Otolaryngology Team Research Articles

Eagle syndrome masquerading as a chicken bone

This is a brief report of a 17-year-old male who presented to the emergency department with odynophagia and a foreign body sensation in the throat after choking on a chicken wing. A soft tissue neck radiograph was performed which revealed a 4.6-cm linear object in the vallecula read by the radiology department as a chicken bone. The otolaryngology team was consulted and performed a nasopharyngeal laryngoscopy which did not reveal a foreign body in the upper aerodigestive tract. On physical examination, the right tonsillar fossa was tender to palpation. Upon further review of the radiograph, the right stylohyoid ligament was noted to be elongated and calcified. Thereafter, the diagnosis of Eagle syndrome was made. This case provides an important teaching point for providers by pointing out a syndrome that can mimic other disease processes. In addition, it emphasizes the importance of providers reviewing their own films.

P191 Pellets in rigth ventricle. Without entry point?

Abstract Case Report A 39-year-old male patient was transferred to emergency room by mobile intensive care unit after receiving a firearm wound in the neck while hunting: accidentally hit by a shotgun. Physical examination highlighted the existence of multiple entry holes at right side face and neck and some above the shoulder girdle line, the rest of the thorax and abdomen did not present skin lesions. Axial tomography (CT) showed multiple pellets in the face and neck tissues and two intracardiac pellets in the right ventricle. He did not present pneumothorax, pneumopericardium or pericardial effusion. He underwent surgical intervention by otolaryngology and vascular teams due to right cervical hematoma and secondary alterations to the shot in the right internal jugular vein. Enucleation of the right eye was also necessary. Echocardiographic study showed the presence of a small hyperechogenic mass with posterior acoustic shadow located in interventricular septum. Another similar structure was also found, in the right ventricle, next to the tricuspid annulus: normal tricuspid valve function. Considering the trajectory (blue triangle) of the shot and the absence of thoracic complications, we thought about the plausibility of projectile embolization from the right internal jugular vein. Discussion The presence of projectiles in different cardiac structures can occur by direct impact (the most frequent mechanism), passing through thoracic and/or abdominal structures to be lodged in the pericardium and/or myocardium. They are often accompanied by manifestations such as pericardial effusion or pneumothorax as a result of their trajectory. Embolization to the heart is a much more uncommon mechanism by impacting in another anatomical location such as the neck or lower extremitie. In these cases there may be no extra-cardiac manifestations and can be an incidental finding of a previous event. In our case the intracardiac pellets were s was handled conservatively and the rest of the wounds produced by the shot showed a good evolution. The patient remained asymptomatic from a cardiological point of view during hospitalization and follow up. There is no evidence to support the therapeutic attitude that should be followed in these cases. When the patient is stable and the projectiles are non-mobile, conservative treatment with periodic follow-up is a suitable option. Abstract P191 Figure. A. 3D echo, B. Xplane, C. CT VR.

A visual analog scale for patient-reported voice outcomes: The VAS voice.

ObjectivesAlthough patient‐reported outcome measures (PROMs) can be useful for assessing quality of life, they can be complex and cognitively burdensome. In this study, we prospectively evaluated a simple patient‐reported voice assessment measure on a visual analog scale (VAS voice) and compared it with the Voice Handicap Index (VHI‐10).Study designProspective survey.MethodsAn abbreviated voice measure was designed by a team of otolaryngologists, speech pathologists, and patients that consisted of four VAS questions related to (a) a global question of voice disturbance, (b) physical function of voice, (c) functional issues, and (d) emotional handicap. All English‐speaking patients presenting to an academic laryngology clinic for a voice complaint were included. Internal consistency and validity were assessed with comparison to the VHI‐10.ResultsA total of 209 patients were enrolled. Ninety‐two percent of patients reported understanding the survey. The four‐item VAS survey was highly correlated with VHI‐10 score (Pearson correlation .81, P < .0001), and the Cronbach's alpha between all four VAS questions was .94. Age, gender, and diagnosis were not associated with either the global VAS or VHI‐10 tool.ConclusionReducing the complexity of instruments assessing voice‐related quality of life is feasible, and the VAS voice correlated with existing measures. Simplified assessments may offer advantages compared to more cumbersome PROMs.Level of Evidence2c

Improving Tracheostomy Care in Resource-Limited Settings.

