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Management of benign middle ear tumors: A series of 7 cases

November 3, 2017     Z. Jason Qian, MD; Amy M. Coffey, MD; Kathleen M. O'Toole, MD; Anil K. Lalwani, MD


Benign middle ear tumors represent a rare group of neoplasms that vary widely in their pathology, anatomy, and clinical findings. These factors have made it difficult to establish guidelines for the resection of such tumors. Here we present 7 unique cases of these rare and diverse tumors and draw from our experience to recommend optimal surgical management. Based on our experience, a postauricular incision is necessary in nearly all cases. Mastoidectomy is required for tumors that extend into the mastoid cavity. Whenever exposure or hemostasis is believed to be inadequate with simple mastoidectomy, canal-wall-down mastoidectomy should be performed. Finally, disarticulation of the ossicular chain greatly facilitates tumor excision and should be performed early in the procedure.

A novel etiology for pneumolabyrinth after temporal bone fracture without otic capsule involvement

November 3, 2017     Thomas J. Muelleman, MD; Vidur Bhalla, MD; Hinrich Staecker, MD, PhD


Pneumolabyrinth has been considered an indicator of otic capsule involvement in temporal bone fractures. We present a novel theory for the etiology of pneumolabyrinth in a trauma patient without an otic capsule fracture: passage of intrathecal air into the labyrinth. Our patient experienced transient bilateral pneumolabyrinth after head trauma due to a motor vehicle collision. The patient was noted to have extensive pneumocephalus and a unilateral temporal bone fracture that spared the otic capsule. Initial computed tomography (CT) scans demonstrated air in the cochlea and both internal auditory canals. A high-resolution CT scan 6 hours later showed resolution of this air. Pneumolabyrinth may not be a sensitive indicator of otic capsule involvement in temporal bone fractures. In addition to middle ear sources, air in the labyrinth can also plausibly originate intrathecally, especially in the setting of pneumocephalus.

Good teaching is not a race to cover content: Less can be more

November 3, 2017     Kenneth D. Royal, PhD, MSEd; Todd Zakrajsek, PhD

A controlled comparison of auditory steady-state responses and pure-tone audiometry in patients with hearing loss

November 3, 2017     Raman Wadhera, MS; Sharad Hernot, MS; Sat Paul Gulati, MS; Vijay Kalra, MS


We performed a prospective interventional study to evaluate correlations between hearing thresholds determined by pure-tone audiometry (PTA) and auditory steady-state response (ASSR) testing in two types of patients with hearing loss and a control group of persons with normal hearing. The study was conducted on 240 ears-80 ears with conductive hearing loss, 80 ears with sensorineural hearing loss, and 80 normal-hearing ears. We found that mean threshold differences between PTA results and ASSR testing at different frequencies did not exceed 15 dB in any group. Using Pearson correlation coefficient calculations, we determined that the two responses correlated better in patients with sensorineural hearing loss than in those with conductive hearing loss. We conclude that measuring ASSRs can be an excellent complement to other diagnostic methods in determining hearing thresholds.

Laryngeal hemangioma presenting as a laryngocele

November 3, 2017     Kevin Shaigany, MD; Sidrah M. Ahmad, MD; Nausheen Jamal, MD

Laryngeal hemangiomas and laryngoceles share similar characteristics and should be considered in the differential diagnosis.

Endoscopic view of a drainage pathway of a concha bullosa

November 3, 2017     Eiji Yanagisawa, MD, FACS; Dewey A. Christmas, MD; Joseph P. Mirante, MD, MBA, FACS

A concha bullosa does not require surgical intervention unless it creates obstructive problems with respiration or functional drainage problems.

"Live" tinnitus

November 3, 2017     Chia-Chun Liu, MD; Ming-Yee Lin, MD

Insects should be killed before removal with instrumentation, irrigation, or suction.

Myopericytoma of the neck originating in the middle scalene muscle: A case report

November 3, 2017     Mark B. Chaskes, MD, MBA; John W. Bishop, MD; Matthew Bobinski, MD, PhD; D. Gregory Farwell, MD


We report a case of myopericytoma of the neck. A 23-year-old woman noticed a small, nontender mass in her left supraclavicular fossa. The mass had grown over a period of 5 months, prompting her to seek evaluation. On examination, no motor or sensory deficits were present. Imaging suggested that a mass had originated in the middle scalene muscle. Computed-tomography-guided core needle biopsy demonstrated a spindle-cell neoplasm with smooth-muscle differentiation. Complete surgical excision was performed. Histopathologic and immunohistochemical evaluations of the tissue sample suggested a myopericytoma. Myopericytoma is an extremely rare tumor of the head and neck. To the best of our knowledge, this is the first reported case of a myopericytoma originating in a scalene muscle.

