Flexible Fiberoptic Laryngoscopy Research Articles

Long-term functional outcomes and quality of life after oncologic surgery and microvascular reconstruction in patients with oral or oropharyngeal cancer

Conclusions: Surgery for oral or oropharyngeal cancer with free-flap reconstruction is associated with moderate but persistent functional and quality of life (QoL) problems. Patient age, tumor stage, tumor site, and radiotherapy were the main predictors of functional outcome. Objectives: To evaluate long-term functional outcomes and QoL, and to determine their predictive factors in patients with oral or oropharyngeal cancer after oncologic surgery and free-flap reconstruction. Methods: Patients who underwent surgery with free-flap reconstruction for oral or oropharyngeal cancer between 2000 and 2009 who were alive at least 1 year after therapy were included in this study. Patients completed the Voice Handicap Index (VHI-10) questionnaire and the European Organization for Research and Treatment of Cancer (EORTC) QoL questionnaires QLQ-C30 and H&N35. Swallowing was evaluated using the Dysphagia Outcome and Severity Scale (DOSS) and by flexible fiberoptic laryngoscopy. Results: Sixty-four patients were included in the study. VHI-10 mean score was 11.2 ± 9 and its predictive factors were T stage (p = 0.005) and tumor involvement of the tongue base (p = 0.01). The mean DOSS score was 4 ± 0.8. Age (p = 0.008), gender (p = 0.04), and radiotherapy (p = 0.001) were the main predictive factors of the DOSS score.

An evaluation of varying protocols for high‐level disinfection of flexible fiberoptic laryngoscopes

The use of flexible fiberoptic laryngoscopes (FFLs) is ubiquitous in otolaryngology practices. As with any medical device, there exists a small risk for transmission of pathogenic microorganisms between patients, necessitating high-level decontamination between uses. Most of the literature to date has studied channeled scopes such as those used in esophagogastroduodenoscopy and colonoscopy. A recent study of nonchanneled flexible laryngoscopes suggested that current high-level decontamination practices in use at some institutions, including ours, may be overly aggressive. We sought to evaluate and compare the efficacy of varying techniques of high-level disinfection of FFLs. FFLs were used in routine clinical encounters and then disinfected with a variety of techniques. The FFLs were then cultured for bacteria and fungi, and the rates of positive cultures were compared between the techniques and the controls. In this study, we took FFLs following use in routine clinical practice and disinfected them using one of eight decontamination protocols. We compared the bacterial and fungal culture results to positive and negative controls. We demonstrated that each of the eight cleaning protocols was statistically efficacious at removing bacterial contamination. Our results for fungal cultures did not reach statistical significance. Using in vitro inoculation of FFLs, this study demonstrated that quicker and more cost-effective practices are equally efficacious to more time-consuming and expensive techniques with regard to bacterial contamination of FFLs. NA

Unusual Presentation of a Laryngeal Mass

Awomaninher50swithahistoryofhypertensionandchronicback painpresented to theemergencydepartment. Shehadbeendiscoveredunresponsive inbed,wasapneic, andwas intubated in the field. Shehadexperiencedmultiple episodesof emesis. Atpresentation, a computed tomographic (CT) scan demonstrated diffuse subarachnoidhemorrhage, intraventricular hemorrhage, andcommunicating hydrocephaluswithtonsillarandcentralherniation.Shereceivedmannitolandanemergentextraventriculardrain.Duringherhospital stay, a cerebral aneurysm was successfully treated by an endovascular route. She required a tracheostomy and percutaneous gastrostomy tube placement. Twenty-eight days after her tracheostomy, a flexible endoscopic evaluation of swallowing with sensory testing (FEESST) revealed a submucosal mass. The mass did not fully obstruct the airway, and the patient tolerated a Passy-Muir valve with no respiratory distress. The primary teamadministered dexamethasonesodiumphosphateandconsultedtheotolaryngologyservice.On examination, her vital signs werewithin normal limits, shewas nonverbalbut innoacutedistress,herbreathingunlaboredandsilent,with no stridor or stertor. Passing a flexible fiber-optic laryngoscope confirmedthepresenceofanapparentsubmucosalmassthateitheroriginated from the epiglottis or deep to a severely edematous right aryepiglottic (AE) fold or arytenoid, or completely obstructed the vocal cords from view. Themass did not respond to steroids. A CT scan of the neck with intravenous contrast was performed (Figure, A). The mass was nonenhancing. Subsequently, a retrospective review of a magnetic resonance imaging (MRI) examination demonstrated the mass compressed by the endotracheal catheter (Figure, B). What is your diagnosis? A

A new scoring system for upper airway pediatric sleep endoscopy.

