck” deformity, represents a cosmetic problem for many older patients. Direct excision of the excess skin fold with Z-plasty closure, also known as anterior cervicoplasty or T-Z-plasty, was introduced in the 1970s by Cronin and Biggs.1-4 However, this procedure...

Tympanic paraganglioma

May 7, 2014     Danielle M. Blake, BA; Senja Tomovic, MD; Robert W. Jyung, MD

Patients classically present with pulsatile tinnitus and a red mass medial to the tympanic membrane. Some patients may have findings of a red mass that blanches with pneumatic otoscopy, called Brown's sign.

A 63-year-old woman with suspected sleep apnea was referred to our facility for right-sided tinnitus and hearing loss. She had first noticed the hearing loss 3 years earlier but reported that it had gotten worse recently. She also reported constant right-sided, pulsatile tinnitus for at least 3 years, although it was initially intermittent. She...

Postoperative shoulder function after different types of neck dissection in head and neck cancer

May 7, 2014     Adil Sheikh, MBBS; Hussain Shallwani, MBBS; Shehzad Ghaffar, FCPS, FRCS


Reported complications of neck dissection surgery have included decreases in shoulder muscle power and range of motion, drooping shoulder, and shoulder pain. We conducted a cross-sectional study to assess postoperative shoulder function following three different types of neck dissection surgery that were performed at Aga Khan University Hospital and to determine how various treatment factors and patient characteristics affected postoperative shoulder function. Our study population included 70 patients-51 men and 19 women, aged 18 to 70 years (mean: 48.6 ± 11.6)-who had undergone a total of 92 neck dissections (22 patients underwent bilateral procedures). Patients were assessed by physical examination and questionnaire responses. The physical examination included objective assessments of shoulder muscle power against resistance, active range of motion, maximum possible forward flexion, the length of time needed to repeat active shoulder flexion 5 times, and shoulder abduction. The questionnaire covered shoulder mobility during activities of daily living, the results of physiotherapy (and exercise), postoperative radiation status, and shoulder pain. Of the 92 neck dissections, 17 were selective (18.5%), 64 were modified radical (69.6%), and 11 were radical (12.0%). We found that patients who had undergone a nerve-sparing procedure (i.e., selective neck dissection or a modified radical neck dissection) exhibited significantly better shoulder function than did patients who had undergone radical neck dissections (p < 0.01). In addition, increasing age (p < 0.001) and a history of diabetes (p = 0.003) were associated with worse shoulder function, and postoperative physiotherapy was associated with better shoulder function (p = 0.002). Neither sex, weight, the side of the neck operated on (left or right), the administration of postoperative radiation, the length of time between surgery and shoulder function assessment, comorbidities such as hypertension and ischemic heart disease, nor the status of the level V lymph nodes had any statistically significant association with shoulder function.

Introduction Pakistan is in a geographic area of high risk for head and neck cancer.1 Adding to the gravity of this situation is a rising incidence of these cancers, including a significant number of cases in patients younger than 40 years.

Complex posterior arytenoid dislocation

May 7, 2014     Rima A. DeFatta, MD; Jenna Briddell, MD; Robert T. Sataloff, MD, DMA, FACS

Arytenoid cartilage dislocation is an uncommon entity that is frequently misdiagnosed as vocal fold paresis or paralysis. The most common cause of dislocation is endotracheal intubation injury.

A 42-year-old man fell 15 feet from a porch, sustained hypoxic brain injury, and underwent a tracheotomy after 4 weeks of intubation. He was aphonic after decannulation and was diagnosed with “vocal fold paralysis.” He was treated twice by another physician with calcium hydroxylapatite injection into the immobile vocal fold, but his...

Endoscopic view of a concha bullosa of the inferior nasal turbinate

May 7, 2014     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

Pneumatization of the inferior turbinate, or concha bullosa of the inferior turbinate, is clinically significant when it causes persistent nasal airway obstruction.

A 42-year-old woman presented with a left nasal airway obstruction. Endoscopic examination of her nose showed an extremely hypertrophic left inferior turbinate (figure, A). The right inferior turbinate was of normal size. She elected to undergo nasal airway reconstruction with partial inferior turbinate reduction of the left inferior turbinate.

Retropharyngeal pseudoabscess manifesting in nephrotic syndrome

May 7, 2014     Shirish Johari, DLO, MRCSEd, DOHNS(Edin); Pankaj Handa, MD, MRCP(Ire), FAMS; Jin Keat Siow, MD, MBBS, FRCSEd


We describe a case of nephrotic syndrome that manifested as a retropharyngeal pseudoabscess. The patient was a 32-year-old man who presented with a short history of throat discomfort and a choking sensation. Laryngoscopy identified bulging of the posterior pharyngeal wall that partially occluded the laryngeal inlet. A lateral neck x-ray revealed that the prevertebral space was widened, and computed tomography detected fluid in the retropharyngeal and parapharyngeal spaces. Neck exploration revealed that the edema had been caused by nonsuppurative fluid. Biochemical analyses revealed marked hypoalbuminemia and heavy proteinuria suggestive of nephrotic syndrome. Following surgery, the patient's symptoms resolved. Aseptic effusion into the retropharyngeal space is rare; reported etiologies include internal jugular vein thrombosis, neoplasia, radiation therapy, trauma, acute calcific tendinitis, hereditary angioedema, and myxedema of hypothyroidism. To the best of our knowledge, this is the first case of nephrotic syndrome initially manifesting as retropharyngeal pseudoabscess to be reported in the literature. Thrombotic occlusion of the pharyngeal venous plexus secondary to hypercoagulability is a plausible explanation for such isolated retropharyngeal effusion.