Clinical application of nasometry in patients with nasal obstruction

November 3, 2017     Georges Ziade, MD; Maher Kasti, MD; Doja Sarieddine, BS; Zein Saadeddine, BS; Abdul-Latif Hamdan, MD


The purpose of this case-control study is to report on the clinical application of nasometry as a diagnostic tool in patients with the symptom of nasal obstruction compared with subjects with no history of nasal obstruction. Thirty-eight adult patients (mean age: 28.1 years) complaining of nasal obstruction were enrolled in the study, and another group of 38 adults (mean age: 25.9 years) with no history of nasal obstruction served as controls. Demographic data, including age and sex, were collected. Patients were asked to read three passages; the Zoo passage, the Rainbow passage, and nasal sentences. Nasalance scores were reported on all subjects using a Nasometer II instrument. The control and patient groups each included 22 men and 16 women. No statistically significant difference in nasalance score was found between the study group and the control group in any of the Zoo passage, Rainbow passage and nasal sentences. We conclude that nasometry has limited value in the objective assessment of nasal obstruction as a symptom, which we attribute to nasal obstruction's not always reflecting the volume and pressure in the nasal cavity.

Guidelines for radiographic imaging of cranial neuropathies

November 3, 2017     Aliasgher Khaku, BS; Vijay Patel, BS; Thomas Zacharia, MD; David Goldenberg, MD; Johnathan McGinn, MD


Disruption of the complex pathways of the 12 cranial nerves can occur at any site along their course, and many, varied pathologic processes may initially manifest as dysfunction and neuropathy. Radiographic imaging (computed topography or magnetic resonance imaging) is frequently used to evaluate cranial neuropathies; however, indications for imaging and imaging method of choice vary considerably between the cranial nerves. The purpose of this review is to provide an analysis of the diagnostic yield and the most clinically appropriate means to evaluate cranial neuropathies using radiographic imaging. Using the PubMed MEDLINE NCBI database, a total of 49,079 articles' results were retrieved on September 20, 2014. Scholarly articles that discuss the etiology, incidence, and use of imaging in the context of evaluation and diagnostic yield of the 12 cranial nerves were evaluated for the purposes of this review. We combined primary research, guidelines, and best practice recommendations to create a practical framework for the radiographic evaluation of cranial neuropathies.

Nasal septum granuloma gravidarum

November 3, 2017     Daniel Thomas Ginat, MD, MS; Charles J. Schatz, MD, FACR

Granuloma gravidarum lesions tend to be highly vascular and demonstrate avid enhancement, but they do not have large draining veins.

Boomerang-shaped vs. shield-shaped chondroperichondrial cartilage grafts for type 1 tympanoplasty in children: A study of 121 patients

November 3, 2017     Can Ozbay, MD; Fatih Kemal Soy, MD; Erkan Kulduk, MD; Riza Dundar, MD; Ahmet Yukkaldiran, MD; Osman Kadir Guler, MD; Ertan Koc


Many techniques and graft materials have been used for the reconstruction of the tympanic membrane. We conducted a retrospective study to compare anatomic and functional outcomes of type 1 tympanoplasty that we performed with boomerang-shaped chondroperichondrial cartilage grafts (BSGs) and shield-shaped chondroperichondrial cartilage grafts (SSGs) in pediatric patients. Our study population was made up 121 patients-61 boys and 60 girls, aged 7 to 16 years (mean: 12.4)-who had undergone a type 1 tympanoplasty. Patients were divided into two groups according to the grafting technique used; there were 59 patients in the BSG group and 62 patients in the SSG group. Ear examinations were performed at postoperative months 3, 6, 12, and 24, and pure-tone average (PTA) for air-conduction threshold values and air-bone gaps (ABGs) were evaluated at 0.5, 1.0, 2.0, and 4.0 kHz at the same visits. We also investigated the impact of the graft material on functional graft success and intergroup differences (if any) in surgical success. Mean postoperative follow-up periods were 30.5 and 30.2 months in the BSG and SSG groups, respectively. We found that the success rates for tympanic membrane reconstruction were not significantly different in the two groups (91.5 and 88.7%). Postoperatively, the mean PTA and ABG values in both groups at 3, 6, 12, and 24 months were significantly lower than the preoperative values (p < 0.05). There were no significant differences in mean PTA values between the two groups at 3, 6, 12, and 24 months. However, the extent of the decrease in PTA values in the BSG group at 3 months was significantly greater than that of the SSG group (p < 0.05). There were no significant differences in mean ABG values between the two groups at 3, 6, and 12 months, but at 24 months, the value was significantly higher in the BSG group (p < 0.05). Finally, the extent of the decrease in ABG in the BSG group at both 3 and 6 months was significantly greater than that of the SSG group (p < 0.05). We conclude that the BSG procedure is a reliable and safe method of performing pediatric tympanoplasty.