Tracheostomy care in leading pediatric hospitals is both multidisciplinary and comprehensive, including generalized care protocols and thorough family training programs. This level of care is more difficult in resource-limited settings lacking developed healthcare infrastructure and tracheostomy education among nursing and resident staff. The objective of this study was to improve pediatric tracheostomy care in resource-limited settings. In collaboration with a team of otolaryngologists, respiratory therapists, tracheostomy nurses, medical illustrators, and global health educators, image-based tracheostomy education materials and low-cost tracheostomy care kits were developed for use in resource-limited settings. In addition, a pilot study was conducted, implementing the image-based tracheostomy pamphlet, manual suctioning device and low-cost ambulatory supply kit ("Go-Bags"), within a low-fidelity simulated training course for nurses and residents in Kigali, Rwanda. An image-based language and literacy-independent tracheostomy care manual was created and published on OPENPediatrics, an open-access online database of clinician-reviewed learning content. Participants of the training program pilot study reported the course to be of high educational and practical value, and described improved confidence in their ability to perform tracheostomy care procedures. Outpatient tracheostomy care may be improved upon by implementing image-based tracheostomy care manuals, locally-sourced tracheostomy care kits, and tailored educational material into a low-fidelity simulated tracheostomy care course. These materials were effective in improving technical skills and confidence among nurses and residents. These tools are expected to improve knowledge and skills with outpatient tracheostomy care, and ultimately, to reduce tracheostomy-related complications.

Dyspnea-Think outside of the box, a case of subglottic stenosis.

Dyspnea is a common presentation in upper and lower airway obstructive causes. However, biphasic stridor and hoarseness should prompt evaluation of the upper airway. Nasendoscopy carried out by the otolaryngology team is a quick and an effective way of evaluating the upper airway.

Michigan Medicine: The University of Michigan Head and Neck Anesthesiology and Advanced Airway Management Fellowship

Michigan Medicine: The University of Michigan Head and Neck Anesthesiology and Advanced Airway Management Fellowship

Endoscopic transsphenoidal pituitary surgery in children

With increasing adoption of endoscopic techniques and improved knowledge of skull base anatomy and approaches, transsphenoidal pituitary surgery is now being performed on patients of all ages. Surgical principles are similar between pediatric and adult patients, but there are special considerations for the pediatric population in terms of instrumentation, surgical anatomy, and postoperative care. Wide exposure to the sella, oftentimes to accommodate multiple instruments and the endoscope, is frequently necessary. Persistent collaboration among the otolaryngology, neurosurgery, and anesthesiology teams is of critical importance to ensure optimal outcomes.

Safety and utility of direct laryngoscopy and bronchoscopy in patients hospitalized with croup.

Acute croup is a common admitting diagnosis for pediatric patients. If a patient is not responding to medical management for presumed croup, the otolaryngology team is occasionally consulted for direct laryngoscopy and bronchoscopy (DLB) to rule out tracheitis or another airway pathology. We conducted a study to determine if inpatient DLB in acute croup is safe and efficacious and to correlate preoperative vital signs with intraoperative findings. We reviewed the charts of 521 patients with an admitting diagnosis of acute tracheitis, acute laryngotracheitis, or croup. Of this group, 18 patients-11 boys and 7 girls, aged 1 month to 3.3 years (mean: 1.3 yr)-had undergone inpatient DLB. Comorbidities, complications, and level of care were also analyzed. Five patients (28%) had gastrointestinal reflux disease (GERD), and 4 had previously undergone intubation (22%). Eleven patients (61%) had concurrent airway pathology, 7 of whom (39%) required operative intervention. Preoperative mean body temperature and the increase in mean temperature were significantly higher in tracheitis patients than in the non-tracheitis patients. Preoperative change in respiratory rate was elevated when another airway pathology was present (p = 0.047). Only patients who were in the intensive care unit (ICU) preoperatively were intubated in the operating room, and only 1 patient required a postoperative escalation in the level of care. Our study found that performing inpatient DLB in patients hospitalized with croup is reasonably safe and provides a sufficient yield for identifying tracheitis or other airway pathology in selected populations. Preoperative vital signs can be suggestive of tracheitis or additional unexpected airway pathology. Recurrent croup, a history of GERD or previous intubation, and preoperative admission to the ICU increase the yield of DLB.