Sleep-associated upper-airway obstruction in children is a significant cause of morbidity. Development of a simple, standardized, quantitative technique to assess anatomic causes of sleep-related breathing disorder is important for surgical planning, clinical communication, and research. To design, implement, and evaluate a scoring system to quantify airway obstruction in pediatric drug-induced sleep endoscopy. This study was a retrospective case series conducted at a tertiary pediatric hospital. The patients were children with sleep-related breathing disorder who underwent polysomnography and drug-induced sleep endoscopy. Flexible fiber-optic laryngoscopy was performed. Endoscopic examinations were recorded on video and assessed by 4 independent raters based on a scoring template. Five locations in the upper aerodigestive tract (adenoid, velum, lateral pharyngeal wall, tongue base, and supraglottis) were evaluated on a 4-point scale for minimum and maximum obstruction. Internal reliability was assessed by calculating interrater and intrarater intraclass correlation coefficients (ICCs). For external validation, aggregate and site-specific scores were correlated with preoperative polysomnographic indices. Videos recorded of sleep endoscopies from 23 children (mean age, 2.2 years) were reviewed and rated. Children had an average apnea-hypopnea index of 24.8. Seventy percent of interrater and intrarater ICC values (7 of 10 for each set) were above 0.6, demonstrating substantial agreement. Higher total obstructive scores were associated with lower oxygen saturation nadir (P = .04). The scoring system was also used to quantitatively identify children with multilevel airway obstruction, who were found to have significantly worse polysomnographic indices compared with children with single-level obstruction (P = .02). The proposed scoring system, which is designed to be easy to use and allow for subjectivity in evaluating obstruction at multiple levels, nonetheless achieves good internal reliability and external validity. Implementing this system will allow for standardization of reporting for sleep endoscopy outcomes, as well as aid the practicing clinician in the interpretation of sleep endoscopy findings to inform site-directed surgical intervention in cases of complicated obstructive sleep apnea.

Neurofibromatosis of the larynx causing stridor and sleep apnea

BackgroundNeurofibromatosis type 1 can rarely present in the larynx. Patients typically do not present with complete obstructive symptoms, but partial obstruction and stridor. We review our health centers’ case series of two patients, the first of whom presented with persistent sleep apnea post tonsillectomy and adenoidectomy, and the second who presented with noisy breathing. Additionally, we will review the literature on the management and treatment options for children with this rare clinical entity. MethodsRetrospective case review. Case report & resultsA two-year old male underwent a sleep endoscopy following persistent evidence of obstructive sleep apnea on polysomnography after initial tonsillectomy and adenoidectomy. Family elicited concerns about noisy breathing at night and an accompanying video documented stridor while sleeping during the monitored polysomnography. Flexible fiberoptic laryngoscopy in the operating room revealed what appeared to be a cystic mass along the right aryepiglottic fold causing deviation of the laryngeal introitus towards the contralateral side. Subsequent direct laryngoscopy and excisional biopsy revealed pathology results consistent with a plexiform neurofibroma.A six-month-old patient with stertor and stridor was found to have a laryngeal mass, subglottic stensosis, and progressive airway obstruction due to plexiform neurofirboma in the supraglottis, subglottis, and trachea.We present a series of two patients incidentally diagnosed with neurofibromatosis type 1 by way of a laryngeal neurofibroma and review the literature on management options. Both patients were found to have accompanying café au lait spots. Both patients required tracheostomy for airway management, and one was successfully decannulated. ConclusionLaryngeal neurofibroma is a rare anomaly that can manifest with airway obstruction. Both patients presented here subsequently were noted to have café au lait spots on physical examination. The Otolaryngologist should be reminded of this anomaly when evaluating a child with evidence of a submucosal laryngeal mass. We present our series including that of a patient whose diagnosis was prompted by persistent sleep apnea following adenotonsillectomy tonsillectomy and a patient with airway obstruction and subglottic stenosis due to a neurofibroma. The treatment of choice is complete excision of the neurofibroma while maintaining functionality of the larynx. This can lead to successful decannulation.