Olfactory dysfunction in beta-thalassemia major patients treated with iron-chelating agents

November 3, 2017     Serhan Derin, MD; Selvet Erdogan, MD; Murat Sahan, MD; Mehmet Fatih Azik, MD; Hatice Derin, MD; Yasar Topal, MD; Hatice Topal, MD


Ocular and ophthalmologic adverse effects may occur in patients with β-thalassemia major (BTM) treated regularly with blood transfusions and iron-chelating agents. We hypothesized that olfactory dysfunction may be present in this patient population. We aimed to investigate olfactory dysfunction in patients with BTM and to determine etiologic factors. A total of 43 patients with BTM were included in the study. Forty-three subjects without nasal complaints, history of facial trauma, or nasal surgery were included as the controls. All participants had nasal endoscopy. The use of iron-chelating agents by patients with BTM and their duration of use were recorded, as well as hemoglobin and ferritin levels. The Sniffin' Sticks test (SST) was used to assess olfactory function, comparing results between the BTM and control groups. The correlations of SST scores with the other study parameters were analyzed. Eight (18.6%) of 43 patients in the BTM group and none of the subjects in the control group had hyposmia (p < 0.001). Older age, low hemoglobin level, and longer use of deferoxamine were found to be correlated with olfactory dysfunction. Olfactory dysfunction can occur in patients with BTM treated with iron-chelating agents. The results suggest that screening for olfactory function should be part of the routine follow-up of patients with BTM.

Managing head and neck malignancy arising in a field of Crohn disease inflammation: Report of a case

November 3, 2017     Christina Yver, MD, MBA; Darshana Jhala, MD; Amanda Muir, MD; Devraj Basu, MD, PhD


Some of the clinical characteristics of Crohn disease of the head and neck overlap those of squamous cell carcinoma of the head and neck. We describe the diagnostic and therapeutic complexities we encountered in an unusual case of piriform sinus cancer that had arisen in a field of pharyngeal Crohn disease. Based on our initial failure to recognize the predominant inflammatory component of the lesion, we discuss the special considerations that must be made for the detection, staging, and management of head and neck cancer in Crohn disease patients. We further describe the multiple potential interactions among smoking, inflammation, and immunosuppression therapy in the colocalized pathogenesis of the two disease states.

Nasal smear eosinophils and allergic rhinitis

November 3, 2017     Indranil Pal, MS; Anindita Sinha Babu, MD; Indranil Halder, MD; Saumitra Kumar, MS


Our aim was to find out the association between nasal smear eosinophil count and allergic rhinitis (AR) and to determine a cutoff value that is significant for a diagnosis of AR. We also wanted to determine whether this count is related to the predominant symptoms, duration, or type and severity of AR, or to the presence of coexisting asthma. We selected 100 patients with a clinical diagnosis of allergic rhinitis across all age groups and an equal number of age- and sex-matched controls for the study. Their nasal smear eosinophil counts were recorded in terms of the number of eosinophils per high-power field (HPF). All patients were then clinically assessed for asthma and underwent spirometry. The data were recorded and appropriate statistical analysis done. The difference in the mean eosinophil counts of patients with AR and controls was found to be statistically significant (p = 0.000). A nasal smear eosinophil count of >0.3 per HPF had a 100% specificity and a 100% positive predictive value for AR. Asthma was associated with allergic rhinitis in 40% of patients; an association was not found between nasal smear eosinophil count and the symptoms, duration, type, and severity of allergic rhinitis or coexistent asthma. We conclude that an eosinophil count of >0.3 per HPF in nasal smears is a highly specific criterion for the diagnosis of AR. However, nasal smear eosinophil counts are poor indicators of the degree, duration, or type of upper or associated lower airway inflammation due to allergy.

