Otolaryngology

Reliability of clinical diagnosis of masses of the cerebellopontine angle: A retrospective multi-institutional study Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Alexander L. Luryi, Elias M. Michaelides, Seilesh Babu, Dennis I. Bojrab, John F. Kveton, Robert S. Hong, John Zappia, Eric W. Sargent, Christopher A. Schutt Abstract Objectives To assess the accuracy of pre-operative diagnosis of masses of the cerebellopontine angle (CPA) when compared to surgical pathology. Design Retrospective chart review. Participants Patients who underwent surgery for CPA masses at two tertiary care institutions from 2007 to 2017. Main outcome measures Percent concordance between pre-operative and surgical pathologic diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value for predicted diagnoses. Results Concordance between pre-operative diagnosis and surgical pathology was 93.2% in 411 sampled patients. Concordance was 57.9% for masses other than vestibular schwannoma. Prediction of vestibular schwannoma and meningioma had high positive (0.95 and 0.97, respectively) and negative (0.76 and 0.99, respectively) predictive values. Prediction of facial neuroma had sensitivity of 0.13 and positive predictive value of 0.25. Headache (p = 0.001) and facial weakness (p = 0.003) were significantly associated with different pathologic profiles. Hearing loss was associated with differences in diagnostic prediction (p = 0.02) but not with differences in surgical pathology (p > 0.05). Conclusions Comparison between pre-operative predicted diagnosis and surgical pathology for cerebellopontine angle masses is presented. Vestibular schwannoma and meningioma were effectively identified while rarer CPA masses including facial neuroma were rarely identified correctly. Clinicians caring for patients with CPA masses should be mindful of diagnostic uncertainty which may lead to changes in treatment plan or prognosis.

Management of jugular bulb injury during drilling of the internal auditory canal (ICA) for vestibular schwannoma surgery Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Sajjad Muhammad, Martin Lehecka, Saku T. Sinkkonen, Mika Niemelä Abstract The retrosigmoid approach for vestibular schwannoma surgery has remained the standard approach by most neurosurgeons. Drilling the posterior wall of the internal auditory meatus (IAM) is an essential step in removing the intrameatal tumor. During IAM drilling, three anatomical structures can be encountered, including the posterior semicircular canal, vestibular aqueduct, and jugular bulb. Any of these can be injured during drilling, especially if the jugular bulb lies above the inferior edge of the IAM. Although IAM drilling is performed in most vestibular schwannoma surgeries, information on how to manage complications such as jugular bulb injury is lacking. Here we use an intraoperative video to demonstrate how to manage the inadvertent injury to the jugular bulb in order to avoid massive blood loss. We present a case of a 39-year-old woman with hearing loss, diagnosed with a cerebellopontine angle mass extending into the IAM. Surgery was required due to tumor progression. We used the retrosigmoid approach to access the tumor. During IAM drilling, the jugular bulb was injured. A thin layer of bone wax was applied under continuous suction. The margins of the wax were then gently compressed with a dissector; great care was taken to avoid pushing the wax into the jugular bulb. Excess bone wax was removed (video 1). A small diamond drill (2 mm) was used for further drilling. Our instructional video shows the surgical approach, microsurgical anatomy, and technical aspects of managing massive bleeding from jugular bulb injury. It should therefore be helpful for young neurosurgeons.

Letter to the editor: Effect of changing postoperative pain management on bleeding rates in tonsillectomy patients Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Zhengcai Lou

Commentary on letter to editor titled "surgical management of patients with Eagle syndrome" Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Frances Mei Hardin, Roy Xiao, Brian B. Burkey

Important factor for pain relief in patients with eagle syndrome: Excision technique of styloid process Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Fatma Caylakli

Vascular malformation of the sphenoid and temporal bone: A diagnostic dilemma Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Celeste Z. Nagy, Sarah Cantrell, Xin Wu, C. Arturo Solares Abstract We present a rare case of a vascular anomaly of the sphenoid and temporal bones causing an expandable mass of the temporal region with dependent patient positioning and characteristic osseous changes on imaging. Initial diagnosis considerations included multiple myeloma (MM), fibrous dysplasia (FD), Paget's disease, lymphoma, meningoencephalocele (MEC), and vascular malformation (VaM). VaMs of the head and neck are rare and typically arise in the mandible and maxilla. However, this case demonstrates a unique finding of a VaM of the sphenoid and temporal bones with important radiological features to distinguish the diagnosis of vascular anomaly from other etiologies.

