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Fiddler's neck: A review

February 20, 2017  |  Calvin W. Myint, MD; Amy L. Rutt, DO; Robert T. Sataloff, MD, DMA, FACS


Fiddler's neck is a common dermatologic condition associated with instrument use in violin and viola players. It typically manifests as a submandibular and/or supraclavicular lesion. It is a benign condition, but it may be mistaken for lymphedema or a salivary gland malignancy. Otolaryngologists who treat patients with fiddler's neck should be aware of appropriate management protocols and the need to avoid surgical excision. We obtained informed consent from 3 violinists to present their cases as specific examples of fiddler's neck. In addition, we present a literature review based on our PubMed search for articles about this instrument-induced dermatitis. The literature suggests that submandibular fiddler's neck is caused by mechanical pressure and shear stress on the skin and that it can present as erythema, scarring, edema, and lichenification. Supraclavicular fiddler's neck, on the other hand, is caused by allergic contact dermatitis, and it can present as an eczematous, scaly, and/or vesicular lesion. In most cases, a good history (especially of string instrument use), physical examination, and a patch test are sufficient to diagnose this condition. Management of fiddler's neck includes a topical steroid, proper instrument handling, neck padding, changing the instrument's materials, and/or reducing the amount of playing time. Surgical excision is usually not advisable.

Mechanical venous anastomosis in head and neck microvascular reconstruction as an equivalent to the gold standard

February 20, 2017  |  Eric Thorpe, MD; Yash Patil, MD


To define the most successful and efficient manner to perform venous microvascular anastomoses, the effectiveness of mechanical venous anastomosis in head and neck microvascular reconstruction is reviewed. Head and neck reconstruction with free flap techniques has become the norm and gold standard for large defects. This retrospective, multicenter case series of a single microvascular surgeon's experience with mechanical venous anastomoses specifically assessed the effectiveness of head and neck reconstruction and the complications associated with it. Data were collected from two separate academic centers and are reported from a consecutive series of patients over the course of 10 years. All patients underwent microvascular reconstruction of the head and neck region using venous couplers and flap survival. Flap survival was greater than 98% using mechanical venous couplers as the primary means for venous outflow in this series of 402 consecutive patients and 431 total microvascular flaps. Venous couplers were performed in every instance. The study shows that mechanical venous anastomosis provides a highly effective and efficient means for venous outflow in head and neck microvascular reconstruction, and should be considered equivalent to the gold standard suture technique, even in the most difficult cases.

Auricular solitary gouty tophus in a young adult

February 20, 2017  |  Chao-Yin Kuo, MD; Chih-Hung Wang, MD, PhD

The auricle, with its supersaturation of blood uric acid due to decreased temperature and reduced blood flow, is prone to develop gouty tophi.

Posterior epistaxis from inferior meatus: An endoscopic view

February 20, 2017  |  Jae Hoon Lee, MD

Most of the bleeding in posterior epistaxis originates from the posterior end of the lateral aspect of the middle and inferior turbinates and the lateral wall of the meatuses.

The use of high-resolution pharyngeal manometry as biofeedback in dysphagia therapy

February 20, 2017  |  Ashli O'Rourke, MD; Kate Humphries, MS

HRPM biofeedback therapy may be particularly beneficial for patients with sensory deficits by providing a visual mechanism for accurate exercise and strategy implementation.

Thyroglossal duct cyst

February 20, 2017  |  Lester D. Thompson, MD

Most patients present with a mobile, painless midline neck mass, usually inferior to the hyoid bone, showing movement with tongue protrusion.

Estimation of partitioning of airflow in septal surgery: A prospective study with reference to the NOSE scale

February 20, 2017  |  Indranil Sen, MS; Mainak Dutta, MS; Dibakar Haldar, MD; Ramanuj Sinha, DLO, MS, DNB


