Otolaryngology

Atypical thyroglossal duct cyst with intra-laryngeal and para-glottic extension Publication date: Available online 8 April 2019 Source: American Journal of Otolaryngology Author(s): Adele Chin Wei Ng, Heng Wai Yuen, Xin Yong Huang Abstract Thyroglossal duct cysts (TDC) are the most common congenital neck masses. Although they are anatomically closely related to the larynx, intra-laryngeal extension is very rare. We present a case, review the literature and discuss the challenges of intra-laryngeal TDC. A 55-year-old man presented with a neck mass associated with dysphagia. Computer Tomography neck scan showed a midline cyst extending to the pre-epiglottic space with partial obliteration of the right pyriform sinus and narrowing of the larynx. The cyst was excised en-bloc via Sistrunk procedure. Intra-laryngeal TDC are surgically challenging due to risk of perforation into the aerodigestive tract.

The etiology, pathogeneses, and treatment of objective tinnitus: Unique case series and literature review Publication date: Available online 5 April 2019 Source: American Journal of Otolaryngology Author(s): Parsa P. Salehi, David Kasle, Sina J. Torabi, Elias Michaelides, Douglas M. Hildrew Abstract We present two unique cases of myoclonus-induced objective tinnitus (OT), along with a comprehensive literature review on the topic. Primary goals include: explore the relationship between palatal myoclonus (PM) and middle ear myoclonus (MEM), highlight the embryologic, neurologic, and anatomical relationship between the involved peri-tubular muscles, exemplify the first case of OT which documents video evidence demonstrating the link between objective tinnitus and eustachian tube movement. Also, we discuss available treatment interventions and why they often do not fully resolve patients' symptoms. Finally we introduce a novel way to objectively quantify the severity of OT. Ultimately, our series hopes to inform future diagnostic and treatment guidelines.

Expression of vimentin (VIM) and metastasis-associated 1 (MTA1) protein in laryngeal squamous cell carcinoma are associated with prognostic outcome of patients Publication date: Available online 3 April 2019 Source: American Journal of Otolaryngology Author(s): Sotirios Karamagkiolas, Ioannis Giotakis, Efthimios Kyrodimos, Evangelos I. Giotakis, Agapi Kataki, Fani Karagianni, Andreas M. Lazaris Abstract Purpose Laryngeal squamous cell carcinoma (LSCC), a common type of head and neck cancer, is associated with high rates of metastasis and recurrence. In this study, we investigated the potential combinatorial prognostic value of NOTCH1, Vimentin (VIM), and Metastasis-associated 1 (MTA1) protein in LSCC, using immunohistochemistry. Materials and methods Tissue specimens from 69 patients with LSCC were immunohistochemically evaluated for the protein expression of NOTCH1, VIM, and MTA1. Then, biostatistical analysis was performed, in order to assess the prognostic value of the expression of each one of these proteins. Results NOTCH1 expression status was not a significant prognosticator in LSCC, as shown in Kaplan-Meier survival analysis. On the contrary, both VIM and MTA1 seem to have an important prognostic potential, independently of TNM staging and histological grade of the tumor. In fact, positive VIM expression was shown to predict patients' relapse and poor outcome regarding patients' overall survival, in contrast with MTA1, the positive expression of which predicts higher disease-free survival (DFS) and overall survival (OS) rates in LSCC. Conclusions VIM and MTA1 constitute potential tumor biomarkers in LSCC and could be integrated into a multiparametric prognostic model. Undoubtedly, their prognostic value needs further validation in larger cohorts of LSCC patients.

Does cervical range of motion affect the outcomes of canalith repositioning procedures for posterior canal benign positional paroxysmal vertigo? Publication date: Available online 2 April 2019 Source: American Journal of Otolaryngology Author(s): Salvatore Martellucci, Giuseppe Attanasio, Massimo Ralli, Vincenzo Marcelli, Marco de Vincentiis, Antonio Greco, Andrea Gallo Abstract Purpose Canalith repositioning procedure (CRP) for posterior canal benign positional paroxysmal vertigo (BPPV), also known as Epley maneuver, is a common procedure for the treatment of BPPV. This maneuver entails flexion, extension and rotation of the patient's neck. This study aims to investigate the impact of cervical range of motion (C-ROM) on CRP efficacy. Materials and methods The study included 47 patients with posterior canal BPPV treated by CRP. The procedure was considered successful if vertigo and nystagmus disappeared at the post-treatment evaluation. If CRP resulted ineffective, it was repeated up to three times per session. C-ROM was measured at BPPV diagnosis before treatment. Patients were followed up for 30 days. Results The first CRP was successful in 29 patients (61.7%), while it was ineffective in 18 patients (38.3%) requiring multiple repositioning maneuvers. Patients who needed two or more CRP showed lower C-ROM in extension (p = .003) and flexion (p = .042), and earlier recurrences (p = .006). Univariate regression analysis showed that lower cervical extension was significantly associated with the failure of the first CRP (OR: 0.899, 95% CI 0.831–0.973, p = .008). Conclusions Our data suggest that a reduced C-ROM can require multiple CRPs to successfully treat BPPV and increase the risk of early recurrences.

