Botulinum Toxin Dosing Trends in Spasmodic Dysphonia Over a 20-year Period.

OBJECTIVES: The study aims to (1) identify the botulinum toxin (BTX) dosing trend in a cohort of patients who received at least 20 injections for the treatment of adductor spasmodic dysphonia (ADSD), (2) describe two distinct BTX dosing trends in treating ADSD (a "classic" dosing trend that initially decreases before stabilizing, and a "fluctuating" dosing trend), and (3) determine if patients with the "classic" dosing trend differed in age or in dosing intervals from those with the "fluctuating" dosing trend. STUDY DESIGN: This is a retrospective case series. METHODS: Of 149 patients who received a total of 2484 BTX injections for the treatment of spasmodic dysphonia in 1993-2013, 49 patients received at least 20 injections. The BTX dose and the interval between doses were recorded. The mean dose of injections 1-20 was determined. The age at initial injection, initial dose, and interval in days between treatments were compared for the "fluctuating" and "classic" groups. RESULTS: The cohort exhibits a significant decrease in dose during the first 10-15 injections. The "fluctuating" group had a significantly shorter interval between injections (mean interval = 97.09 days, SD = 29.41; mean interval = 136.90 days, SD = 43.76, P = 0.002). The mean age at initial dose was not significantly different between the "classic" and "fluctuating" groups. CONCLUSIONS: The average BTX dose of patients with ADSD who receive long-term injections significantly decreases during the initial 10-15 injections before stabilizing. Patients who exhibit the "fluctuating" dosing pattern have a significantly shorter interval between injections than those with the "classic" dosing pattern.

Adult extracardiac rhabdomyoma of the parapharyngeal space.

Adult extracardiac rhabdomyoma (ER) is a rare, slowly growing, benign tumor of skeletal-muscle origin that has a strong predilection for the head and neck. Complete surgical resection has been proposed as the treatment of choice. We describe a case of adult ER that manifested as a nasopharyngeal mass. The diagnosis was made by transnasal endoscopic biopsy, and the patient was managed conservatively. We discuss the current knowledge regarding the clinical presentation, diagnosis, and treatment of adult ER of the parapharyngeal space, and we propose a new concept for treating this tumor nonsurgically in appropriately selected patients.

Voice disorders: abuse, misuse and functional problems.

Having a vocal complaint is not uncommon, especially among professional voice users. Medically managing hoarseness is often delayed because the physician or patient fails to understand the vocal behavior that precipitated the voice disorder. Improper breathing and/or abusive vocal patterns are the main predisposing factors to functional voice disorders, the most common category of vocal pathology. Successful management of functionalvoice disorders includes identifying and then modifying aberrant vocal and breathing patterns. Unless these changes are made, a vocal disorder will either persist or commonly recur.

Intracranial complications of pediatric frontal rhinosinusitis.

BACKGROUND: The aim of this study was to review the presentation and management of children admitted for intracranial complications arising from frontal rhinosinusitis. We performed a retrospective case series review at two academic tertiary care children's hospitals. METHODS: This study consisted of children < 18 years old who presented with intracranial complications from frontal rhinosinusitis between January 1, 1990 and December 31, 2002. Relevant literature was reviewed with the assistance of Medline. Presentation, type of intracranial complication, radiographic evaluations, response to treatment, and prognosis were evaluated. RESULTS: Sixteen patients were identified with intracranial complications due to frontal rhinosinusitis. Patients were usually older (mean age, 14 years and 3 months), of male gender (M/F, 4.3:1.0), and African American (AA/W, 3.0:1.0). Headache, nasal congestion, and visual changes were the most common early symptoms and neurological findings indicated advanced disease. Subdural (56%), epidural (44%), and cerebral abscesses (19%) were the most common complications. Meningitis alone was identified in 13% and was associated with another intracranial complication in 6%. Multiple intracranial complications were noted in 31%. Polymicrobial cultures were obtained in 50% of patients. Although CT was excellent in identifying orbital pathology, MRI was superior for characterization of intracranial disease. CONCLUSION: Intracranial complications of frontal rhinosinusitis are rare in children. Early symptoms often are nonspecific, with neurological findings more commonly seen in advanced disease. Adolescent African American male patients were found to be at highest risk for intracranial complications from frontal rhinosinusitis. Headache and orbital complaints associated with rhinosinusitis in older children failing to respond to initial therapy should prompt an aggressive evaluation including MRI.

Areolar connective tissue grafts in pediatric tympanoplasty: a pilot study.

PURPOSE: To compare the surgical and audiologic success rates of areolar connective tissue with temporalis fascia in pediatric tympanoplasty. METHODS: Retrospective case series review of 10 patients younger than 18 years who underwent primary tympanoplasty between December 1997 and December 2000 using areolar connective tissue grafts. Tympanoplasty patients receiving temporalis fascia grafts during this period were used as a control group. Surgical and audiometric results were gathered after a minimum follow-up of 1 year. RESULTS: Both groups were similar in their clinical characteristics (P <.05). The surgical success rates for areolar and temporalis fascial groups were 90% and 91%, respectively. Closure of the air bone gap to within 25 dB was achieved in 90% and 91% of the areolar and temporalis fascial groups, respectively. CONCLUSIONS: This study showed equivalent surgical and audiometric success rates between areolar connective tissue and temporalis fascia. Both are excellent sources of graft material in pediatric patients.

Neck abscess secondary to cat-scratch disease.

A 7-year-old boy was referred to us for evaluation of an enlarging neck mass. The results of his primary care physician's initial clinical examination suggested lymphadenopathy secondary to lymphadenitis, and the patient was treated over a 4-week period with two rounds of antibiotics. However, the mass did not resolve, and it subsequently became fluctuant. The patient was referred to our institution, where we diagnosed cat-scratch disease.

Pediatric sinonasal rhabdomyosarcoma: three cases and a review of the literature.

OBJECTIVE: To understand the clinical presentation, management, and natural history of paranasal rhabdomyosarcoma. DESIGN: Retrospective case series review. METHODS: Retrospective medical record review of patients less than 20 years of age who presented to our facility with rhabdomyosarcoma of the nasal cavity or paranasal sinuses. RESULTS: Medical records of all pediatric patients seen in our pediatric otolaryngology clinic were reviewed from January 1, 1995, through December 31, 2000. Three patients were identified with sinonasal rhabdomyosarcoma. Their presentation, evaluation, and treatment were evaluated. Relevant literature 1966 to the present was reviewed with the assistance of Medline. CONCLUSIONS: Rhabdomyosarcoma is an aggressive pediatric malignancy, requiring a high index of suspicion to detect it in its earliest stages. Patients with suggestive symptoms should undergo a full evaluation including nasal endoscopy and imaging. Because the current chemotherapy protocols are more effective on localized disease, early diagnosis is crucial to patient survival.