Otolaryngology Literature Research Articles

Giant Eccrine Adenocarcinoma of the Scalp with Intracranial Invasion

To the Editor: We read with interest the article by Donovan and Person (1). This article described the use of vacuum-assisted closure therapy for a large scalp defect resulting from resection of a rare adnexal scalp tumor with intracranial invasion. In this report, the authors demonstrated the use of vacuum-assisted closure therapy for successful closure of a wide scalp defect. Of note, this same case appears to have been published in 2004 in The Laryngoscope by different authors from the same facility (2). The main topic of this article is identical to the previous report and appears to have included the same patient. A review and comparison of the two articles shows that both contain multiple patient photographs and magnetic resonance imaging (MRI) scans. Photographs and MRI reproductions in the two articles are quite similar, and some appear to be identical. Additionally, the Donovan and Person article (1) did not reference the Laryngoscope publication. Although it is possible that the Donovan and Person article in NEUROSURGERY was submitted before publication of the Laryngoscope article and, therefore, was not referenced for that reason, this seems unlikely, given that there was nearly a 2-year interval between the publication of the two articles. The above suggests potential failings at multiple levels. First is the issue of copyright infringement, since, once submitted, photographs and reproductions become the property of the journal. Therefore, patient photographs and MRI reproductions cannot be reprinted without permission of the journal in which the photographs were first published. If the authors were unaware of the previous publication in The Laryngoscope, this still represents a potential failing. It is the primary responsibility of the author(s) to perform an adequate literature search when submitting a journal article. Today, with the advent of Medline searches, thorough reviews are mandatory. It is less surprising that neither the NEUROSURGERY reviewers nor the two invited discussants noted the above inconsistencies, since the original article was published in the otolaryngology (Ear, Nose, Throat [ENT]) literature. It is not the norm, nor is it reasonable, to expect reviewers and/or discussants to perform exhaustive literature searches of each article that they review. Therefore, it is imperative that situations such as this be reported and highlighted by NEUROSURGERY. This is the best way to minimize such instances and to assure the highest quality of our journal. Serdar Nasir James E. Zins Cleveland, Ohio

Is Surgical Innovation Reduced with More Strict Regulations?

Objective With ever-increasing regulatory requirements on human subject research, we postulated that there would be a corresponding decline in the number of published reports of surgical innovation in the otolaryngology literature. Methods We defined innovations as new procedures, techniques, or approaches that should require IRB approval in 2007, and modifications as non-substantive changes in existing procedures or techniques that should not require IRB approval. We reviewed every abstract from 4 months of the years 1988 and 2006, from the journals Laryngoscope, Oto-HNS, and Archives. After identifying information was concealed, abstracts were reviewed and classified independently by two authors, for innovation, modification, or neither. All disagreements were judged by a third author, who reviewed the entire article. Proportions were compared using chi-square analysis. Results There were 367 publications reviewed from 1988, and 548 from 2006. The proportion of articles representing either innovation or modification was significantly lower in 2006 than 1988: 59/548 (10.8%) vs. 67/367 (18.3%), p<0.001. Eliminating radiology and pathology quiz cases yielded similar results: 11.1% vs. 18.9%, p<0.001. Very few articles (4 total) were classified as innovation. Conclusions The proportion of published studies describing surgical innovations and modifications was significantly lower in 2006 than in 1988. One cause of this decrease in innovation could be increased barriers for research approval in the current era. However, other explanations are plausible, such as increased publication of other study types, e.g., basic research. While our analysis does not prove cause and effect, it is an important finding that deserves further study.

S264 – Pediatric Vagal Nerve Stimulator Implantation

Objectives 1) Learn the indications and procedure for vagal nerve stimulator implantation (VNSI) in pediatric patients with refractory seizures. 2) Understand the surgical outcomes and complications for the procedure. Methods A retrospective review of prospectively collected data from 2002–2007 was undertaken on VNSI. The cohort consisted of all pediatric patients ages 0–21 at a single institution tertiary children's hospital. All patients were included if they had treatment resistant seizures and had not previously undergone VNSI. The surgical indications, outcomes, complications, and follow-up were recorded. Results Over the 5-year period, 36 patients underwent VNSI. Age at surgery ranged from 3 to 20 years (mean 10.5 years). The indications for surgery for all patients included seizures refractory to antiepileptic medications (>5 medications). There were no intraoperative complications and all patients had successful electrode placement as measured by intraoperative testing. After an overnight hospital stay, patients were discharged and programmed by the pediatric neurologist at 2 weeks postoperatively. There were 2 postoperative complications (5.5%), scar hypertrophy of a chest incision and left-sided Horner's syndrome. Both patients have been managed conservatively without sequelae. Follow-up ranged from 6 to 72 months (mean 42 months). There were no device failures and all patients and families were subjectively satisfied with the postoperative result. Intraoperative and postoperative photos will demonstrate technique and outcomes. Conclusions Pediatric VNSI is a reliable procedure for refractory seizures with a low complication rate and can be performed safely by otolaryngologists. This represents the largest cohort of pediatric patients in the otolaryngology literature.