Utilization of a handheld metal detector protocol to reduce radiation exposure in pediatric patients with esophageal coins

ObjectiveThe primary objective of this study is to assess the utility of a handheld metal detector for identification and surveillance of patients with known esophageal coin ingestion to reduce repeat x-rays and associated radiation exposure. MethodsProspective study of children presented to the emergency department with esophageal coins confirmed by an initial x-ray were enrolled. The otolaryngology team used the handheld metal detector to detect and localize the coin on patient. If admitted for observation, the metal detector was used to ensure coin persistence prior to going to operating room for removal. No further x-rays were done if same location is confirmed. ResultsA total of 19 patients (10 months-14 years) with 20 esophageal coins were enrolled. 14 patients (73.7%) were initially detected in the emergency department by the metal detector. 11 (58%) asymptomatic patients admitted for period of observation, repeat x-rays were avoided in 10 (90.9%) patients prior to removal in the OR. All proximal esophageal coins were detected with the metal detector. There were 5 (26.3%) patients who failed initial detection of coin, and all of these were in the mid-distal esophageal location with depth from skin >7 cm. ConclusionA handheld metal detector is rapid, cost-effective surveillance tool to reduce exposure to radiation from repeated x-rays in patients with esophageal coins. In contrast to all prior published studies, which did not objectively examine depth, the distance of the coin from skin surface appears to be a major limitation. Parents have provided positive feedback on the protocol.

Transoral robotic surgery (TORS): a new tool for high risk tracheostomy decannulation

SUMMARYTracheostomy decannulation has always been considered a procedure with an attendant risk, especially in patients with a reduced upper airway diameter as is commonly observed in the obstructive sleep apnoea (OSA) population. We report on 4 cases where transoral robotic surgery (TORS) helped in the management of long-term cannulated patients. The aims of our paper are: 1. To demonstrate how the otolaryngology team can help identify patients at high risk for decannulation failure; and 2. To demonstrate how TORS may aid in the decannulation process of patients at high risk for failure due to severe tongue base hypertrophy. From our experience, TORS appears to offer an effective option to aid in the decannulation of patients with a severe hypertrophy of the base of tongue and floppy epiglottis.

A Newborn with Multiple Anomalies

A late preterm neonate is born with an occipital encephalocele and other anomalies. ### Prenatal and Birth Histories ### Presentation The neurosurgery, otolaryngology, and neonatology departments were present at delivery. The encephalocele was large (Fig 1) and was initially placed in a sterile bag. Some spontaneous breaths were noted. Given the infant’s micrognathia, the otolaryngology team provided nasal intubation and placed the infant on positive pressure ventilation (Fig 2). The encephalocele was cleaned, wrapped in wet gauze, and placed in a polyethylene skin wrap by the neurosurgery team. The infant’s Apgar scores were 2, 6, and 8 at 1, 5, and 10 minutes, respectively. Before arrival at the NICU, a peripheral intravenous line was placed. The infant required 2 dextrose boluses to obtain a normal serum glucose value, and 1 normal saline fluid bolus to maintain appropriate blood pressure. She was then brought to the NICU and placed on assisted ventilation. …

40. Hoarseness of voice as a primary presentation of pulmonary hypertension: A rare case of Ortner’s (cardio-vocal) syndrome

