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Positron-emission tomography enhancement after vocal fold injection medialization

June 20, 2017     Nazaneen Grant, MD; Richard J. Wong, MD; Dennis H. Kraus, MD; Heiko Schoder, MD; Ryan C. Branski, PhD


The potential for the misinterpretation of positron-emission tomography (PET) scans in the context of a possible malignancy has been confirmed in a case report showing increased 18F-fluorodeoxyglucose (FDG) uptake after unilateral vocal fold augmentation medialization. We sought to expand these findings by investigating FDG uptake in a larger cohort of patients via a retrospective chart review. We examined the records of 15 adults-8 men and 7 women-who had undergone vocal fold augmentation for unilateral vocal fold paralysis and at least one subsequent PET scan. The differences in PET standard uptake value (SUV) between the injected and noninjected vocal folds were assessed via the Wilcoxon signed-rank test. A Spearman rank correlation coefficient was then used to estimate the relationship between differences in PET uptake and the length of time between the injection and the follow-up PET scan. The mean SUV of the injected vocal folds was 3.70, and the mean in the noninjected folds was 2.97. The difference did not achieve statistical significance (p = 0.34). In addition, the rank correlation coefficient with regard to the association between the difference in PET uptake and the duration between injection and PET was -0.24, suggesting an inverse relationship. However, the correlation coefficient did not differ significantly from zero (p = 0.34). We conclude that PET uptake after vocal fold augmentation medialization is variable and that it can increase substantially. This information should be considered in the context of the diagnostic accuracy of malignancy on PET.

Initial experience of a hereditary hemorrhagic telangiectasia center of excellence

June 20, 2017     Christopher F. Thompson, MD; Jeffrey D. Suh, MD; Justin McWilliams, MD; Gary Duckwiler, MD; Marilene B. Wang, MD


Our objectives in reviewing the initial experience of a hereditary hemorrhagic telangiectasia center of excellence (HHT COE) were to better understand the interventions being performed in the comprehensive care of these patients and to present the early data as a reference for other tertiary centers considering starting an HHT COE. We conducted a retrospective review of consecutive patients referred to our newly developed HHT COE for evaluation and treatment between May 2010 and June 2013. Clinical presentation, otolaryngologic treatments, and other operative interventions were analyzed. One hundred forty-four of the 198 patients (73%) evaluated at the HHT COE had definite HHT based on the Curaçao diagnostic criteria, with 20 additional patients possibly having HHT and undergoing further evaluation to confirm the diagnosis. Sixteen of the 31 patients (52%) referred to otolaryngology required intervention in the operating room for epistaxis. Seventy-two of the 164 (44%) patients with definite or possible HHT required other interventions for internal organ arteriovenous malformations (AVMs), with interventional radiology embolization of pulmonary AVMs being the most common procedure. An HHT COE is important in providing comprehensive care for patients with this rare disease, which has significant clinical sequelae. Having an HHT COE allows for early screening and subspecialty referral within a system of specialists experienced in preventing the morbidity and mortality associated with severe epistaxis and internal organ AVMs.

June is National Dysphagia Awareness Month

June 20, 2017     Amanda Hu, MD, FRCSC

The Agency for Healthcare Research and Quality has estimated that 60,000 people in the United States die annually from complications associated with swallowing disorders.

Results of endonasal dacryocystorhinostomy in pediatric patients

June 20, 2017     Sat Paul Gulati, MS; Raman Wadhera, MS; Ashok Kumar Khurana, MS; Nidhi Singh, MS; Vijay Kalra, MS; Anju Ghai, MD


We conducted a prospective interventional study to evaluate the role of endoscopic endonasal dacryocystorhinostomy in children. Our study population was made up of 20 patients-18 boys and 2 girls, aged 2 to 12 years (mean: 5.3)-who presented with signs and symptoms suggestive of nasolacrimal duct blockage that was refractory to conventional medical treatment. In all cases, blockage was confirmed by nasolacrimal duct syringing that demonstrated regurgitation from the opposite punctum. The primary outcome measures for success were resolution of symptoms and duct patency on lacrimal irrigation. At 6 months, 17 patients (85%) experienced complete symptomatic relief, 1 (5%) had partial relief, and 2 (10%) reported no relief. Moreover, the nasolacrimal duct was patent in 17 patients, partially patent in 2, and blocked in 1. We conclude that endoscopic endonasal dacryocystorhinostomy is a safe and effective procedure in children with nasolacrimal duct blockage when medical therapy and probing have been unsuccessful.