The effect of endoscopic sheaths on visualization in distal chip and fiberoptic laryngoscopy.

Endoscopic sheaths covering the laryngoscope are advised to prevent cross contamination, but might hamper visualization as the most important tool in the diagnostic approach of laryngeal disease. We evaluated whether endoscopic sheaths change image quality and diagnostic accuracy of flexible distal chip laryngoscopy (DCL) and flexible fiberoptic laryngoscopy (FOL). Twelve healthy volunteers underwent a flexible laryngoscopy using a distal chip and a fiberoptic laryngoscope with and without endoscopic sheaths, and in this way 48 images were collected. To determine diagnostic accuracy, the 48 images were mixed with images of 40 patients. All images were randomly shown to four experts in the field of laryngology and head and neck oncology. Observers were asked to validate image quality, choose a diagnosis, and express their confidence level of that diagnosis. Image quality was validated better in DCL as compared to FOL (p < 0.05) both with or without endoscopic sheaths. Endoscopic sheaths worsened image quality in DCL (p < 0.05) but not in FOL. No differences were observed between DCL and FOL with or without endoscopic sheaths in diagnostic accuracy (79-89%). Confidence levels (7.7-8.1) were comparable in DCL and FOL and not influenced by endoscopic sheaths. Image quality in DCL is superior to FOL, but significantly hampered by the use of endoscopic sheaths. In FOL the image quality is already low and not further diminished by endoscopic sheaths.

Effect of whole process nursing care in flexible fiberoptic laryngoscope examination for children

Objective To investigate the effects of the-whole-process nursing care in flexible fiberoptic laryngoscopy examination for children .Methods Totals of 104 children were randomly divided into control group and care group .The control group received routine nursing care , and the care group received the-whole-process nursing care during the examination .The degree of discomfort , consumed time and physical indexes before and after examination , such as blood pressure , heart rate and respiratory frequency , were measured and compared.Results The median consumed time was 2.8 min in the care group , and 3.5 min in the control group, with a significant difference （Z=-2.277, P=0.023）.The degree of intense fear of the care group was less than that of the control group , with a significant difference （χ2 =12.054,P=0.007）, while no significant difference was found in the degree of nausea and vomiting （χ2 =0.358,P=0.949）.Except for systolic blood pressure（t=-2.440,P=0.022）, the diastolic blood pressure, heart rate and respiratory frequency did not change statistically significantly in the care group （ P 〉0.05）.While all the indexes changed statistically significantly in the control group （P〈0.05）.Conclusions The-whole-process nursing care plays a great role in relieving children’s psychological and physical suffering during flexible fiberoptic laryngoscopy examination , and help to complete it smoothly . Key words: Whole-process nursing care; Flexible fiberoptic laryngoscopy examination; Children

Hoarseness Misattributed to Reflux

This study aimed to identify voice disorders commonly misidentified as reflux and sources of such misattribution. Retrospective chart review. Twenty-six patients carrying a diagnosis of reflux alone presenting for second-opinion evaluation were identified from among 381 new patients presenting with a chief complaint of hoarseness over an 8-month period. Patients specifically referred for further workup were excluded. Average duration of reflux treatment was 10.6 +/- 9.0 weeks. In no case was reflux alone the cause of hoarseness. Eleven (42%) had phonotraumatic lesions, 9 (34%) had neurologic disorders, 5 (19%) had age-related changes, and I (4%) was infectious. Twenty-two (85%) abnormalities were diagnosed by dynamic laryngeal examination with improved optics, including stroboscopy. Only 4 (15%) represented disorders routinely diagnosed with flexible fiberoptic laryngoscopy. Hoarse patients with no apparent cause for dysphonia other than reflux after flexible laryngoscopy, or who fail to improve with appropriate treatment, may benefit from further laryngeal investigation rather than continued empiric treatment or further reflux evaluation.