Early experience with minimally invasive esophagectomy in head and neck surgical patients

Minimally invasive esophagectomy (MIE) via thoracoscopy and laparoscopy have reduced the morbidity and mortality of total esophagectomy at experienced centers. MIE has not been evaluated in combination with major head and neck surgery, or in the otolaryngology literature. Case series of 11 consecutive patients undergoing either open or MIE with an ablative neck procedure. Comparing 4 MIEs and 7 open operations, similar operative time, blood loss, and ICU and hospital length of stay were observed. There was one mortality in the open group. A 100% rate of major complications was observed in the MIE group. Our multidisciplinary team was unable to achieve improved outcomes in a series of head and neck surgical patients undergoing MIE. This result may represent an early stage of the learning curve for MIE, but may also be attributed to the escalated surgical requirements of head and neck patients.

Otophyma: a case report

We report a rare case of otophyma. A case report of otophyma and a review of the current literature concerning otophyma and the more common rhinophyma, are presented. A 46-year-old male presented with slow growing fleshy growths on both auricles which were excised. A diagnosis of otophyma was made. Although rosacea is more common, otophyma and other 'phymas' are thought to be the end stage of the rosacea spectrum of skin disease. However, unlike rhinophyma, otophyma is rarely seen and as a result there is little in the English language literature regarding it. Consequently, the management of otophyma is largely based on previous experiences with rhinophyma. To our knowledge this is the first case report of otophyma in the otolaryngology literature and only the second described in the English language literature. This case demonstrates the difficulties faced in diagnosing this rare condition and our successful management of this case.

Zespół cichej zatoki u dziecka

Silent sinus syndrome (SSS) is rare clinical entity described in ophthalmology and otolaryngology literature. It is characterized by spontaneous and progressive enophthalmos and hypoglobus caused by maxillary collapse in the setting of chronic maxillary sinus hypoventilation. The authors report an unusual case of SSS in child. A 15 year old boy presented with 6 months history of developing of right cheek deformity with no clinically signs and symptoms of chronic rhinosinusitis. According to nasal endoscopy and CT and NMR scans the silent sinus syndrome was recognized. What is the most important, the deformity of anterior maxillary wall was the main problem and complaint. The patient underwent surgical endoscopic uncinectomy with medial antrostomy. The performed treatment successfully corrected both the cheek and the upper eyelid sulcus deformity. The control CT scans performed 3 months after surgery showed normal sinus ventilation with wide medial antrostomy. Silent sinus syndrome in a child is characterized by more active resorption and remodeling of anterior maxillary wall with clinically visible deformity. The goal of the treatment is restoration of normal maxillary sinus aeration and this guaranty further normal sinus development.

WITHDRAWN: Management of Congenital Incudostapedial Anomalies in Stapes Surgery.

OBJECTIVES:: The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist's diagnostic skills and flexibility in technique and prosthesis choice. Although congenital malleus fixation and perilymph gusher are important clinical entities that have received considerable attention in the otolaryngology literature, congenital anomalies of the incus and stapes are less well described, can often be subtle, and have a distinct influence on management choice and hearing outcome. STUDY DESIGN AND PATIENTS:: A review of more than 200 stapes procedures yielded eight cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory. The developmental anatomy and surgical technique in each case are reviewed and hearing outcome is presented. RESULTS:: The surgical technique used in each case varied depending on the nuances of the ossicular anomaly and whether both the stapes and incus were affected. All eight ears (seven patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome with seven ears improving to within 10-dB and one ear to within 13-dB air-bone gap on postoperative audiometry. CONCLUSION:: Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.