Pyogenic granuloma of the larynx: A rare cause of hemoptysis Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Andrea L. Hanick, Joseph B. Meleca, Steven D. Billings, Paul C. Bryson Abstract Pyogenic granuloma (PG) may involve gingival mucosa (granuloma gravidarum) in pregnancy but rarely involves the airway. This case report is perhaps the only reported presentation of PG in the larynx causing hemoptysis at a late stage of pregnancy. On laryngoscopic exam, a vascular, right false vocal fold neoplasm was identified with pathological characteristics consistent with PG. Conclusions: Pyogenic granuloma is a relatively common tumor of pregnancy but rarely involves the larynx. In the case of airway involvement during pregnancy, it is best managed in coordination with the high-risk obstetrical team and can be removed safely via standard microsurgical techniques.

Application of indocyanine green in the parathyroid detection and protection: Report of 3 cases Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Hao Jin, Jinrui Fan, Jun Yang, Kun Liao, Zhuocheng He, Min Cui Abstract Background It was thought that identifying the parathyroid gland during surgery was difficult for surgeons. It may be critical to locate the parathyroid for surgeons during thyroidectomy or parathyroidectomy due to the significant function of the parathyroid in calcium balance. According to recent reports, intrinsic fluorescence of the parathyroid has been found. There is some evidence to suggest that new equipment can detect the intrinsic fluorescence via imaging technology. In this case reports, a newly-invented intraoperative fluorescence imaging system and indocyanine green dye were applied to detect the parathyroid gland and evaluate the vascularization of parathyroid. Case presentation From July 1st to August 8st, 2018, 3 patients underwent total thyroidectomy in Zhuhai People's Hospital. The 3 subjects were recruited into our research. Indocyanine green angiography was performed on all the three participants. By ICG angiography, parathyroid glands were identified and protected. In the 3 patients, postoperative PTH levels were in the normal range. No one of them developed transient hypoparathyroidism. Conclusions This study has identified that the fluorescence imaging system applied with indocyanine green is a safe, easy and effective method to protect the parathyroid and predict postoperative parathyroidism.

Isolated horizontal canal hypofunction differentiating a canalith jam from an acute peripheral vestibular loss Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Andrea Castellucci, Pasquale Malara, Cristina Brandolini, Valeria Del Vecchio, Davide Giordano, Angelo Ghidini, Gian Gaetano Ferri, Antonio Pirodda Abstract Objectives To describe a unique case of acute vertigo presenting with spontaneous horizontal nystagmus (SHN) and a clinical picture consistent with right acute peripheral vestibular loss (APVL) in which an isolated hypofunction of a horizontal semicircular canal (HSC) permitted to detect a spontaneous canalith jam and treat the patient accordingly. Methods Case report and literature review. Results A 74-year old woman presented with acute vertigo, left-beating SHN and a clinical picture consistent with right APVL. Nevertheless, vestibular evoked myogenic potentials were normal with symmetrical amplitudes and the video head impulse test (vHIT) revealed an isolated hypofunction of the right HSC. After repeated head shakings, the supine roll test evoked bilaterally a positioning paroxysmal geotropic horizontal nystagmus suggesting benign paroxysmal positional vertigo involving the non-ampullated arm of the right HSC. vHIT and caloric testing confirmed restitution of HSC function after repositioning maneuvers. Conclusions In case of acute vertigo with SHN, a complete functional assessment of vestibular receptors and afferents should always be given in order to avoid misdiagnosis. Canalith jam should be considered in case of spontaneous nystagmus and isolated canal hypofunction.

Osteoradionecrosis of the hyoid bone complicated by pharyngocutaneous fistula: A case report and literature review Publication date: March–April 2019 Source: American Journal of Otolaryngology, Volume 40, Issue 2 Author(s): Kayvon F. Sharif, Fred M. Baik, Lauren E. Yue, Muhammad Qazi, Margaret Brandwein-Weber, Azita S. Khorsandi, Mark L. Urken Abstract Background Osteoradionecrosis (ORN) is a well-known complication following irradiation of head and neck malignancies. ORN commonly occurs in the mandible but is rarely reported in the hyoid bone. Case presentation A 76-year-old female with a history of oropharyngeal squamous cell carcinoma presented with pharyngocutaneous fistula 14 years after primary chemoradiation. Imaging showed necrosis of the hyoid bone. She underwent excision of the hyoid to rule out malignancy. Pathology was negative for carcinoma, but did show extensive fragmentation and bony necrosis consistent with ORN. The patient's clinical course, surgical treatment, and management considerations are discussed here. Conclusions Hyoid ORN should remain in the differential during diagnostic workup of previously irradiated head and neck cancer patients. The presentation of a pharyngocutaneous fistula should prompt workup to rule out malignancy before assigning a diagnosis of ORN.