Vocal fold hemorrhage into a physiologic sulcus

June 20, 2017     Daniel A. Benito, MD; Jonathan J. Romak, MD; Robert T. Sataloff, MD, DMA, FACS

Predisposing factors include traumatic vocal activities such as aggressive singing, throat clearing, coughing, or shouting, especially with the use of anticoagulants.

Endoscopic view of a dumbbell-shaped sphenoid fungal mass

June 20, 2017     Dewey A. Christmas, MD; Joseph P. Mirante, MD, FACS; Eiji Yanagisawa, MD, FACS

In cases of sinus mycetoma, endoscopic debridement and adequate drainage of the sinus is a very effective course of treatment.

Infestation of mites in external auditory canal

June 20, 2017     Denis Massatsugu Ueda, MD; Ricardo Borges, MD; José Eduardo Poloni da Silva, BS

Dermatophagoides spp comprise one of the most prevalent genera of house mites that, although well-known as allergens, rarely also parasitize the human body.

Salivary epidermal growth factor concentrations in patients with Sjogren syndrome and laryngopharyngeal reflux

June 20, 2017     Claudia A. Eckley, MD; Marco Antônio dos Anjos Corvo, MD; Luis Roberto Sardinha, PhD; Bianca Liquidato, MD; Luiz Vicente Rizzo, MD


Sjögren syndrome was chosen as a clinical model to study acinar salivary deficiencies in the development of laryngopharyngeal reflux (LPR). The objective of this prospective cohort study was to compare salivary epidermal growth factor (EGF) concentrations of patients with Sjögren syndrome with and without LPR and gastroesophageal reflux disease (GERD) with normal controls. LPR was diagnosed with positive scores on the Reflux Symptom Index and Reflux and Reflux Finding Score, corroborated by esophagogastroduodenoscopy and/or 24-hour pH-metry. Salivary EGF concentrations of both unstimulated and mechanically stimulated saliva were established using enzyme-linked immunosorbent assay, and the significance level was set at 95%. Twenty-one patients and 19 controls were studied. All patients had LPR and 60% also had GERD. The mean salivary EGF concentration of unstimulated and stimulated saliva in the control group was 1,751.37 pg/ml and 544.76 pg/ml, respectively. Unstimulated and stimulated salivary EGF concentrations in the study group were 2,534.65 pg/ml and 920.69 pg/ml, respectively. These differences were not statistically significant. Body mass index, presence of erosive esophagitis, or severity of hyposalivation did not significantly influence salivary EGF concentrations. LPR and GERD are highly prevalent in patients with Sjögren syndrome. Unlike previous studies in which significant EGF deficiencies were found in patients with reflux laryngitis and GERD, patients with Sjögren syndrome seem to have reflux caused by a decrease in clearance capacity and not in specific salivary components.

Is there an association between migraine and allergic rhinitis?

June 20, 2017     Isil Adadan Guvenc, MD; Mustafa Acar, MD; Nuray Bayar Muluk, MD; Nagehan Erdogmus Kucukcan, MD; Cemal Cingi, MD


