A case of neck paraganglioma in a 49-year-old male: Case report and review of the literature.

INTRODUCTION AND SIGNIFICANCE: Paragangliomas are rare tumors that most commonly occur in the head and neck. They are typically slow-growing tumors that are often associated with genetic syndromes and mutations in the enzyme succinate dehydrogenase. CASE PRESENTATION: We describe a case of a male patient who presented with ear pain and dysphagia. On physical examination, there was a left neck mass and swalling in the left oropharynx. The mass was excised through a cervical approach and it was found to be a vagal paraganglioma. CLINICAL DISCUSSION: A few cases of head and neck paragangliomas (HNPGLs) have been reported in the medical literature. These tumors often present as asymptomatic masses, but this case, the patient presented with ear pain and dysphagia the location of the mass in the parapharyngeal space presents a surgical challenge. HNPGLs should be considered in the differential diagnosis of any neck mass. CONCLUSION: Paragangliomas are generally considered to have a good prognosis when they are completely excised. They rarely metastasize to adjacent or distant tissues. Cervical approach is a valid option for complete excision of cervical paraganglioma.

Rhinotopic therapy for refractory chronic rhinosinusitis: a study of 20 cases.

The management of refractory chronic rhinosinusitis (CRS) after endoscopic sinus surgery is complex and challenging. We conducted a prospective clinical pilot study to evaluate the effectiveness of a rhinotopic protocol for the treatment of refractory CRS. Our study population was made up of 20 patients--8 men and 12 women, aged 31 to 76 years (mean: 50.1)--who were treated in our tertiary care rhinology fellowship training program. The rhinotopic protocol consisted of twice-daily saline rinses, each of which was followed by the administration of a nebulized corticosteroid and then a nebulized antibiotic. This regimen was administered for 6 weeks. Thereafter, patients underwent a once-weekly endoscopic sinus debridement followed by topical intrasinus installation of a corticosteroid and antibiotic. The duration of follow-up was 24 weeks, and thus the total study duration was 30 weeks. Treatment outcomes were based on Lund-Kennedy symptom scores and Lund-Kennedy endoscopic appearance scores. We found a 56% improvement in the mean symptom score after 3 weeks of therapy and 77% after 6 weeks. Subsequent follow-up revealed 90% improvement 4 weeks following the completion of therapy and 95% at 8 weeks post-therapy. Thereafter, we saw a small decrease in improvement: 73% at 16 weeks of follow-up and 65% at 24 weeks. Analysis of endoscopic appearance scores revealed a 55% improvement at 3 weeks of therapy and 84% at 6 weeks. The same general pattern emerged during follow-up, with 94% improvement 4 weeks after the cessation of therapy, 96% at 8 weeks, 76% at 16 weeks, and 75% at 24 weeks. Sinus cultures performed 4 weeks after the cessation of therapy found no growth in 13 patients (65%), normal respiratory flora in 5 patients (25%), a persistent pathogen in 1 patient (5%), and the emergence of a new pathogen in another (5%). Analysis of symptom scores and endoscopic appearance scores revealed that the rhinotopic protocol resulted in statistically significant improvement (p < 0.001) throughout the treatment period and follow-up period, although the improvement gradually declined over time. We therefore conclude that a rhinotopic protocol can be an effective treatment for refractory CRS.

The benefit of the reverse transfer function in the fitting process of the Vibrant Soundbridge middle ear implant.

CONCLUSION: Reverse transfer function (RTF) measurement of the Vibrant Soundbridge (VSB) middle ear implant (MEI) is an objective method to evaluate the function of the VSB and can be used to adjust the Connexx value required to reach the optimal VSB gain during fitting sessions. OBJECTIVES: To investigate the sound transfer of the VSB with the RTF in implanted patients and evaluate the role of RTF in the fitting process of the VSB. METHODS: This was a prospective study including patients undergoing VSB implantation and RTF recording from March 2007 to October 2010. Three parameters were analyzed. 1) RTF: energy transmitted in dB SPL to ear canal by retrograde vibration of malleus and tympanic membrane. 2) Connexx value: level of amplification in dB delivered by the audioprocessor to the floating mass transducer (FMT). 3) VSB gain: difference in dB HL in free field between aided and unaided conditions. RESULTS: Ten patients fitted the criteria. RTF measurements revealed a significant inter-patient disparity. We adjusted the Connexx value according to the RTF value to obtain an optimal VSB gain within comfort levels. The VSB gain and RTF with Connexx value were closely correlated together. The mean VSB gain and RTF value converted to dB HL had comparable values.

