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Endoscopic endonasal management of recurrent maxillary mucoceles using biliary T-tube stenting

December 12, 2017  |  Noritsugu Ono, MD; Shin Ito, MD; Hirotomo Homma, MD; Hiroko Okada, MD; Junko Murata, MD; Katsuhisa Ikeda, MD, PhD


Mucoceles of the paranasal sinus can be managed endoscopically with an extremely low recurrence rate. Frontal sinus mucoceles can sometimes be prevented from closing and reforming by stenting, which to the best of our knowledge has not yet been reported in the maxillary sinus. We describe the cases of 5 patients-3 men and 2 women, aged 47 to 75 years (mean: 59.6)-with a recurrent and intractable maxillary sinus mucocele that was managed with biliary T-tube stenting. The indications for stenting included recurrent episodes of mucocele with or without a lateral location with a relatively thick bony wall. A latex rubber pediatric biliary T-tube was endoscopically inserted through a window opening into the marsupialized mucocele. The stent was removed 6 to 14 months postoperatively in 4 cases; in the other case, the stent remained adequately positioned for 35 months. None of the patients experienced signs or symptoms of recurrence. We conclude that a T-tube stent can be used successfully to maintain long-term patency in patients with a recurrent and intractable maxillary mucocele, with patency being maintained even after removal of the stent.

Head and neck surgical reconstruction in Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan: A systematic review

December 12, 2017  |  Samantha J. Mikals, MD; Joshua M. Jabaut, MD; Art A. Ambrosio, MD


Historically, head and neck injuries constituted 16 to 20% of all nonfatal combat injuries. However, advances in body and vehicle armor in the context of the use of ambushes and improvised explosive devices by enemy combatants have resulted in fewer fatalities from head and neck wounds, and thus the incidence of nonfatal head and neck injuries has risen to as high as 52%. Despite this increase, data regarding specific injury distributions, surgical cases, and approaches to repair are lacking in the current literature. We conducted a study to systematically review the current literature regarding head and neck injuries and reconstructions during Operation Iraqi Freedom and Operation Enduring Freedom-Afghanistan. We found 44 articles that met our inclusion criteria. These articles covered 17,461 head and neck wounds sustained by 12,105 patients. Superficial soft-tissue facial injuries were most common wounds (31.7% of cases), followed by wounds to the neck (25.2%) and midface (17.9%). The 44 articles listed 5,122 discrete surgical reports covering 5,758 procedures. Of these procedures, simple facial laceration repairs (25.2%) and ophthalmologic surgeries (12.1%) were the most common soft-tissue repairs, and mandibular reconstructions (11.3%) were the most common type of bony reconstruction. Major flap reconstructions for coverage were required in only 0.4% of procedures. This information will be valuable for educating those involved in otolaryngology training programs, as well as civilian otolaryngologists regarding the types of injury patterns they should expect to see and treat in the returning veteran population.

Intracranial abscess formation following sphenoid sinus occlusion with nasoseptal flap skull base reconstruction: A cautionary tale

December 12, 2017  |  George S. Tarasidis, MD; Jeremiah A. Alt, MD, PhD; Richard R. Orlandi, MD


The formation of an intracranial abscess secondary to sphenoid sinus occlusion after nasoseptal flap skull base reconstruction has not been previously described. We report such a case that occurred at our institution in a 23-year-old man who underwent flap reconstruction for a cerebrospinal fluid leak. We determined that occlusion of the sphenoid sinus outflow might have played a role in this complication. The patient was treated via a combined surgical and medical approach that entailed a bur-hole craniotomy and endoscopic debridement followed by administration of an intravenous antibiotic. The patient recovered without long-term deficit. When closing a defect of the posterior ethmoid and sphenoid skull base, especially with a pedicled graft, care must be taken to reduce the potential for retention of secretions and blood because this may lead to an intracranial complication.

Nasopharyngeal papillary adenocarcinoma

December 12, 2017  |  Lester D. Thompson, MD

Nasopharyngeal papillary adenocarcinoma may appear grossly as an exophytic, nodular, or polypoid mass, sometimes gritty if psammoma bodies are present.

Skin necrosis in a magnet-based bone-conduction implant

December 12, 2017  |  Sara Gallant, MD; Judy Lee, MD; Daniel Jethanamest, MD

Patients with complicated wound sites or multiple surgeries should be counseled to carefully monitor their skin as they have reduced sensation.

Preoperative evaluation and intraoperative protection of the facial nerve in congenital aural atresia

December 12, 2017  |  Jie Li, MD; Shouqin Zhao, PhD; Lin Yang, MD; Yi Li, PhD; Xiaobo Ma, PhD; Danni Wang, PhD; Ran Ren, MD; Ying Li, MD


We conducted a prospective study to assess the value of high-resolution computed tomography (HRCT) in identifying facial nerve variations in patients with congenital aural atresia and to determine how they affect otologic reconstruction surgery. Our study population was made up of 65 patients (69 ears) aged 6 to 22 years (mean: 13.7) without regard to sex. They were classified into three groups according to their scores on the Jahrsdoerfer grading scale: 46 ears scored 8 or more, 18 had a score of 6 or 7, and 5 scored 5 or less. The course of each facial nerve as determined intraoperatively was compared with the preoperative HRCT findings. HRCT revealed that in most of the facial nerves, the tympanic segments overlapped the oval window partly or completely; this was confirmed by surgical findings in most cases. Three of the 69 facial nerves (4.3%) were bifurcated. It is interesting that in 1 ear in which the facial nerve completely covered the oval window, the angle of the second genu was acute, exhibiting a “sharp turn.” We conclude that HRCT is undoubtedly of value in identifying the course of the facial nerve and is of critical importance in helping surgeons make correct decisions in otologic reconstruction surgery.