Total vs hemithyroidectomy for intermediate risk papillary thyroid cancer: A 23 year retrospective study in a tertiary center Publication date: Available online 2 April 2019 Source: American Journal of Otolaryngology Author(s): Kwan Pok Tsui, Wai Yin Kwan, Tam Lin Chow Abstract Background There is much debate in the literature over the extent of surgery for patients with intermediate risk papillary thyroid cancer. We herein report our results in a local tertiary hospital. Method We identify from our database patients with papillary thyroid cancer who underwent surgery in our hospital and were stratified to be of intermediate risk from the GAMES stratification system. Patients' demographic data, surgical and pathological details were recorded. Primary end points were disease specific survival (DSS) and recurrence free survival (RFS). Results From January 1993 to December 2016, 231 patients with papillary thyroid cancer underwent surgery of which 137 (59%) were of intermediate risk. 45 (33%) patients had hemithyroidectomy and 92 (67%) patients had total thyroidectomy. In the total thyroidectomy group, patients had a higher tumor (T) (p value = 0.009) and nodal (N) staging (p value = 0.001). They were also predicted to have a higher risk of recurrence according to the American Thyroid Association (ATA) classification (p value = 0.005). The 5 year DSS in both groups were 100%. The 5 year RFS in the total thyroidectomy and hemithyroidectomy groups were 92% and 100% respectively and were significantly different by the log rank test (p value = 0.02). The median follow up time was 54 months (range 4–276 months). Conclusion The 5 year survival in intermediate risk papillary thyroid cancer is favorable. Hemithyroidectomy is an acceptable choice of operation in intermediate risk patients with a better risk profile.

Translation and validation of the Parotidectomy Outcome Inventory 8 (POI-8) to Spanish Publication date: Available online 2 April 2019 Source: American Journal of Otolaryngology Author(s): Carlos Miguel Chiesa-Estomba, Elizabeth Ninchritz, Teresa Rivera Schmitz, Jose Angel González-García, Ekhiñe Larruscain-Sarasola, Jon Alexander Sistiaga-Suarez, Christian Calvo-Henríquez, Xabier Altuna-Mariezcurrena Abstract Introduction There are >400 million of native Spanish speakers around the world, being the second most spoken language in regard to the number of native speakers. For this reason, a valid questionnaire to access the quality of our patients after parotidectomy is necessary. Material and methods Validation and cross-cultural adaptation of the POI-8 questionnaire to the Spanish language. Internal consistency of Sp-POI 8 measured with Cronbach α. Results 35 patients met the inclusion criteria during the mentioned period. Mean age was 59 ± 15,37 (Min: 18/Max: 87). 20 patients (57,1%) were male and 15 (42,9%) were female. Internal consistency with Cronbach α was 0.868. The intraclass correlation coefficient was 0.830 [CI] (95%: 0,791–925). Hypoesthesia was the most severely weighted problem (0,91) and xerostomia was the second (0,89). However, the high score was for fear of revision surgery (1,26). Conclusion The Spanish Language is the second most spoken language with regard to the number of native speakers and the Sp-POI 8 translation represents a valid option for the Spanish-speaking medical community, from which a large number of patients can benefit.

Spontaneous cervical chyle fistula: A case report Publication date: Available online 2 April 2019 Source: American Journal of Otolaryngology Author(s): Swathi Appachi, Joseph B. Meleca, Paul C. Bryson Abstract Background Cervical chylous fistulae are rare complications usually occurring from iatrogenic injury to the thoracic duct. There have been no reported cases of spontaneous chyle leaks in surgical naïve necks. Methods Case report. Results A 50 year-old female presented with progressive left neck swelling without fever, dyspnea, or dysphagia. Imaging demonstrated extensive infiltrative changes of the left neck with retropharyngeal fluid extending into strap musculature and the mediastinum. Flexible laryngoscopy revealed posterior pharyngeal wall edema. Differential diagnosis included abscess versus necrotizing fasciitis. Broad-spectrum antibiotics were initiated and she was taken to the OR for neck exploration. Intra-operatively, milky fluid was present around the carotid sheath and in the retropharyngeal space. Fluid analysis demonstrated chylomicrons and triglycerides >2400 mg/dL. Repeat imaging of the neck, chest, and abdomen did not reveal malignancy or obstructive masses. A lymphangiogram showed dilated lymphatic vessels near the cervical thoracic duct. On post-operative day four, the patient was taken back to the OR for thoracic duct ligation and biopsy of nearby tissue. Pathology demonstrated benign lymph nodes with dilated sinusoids. A low-fat diet was started and she was discharged home on hospital day nine. She has followed up regularly with no signs of recurrence. Conclusion A cervical chylous fistula usually results from iatrogenic injury to the thoracic duct. To our knowledge, this is the first reported case of a spontaneous cervical chyle leak.