We conducted a prospective study to evaluate nasal signs and symptoms and to perform allergen-specific immunoglobulin E (IgE) testing to investigate the relationship between migraine and allergic rhinitis. Our study group consisted of 40 patients diagnosed with migraine-22 men and 18 women, aged 21 to 38 years (mean: 25.7). We compared their findings with a control group of 40 healthy adults-15 men and 25 women, aged 19 to 36 years (mean: 25.1). Allergen-specific IgE measurements were obtained with six groups of allergens: fungi, grass pollens, tree pollens, wild herbs, house dust mite 1, and house dust mite 2. We found no significant difference between the migraine patients and the controls in the incidence of nasal signs and symptoms (i.e., discharge, congestion, itching, and sneezing) or inferior turbinate signs (i.e., color and edema). According to the IgE assays, 14 migraine patients (35.0%) were sensitized to one or more allergens, compared with 11 of the controls (27.5%); the difference was not statistically significant. Sensitization was highest for the grass pollens panel in both groups. Even though we did not find an association between migraine and allergic rhinitis, the recent literature supports a correlation between migraine and atopy. The two conditions share common neural pathways and common mediators, and they can be linked statistically in patients and their families. A pathophysiologic association between the two conditions seems more likely than an etiologic association. In this regard, future efforts could be focused on the determination of atopy in migraine patients and the therapeutic implications of this diagnosis.

A comparison of tonsillar surface swabbing, fine-needle aspiration core sampling, and dissected tonsillar core biopsy culture in children with recurrent tonsillitis

June 20, 2017     Saurav Sarkar, MBBS, MS, FACS; Abheek Sil, MBBS; Soma Sarkar, MBBS, MD; Biswajit Sikder, MBBS, MS


In recurrent tonsillitis, the pathogenic bacteria are harbored in the tonsil core, and therefore cultures of superficial swab samples are not particularly accurate in identifying specific types of core bacteria. On the other hand, the results of fine-needle aspiration (FNA) cultures of core samples have been closely correlated with the findings of core cultures in excised tonsils, and both methods are far superior to surface swabbing. We conducted a prospective study to compare the accuracy of culture findings from tonsillar tissue obtained by surface swabbing, FNA sampling of the tonsil core in situ, and core sampling of the excised tonsil in children with recurrent tonsillitis. Our patient population was made up of 54 children-22 boys and 32 girls, aged 4 to 14 years (mean: 10.7)-who were undergoing elective tonsillectomy during a 1-year period. On the day of surgery, a surface swab, core FNA sample, and dissected core sample were obtained from each patient and sent for culture. Culture showed that the three methods were in agreement in 34 cases (63.0%). In 9 cases (16.7%) the surface swab culture grew different pathogens from those of the two core cultures, and in 3 other cases (5.6%) the surface swab culture was negative while the two core cultures were positive for the same pathogens. In all, the results of core FNA culture and dissected core culture were in agreement in 46 cases (85.2%); in only 4 cases (7.4%) did the core FNA culture fail to accurately identify the causative pathogens. Overall, the sensitivity and specificity of core FNA sampling were 100 and 50% respectively, compared with 82.9 and 30.8% for the superficial tonsillar swab. We conclude that routine culture of surface swab specimens in patients with chronic or recurrent tonsillitis is neither reliable nor valid. We recommend that core FNA sampling be considered the diagnostic method of choice since it can be done on an outpatient basis, it would reliably allow for culture-directed antibiotic therapy, and it could obviate the need for elective tonsillectomy in many cases. However, its feasibility as an office procedure in children remains to be determined.

Synchronous lesions of the right accessory parotid gland and left main parotid gland

June 20, 2017     Ba D. Nguyen, MD

Tumoral involvement of parotid glands is usually solitary; multifocality is rare

Correlation among external auditory canal anomaly, temporal bone malformation, and hearing levels in patients with microtia

June 20, 2017     Kun Chen, MS; Liu Liu, MS; Runjie Shi, MD; Peihua Wang, MD; Dong Chen, MD; Hua Xiao, MD


We conducted a retrospective study to evaluate the relationship between external auditory canal (EAC) anomaly, temporal bone abnormality, and hearing levels using objective scoring systems in Chinese patients with microtia. The study population consisted of 106 ears of 94 Chinese patients (67 male and 27 female) aged 5 to 45 years (mean: 12.6) with microtia. The EAC abnormalities were classified into 4 types according to Schuknecht's criteria: type A, type B, type C, and type D. Developmental anomalies of the temporal bone were evaluated by Jahrsdoerfer computed tomography (CT) scoring system using high-resolution CT scans of the temporal bone. Temporal bone malformation parameters were divided into 4 subgroups: ossicular chain development, windows connected to the cochlea, aeration development of the middle ear, and facial nerve aberration. Hearing levels (air conduction and bone conduction) were examined. Outcomes parameters included correlation coefficients (r) and a number of other variables. The total points (10 points) and subtotal points related to ossicles (4 points), windows (2 points), aeration (2 points), and facial nerve (1 point) correlated inversely with the EAC abnormalities. The hearing levels (air conduction, r = 0.396, p <0.01; bone conduction, r = 0.21, p = 0.03) correlated significantly with the EAC abnormalities of Schuknecht's classification. We conclude that the better developed the external auditory canal, the better developed the temporal bone and the better developed the external auditory canal, the better hearing level. The hearing level also can serve as an indicator to determine whether a patient will be suitable for reconstructive surgery.