Introduction Widening of the prevertebral space as seen on a lateral neck x-ray is a sign of much concern in ENT practice. The most common and foremost diagnosis is a retropharyngeal abscess. Aseptic effusion into the retropharyngeal space is rare. We describe a previously undiagnosed case of nephrotic syndrome that initially manifested as...

Evaluating the role of single-photon emission computed tomography in the assessment of neurotologic complaints

May 7, 2014     Shruti S. Joglekar, MD; Jason R. Bell, MD; Malka Caroline, MD; Paul J. Chase, DO, FAOCR; James Domesek, MD; Pinal S. Patel, ARRT, CNMT; Robert T. Sataloff, MD, DMA, FACS


We conducted a retrospective study to reexamine the value of single-photon emission computed tomography (SPECT) in the evaluation of patients with neurotologic complaints, and to assess the intra- and inter-radiologist variability of SPECT readings. Our study population was made up of 63 patients-23 men and 40 women, aged 34 to 91 years (mean: 59)-who had presented to a tertiary care otolaryngology practice and university hospital for evaluation of head trauma, sensorineural hearing loss, tinnitus, and/or vertigo. All patients had undergone brain scanning with SPECT during their evaluation, and almost all had also undergone magnetic resonance imaging (MRI) and standard computed tomography (CT). We compared the findings of all three imaging modalities in terms of their ability to detect neurotologic abnormalities. We found that detection rates were very similar among the three modalities; abnormalities were found in 24% of SPECT scans, 26% of MRIs, and 23% of CTs. Nevertheless, we did find that among 60 patients who underwent all three types of imaging, 13 (22%) exhibited areas of cerebral hypoperfusion on SPECT while their MRIs and CTs were read as either normal or nonspecific. In all, 18 of these 60 patients (30%) exhibited normal or nonspecific findings on all three types of imaging. In addition, when SPECT scans were read by the same radiologist at different times, different results were reported for 17 of the 63 scans (27%). Likewise, when SPECT scans were read by different radiologists, different results were reported for 21 of 63 scans (33%). We conclude that SPECT may be a valuable complementary diagnostic modality for making a comprehensive neurotologic evaluation and that it may detect abnormalities in some patients whose other imaging is read as normal. However, we did not find that SPECT was the most sensitive of the three modalities in neurotologic evaluation, as we had previously found in a preliminary study that the senior author (R.T.S.) published in 1996. In addition, with respect to our radiologists, both their intra- and inter-reader reliability was low, and we recommend additional study on this matter.

The role of contact endoscopy in screening for premalignant laryngeal lesions: A study of 141 patients

May 7, 2014     Marisa Klancnik, MD; Ivo Gluncic, MD, PhD; Drasko Cikojevic, MD, PhD


At their earliest stage, pathologic lesions of the laryngeal epithelium are macroscopically invisible. Ideally, these lesions should be detected before their clinical manifestations appear so that prompt management can be initiated. However, most diagnostic modalities are unable to detect early premalignant lesions. We conducted a retrospective study of the use of contact endoscopy in analyzing the vocal fold mucosal epithelium in adults who had been operated on at our hospital under general anesthesia for various nonlaryngeal diseases. After we identified 71 such patients who were smokers, we chose an almost equal number of nonsmokers (n = 70) for comparison purposes. In all, our study population was made up of 141 patients-51 men and 90 women, aged 21 to 78 years (mean: 52). All patients had normal findings on preoperative laryngeal endoscopy. Our goal was to determine if the routine use of this diagnostic modality is justified in selected cases. Contact endoscopy identified dysplastic vocal fold lesions in 4 patients and chronic laryngitis in 3; all 7 of these patients were smokers. Since early laryngeal lesions are not macroscopically evident, early detection of these changes by other means is associated with a better prognosis and easier management. Our study demonstrates that the use of contact endoscopy during general anesthesia as a standard diagnostic method in long-time cigarette smokers is fully justified.

Introduction Even the mildest abnormality of the vocal folds can lead to hoarseness. Ideally, changes in the vocal fold mucosa will be detected early on, before they manifest clinically. One diagnostic modality that is useful in this regard is contact endoscopy. This noninvasive method provides an insight into the microscopic picture of laryngeal...

Chondroid syringoma of the ear lobule: A unique case

May 7, 2014     Yasser Al Omran, BSc (Hons); Rawia Mohamed, MBBS, FRCPA; Mohammed-Kamal Al-Omran, MBBS, FRCS Ed, FRCS (Glasg)

Because of the inconspicuous clinical presentation of chondroid syringomas, they are often disregarded; other, more common, differential diagnoses are usually considered.

Chondroid syringomas, also known as mixed tumors of the skin, are highly uncommon, usually benign adnexal neoplasms with an unknown pathogenesis.1 They typically present as slowly growing, asymptomatic masses and are located on the head and neck, with the cheek, nose, and skin above the lip being the most common sites.2 We report a case of a...
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