Ortner’s (cardio-vocal) syndrome is a rare disease entity that involves compression of the left recurrent laryngeal nerve due to enlargement of cardiovascular structures. The syndrome was first described by Norbert Ortner (an Austrian physician) in 1897 and is usually reported to be associated with mitral stenosis. However, we report a rare case when a 20-year-old girl presented with hoarseness of voice and was found to have an enlarged main pulmonary trunk due to pulmonary hypertension that was compressing the left recurrent laryngeal nerve. The case highlights a rare presentation of a relatively common disease and stresses the importance of detailed cardiac workup in a patient with hoarseness of voice. We present the case and review the literature. A 20-year-old lady was referred from primary health center due to complaints of hoarseness of voice for the last four months. She reported only mild exertional palpitations and shortness of breath. She did not report any previous cardiac problem in childhood. Examination revealed a loud pulmonary component of 2nd heart sound, a pan-systolic murmur at the tricuspid area, and a palpable thrill. There was no evidence of right heart failure or any stigmata of connective tissue disease. Electrocardiography showed sinus rhythm with dominant R-wave in lead V1 indicating right ventricular hypertrophy. Laboratory tests did not reveal any abnormality. 2-D transthoracic echocardiograhy revealed normal left ventricle in size and function, right ventricular hypertrophy (6 mm thickness of free wall), mild to moderate tricuspid regurgitation, pulmonary hypertension (pulmonary pressure 60–65 mmHg) and an enlarged main pulmonary trunk. Computed tomography (CT) of the chest showed dilated main pulmonary trunk (max diameter 42 mm). An angiogram excluded pulmonary emboli. The patient was also seen by the Otolaryngology team in view of the main complaint of hoarseness of voice. Indirect laryngoscopy showed left vocal cord palsy. CT scan of the neck excluded a mass lesion or enlarged lymph nodes. We concluded that the enlarged pulmonary trunk secondary to pulmonary hypertension has compressed the left recurrent laryngeal nerve as it passes between the aorta and the pulmonary artery, thus causing left vocal cord paralysis. The case has been referred to the tertiary center where she will be reviewed by the pulmonary hypertension team and the thoracic surgeons, and will be followed in our clinic. Ortner’s syndrome is rare. Although aortic aneurysms are the most common risk factor, pulmonary hypertension with dilated pulmonary artery can compress the left recurrent laryngeal nerve and cause hoarseness of voice. The case clearly identifies the importance of detailed cardiac workup in patients presenting with hoarseness. Early diagnosis helps in guiding immediate treatment and may alleviate the distressing symptoms.

Diagnosis and Clinical Management of Human Papilloma Virus-Related Gingival Squamous Cell Carcinoma in a Patient With Leukemia: A Case Report.

Close clinical inspection for intraoral lesions in patients with leukemia that develop chronic graft-versus-host disease (cGVHD) is critical. Additionally, neoplasias developing in bone marrow transplant patients after treatment for leukemia represent a significant obstacle for long-term patient survival, necessitating lifetime follow-up by health care providers. This case report describes the identification, diagnosis, and treatment of gingival squamous cell carcinoma (SCC) in a patient with leukemia who was treated previously with a stem cell transplant and referred for routine periodontal care. A 53-year-old male was referred to the Department of Periodontics for an assessment of tooth #10 with 2+ mobility and associated cross-bite occlusion. The patient was diagnosed with acute myeloid leukemia at age 39 years, received hematopoietic stem cell transplantation (HSCT), and later developed cGVHD followed by human papilloma virus (HPV) infections. During the periodontal evaluation, a large, non-painful, exophytic, alveolar gingival mass was identified and later diagnosed as SCC. It is unusual that oral SCC presents as an exophytic, gingival swelling. The patient received comprehensive periodontal management in coordination with his otolaryngology team before and during the diagnosis of SCC secondary to cGVHD and HPV infection. Patients with a history of HSCT treatment for leukemia and subsequent cGVHD are at a high risk of developing second primary oral malignancies, including SCC. Exposure to oncogenic HPV infection may compound this risk. Therefore, it is important for dentists to be aware of special treatment concerns and to frequently screen these patients to achieve early diagnosis and treatment of these neoplasms.