High-frequency skull vibration-induced nystagmus test in partial vestibular lesions.

OBJECTIVES: To establish the effectiveness of the skull vibration-induced nystagmus test (SVINT) as a rapid high-frequency stimulation test, in the evaluation of partial unilateral vestibular lesions (pUVL). METHODS: SVINT (30, 60, and 100 Hz), caloric, and head-shaking tests were performed in 99 patients with pUVL. These results were compared with those in 9 patients with symmetrical partial bilateral labyrinthine malformations, 131 patients with total unilateral vestibular lesions (tUVL), and 95 control subjects. RESULTS: A skull vibratory nystagmus (SVN) was found in 75% of patients with pUVL and 98% with tUVL. In pUVL: SVINT revealed asymmetric responses in 20% of patients where other tests were normal; SVN direction at 100 Hz was opposite to the head-shaking nystagmus direction in 30% and opposite to SVN at 30 Hz in 10% of cases. At 100 Hz, SVN beat toward the safe side in 91% of cases; SVN values at 60 and 100 Hz were higher than those at 30 Hz (p < 0.005). SVN was found in unilateral superior canal dehiscences. Partial bilateral labyrinthine malformations revealed no nystagmus. CONCLUSION: SVINT complements head-shaking and caloric tests in multifrequency assessment of patients with pUVL, as a global vestibular test. In contrast with tUVL results, SVINT does not always indicate the side of partial lesions, neither does it locate their level on the vestibulo-ocular pathway. This test is useful to reveal a vestibular asymmetry as a bedside examination test and may be used as a "vestibular Weber."

Endoscopically guided chitosan nasal packing for intractable epistaxis.

BACKGROUND: The purpose of this study was to evaluate the effectiveness and safety of endoscopically guided chitosan packing in controlling intractable epistaxis. A prospective case series was performed. METHODS: This is a prospective clinical study conducted in a tertiary rhinology fellowship training hospital between January 2009 and November 2009. The study population consisted of patients with intractable epistaxis that failed to respond to traditional anterior-posterior nasal packing using either a 10-cm Pope PVA Merocel or a Rapid-Rhino. The bleeding site was identified using a nasal endoscope and controlled using a pack made of a ChitoFlex chitosan dressing wrapped around a polyvinyl acetal nasal sponge. RESULTS: The intent-to-treat population consisted of 20 severe epistaxis subjects (8 men and 12 women) who continued to bleed despite traditional anterior-posterior nasal packing. The mean age was 67 years (±19 years). Sixteen subjects were on antiplatelets and/or anticoagulants. Eleven subjects (55%) presented with anterior epistaxis, and 7 subjects (35%) presented with posterior epistaxis. Chitosan nasal packing was performed on an outpatient basis and resulted in effective and immediate hemostasis in 19/20 subjects (95%). One subject had persistent bleeding after the first packing attempt and was successfully repacked within 30 minutes. Time to complete cessation of bleeding was 3.6 ± 2.2 minutes in the 19 subjects; the pack was removed after 48 hours, without any evidence of rebleeding or any serious side effects. CONCLUSION: Endoscopically guided chitosan packing is a safe, effective, and well-tolerated outpatient treatment for the management of intractable epistaxis.

Right versus left stapes surgery: is there a difference?

OBJECTIVES: To search for a statistically significant difference in auditory results between right and left ears after surgery for otosclerosis. STUDY DESIGN: Retrospective case-review study. SETTING: Academic tertiary referral center. PATIENTS: Eight hundred ninety-four cases of stapes surgery were reviewed. Patients were divided into 2 groups: right ear (474 cases) and left ear (420 cases). There were 4 classes in each group depending on the preoperative air-bone gap (ABG). Each class was divided into 3 subclasses depending on the preoperative bone conduction (BC). MAIN OUTCOME MEASURES: Two parameters were analyzed: ABG and BC. The parameters compared between right and left ears were 1) the difference between mean preoperative and 4-month postoperative ABG (DeltaABG) and 2) the difference between mean preoperative and 4-month postoperative BC (DeltaBC). We used the analysis of variance statistical test. Furthermore, we calculated the number of patients who have had postoperative sensorineural hearing loss at 4 months defined as a fall in BC of more than 10 dB and compared the results between right and left ears using chi test. RESULTS: There was no statistically significant difference in the DeltaABG and the DeltaBC between the right and left ear (p = 0.742 and 0.426, respectively) taking into consideration all classes and subclasses. We found 19 cases of postoperative sensorineural hearing loss, among which are 10 right ears and 9 left ears. The difference was not statistically significant (p = 0.973). CONCLUSION: There is no functional difference between stapes surgery performed in the right ear as compared with that performed in the left ear.

