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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.

Congenital granular cell tumor in a child with tetralogy of Fallot

July 18, 2016  |  Felicity Lenes-Voit, MD; Anthony Sheyn, MD; Debra Weinberger, MD

Although congenital granular cell tumors are always benign, they can cause feeding difficulties and airway obstruction.

Epitympanic meningoencephalocele presenting as a growing middle ear mass

July 18, 2016  |  James G. Naples, MD; John W. House, MD; Benjamin J. Wycherly, MD

This patient had a subtle middle ear mass without an obvious effusion at the initial presentation; on repeat examination, it became more obvious that this was a meningoencephalocele

Spontaneous bleeding from a thyroid adenoma

July 18, 2016  |  Tsung-Jung Liang, MD; Shiuh-Inn Liu, MD, PhD

Massive thyroid hemorrhage with airway obstruction warrants urgent management, and the importance of definite airway establishment for ventilation and oxygenation cannot be overemphasized.

Malignant transformation of a high-grade osteoblastoma of the petrous apex with subcutaneous metastasis

June 14, 2016  |  Casey T. Kraft, BS; Robert J. Morrison, MD; H. Alexander Arts, MD, FACS


We describe the clinical presentation, management, and pathologic findings in a case of osteosarcoma of the petrous apex with an atypical metastasis to the lower abdominal wall. We retrospectively reviewed the record of a 49-year-old man who was diagnosed with a right petrous apex lesion, which biopsy identified as a high-grade osteoblastoma. After two attempts at en bloc resection were not curative, radiation and chemotherapy were recommended. The patient subsequently developed a cutaneous lower abdominal mass that was diagnosed as an osteosarcoma. Meanwhile, the petrous apex tumor continued to grow despite treatment until the patient died from the burden of disease. Temporal bone osteoblastomas and osteosarcomas are both extremely rare, and they can be difficult to differentiate histologically. Our case illustrates this difficulty and demonstrates the possibility of a high-grade osteoblastoma's malignant conversion to an osteosarcoma.

Aberrant position of nonrecurrent inferior laryngeal nerve: Report of 3 cases and a review of the literature

June 14, 2016  |  Thomas J. Willson, MD; Jayne Stevens, MD; Nathan Salinas, MD; Joseph A. Brennan, MD


The presence of a nonrecurrent inferior laryngeal nerve (NRILN) is a significant risk factor for nerve injury during thyroid, parathyroid, and vascular surgeries involving the paratracheal area of the head and neck. The objective of this report is to review the association between an aberrant right subclavian artery (SCA) identified on preoperative imaging and an NRILN identified intraoperatively during thyroid and parathyroid surgery. We reviewed 3 selected cases in which we preoperatively identified an aberrant right SCA and determined the intraoperative position of the inferior laryngeal nerve on the right. It is important to note that 1 of these cases demonstrated that the inferior laryngeal nerve may be found in its normal anatomic position, coursing inferiorly through the tracheoesophageal groove. This anatomic finding is unexpected in a patient with a preoperatively identified aberrant right SCA. We also performed a literature review of more than 250 cases to investigate the association between an intraoperative finding of NRILN and vascular anomalies on imaging. We found 5 reported cases that involved an aberrant right SCA, predictive of NRILN, with the nerve identified in the tracheoesophageal groove.