Nodular hidradenocarcinoma over the parotid gland: A pathologic presentation

Nodular hidradenocarcinoma (NHAC), an eccrine carcinoma, has been reported in the dermatology and pathology literature, but few references have been made in the otolaryngology literature even though the head and neck is a common site of occurrence. A case report of a 37-year-old Hispanic man with a right-sided neck mass diagnosed preoperatively as a parotid mass by imaging and fine-needle aspiration is presented. After presentation at our multidisciplinary tumor board, excision of the mass was undertaken. Final pathology revealed a NHAC, which is presented in our report. NHAC is an aggressive malignant tumor that is often misdiagnosed preoperatively and that must be treated with aggressive multimodality therapy for increased survival.

Tricholemmoma of the nose

Objectives The objectives of this case report are to (1) identify clinical presentations of tricholemmoma, (2) discuss the characteristics of Cowden syndrome and the relationship between this syndrome and tricholemmoma, and (3) differentiate tricholemmoma from other superficial cutaneous tumors such as basal cell carcinoma and granulomas. Study design We present a literature review and a case report. Methods A literature review of tricholemmoma and a case report of an unusual manifestation of this neoplasm were presented. Results Tricholemmoma was first described as a cutaneous neoplasm in 1962. It is associated with the Cowden syndrome and can be misdiagnosed as a more aggressive cutaneous malignancy. We report an unusual case of tricholemmoma presenting as a nasal mass. Conclusions Tricholemmoma is described as having a predilection for the head and neck, yet little information has been published about this disorder within the Otolaryngology literature. Otolaryngologist-head and neck surgeons must be familiar with this neoplasm because it can be frequently misdiagnosed as an aggressive cutaneous malignancy and hence can be incorrectly treated. We describe the presentation and diagnosis of tricholemmoma, describe the frequent association of this neoplasm with Cowden syndrome, and report an unusual presentation of tricholemmoma as an intranasal mass.

Quality of life assessment after non‐laser endonasal dacryocystorhinostomy

There has been a lack of patient-centred evidence in the Otolaryngology literature, that non-laser endonasal dacryocystorhinostomy improves the quality of life of patients. Many studies demonstrate successful outcomes based on non-validated subjective patient reporting. The aim of this survey was to evaluate the impact of non-laser endonasal dacryocystorhinostomy on the quality of life of patients using a validated questionnaire, the Glasgow Benefit Inventory (GBI). Prospective non-randomised case series. Secondary otorhinolaryngology-ophthalmology centre, single centre. Sixty-five consecutive patients undergoing non-laser endonasal dacryocystorhinostomy were asked to complete a questionnaire at their follow-up clinic appointment. All patients had a minimum of 9 months follow-up. A consultant ophthalmologist reviewed each patient six months after surgery and recorded the outcomes as 'cure', 'better', 'no change' or 'worse'. We defined 'success' as cured or better. 'Failure' suggests no improvement or worsening epiphora. The validated 18-item GBI was used. Fully completed questionnaires were received from 55 patients. Mean total GBI scores were +34 for successful non-laser endonasal dacryocystorhinostomy and -19 for failed non-laser endonasal dacryocystorhinostomy (Mann-Whitney z = 3.8, P < 0.001). Successful non-laser endonasal dacryocystorhinostomy does confer significant quality of life improvement.

Congenital midline cervical cleft: A practical approach to Z-plasty closure

A congenital midline cervical cleft (CMCC) is a rare developmental abnormality with several common features of variable severity: a midline defect of anterior neck skin, a superior nipple-like skin projection, and a subcutaneous fibrous cord. Congenital midline cervical clefts have important functional and cosmetic implications as cicatrical contracture with subsequent deformity may result without early surgical intervention. Treatment involves excision of all abnormal tissue, and reconstruction with Z-plasty techniques is favored because linear closure results in hypertrophic scarring and recurrent contracture. Z-plasty allows broken-line closure, reorientation of the defect in the horizontal plane with re-creation of a cervicomental angle, and most importantly, a lengthening of the anterior neck skin that aids in preventing recurrent contracture. We present our experience managing a congenital cervical midline cleft in a 3-month-old patient and describe a simple technique for planning the ideal Z-plasty closure. No simple description for planning the ideal closure for this defect could be found in the otolaryngology literature.