Gastro-omental free flap in the reconstruction of the unfavourable hypopharyngeal defects: a functional assessment.

BACKGROUND: Reconstruction flaps following major head and neck cancer surgery should consider the state of tissue at the recipient site. This study presents the cumulative experience of the use of the gastro-omental free flap (GOFF) for pharyngeal reconstruction in cases with unfavourable recipient site conditions. METHODS: The GOFF reconstruction procedure and postoperative follow-up are described in details, and the functional results are analysed retrospectively. RESULTS: Fifteen patients underwent GOFF reconstruction. Previous treatments included radiotherapy, chemotherapy and surgery. Postoperatively, two patients (13%) developed partial flap necrosis, and four (27%) patients developed fistula and flap stenosis. On the functional level, eight (53%) patients developed oesophageal speech at different levels of audibility, and all patients developed oral alimentation ranging from a mixed diet with supplements to a regular oral diet. CONCLUSIONS: The GOFF is characterised by multiple survival advantages that favour its use in the presence of inhospitable recipient site conditions.

Vestibular neurectomy vs. chemical labyrinthectomy in the treatment of disabling Menière's disease: a long-term comparative study.

OBJECTIVE: To compare the efficiency of vestibular neurectomy (VN) and chemical labyrinthectomy (CL) in the treatment of Menière's disease's disabling vertigo, and to assess their subsequent effects on hearing. METHODS: This is a retrospective study of 58 VN procedures and 35 CL procedures. Treatment results were assessed by caloric testing and pure-tone audiometry performed before and after treatment. Subjective success was defined by the number of recurrent attacks of vertigo and by the AAO-HNS vertigo scale. RESULTS: Caloric testing revealed strong vestibular hyporeflexia in 91.0% of VN cases and 86.0% of CL cases. Vertigo recurred in 7.0% of cases in the VN group and in 11.4% of cases in the CL group. Mean pure-tone auditory thresholds increased from 45.00dB HL to 50.84dB HL (p=0.19) in the VN group and from 69.11dB HL to 74.51dB HL (p=0.41) in the CL group. CONCLUSION: Vestibular neurectomy and chemical labyrinthectomy offer similar control of vertigo in patients with Menière's disease. CL is a simple, minimally invasive procedure that emerges as an effective method for treating Menière's disabling vertigo without causing significant hearing deterioration.

Internal carotid false aneurysm after thermocoagulation of the gasserian ganglion.

OBJECTIVE: To identify petrous internal carotid bleeding aneurysm as a complication of gasserian ganglion thermocoagulation. PATIENTS: A single case presenting with epistaxis and otorrhagia 1 month after gasserian ganglion thermocoagulation in the treatment of refractory trigeminal neuralgia. INTERVENTION(S): Gasserian ganglion thermocoagulation, computed tomographic scan, and angiocomputed tomographic scan revealing petrous internal carotid ruptured aneurysm and internal carotid embolization. MAIN OUTCOME MEASURE(S): Radiologic diagnosis of the vascular injury after gasserian ganglion thermocoagulation. RESULTS: Radiologic identification of ruptured internal carotid artery as the cause of simultaneous epistaxis and otorrhagia. CONCLUSION: Gasserian ganglion thermocoagulation may cause aneurysm and rupture of the petrous portion of the internal carotid artery.

Cervical cellulitis and mediastinitis following esophageal perforation: a case report.