Prognosticating hearing outcome in patients with idiopathic sudden sensorineural hearing loss by means of otoacoustic emissions and auditory brainstem response

December 12, 2017  |  Masoud Motasaddi Zarandy, MD; Mohammad Taghi Khorsandi Ashtiani, MD; Shahin Bastaninejad, MD; Sasan Dabiri Satri, MD; Sevil Nasirmohtaram, MD; Nourullah Agha Ebrahimi, BSC


This is an analytic-descriptive study, parallel with a randomized, controlled trial performed at Amir'Alam Hospital, a tertiary referral center, with the aim of evaluating the correlation between otoacoustic emission (OAE) and auditory brainstem response (ABR) findings with hearing outcome after treatment of idiopathic sudden sensorineural hearing loss (SSNHL). Sixty patients with idiopathic SSNHL who presented to the emergency services and otology clinics between 2012 and 2014, and whose symptoms had begun <10 days previously, enrolled in this study. Before commencing treatment, distortion-product OAE (DP-OAE) and ABR were performed for all patients. They also underwent magnetic resonance imaging ± gadolinium. Therapeutic intervention was done in a parallel randomized, controlled trial, and responders to the medical therapy were selected for our final analysis. There was no significant correlation between the OAE record and responsiveness to treatment, but there was a correlation between ABR presence and the probability of responsiveness in patients with profound hearing loss who responded to medical therapy and had at least wave V ABR. However, in those who had no recorded wave, the response to treatment was variable. In conclusion, in patients with profound hearing loss, studying the waves of ABR could be a factor in predicting hearing loss resolution after treatment.

Multidisciplinary management of a giant cervico-mediastinal liposarcoma: A case report and literature review

December 12, 2017  |  Andrea Galli, MD; Leone Giordano, MD; Piergiorgio Muriana, MD; Alessandro Bandiera, MD; Giampiero Negri, MD; Piero Zannini, MD; Mario Bussi, MD


Liposarcomas are rare mesenchymal tumors that usually develop in lower extremities or retroperitoneum; cervico-mediastinal presentation is quite uncommon. These neoplasms are commonly diagnosed at a late stage because they remain asymptomatic until nearby structures are compressed. This makes radical excision particularly challenging. To date, alternative chemoradiotherapy protocols have not yet been standardized. We report a case of a 55-year-old man with a right laterocervical mass and without substantial symptoms. Fine-needle aspiration cytology results were compatible with a well-differentiated liposarcoma. Contrast-enhanced magnetic resonance imaging revealed the magnitude of the mass, which was expanding into the mediastinum; displacing the trachea, esophagus, cervical neurovascular bundle, and thoracic aorta; and encasing the brachiocephalic artery. Compression of the left brachiocephalic vein resulted in a focal enhancement spot in the fourth liver segment, the expression of superior vena cava compression, which can promote the development of collateral venous pathways, such as the caval-mammary-phrenic-hepatic capsule-portal venous pathway. The mass was successfully excised by a team of surgical subspecialists (otorhinolaryngologists and thoracic, cardiac, and vascular surgeons). Adjuvant tomotherapy was administered to increase local disease control. The patient remained disease-free 38 months postoperatively. This case underlines the importance of accurate preoperative radiologic evaluation in patients presenting with neck masses but without substantial symptoms. Because of the involvement of many critical structures, the cooperation of many surgical subspecialties is mandatory to achieve a satisfying oncologic outcome.

Clouds of different colors: A prospective look at head and neck surgical resident call experience

December 12, 2017  |  Jonathan Melzer, MD, LCDR, MC, USN


Graduate medical education programs typically set up call under the assumption that residents will have similar experiences. The terms black cloud and white cloud have frequently been used to describe residents with more difficult (black) or less difficult (white) call experiences. This study followed residents in the department of head and neck surgery during call to determine whether certain residents have a significantly different call experience than the norm. It is a prospective observational study conducted over 16 months in a tertiary care center with a resident training program in otolaryngology. Resident call data on total pages, consults, and operative interventions were examined, as well as subjective survey data about sleep and perceived difficulty of resident call. Analysis showed no significant difference in call activity (pages, consults, operative interventions) among residents. However, data from the resident call surveys revealed perceived disparities in call difficulty that were significant. Two residents were clearly labeled as black clouds compared to the rest. These residents did not have the highest average number of pages, consults, or operative interventions. This study suggests that factors affecting call perception are outside the objective, absolute workload. These results may be used to improve resident education on sleep training and nighttime patient management in the field of otolaryngology and may influence otolaryngology residency programs.

Proliferative pilomatricoma of the eyebrow in a 94-year-old patient

December 12, 2017  |  Christopher P. Nyte, DO

While pilomatricomas affect both the young and elderly, it is the elderly that tend to experience the advancing proliferative tumor type.