Distal chip versus fiberoptic laryngoscopy using endoscopic sheaths: diagnostic accuracy and image quality

Laryngeal visualization is the hallmark in the diagnostic approach of laryngeal disease. In addition to fiberoptic techniques, digital distal chip technology has been developed to improve visualization. Endoscopic sheaths are used in daily clinical practice to prevent cross-contamination. The objective of the study was to evaluate diagnostic accuracy, image quality and interrater reliability of both flexible distal chip laryngoscopy (DCL) and flexible fiberoptic laryngoscopy (FOL) using contamination preventing endoscopic sheaths. In 53 cases both DCL and FOL images were collected during routine examination using endoscopic sheaths. All images were randomly shown to four experts in the field of laryngology and head and neck oncology. Observers were asked to choose a diagnosis, express their confidence level of that diagnosis and validate image quality: in this way 420 observations (four observers using two techniques) were analyzed. Accuracy in detecting laryngeal disease was 78 % (both DCL and FOL). Confidence level of diagnosis tended to be higher in DCL (p = 0.05). Image quality was validated better in DCL as compared to FOL (p < 0.05). Interrater agreement in identifying laryngeal disease was 1.5 times higher in DCL (κ = 0.44) as compared to FOL (κ = 0.29). In this study, reflecting daily clinical setting using sheathed endoscopes, DCL is identical to FOL regarding diagnostic accuracy, but DCL is superior to FOL in image quality and interrater reliability.

A Hypopharyngeal Ductal Cyst Masquerading as a Laryngopharyngeal Reflux Disease

The ductal cyst of the hypopharynx is a very rare tumor. We report a case of hypopharyngeal ductal cyst in a 63-year-old man presenting with globus sensation. It was removed by a laryngomicrosurgical technique, using a microdissection electrode. Masses of the hypopharynx may not always be easily visible on routine examination of the hypopharynx with flexible fiberoptic laryngoscopes. Particularly in cases of benign tumors, the diagnosis may be delayed due to a prolonged history of mild and subtle symptoms. We missed the hypopharyngeal mass at the initial presentation, but could detect the mass in the pyriform sinus with a double contrast barium swallow study. We describe the diagnostic method to detect hypopharyngeal tumors and the treatment of benign hypopharyngeal masses.

Arytenoid cartilage dislocation from external blunt laryngeal trauma: evaluation and therapy without laryngeal electromyography.

BackgroundIntubation trauma is the most common cause of arytenoid dislocation. The aim of this study was to investigate the diagnosis and treatment of arytenoid cartilage dislocation from external blunt laryngeal trauma in the absence of laryngeal electromyography (LEMG) and to explore the role of early attempted closed reduction in arytenoids cartilage reposition.Material/MethodsThis 15-year retrospective study recruited 12 patients with suspected arytenoid dislocation from external blunt laryngeal trauma, who were evaluated through 7 approaches: detailed personal history, voice handicap index (VHI) test, indirect laryngoscope, flexible fiberoptic laryngoscope, video strobolaryngoscope, and/or high-resolution computed tomography (CT), and, most importantly, the outcomes after attempted closed reduction under local anesthesia. They were divided into satisfied group (n=9) and dissatisfied group (n=3) based on their satisfied with voice qualities at 1 week after the last closed reduction manipulation.ResultsEach patient was diagnosed with arytenoid dislocation caused by external blunt laryngeal trauma. In the satisfied group, VHI scores and maximum phonation time (MPT) at 1 week after the last reduction were significantly improved compared with those before the procedure (P<0.05). Normal or improved mobility and length of the affected vocal fold were also noted immediately after the end of the last closed reduction. The median time interval between injury and clinical intervention in satisfied group was 43.44±34.13 days, much shorter than the median time of 157.67±76.07 days in the dissatisfied group (P<0.05).ConclusionsMultimodality assessment protocols are essential for suspected arytenoid dislocation after external blunt laryngeal trauma. Early attempted closed reduction should be widely recommended, especially in health facilities without LEMG, mainly, because it could be helpful for early diagnosis and treatment of this disease. In addition, early closed reduction could also improve the success of arytenoid reduction.