Clinical and audiometric outcomes of palisade cartilage myringoplasty under local anesthetic in an office setting Publication date: Available online 29 March 2019 Source: American Journal of Otolaryngology Author(s): Nael M. Shoman Abstract Objective Assess clinical and functional outcomes of a modified palisade cartilage-perichondrium graft myringoplasty under local in an office setting. Study design Retrospective case series. Setting Tertiary care facility. Patients Patients with a tympanic membrane perforation presenting between March 2013 and October 2017. Inclusion criteria included age ≥ 7 years, entire perforation margin visualized through a transcanal view, and the ability to lie supine for up to 45 min. Exclusion criteria included a conductive hearing loss larger than expected, and presence of active infection. Intervention In-office modified myringoplasty technique under local anesthesia without sedation. Main outcome measures Complete perforation closure rate and audiometric outcomes. Results 250 patients underwent the procedure, of whom 13 had bilateral sequential procedures (total 263 ears). Of those, 197 were primary and 66 revision. Average age was 46.3 years. Perforation sizes were categorized as small (32), moderate (109), large (78), and subtotal (44). Complete perforation closure was evident in 219 of the 250 cases (88%). Preoperative mean air pure tone average (PTA) was 56.7 dB and mean bone PTA was 27.5 dB (pre-operative ABG 29.2 dB). AC-PTA significantly improved to 35.0 dB (p < 0.0001), and ABG to 9.6 dB (p < 0.0001). Only subtotal perforations showed a statistically significant negative relationship with outcome (p = 0.04). Conclusion The modified palisade cartilage-perichondrium graft myringoplasty under local anesthetic is a highly successful procedure well tolerated by adult and pediatric patients with variable perforation sizes. This may have significant potential patient benefits, as well as cost savings to the health care system.

Sex-specific enlarged vestibular aqueduct morphology and audiometry Publication date: Available online 29 March 2019 Source: American Journal of Otolaryngology Author(s): Jeremy Ruthberg, Mustafa S. Ascha, Armine Kocharyan, Amit Gupta, Gail S. Murray, Cliff A. Megerian, Todd D. Otteson Abstract Objective Enlargement of the vestibular aqueduct (EVA) is one of the most common congenital malformations in pediatric patients presenting with sensorineural or mixed hearing loss. The relationship between vestibular aqueduct (VA) morphology and hearing loss across sex is not well characterized. This study assesses VA morphology and frequency-specific hearing thresholds with sex as the primary predictor of interest. Materials and methods A retrospective, longitudinal, and repeated-measures study was used. 47 patients at an academic tertiary care center with hearing loss and a record of CT scan of the internal auditory canal were candidates, and included upon meeting EVA criteria after confirmatory measurements of vestibular aqueduct midpoint and operculum widths. Audiometric measures included pure-tone average and frequency-specific thresholds. Results Of the 47 patients (23 female and 24 male), 79 total ears were affected by EVA; the median age at diagnosis was 6.60 years. After comparing morphological measurements between sexes, ears from female patients were observed to have a greater average operculum width (3.25 vs. 2.70 mm for males, p = 0.006) and a greater average VA midpoint width (2.80 vs. 1.90 mm for males, p = 0.004). After adjusting for morphology, male patients' ears had pure-tone average thresholds 17.6 dB greater than female patients' ears (95% CI, 3.8 to 31.3 dB). Conclusions Though females seem to have greater enlargement of the vestibular aqueduct, this difference does not extend to hearing loss. Therefore, our results indicate that criteria for EVA diagnoses may benefit from re-evaluation. Further exploration into morphological and audiometric discrepancies across sex may help inform both clinician and patient expectations.

Cricoarytenoid joint abscess associated with rheumatoid arthritis Publication date: Available online 28 March 2019 Source: American Journal of Otolaryngology Author(s): Megan J. Foggia, Henry T. Hoffman Abstract Cricoarytenoid joint arthritis is an uncommon manifestation of rheumatoid arthritis. We encountered a 68-year-old woman with rheumatoid arthritis who presented with odynophagia, dysphagia, and progressive shortness of breath. Examination findings showed diminished mobility of the left vocal cord and right arytenoid swelling associated with an immobile right vocal cord. Computed tomography (CT) imaging identified a ring-enhancing lesion of the right lateral cricoarytenoid joint. Microdirect laryngoscopy with drainage of the cricoarytenoid abscess and tracheotomy were performed. Development of a laterally based cricoarytenoid joint abscess is identified as a complication of chronic rheumatoid arthritis with successful management described.