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Paresis podule on a paralyzed vocal fold

August 24, 2017  |  Karthik S. Shastri, MD; Aaron J. Jaworek, MD; Robert T. Sataloff, MD, DMA, FACS

Paresis podules are localized areas of Reinke edema that can develop on paretic or paralyzed vocal folds, or on the contralateral vocal fold.

Otolaryngic manifestations of Cushing disease

August 24, 2017  |  Edward C. Kuan, MD, MBA; Kevin A. Peng, MD; Jeffrey D. Suh, MD; Marvin Bergsneider, MD; Marilene B. Wang, MD


Cushing disease is a relatively rare cause of Cushing syndrome secondary to a hyperfunctioning pituitary adenoma. In addition to signs and symptoms of hypercortisolism, Cushing disease may present with diverse otolaryngic manifestations, which may guide diagnosis and management. We performed a retrospective chart review of patients who were found to have Cushing disease and who underwent transnasal transsphenoidal surgery for pituitary adenomas between January 1, 2007, and July 1, 2014, at a tertiary academic medical center. There were 37 consecutive patients in this series with Cushing disease caused by a pituitary adenoma. Fifteen (41%) patients complained of visual changes. Five (14%) patients suffered from obstructive sleep apnea. Four (11%) patients had thyroid disease. Other symptoms included hearing loss, vertigo, tinnitus, epistaxis, dysphagia, and salivary gland swelling. Although Cushing disease traditionally presents with classic “Cushingoid” systemic features, it also may present with various otolaryngic manifestations. A thorough workup by otolaryngologists is critical in the comprehensive management of these patients.

Cornelia de Lange syndrome: What every otolaryngologist should know

August 24, 2017  |  Michael J. Eliason, MD, USN, LCDR; Jonathan M. Melzer, MD, USN, LCDR; Thomas Q. Gallagher, DO, USN, CDR


Cornelia de Lange Syndrome (CdLS) can be expressed in multiple organ systems requiring a variety of specialists, including pediatric otolaryngology. We present the case of a 20-month-old boy with CdLS actively managed by an aerodigestive team consisting of pediatric otolaryngology, pediatric pulmonology, pediatric gastroenterology, with support staff from audiology, speech, and nutrition. His presentation included mixed hearing loss, dysphagia, microaspiration, gastroesophageal reflux, and failure to thrive. We submit this challenging case of CdLS with a review of the literature to focus specific attention on the otolaryngic manifestations of the syndrome and to discuss the benefits of a multidisciplinary approach to these unique patients.

A clinicopathologic and epidemiologic study of chronic white lesions in the oral mucosa

August 24, 2017  |  Sampurna Ghosh, MS; Sudipta Pal, MS; Soumya Ghatak, MS; Somnath Saha, MS; Surajit Biswas, MD; Prabha Srivastava, MD


Invasive oral squamous cell carcinoma is often preceded by the presence of clinically identifiable premalignant changes of the oral mucosa, including white lesions. We conducted a cross-sectional, observational study to assess the clinicopathologic and epidemiologic aspects of chronic oral mucosal white lesions to determine the necessity of early biopsy in these cases. Our study population was made up of 77 patients-50 males and 27 females, aged 15 to 70 years (mean: 42.9)-who presented with white lesions persisting for at least 4 weeks. All but 3 patients underwent a biopsy; the 3 exceptions were diagnosed with smear-proven candidiasis. Patients with moderate or severe dysplasia underwent an excision biopsy. The buccal mucosa was the single most common site of white lesions, occurring in 15 patients (19.5%), although 21 patients (27.3%) exhibited a diffuse involvement of the oral mucosa. Of the 77 patients, 59 (76.6%) had concerning findings: premalignant lesions in 45 patients (58.4%) and malignant lesions in 14 (18.2%). Also, dysplasia was seen in 8 patients (10.4%), all of whom had premalignant lesions. Tobacco chewing (p = 0.008) and betel quid chewing (p = 0.029) were significantly associated with the development of premalignant and malignant lesions; a longer duration of tobacco chewing (≥10 yr) was significantly associated with a higher risk of malignant but not premalignant lesions (p = 0.031). Finally, illiteracy was a significant risk factor for premalignant and malignant lesions (p = 0.03). Our findings support the necessity of biopsy in every case. Early detection of oral carcinoma by biopsy of all oral white lesions would not only prevent patients from undergoing disfiguring surgery and chemoradiation, but it also would increase the 5-year survival rate.