The protective effect of intratympanic dexamethasone on streptomycin ototoxicity in rats

June 20, 2017     Aylin Gul, MD; Engin Sengul, MD; Beyhan Yilmaz, MD; Fazil Emre Ozkurt, MD; Mehmet Akdag, MD; Aysenur Keles, MD; Ismail Topcu, MD


The purpose of this experimental study was to investigate the protective role of intratympanically administered dexamethasone on the inner ears of rats that were exposed to streptomycin ototoxicity. Twenty-four adult Wistar albino rats were separated into 4 groups: Group 1 (only streptomycin), Group 2 (only intratympanic dexamethasone), Group 3 (streptomycin and intratympanic dexamethasone), and Group 4 (streptomycin and intratympanic saline). All rats were evaluated with distortion product otoacoustic emissions (DPOAE) tests before the start of treatment and on the day it ended. On the 45th day, after the final DPOAE tests, animals of all groups were sacrificed under general anesthesia. The differences between the amplitudes of DPOAE results were determined, and hearing results were statistically analyzed. Also, the cochleas of each rat were histopathologically evaluated under a light microscope with hematoxylin and eosin staining. In the intratympanic dexamethasone group it was observed that cochlear hair cells were mostly protected. No significant difference was seen between the DPOAE results before and after treatment (p >0.05). On the other hand, loss was observed in the hearing functions and hair cells of the rats that received streptomycin and streptomycin plus intratympanic saline (p <0.05). In the streptomycin plus intratympanic dexamethasone group, the cochlear hair cells were partially protected. A significant difference was observed when the DPOAE results (DP-grams) of the streptomycin plus intratypmanic dexamethasone group were compared to those of the streptomycin plus intratympanic saline group (p <0.05). After the experimental study, ototoxic effects of the administration of streptomycin and intratympanic dexamethasone were observed on the rats' cochlear hair cells. We conclude that intratympanic dexamethasone has protective effects against this cochlear damage in rats.

Is computed tomography perfusion a useful method for distinguishing between benign and malignant neck masses?

June 20, 2017     Fatih Duzgun, MD; Serdar Tarhan, MD; Gulgun Yilmaz Ovali, MD; Gorkem Eskiizmir, MD; Yuksel Pabuscu, MD


Evaluation of neck masses is frequent in ear, nose, and throat clinics. Successful outcomes associated with neck mass are directly related to rapid diagnosis and accurate treatment for each patient. Late diagnosis of a malignant mass increases the magnitude of morbidity and the rate of mortality of the disease. Although magnetic resonance imaging and computed tomography (CT) examinations are important tools for evaluating head and neck pathologies, they do not allow functional evaluation. For this reason, CT perfusion (CTP) as a method of functional evaluation for distinguishing benign from malignant masses is gaining attention. The utility of CTP for distinguishing between benign and malignant mass lesions was investigated in 35 patients with masses in the neck (11 benign, 24 malignant). CTP was shown to be a useful method for identifying head and neck tumors and blood volume values to enable the differential diagnosis of benign and malignant head and neck tumors.