Osteonecrosis of the Mandible or Maxilla Associated with the use of New Generation Bisphosphonates

The use of bisphosphonates is well established for the treatment of patients with metastatic bone disease, osteoporosis, and Paget's disease. Osteonecrosis of the mandible or maxilla associated with the use of bisphosphonates is a newly described entity never before discussed in the otolaryngology literature. In this paper, we review a series of patients diagnosed with osteonecrosis, all treated with new generation bisphosphonates. Our objective is to inform and educate others, particularly otolaryngologists/head and neck surgeons, about this drug induced entity, a condition that should be recognized early to avoid potential devastating consequences. Retrospective chart review of a series of patients from a tertiary referral center. Pathology reports of specimens submitted from either the mandible or maxilla were reviewed from the previous 12 months. Any patient diagnosed with osteonecrosis without evidence of metastatic disease at that site was included; those with a previous history of radiation therapy were excluded. Each patient's medical history and profile were reviewed. Twenty-three patients were identified with osteonecrosis of the mandible or maxilla. All of these were associated with the use of new generation bisphosphonates: zolendronate (Zometa, Novartis), pamidronate (Aredia, Novartis), and alendronate (Fosamax, Merck). Eighteen patients with known bone metastases had been treated with the intravenous form, whereas five patients with either osteoporosis or Paget's disease were using oral therapy. Patients typically presented with a nonhealing lesion, often times the result of previous dental intervention. Although the majority of these patients were treated with conservative surgical debridement, we present a case requiring a near total maxillectomy. Drug induced osteonecrosis of the mandible or maxilla has been recently recognized as a sequelae of treatment with the new generation of bisphosphonates. Most patients can be treated with conservative surgical debridement and cessation of bisphosphonate therapy, whereas a few may require radical surgical intervention. Other recommendations include regimented prophylactic care with an assessment of dental status before the administration of bisphosphonates, avoidance of dental procedures, and close monitoring of oral hygiene.

Airway Complications from Topical Mitomycin C

Topical application of mitomycin C appears to be a useful adjunct in reducing cicatricial scarring of the airways. Human and animal studies have demonstrated the efficacy and safety of mitomycin C topically in the treatment of airway stenosis at concentrations ranging from 0.4 mg/mL to 10 mg/mL. Although no reports of mitomycin C toxicity have been reported in the otolaryngology literature, the ophthalmologic literature has documented serious, vision-threatening complications resulting from the use of topical mitomycin C. The purpose of this study is to report complications related to mitomycin C use in the treatment of glottic and subglottic stenosis. Risk factors associated with these complications are identified. A retrospective chart review of all patients treated by the senior author for laryngotracheal stenosis with endoscopic CO(2) laser incisions/dilation and adjuvant topical mitomycin C was performed to determine the incidence of complications. Variables studied included patient age and gender, location and severity of stenosis, medical comorbidities, length of procedure, postoperative instrumentation of the airway, and mitomycin C concentration. Eighty-five cases of adjuvant topical mitomycin C use after CO(2) laser endoscopic treatment and dilation for upper airway stenosis were identified in a total of 44 patients. Complications that were believed to be caused by the local toxicity of mitomycin C occurred in 4 cases out of 85 (or 4.7%), manifested by accumulation of fibrinous debris at the operative site, resulting in partial airway obstruction and the need for emergent airway intervention. Caution should be exercised when topical mitomycin C is used in the treatment of airway stenosis.

Combined Laryngotracheal Separation and Esophageal Injury Following Blunt Neck Trauma

In this article we describe the first case of combined laryngotracheal and esophageal injury following blunt neck trauma in the otolaryngology literature and delineate appropriate management considerations. Successful reconstruction requires appropriate airway management, restoration of esophageal and laryngeal mucosal integrity, and reduction of tracheal and laryngeal fractures with appropriate stenting. Laryngotracheal separation following blunt neck trauma is rare and can be initially overlooked. After the airway is secure, injury severity dictates repair and postoperative care. Immediate reconstruction with restoration of the laryngotracheal framework and mucosal integrity enables patients to recover a patent airway, functional voice, and normal swallow.

Kaposiform Hemangioendothelioma: Case Report and Literature Review

We report the identification of a kaposiform hemangioendothelioma (KH) in the oropharynx of a 3-year-old boy. This is a rare endothelial-derived spindle cell neoplasm affecting children and early adolescents with features common to capillary hemangioma and Kaposi sarcoma. Nine cases of head and neck KH have been reported, this being the first in the otolaryngology literature. Our patient underwent wide local excision and has remained tumor free for over 1 year. KH should be considered in the differential diagnosis of a vascular lesion demonstrating unexpected behavior from that of a hemangioma.