An Interesting Association of Cystic Hygroma of the Neck and Lymphangioma Causing a Paediatric Swollen Tongue.

Up to 75% of lymphatic malformations occur in the head and neck region. Of these, cystic hygromas and lymphangiomas have been widely reported; however they rarely occur in the same patient. We report the case of a 5-year-old girl who presented to the Department of Paediatrics of a district general hospital with a short history of recurrent, painful swelling of the anterior one-third of her tongue. She was reviewed under the joint care of the Oral and Maxillofacial Surgery and Otolaryngology Teams. Relevant past medical history included a previously excised cystic hygroma from her right neck when she was aged 2 years. Diagnosis of lymphangioma was made and of the potential management options available active monitoring was favoured due to the patient's age. To our knowledge the occurrence of both tongue lymphangioma and cystic hygroma has not been previously reported in a paediatric patient. This case report therefore shows a rare association between a cystic hygroma of the neck and lymphangioma of the tongue.

Oropharyngeal Edema in an 8-Month-Old Girl after Woolly Bear Caterpillar Exposure

BackgroundLepidopterism refers to the manifestations of contact from any number of moths, butterflies, and caterpillars. Various symptoms have been described, ranging from localized skin irritation to systemic anaphylactic reactions. Case ReportWe present a case of airway edema in an 8-month-old child from oral exposure to Woolly Bear Caterpillar (Pyrrharctia Isabella). After prompt emergency department recognition, her symptoms necessitated urgent operating room management by a team of otolaryngologists and close monitoring in a pediatric intensive care unit. A similar presentation in this species has not been described previously in the English literature. Why Should an Emergency Physician Be Aware of This?Leptidopterism is rare, but recognition by the emergency practitioner is necessary for prompt and appropriate treatment. Rapid identification by the emergency physician of oral exposure and careful spine removal can be lifesaving in cases of significant oropharyngeal edema.

Integrated Anterior, Central, and Posterior Skull Base Unit - A New Perspective.

The skull base is one of the most complex anatomical regions and forms the floor of the cranial cavity. Skull base surgery involves open, microscopic, and endoscopic approaches to the anterior, middle, or posterior cranial fossa. A multispecialty team approach is essential in treating patients with skull base lesions. Traditionally, rhinologists are involved in providing access to anterior skull base lesions while otologists are involved in the treatment of lesions of the posterior skull base. This is the case in most skull base centers today. In this article, we share a new perspective of an integrated skull base unit where a team of otolaryngologists and neurosurgeons treat anterior, middle, and posterior skull base pathologies. The rationale for this approach is that most technical skills required in skull base surgery are interchangeable and apply whether an endoscopic or microscopic approach is used. We show how the different skills apply to the different approaches and share our experience with an integrated skull base unit.

Chronic Esophageal Foreign Body Presenting as Wheezing and Cough in a Toddler.

The presentation, evaluation, and management of chronic esophageal foreign bodies are not well described in pediatric patients. Many patients present with ill-defined respiratory symptoms, making diagnosis challenging. We report on a 2-year-old girl who presented with several months of worsening cough and wheezing unresponsive to medical management. She also had recent onset of feeding difficulty with certain consistencies. She underwent a joint bronchoscopy with the otolaryngology team. Bronchoscopy demonstrated severe tracheal narrowing and esophagoscopy showed severe inflammation. A chest computed tomography scan showed inflammation between the esophagus and trachea. Repeat esophagoscopy revealed an esophageal foreign body embedded into the anterior wall, which was removed via thoracotomy.