An incidental thyroid nodule

August 24, 2017  |  John P. Flynn, MD; Peter A. Morawiecki, MD; Marco A. Ayala, MD

Preoperative diagnosis of intrathyroidal parathyroid adenomas is essential to determining correct surgical management

Platelet-rich plasma myringoplasty: A new office procedure for the repair of small tympanic membrane perforations

August 24, 2017  |  Mohammad Waheed El-Anwar, MD; Ismail Elnashar, MD; Yaser Ahmad Foad, MD


We conducted a prospective study to assess the effectiveness of a platelet-rich plasma hourglass graft in the repair of small tympanic membrane perforations as an office-based procedure. Our study population was made up of 25 patients-10 men and 15 women, aged 19 to 45 years (mean: 30.4 ± 7.2)-who each underwent repair of one eardrum. After administration of topical anesthesia, a single piece of platelet-rich plasma approximately double the size of the perforation was obtained from each patient's intravenous blood sample. After the margin of the perforation was freshened, the platelet-rich plasma was placed in an hourglass configuration, with equal portions lying medial and lateral to the perforation. Successful perforation repair was achieved in 21 of the 25 ears (84%). No patient developed an infection, hearing impairment, tinnitus, vertigo, bleeding, taste disturbance, or hyperkeratosis. We conclude that office-based platelet-rich plasma myringoplasty is a safe and effective minimally invasive procedure that is suitable for repairing small tympanic membrane perforations.

Can lateral nasopharyngeal radiographs be used to predict eustachian tube dysfunction?

August 24, 2017  |  Karen Hawley, MD; Neil Vachhani, MD; Samantha Anne, MD, MS


The objective of our case-control study was to determine whether craniofacial features on lateral nasopharyngeal radiographs (LNPRs) can predict eustachian tube dysfunction (ETD). The study included patients seen in the otolaryngology clinic from 2005 to 2011. Patients 0 to 10 years old with pressure equalization tube (PET) placement and LNPR within 6 months were included. Measurements were compared with age-matched controls selected at random to identify craniofacial features associated with ETD. Using receiver operating curve methodology, selected measurements were used to correlate age, craniofacial features, and ETD. The study population consisted of 32 patients and 34 controls. No significant differences were found between groups on any individual measurement: cranial base angle; lengths of anterior, middle, and total skull base; mandible; hard and soft palates; sella-soft-palate tip; sella-posterior nasal spine; and nasopharyngeal and palatal airway. Further statistical analysis demonstrated that patients who required PETs were more likely to have shortened anterior cranial base and maxilla relative to mandibular length. Contrary to the findings of previous studies, no single measurement was found to identify craniofacial features that may select for children with ETD requiring PETs. However, younger patients with a smaller cranial base and/or maxilla relative to mandibular length are more likely to require PETs, implying persistent ETD.

Multinodular goiter: A study of malignancy risk in nondominant nodules

August 24, 2017  |  Jenica Su-ern Yong, MBBS, MRCS, MMED ORL; Kwok Seng Loh, MBBS, FRCS, FAMS; Bengt Fredrik Petersson, MD, PhD; Mark Thong, MBBS, MRCS, MMED ORL


The long-standing belief that multinodular goiters are associated with a lower risk of developing into carcinoma has been challenged by the results of some recent studies. In addition, we have noticed in our practice that a sizable proportion of cancers have been arising from nondominant nodules. We performed a retrospective study of 223 cases to determine (1) the incidence of carcinoma in multinodular goiters that required surgical management in our local, predominantly Asian population and (2) the incidence of carcinoma arising from nondominant nodules. We reviewed the records of all patients with a multinodular goiter who had undergone a thyroidectomy over a period of more than 10 years in our Department of Otolaryngology-Head and Neck Surgery. We examined the histopathology reports for (1) the presence of carcinoma, (2) whether the carcinoma was isolated/unifocal or multifocal, (3) the histologic type of cancer, and (4) whether the isolated/unifocal cancers arose from the dominant or nondominant nodule. Our study population was made up of 47 males and 176 females, aged 15 to 90 years (mean: 53). We found that the incidence of malignancy in surgically treated multinodular goiters was 14.3% (32 of 223 patients). Of the 32 malignancies, 18 (56.3%) were isolated/unifocal and 14 (43.8%) were multifocal. In the isolated/unifocal group, 9 malignancies (50.0%) arose from nondominant nodules and 8 (44.4%) from dominant nodules; in the remaining case, the nodule of origin could not be determined. Our findings corroborate those in the recent literature in that the risk of malignancy associated with multinodular goiters is comparable to that of single thyroid nodules. We recommend that physicians be equally vigilant when monitoring dominant and nondominant nodules.

Computerized dynamic posturography for evaluating dizziness in patients with scarred orbital content

August 24, 2017  |  Nathan Shlamkovitch, MD; Ephraim Eviatar, MD; Haim Gavriel, MD


Our objective was to assess the capability of computerized dynamic posturography (CDP) to evaluate dizziness in blind patients who lack corneoretinal potential. We performed a retrospective analysis of 2 young blind subjects with intraorbital scarring who complained of dizziness and underwent CDP. Tests were carried out at our center for balance disorders using the NeuroCom's EquiTest System version 4.0. CDP demonstrated vestibular dysfunction and revealed it to be severe. We conclude that CDP can serve as a potentially reliable tool for assessing dizziness in blind patients who have no corneoretinal potential.

Recognizing malleus fracture in a woman with a head injury after a fall

August 24, 2017  |  Janet S. Choi, MD, MPH; Nathan Tu, MD; John L. Go, MD; Elina Kari, MD

Diagnosis of ossicular injuries is often challenging due to their subtle appearance on CT scans, especially in the presence of hemotympanum or opacification of the middle ear cavity.