Numb Chin: A Neglected Syndrome in the Otolaryngology Literature?

Introduction: Numb chin syndrome (NCS) represents sensory loss and paresthesias involving half of the lower lip and chin. The syndrome is usually indicative of underlying malignancy. To our knowledge, the numb chin syndrome has not been previously described in the otolaryngology literature.

Internal jugular vein thrombosis due to ovarian hyper-stimulation syndrome

Internal jugular vein thrombosis from non-otological causes is not well documented in the otolaryngology literature. The authors report a case of left internal jugular vein thrombosis due to severe ovarian hyperstimulation syndrome. Causes, investigations and treatment of internal jugular vein thrombosis from non-otological causes are discussed.

Cervical Spine Fracture in the Ankylosing Spondylitis Patient

I read with interest the precautionary article by Shen and Samartzis, “Cervical Spine Fracture in the Ankylosing Spondylitis Patient,” describing the potential for cervical spine fractures in these patients as a result of trauma. I, as a resident, had experience with this type of injury and would like to expand a bit on their observations from the standpoint of the airway. Some of our experience was published in the otolaryngology literature, but a few important points would be worth emphasizing here. We were called to see patients who presented with progressive stridor as a result of an expanding hematoma in the prevertebral space from cervical spine fracture at a higher level than these authors reported. I still remember one gentleman lying there, struggling to breathe, and moving his head back and forth happily stating, “I haven’t been able to move my head around like this for years!” He did not do well. The points I would like to make with this letter are in addition to the information presented and are in no way critical of the authors’ work. First, it does not take much trauma to cause these injuries. One of our patients simply fell back into a chair when he was trying to sit down. It is typically an elderly patient. Next, any elderly patient presenting with progressive stridor, arthritis, or spondylitis by history and any recent falls or trauma should be presumed to have a cervical spine fracture until proved otherwise. This is extremely important with regard to airway management. We were called to intubate these patients transorally. If that had been done by an unsuspecting physician or nurse anesthetist, the results would have been a disaster. To secure the airway, these patients require the neck to be stabilized and either have a tracheotomy done under local anesthetic or intubated transnasally using a fiber optic laryngoscope to pass the endotracheal tube. My concern is that this information is in the otolaryngology literature but not in the general trauma literature. I hope this is of some benefit to others seeing these patients and my congratulations to the authors for a concise but important article. REFERENCES

Vocal Cord Paralysis after Laryngeal Mask Airway Ventilation

The laryngeal mask airway (LMA) is being used with increasing frequency since its introduction into the United States in 1991. Currently, the LMA is being used in the United States in approximately one third of all operations or greater than 100 million surgeries. In Britain, where it was first introduced for use in 1988, the LMA is estimated to be used in up to 50% of cases. Not only has its use in elective cases increased, but the scope of indications for the LMA has also grown. Its use in emergent and difficult airway management has increased, and new LMA products have been introduced to address the limitations of the classic model. As the LMA has increased in popularity, however, so has the incidence of LMA-related complications. Cases of mucosal trauma, hematoma, tongue cyanosis, arytenoid dislocation, and lingual, hypoglossal, and recurrent laryngeal nerve paralyses have been documented in various anesthesia journals. Reports of these injuries are sparse in the otolaryngology literature. As otolaryngologists who will manage the sequelae of LMA-related injuries, we must remain cognizant of potential problems and their underlying mechanisms. We report a case of unilateral vocal cord paralysis, which required operative repair after the use of an LMA. We review the existing case reports, propose mechanisms of injury, and discuss practical applications of our findings.

Extraskeletal myxoid chondrosarcoma: A report of a gynecologic case

Background. Extraskeletal myxoid chondrosarcoma is a rare tumor that has been reported and discussed in neurosurgical, orthopedic, and otolaryngologic literature. We report a case of vulvar extraskeletal myxoid chondrosarcoma. Case. This is a case of a 46-year-old woman who presented with a soft tissue mass in the left vulva and underwent local excision. Grossly, the tumors appeared to be leiomyomas. Pathology revealed an extraskeletal myxoid chondrosarcoma. Conclusion. We report the first case of an extraskeletal myxoid chondrosarcoma arising in the vulva.