Editorial

On the evening of April 15th, the emergency department at Massachusetts Eye and Ear Infirmary was full. Patients who were cleared of other major medical trauma next door at Massachusetts General Hospital arrived to be evaluated for ear pain, hearing loss, and other head and neck injuries. Over 250 people were maimed by the dual blasts at the Boston Marathon earlier in the day, and we were seeing the aftermath.Figure: Aaron Remenschneider, MD, MPHMost patients had hearing loss, tinnitus, and mild disequilibrium. On exam, they had tympanic membrane perforations, large and small. Pieces of metallic shrapnel were identified and carefully removed from patients' faces, necks, and arms. Audiograms revealed both conductive and sensorineural hearing loss, often worse in the ear facing the blast. Careful eversion of perforated drum edges was performed, and selected patients with sensorineural hearing loss were treated with oral steroids. Later in the evening, the otolaryngology team visited patients with significant soft tissue and limb injury in the intensive care unit—proximity to the blast seemed to predict substantial tympanic membrane loss. Examination of patient after patient continued through the night and into the next day.Figure: Daniel Lee, MDIn the ensuing weeks, we have seen dozens of these victims in our clinic and emergency room. Our treatment recommendations were based on experience with traumatic perforations from other causes, clinical and scientific literature on noise-induced hearing loss, and recommendations from the military literature and military colleagues. Whether differences exist in the expected outcomes between civilians and military personnel is unknown. Fortunately, blast injuries to the ear are rare occurrences in our society. The otologic morbidity from this single event was unprecedented for our city, and it has led otolaryngologists and audiologists from each of Boston's major medical centers to come together in an effort to study the nature of patient injuries and to document their outcomes over time.Figure: Alicia Quesnel, MDThe primary aim of the study is to correlate tympanic membrane perforation size with rates of healing, including the success of tympanoplasty. Secondary aims include understanding the effect of steroids on sensorineural hearing loss after acoustic trauma, and relating distance from the blast to sensorineural hearing loss and tympanic membrane perforation. Massachusetts Eye and Ear Infirmary, Beth Israel Deaconess Medical Center, Boston Children's Hospital, Boston Medical Center, Brigham and Women's Hospital, Harvard Vanguard Medical Associates, and Tufts Medical Center all saw patients affected by the events of April 15 and agreed to pool data for meaningful analysis. Standardized data collection forms with serial audiograms will comprise the core data set. We have evaluated over 100 patients, and we expect to enroll and follow these individuals over the next twelve months. Data collection has already begun in this multicenter study. In our effort to provide the highest quality of care to the Boston Marathon bombing victims, we must acknowledge what we do not know about blast-related ear injury. We hope to learn more about the consequences of acoustic trauma through this research, and we appreciate all we have already learned from these individuals about inner strength and resilience.

Mechanical airway obstruction due to dislodged spinal hardware

A difficult airway caused by mechanical obstruction from dislodged spinal hardware in a patient undergoing revision surgery for a cervical chordoma is presented. Due to the logical, sequential multidisciplinary airway and patient management by the anesthesiology, neurosurgery, and otolaryngology teams working together in an environment of clear communication, a potential life-threatening crisis was averted with successful outcome for the patient.

Changing incidence and management of penetrating neck injuries in the South East London trauma centre.

INTRODUCTIONA total of 17 cases of penetrating neck injury were managed by the otolaryngology team at King’s College Hospital over a 3-year period in the 1980s. In April 2010 King’s College Hospital became the major trauma centre for South East London. This prospective cohort study compares the incidence, changing demographic features and treatment outcomes of penetrating neck trauma in South East London over the previous 23 years.METHODSData were collected over a 12-month period (April 2010 to March 2011) and a selective management protocol was introduced to standardise initial investigations and further treatment.RESULTSThe past 23 years have seen a 550% increase in the incidence of penetrating neck injuries in South East London, with a marked increase in gun crime. Only 38% of cases underwent negative neck exploration in 2011 compared with 65% in 1987. Selective conservative management based on the absence of haemodynamic instability or radiological findings reduces length of hospital stay, lightens surgical workload and cuts costs without affecting morbidity or mortality.CONCLUSIONSThe increased incidence of penetrating neck injury is a reflection of more interpersonal violence rather than a consequence of the larger South East London trauma centre catchment area. Tackling this problem requires focus on wider issues of community prevention. Sharing of data between the four London trauma centres and the police is needed to help prevent interpersonal violence and develop a universal treatment algorithm for other institutions to follow.