Measles: A missed cause of acute tonsillitis

November 3, 2017     Wen-Sen Lai, MD; Yuan-Yung Lin, MD; Chih-Hung Wang, MD, PhD; Hsin-Chien Chen, MD, PhD

Although widespread measles vaccinations have resulted in a low incidence of measles in developed countries, clinicians should keep in mind the possibility of measles in patients with Koplik spots and acute tonsillitis.

Effects of septoplasty on olfactory function evaluated by the Brief Smell Identification Test: A study of 116 patients

November 3, 2017     S&uuml;heyl Hayto&gbreve;lu, MD; Ramazan Dengiz, MD; Nuray Bayar Muluk, MD; G&ouml;khan Kuran, MD; Osman Kursat Arikan, MD


We conducted a prospective study of 116 patients-61 men and 55 women, aged 17 to 64 years (mean: 26.4)-to investigate the effects of septoplasty on olfactory function in patients with septal deviation (SD). The Mladina classification system was used to define SD types, and olfactory function was assessed with the Brief Smell Identification test (BSIT). The BSIT, which includes 12 odorants, was administered preoperatively and at postoperative months 1 and 3. The most common SD types were types 2 (20.7% of patients) and 1 (19.0%), followed by types 3 and 5 (both 16.4%). At postoperative month 1, the mean BSIT score was significantly higher in men than in the women. For patients with types 1 and 2 SD, BSIT scores at 1 month were significantly lower than the scores preoperatively and 3 months postoperatively. For types 3 and 4, BSIT values were significantly higher at 3 months than preoperatively or at 1 month. For type 3 SD, the preoperative mean score was significantly lower than those for types 1, 4, 5, 6, and 7; for type 2 SD, the BSIT score was significantly lower than those of types 5 and 6 only. At 1 month, the scores for types 2 and 3 were significantly lower than those for types 4, 5, 6, and 7. At 3 months, the BSIT score for type 2 was significantly lower than those of types 1, 3, 4, 5, and 6; the type 3 SD score at 3 months was significantly higher than those for types 1, 2, 5, 6, and 7. We conclude that septoplasty surgery for patients with a type 3 SD may improve olfactory function. In contrast, we found that olfactory function in patients with a type 2 SD did not improve to a satisfactory degree, even when good nasal patency was achieved with a corrected septum and an enlarged intranasal volume. Our findings should be investigated further in future studies.

Acrokeratosis paraneoplastica (Bazex syndrome)

November 3, 2017     Jerome R. Lechien, MD, PhD, MS; Mohamad Khalife, MD; Sven Saussez, MD, PhD

The first stage of acrokeratosis paraneoplastica involves symmetrical lesions in the ears, nose, and fingers.

Correlation between sensorineural hearing loss and chronic otorrhea

November 3, 2017     Fernanda Martinho Dobrianskyj, MS; Isis Rocha Dias Goncalves, DO; Yumi Tamaoki, DO; Edson Ibrahim Mitre, MD; Fernando A. Quintanilha Ribeiro, PhD


Many studies have attempted to correlate chronic otorrhea in children and in adults with the sensorineural hearing loss in the affected ear, with contradictory results. This loss might be the result of the likely toxicity of the bacteria involved, effects of inflammatory cytokines, or constant use of ototoxic antibiotics. All studies evaluated to date compared the affected ear with the normal contralateral ear. From the digitized archive of otologic surgery files of the Department of Otorhinolaryngology at Santa Casa de São Paulo School of Medical Sciences, the ears of patients with chronic otorrhea were evaluated visually and compared with the normal contralateral ears. Ears with otorrhea were also compared with ears of other patients with dry tympanic perforation. Ears with suppuration were evaluated for cholesteatoma. The duration of otorrhea was considered. The sensorineural hearing threshold was evaluated for the frequencies of 500, 1,000, 2,000, and 4,000 Hz. A total of 98 patients with chronic otorrhea and 60 with dry tympanic membrane perforation were evaluated. A correlation between sensorineural hearing loss and chronic otorrhea was observed when compared with both contralateral normal ears and dry perforated ears of other patients. No relationship between hearing loss and the duration of suppuration or cholesteatoma was found. Sensorineural hearing loss occurs in ears with chronic otorrhea. The duration of otorrhea and the etiology of suppuration did not influence the hearing loss.

Pediatric sinonasal desmoid tumor

November 3, 2017     Jonathan Choi, MD; Evan Walgama, MD; John McClay, MD; Pete S. Batra, MD, FACS; Ron B. Mitchell, MD

Desmoid-type fibromatosis is clinically characterized by a tendency for local recurrence but no metastatic potential.