UNLABELLED: Chicken bone is one of the most frequent foreign bodies (FB) associated with upper esophageal perforation. Upper digestive tract penetrating FB may lead to life threatening complications and requires prompt management. We present the case of a 52-year-old man who sustained an upper esophageal perforation associated with cervical cellulitis and mediastinitis. Following CT-scan evidence of FB penetrating the esophagus, the impacted FB was successfully extracted under rigid esophagoscopy. Direct suture was required to close the esophageal perforation. Cervical and mediastinal drainage were made immediately. Naso-gastric tube decompression, broad-spectrum intravenous antibiotics, and parenteral hyperalimentation were administered for 10 d postoperatively. An esophagogram at d 10 revealed no leak at the repair site, and oral alimentation was successfully reinstituted. CONCLUSION: Rigid endoscope management of FB esophageal penetration is a simple, safe and effective procedure. Primary esophageal repair with drainage of all affected compartments are necessary to avoid life-threatening complications.

The quartile benefit plot: a middle ear surgery benefit assessment scheme.

OBJECTIVE: The purpose of this study is to present a new method for the assessment of hearing improvement following stapes surgery, taking into account additional, previously omitted evaluation criteria. STUDY DESIGN: Retrospective. METHODS: A quartile plot, based on the currently used Glasgow benefit plot, is structured to include two additional criteria of hearing assessment, namely the absence of postoperative sensorineural hearing loss and the closure of the air-bone gap to <10 dB. Pre- and postoperative hearing results of 132 patients diagnosed with bilateral otosclerosis and treated with bilateral stapes surgery were plotted on both the classical Glasgow benefit plot and the new quartile benefit plot. The difference in success assessment due to stricter assessment criteria is demonstrated. RESULTS: Functional success rate following bilateral stapes surgery as plotted on the traditional Glasgow benefit plot was 51.5%. Success rate for bilateral stapes surgery assessed on the new quartile plot with the addition of the two new criteria was 38.64%. The difference in success rates was found to be statistically significant. CONCLUSION: The basis of benefit assessment in stapes surgery solely on the mean deficit in air conduction results in overestimation of success rate. This study demonstrates that results that appear satisfactory when judged by the Glasgow benefit plot are of modest success when assessed by the new quartile plot. The quartile benefit plot presented in this paper provides a strict measure of presentation and evaluation of stapes surgery results.

Cavernous hemangioma of the parotid gland.

In adults, hemangioma is a rare presentation of a parotid mass. In this report, we present a case of a 40-year-old lady complaining of a swelling in the right inferior parotid region. Imaging studies revealed a cystic lesion of the right parotid gland. Fine needle aspiration cytology was not significantly helpful in revealing the diagnosis. In the operating room, a vascular cystic lesion was found in the deep lobe of the right parotid gland. Pathological analysis confirmed the diagnosis of cavernous hemangioma. In this case report, we discuss a rare pathology in the adult population, and review different aspects in its diagnosis and treatment.

Fibro-osseous and respiratory epithelial hamartoma of the fronto-ethmoid region.

A 31-year-old lady presented to the otorhinolaryngology clinic complaining of right exophtalmus. Imaging studies revealed a right frontal sinus mass, suggestive of a mucocele, and fronto-ethmoidal ground glass opacification. In the operating room, the frontal sinuses were exposed through an osteoplastic flap, and connected to the nasal cavity through a Lothrop-like drainage pathway. The pathologic analysis revealed a frontal sinus mucocele and fibro-osseous and respiratory epithelial hamartoma of the fronto-ethmoid region. In this case report, this rare pathology is discussed, in addition to a thorough elaboration upon the surgical options as dictated by the anatomic complexity of the region.

The outcome of 400 consecutive liver grafts using the aortic perfusion-only technique.

The goal of this study is to establish the effect of cadaveric liver retrieval, using the technique of aortic perfusion only, on liver graft function, and to identify associated potential risk factors for graft dysfunction. The authors reviewed the outcome of 400 consecutive, orthotopic, cadaveric liver transplantation retrieved by the technique of aortic perfusion only. Relevant parameters pertaining to the donor, recipient, procurement, graft and peri-operative variables are analyzed to assess their influence on graft function. The univariant analysis revealed that donor age, body mass index, blood pressure, and vasopressor dependence influence graft function. Furthermore, predictors of dysfunction included prolonged anhepatic phase, transplantation duration and partial grafts. In addition, multivariant analysis revealed significant association between obesity of donors, partial graft, and dysfunction. The technique of aortic perfusion only, is a simple and reproducible procedure. The post-transplantation outcomes appear to be similar to those reported for the traditional liver procurement technique.