Improper patient selection for septal surgery often has been found to result in therapeutic failure, and there needs to be an objective assessment of nasal obstruction before the surgery and for postoperative follow-up that can be applied in the routine otolaryngology practice. The purpose of this study is to assess the usefulness of a cost-effective device for objective measurement of the nasal airway partitioning in selecting patients for septal surgery and for postoperative outcome evaluation. A hospital-based, prospective, observational study was carried out in a tertiary-care teaching institution involving 74 patients waiting for septal surgery. Each patient was exposed to subjective assessment of nasal obstruction by the Nasal Obstruction Symptom Evaluation (NOSE) scale and objective measurement by Nasal Partitioning Ratio (NPR) using a new device, Nasal Airway Partition Meter (NAPM), once before and twice after surgery. Overall, average NOSE score and NPR values were 66.42 ± 9.42 and 0.57 ± 0.18, respectively, at preoperative assessment (correlation coefficient 0.441). Sixty of the 74 patients had high values for both NPR and NOSE scores (Group 1), but in the remaining 14, NPR values were found to be lower despite high NOSE scores (Group 2). Postsurgery, the NOSE score and NPR values were significantly reduced in Group 1. In contrast, participants in Group 2 showed no alteration in the values of both the parameters after the same operative maneuver. However, 2 patients in Group 1 had NOSE score and NPR values unaltered, while 1 patient in Group 2 had a reduced NOSE score after surgery. Therefore, the validity of the new equipment was calculated to be 96.7% sensitive and 92.9% specific to identify patients who needed to undergo septal surgery for their nasal obstruction. It can be deduced from the present study that NAPM can be a cost-effective device for clinicians to objectively measure nasal airway obstruction and screen patients for septal surgery.

Efficacy of Intralipid infusion in reducing amphotericin-B-associated nephrotoxicity in head and neck invasive fungal infection: A randomized, controlled trial

February 20, 2017  |  Mehrdad Hasibi, MD; Sirous Jafari, MD; Seyyed Ali Dehghan Manshadi, MD; Marjan Asadollahi, MD; Mohammadreza Salehi, MD; Varasteh Vakili Zarch, MD; Ali Kouhi, MD


Amphotericin B deoxycholate (ABD) is the best therapeutic agent available for the treatment of most systemic fungal infections. However, some untoward adverse effects such as nephrotoxicity may limit its appropriate therapeutic use. We conducted a randomized, controlled trial ofthe infusion of fat emulsion (Intralipid) shortly after the infusion of ABD to evaluate its effects on reducing ABD-associated nephrotoxicity. Our patient population was made up of 31 patients who were randomized into two groups: an intervention group (n = 16) and a control group (15 patients). There were no statistically significant differences between the two groups in demographic or clinical variables. All patients received 1mg/kg/day of ABD in dextrose 5%. In addition, the patients in the intervention arm received Intralipid 10%, which was started as soon as possible within 1 hour after the infusion of ABD. ABD-associated nephrotoxicity was defined as a minimum 50% increase in baseline serum creatinine to a minimum of 2mg/dl. We also measured daily serum creatinine changes during the first 2 weeks of treatment, and we compared some other relevant indices of renal function, as well as ABD-related hypokalemia. We found no statistically significant differences between the two treatments in terms of ABD-associated nephrotoxicity or any of the other indices. We conclude that the administration of Intralipid 10% early after infusion of ABD in dextrose 5% does not have any effect in decreasing ABD-associated nephrotoxicity or hypokalemia.

Auricular complications in parotid, temporal bone, infratemporal fossa, and lateral skull base surgery

February 20, 2017  |  Patrick S. Carpenter, MD; Ryan C. Burgette, MD; John P. Leonetti, MD; Sam J. Marzo, MD


Neoplasms located in the parotid region, temporal bone, infratemporal fossa, and lateral skull base represent a challenge due to their difficult anatomic location and surrounding neurovascular structures. A variety of surgical approaches are appropriate to access this area, although several of them can place the auricular blood supply in danger. If the auricular blood supply is compromised, ischemia and, eventually, avascular necrosis of the auricle can occur. Auricular necrosis often can cause patients a delay in adjuvant radiation therapy and result in the need for additional reconstructive procedures. Therefore, it is imperative to identify risk factors associated with the development of this disabling complication. We conducted a retrospective review of 32 individuals undergoing treatment of benign and malignant lesions in the parotid gland, infratemporal fossa, and lateral skull base. To identify potential risk factors for auricular necrosis, the patients were analyzed based on the type of neoplasm (malignant or benign), risk factors affecting blood flow (diabetes mellitus, smoking history, prior radiation, prior surgery), body mass index, and the length of surgery. In our population examined, 3 instances of auricular necrosis occurred. None of the potential risk factors proved to be statistically significant (although malignant pathology approached significance at p = 0.07). Two of the patients required an auriculectomy with reconstruction. The third had multiple postoperative clinic visits for surgical debridement. Although no potential risk factors were statistically significant, surgeons should remain cognizant of the auricular blood supply while performing surgery via preauricular and postauricular approaches to this area.

Atypical parathyroid adenoma with diffuse fibrosis

February 20, 2017  |  Christine M. Clark, BA; Sakeena J. Payne, MD; Joshua I. Warrick, MD; David Goldenberg, MD, FACS

Atypical parathyroid adenomas are infrequently encountered and can present a diagnostic challenge, as they share overlapping clinical and histologic features with parathyroid carcinoma.