Office-based lower airway endoscopy (OLAE) in pediatric patients: A high-value procedure

ObjectivesOffice-based lower airway endoscopy (OLAE) is not a widespread practice in children due to concerns about its safety and efficacy. In 2003, we reported on OLAE in 105 children presenting with airway symptoms and found it both safe and effective as a diagnostic tool. The current study is a follow-up to the 2003 study that reports on an additional 122 pediatric patients who received OLAE with special attention to the safety and efficacy of the procedure. MethodsA retrospective review at a tertiary–quaternary pediatric institution of 122 consecutive pediatric patients in which an airway lesion, by history and initial physical exam, was determined to be present at the level of the supraglottic larynx to the carina. In all patients, airway endoscopy was performed in the office using flexible fiberoptic laryngoscopy (FFL) and the endoscope was passed beyond the glottis to assess the lower airway, including the subglottis, trachea, and carina. The diagnoses were recorded and the number of times each diagnosis was encountered as well as the percent of patients who had each diagnosis was calculated. All cases requiring operating room procedures for further diagnosis or therapy were assessed for office-based and operating room diagnostic agreement. The ease of performing the lower airway assessment and the ease with which the subglottis, trachea, and carina were visualized were graded. An assessment for complications was also performed. ResultsThere were no complications with OLAE in any of the 122 patients. The percent of patients rated as having good visualization of anatomic structures were: 97% for visualization of the subglottis, 98% for visualization of the trachea, and 92% for visualization of the carina. In 93% of the cases the procedure was easily performed. There was excellent correlation between OLAE and operative endoscopy. ConclusionOLAE continues to be a safe, efficacious, and cost-effective tool for the diagnosis of lower airway pathology in pediatric patients.

Microbiological Sampling of the Forgotten Components of a Flexible Fiberoptic Laryngoscope: What Lessons Can We Learn?

The effectiveness of a Cidex-based decontamination protocol was analyzed for its effectiveness in cleaning various components of a flexible fiberoptic laryngoscope (FFL), including the handle, eyepiece, and detachable light cable. A random microbiological sampling and aerobic bacterial culture analysis of 6 FFL eyepieces, 6 FFL driver handles, and 5 light cables prior to patient use was performed. Of 17 samples collected, 7 (41%) were contaminated with bacterial organisms. Organisms recovered represented both environmental organisms from skin and oral flora origin. This study demonstrates that potential contaminants may be present on FFL eyepieces and light cables, which are commonly overlooked in the cleaning protocols of a standard otolaryngology clinic.

Paradoxical vocal fold motion disorder in the elite athlete: Experience at a large division I university

To review our experience at a large division I university with the diagnosis and management of paradoxical vocal fold motion disorder (PVFMD) in elite athletes. A single institution retrospective review and cohort analysis. All elite athletes (division I collegiate athletes, triathletes, and marathon runners) with a diagnosis of PVFMD were identified. All patients underwent flexible fiberoptic laryngoscopy (FFL) to confirm the diagnosis of PVFMD. The type of PVFMD therapy was identified and efficacy of treatment was graded based on symptom resolution. Forty-six consecutive athletes with PVFMD were identified. A total of 30/46 (65%) were division 1 collegiate athletes and 16/46 (35%) were triathletes or marathon runners. In comparison to a nonathlete PVFMD cohort, athletes were less likely to present with a history of reflux (P < 0.01), psychiatric diagnosis (P < 0.01), dysphonia (P < 0.01), cough (P = 0.02), or dysphagia (P < 0.01). The use of postexertion FFL provided additional diagnostic information in 11 (24%) patients. Laryngeal control therapy (LCT) was recommended for 45/46. A total of 36/45 attended at least one LCT session and 25 (69%) reported improvement of symptoms. Additionally, biofeedback, practice-observed therapy, and thyroarytenoid muscle botulinum toxin injection were required in three, two, and two patients, respectively. The addition of postexertion FFL improves the sensitivity to detect PVFMD in athletes. PVFMD in athletes responds well to LCT. However, biofeedback, practice-observed therapy, and botulinum toxin injection may be required for those patients with an inadequate response to therapy. 4.