Impact of a pediatric anesthesiologist on operating room efficiency during pediatric tonsillectomies and adenotonsillectomies

June 20, 2017     Nicholas A. Dewyer, MD; Yoseph A. Kram, MD; Stephen Long, MD; Marika D. Russell, MD, FACS


We conducted a retrospective case review to determine if the presence of an Accreditation Council for Graduate Medical Education (ACGME) fellowship-trained pediatric anesthesiologist improves efficiency during pediatric tonsillectomies and adenotonsillectomies in hospitals that do not have dedicated pediatric operating rooms and, if so, to determine which specific anesthesia practices might account for such a difference. We reviewed the charts of all patients aged 12 years and younger who had undergone a tonsillectomy or adenotonsillectomy from Jan. 1, 2008, through Aug. 1, 2013, at San Francisco General Hospital. A total of 75 cases met our eligibility criteria. We compiled information on patient demographics, surgical time, anesthesia time, and anesthesia practices. Our primary study outcome was the amount of anesthesia-controlled time (ACT), which is the sum of time spent in induction and emergence. Cases were grouped according to whether the operation was staffed by an ACGME fellowship-trained pediatric anesthesiologist or a general anesthesiologist. Data were analyzed for 1 pediatric anesthesiologist and 23 general anesthesiologists. We found that ACT was significantly shorter during the cases staffed by the ACGME fellowship-trained pediatric anesthesiologist, although there were no major differences in anesthesia practices between the types of anesthesiologist. We suggest that staffing pediatric tonsillectomy operations with a fellowship-trained pediatric anesthesiologist may be an effective strategy for increasing operating room efficiency.

Parathyroid carcinoma in a patient with three prior parathyroid adenomas

June 20, 2017     Michael Goldenberg, MA; Henry Crist, MD; Darrin V. Bann, MD, PhD

Fine-needle aspiration is contraindicated because of its inability to distinguish parathyroid carcinoma from benign disease and the risk of seeding tumor along the biopsy tract.

Idiopathic pretracheal deep neck space infection with mediastinal extension: A series of 3 cases and review of the literature

June 20, 2017     Samuel Roberts, BMed; Lyndon Chan, MBBS (Hons); Robert Eisenberg, MBBS, FRACS


Idiopathic pretracheal deep neck space infection is an extremely rare condition with potentially devastating complications. We present a series of 3 cases of pretracheal deep neck space infection that arose in the absence of trauma or a congenital lesion and that exhibited mediastinal spread. To the best of our knowledge, these cases represent the first reported series of this rare condition to be published in the English-language literature. All cultures grew Streptococcus milleri, and all patients had a favorable outcome. A high index of suspicion for a deep neck space infection is warranted in view of the devastating complications of this condition. Computed tomography is the investigation of choice. Treatment with intravenous antibiotics and surgical drainage, particularly when mediastinitis is present, is recommended. This rare presentation warrants a thorough investigation to identify the source of infection.

Massive auricular cutaneous horn

June 20, 2017     Christopher P. Nyte, DO

The importance of preoperative histologic examination of the horn base with a suitable shave or punch biopsy cannot be overstated given the risk of underlying malignancy.

Adenoid cystic carcinoma of the head and neck area: Oncologic treatment and plastic-reconstructive options

June 20, 2017     Johannes A. Veit, MD; Julia Thierauf, MD; Thomas K. Hoffmann, PhD, MD; Jens Greve, PhD, MD; Nicole Rotter, PhD, MD; Patrick J. Schuler, PhD, MD; Marc O. Scheithauer, PhD, MD


Adenoid cystic carcinoma of the head and neck area is a rare malignant tumor with acceptable short-term but mediocre long-term prognosis. Radical tumor excision with clear resection margins, and sometimes resection of the facial nerve due to perineural growth, remains the fundamental therapy. We present 3 distinct clinical cases and discuss the current therapeutic options with special focus on plastic-reconstructive techniques. For reconstruction, the full armament of local and free flaps, as well as prosthetics, may be necessary. Adjuvant radiotherapy increases local control in advanced stages or close resection margins. However, systemic treatment options are limited. Further multicenter clinical trials are necessary due to the rare occurrence of the tumor.

Aggressive differentiated thyroid cancer in the geriatric patient

June 20, 2017     Kourosh Parham, MD, PhD, FACS; Karen M. Kost, MD, FRCSC

Although differentiated thyroid cancer is typically considered a relatively indolent disease, this is not the case in older adults.