Laryngopharyngeal dysfunction independent of vocal fold palsy in infants after aortic arch interventions

Laryngopharyngeal dysfunction contributes significantly to morbidity, length of stay, and increasedresource utilization after aortic arch interventions in infants. Previous studies have focused on postoperative evaluation of selected symptomatic patients with vocal fold palsy (VFP). A prospective evaluation of laryngopharyngeal function was undertaken to assess and determine its importance in perioperative management. A routine preoperative and postoperative assessment was done by flexible fiber optic laryngoscopy, oral feeding evaluation (OFE), and modified barium swallow (mBS) on 101 infants undergoing 113 procedures on the aortic arch (2003 to 2011). The primary outcome was the ability to take full nutrition orally at discharge. Preoperative OFE was abnormal in 33.3% of patients. VFP occurred in 39.3%, 30 of 57 patients had an abnormal OFE. Factors predictive of abnormal postoperative feeding evaluation included genetic syndromes(odds ratio [OR], 5.1; confidence interval [CI], 1.1-23.2) and preoperative mechanical ventilation (OR, 24.1; 95% CI, 2.5-226.6). An abnormal postoperative OFE was highly predictive (OR, 7.0; 95% CI,1.8-27.1) of an abnormal postoperative mBS. There was a trend toward decreased long-term survival among patients who were intubated or had an abnormal preoperative feeding evaluation (P=.07). Postoperative laryngopharyngeal dysfunction is common among infants undergoing aortic arch interventions, and is largely independent of vocal fold function. Preoperative evaluation demonstrates significant intrinsic abnormalities in sensory and motor function. Routine, comprehensive, multimodality preoperative andpostoperative evaluation is required to identify at-risk children and reduce morbidity and resource utilization.

Laryngeal Response Patterns to Mechanical Insufflation-Exsufflation in Healthy Subjects

Mechanical insufflation-exsufflation (MI-E) is used to assist cough in patients with neuromuscular diseases. Clinically, application may be challenging in some patient groups, possibly related to laryngeal dysfunction. Before launching a study in patients, the authors investigated laryngeal responses to MI-E in healthy individuals. Twenty healthy volunteers, aged 21-29 yrs, were studied with video-recorded flexible transnasal fiber-optic laryngoscopy while performing MI-E using the Cough Assist (Respironics, United States) according to a standardized protocol applying pressures of ±20 to ±50 cm H2O. An initial abduction of the vocal folds was observed in all subjects, both during the insufflation and exsufflation phases. Nineteen of the 20 subjects adequately coordinated glottic closure when instructed to cough. When instructed simply to exhale during exsufflation, the glottis stayed open in a majority. Subsequent to an initial abduction during exsufflation and cough, various obstructive laryngeal movements were observed in some subjects, such as narrowing of the vocal folds, retroflexion of the epiglottis, hypopharyngeal constriction, and backward movement of the base of the tongue. The larynx can be studied with transnasal laryngoscopy during MI-E in healthy individuals. Laryngeal responses to MI-E vary, and laryngoscopy may offer valuable clinical information when applying MI-E in patients with bulbar muscle weakness.

Index of Suspicion in the Nursery

A term male infant is transferred to the NICU for persistent hypoglycemia at age 3.5 hours. The infant had a blood sugar level of 21 mg/dL at age 3 hours and despite refeeding 20 mL of 20 calories per ounce of formula, his blood glucose level remained at 20 mg/dL at 3.5 hours. The infant was born via cesarean delivery for a nonreassuring heart rate tracing to a 19-year-old G1P 0 African-American mother. All prenatal laboratory results were negative, including an oral glucose tolerance test. Prenatal ultrasonography was performed during the second trimester and showed no gross fetal anomalies other than the presence of a two-vessel cord. The infant cried spontaneously at birth and had some transient respiratory distress. The infant weighs 2,960 g (50th percentile) with a length of 48 cm (50th percentile) and a head circumference of 32.5 cm (25th–50th percentile). Results of the physical examination are normal except for a small penis (stretched penile length of 1.5 cm, width of 0.6 cm) and an undescended left testicle. Blood glucose levels below 40 mg/dL persist despite two boluses of 10% dextrose and administration of continuous dextrose infusion with a glucose infusion rate of ∼5 mg/kg per minute. Glucose levels above 40 mg/dL are eventually achieved with a glucose infusion rate of 8 mg/kg per minute. The pediatric endocrinology service was consulted on the second day for persistent hypoglycemia. A 3,490-g term male infant is born to a 20-year-old primigravida mother. She received good prenatal care, and her pregnancy was uncomplicated. Antenatal screening for human immunodeficiency virus, hepatitis B, and syphilis were negative, and she had immunity against rubella. Results of the patient’s cervical culture were positive for group B streptococcus, but she received adequate intrapartum penicillin prophylaxis before delivery. There was no abnormality noted on the fetal cardiotocography. …

Swelling of Submandibular Region

A man in his 30s with no significant medical history presented with a subtle soft swelling of his right submandibular region for the past 8 months. In the previous 24 hours it had rapidly expanded with painful neck swelling, dysphagia, andmild shortness of breath with supine and intermittent fever. Physical examination revealed a soft and easily compressible neck mass with overlying skin erythemawith no obvious involvement of the floor of themouth. Flexible fiberoptic laryngoscopy revealed no suspicious lesions and symmetric vocal cord movement. Contrast-enhanced computed tomographic (CT) imaging of the neck revealed a 6-cm wellcircumscribed mass with septations within the right sublingual space herniating through the mylohyoid muscle into the right submandibular space as shown in the Figure (A and B, axial; C, sagittal reformatted; and D, coronal reformatted). The patient was taken to the operating room for transcervical excision of the lesion. What is your diagnosis? A B

Microbiological Sampling of Common Otolaryngological Office Equipment: What Lessons Can We Learn?

Objectives: Analyze whether standard decontamination protocols were effective in cleaning integral components of common otolaryngological office equipment, including flexible fiberoptic laryngoscopes, detachable light cables, and otoscope handles. Methods: A random microbiological sampling of 6 flexible fiberoptic laryngoscopes including the eye piece and the driver handle, 3 light cables, and 5 otoscope handles was performed. All equipment was sampled in the middle of a busy office session. Samples were then subjected to standard aerobic growth culture analysis. Results: From a total of 20 samples collected, 7 (35%) demonstrated contamination with bacterial organisms. 4 of the 20 sample sites (20%) exhibited human contamination, 2 of which were from light cables, 1 from a laryngoscope eye piece, and 1 from an otoscope handle. Conclusions: This microbiological evaluation of common office instruments demonstrates that there are numerous potential contaminates which may be present in the office setting. These include flexible laryngoscope eyepieces, light cables, and otoscopes, which are commonly overlooked in the cleaning protocols of a standard otolaryngology clinic.

Pathology Quiz Case 1

A 57-YEAR-OLD WOMAN PRESENTED WITH A 2-year history of chronic cough. Onset was associated with flulike symptoms. Her cough worsened, and she started to have difficulty in airway functioning and dysphagia. She denied any hoarseness. A physical examination showed that she was in no apparent distress. Her voice was normal. Flexible fiber-optic laryngoscopy showed a large, posterior, broadly based interarytenoid mass significantly obstructing the posterior glottis, splaying open the arytenoids (Figure 1). The vocal cords were mobile. Computed tomographic imaging of the neck showed a soft-tissue lesion in the larynx obstructing the airway and bilateral level II and III lymphadenopathy. Computed tomographic imaging of the abdomen and pelvis showed hypodense liver lesions. A biopsy of the mass was performed under local anesthesia. Hematoxylin-eosin staining at low (original magnification 40) (Figure 2) and higher (original magnification 200) (Figure 3) magnifications is shown. Immunohistochemical staining was positive for c-Kit (CD117) and DOG1 (discovered on GIST), and negative for pancytokeratin, CD34, CD45, melan-A, S100, and CD68. Gomori methenamine silver stain demonstrated focal fungal organisms, and the acid-fast bacilli stain was negative for organisms. The patient then underwent an awake tracheotomy, endoscopic transoral laser partial laryngectomy, and bilateral selective neck dissections. A rubbery mass originating from the right arytenoids, growing over the interarytenoid area and extending to the left arytenoid, was discovered. The left arytenoid itself was free of tumor. Infiltrating portions of the tumor were not completely removed. The postcricoid area, esophageal inlet, and bilateral true cords were free of tumor. The final pathologic findings showed a spindle cell tumor measuring 2.7 1.2 1.7 cm in size with 5 mitoses per 50 high-power fields (HPFs). Twenty of 30 lymph nodes were positive for metastatic disease. What is your diagnosis?