Mucoepidermoid carcinoma of the nasal septum (case report).

We report an extremely rare case of mucoepidermoid carcinoma of the nasal septum. A patient with a history of right-sided nasal obstruction presented to our clinic. Clinical examination revealed a mass in the right nasal cavity originating from the nasal septum. Biopsy revealed a high-grade mucoepidermoid carcinoma. The patient was treated with surgical resection only. Surgery alone might be suitable for small tumors when direct inspection of the surgical site is feasible to detect early recurrence.

Simultaneous non-Hodgkin lymphoma of the external auditory canal and thyroid gland: A case report.

Approximately 25% of all cases of extranodal non-Hodgkin lymphoma (NHL) occur in the head and neck region; NHL of the external auditory canal (EAC) and thyroid gland are rare. Specific immunohistochemical staining of the excised tissue is required to confirm the final pathologic diagnosis. We report the case of a 53-year-old woman with underlying systemic lupus erythematosus and autoimmune hemolytic anemia that were in remission. She presented with chronic left ear pain, a mass in the left EAC, and rapid growth of an anterior neck swelling that had led to left vocal fold palsy. High-resolution computed tomography (CT) of the temporal bone and CT of the neck detected a mass lateral to the left tympanic membrane and another mass in the anterior neck that had infiltrated the thyroid gland. The patient was diagnosed with simultaneous B-cell lymphoma of the left EAC and thyroid gland. She was treated with chemotherapy. She responded well to treatment and was lost to follow-up after 1 year. To the best of our knowledge, the simultaneous occurrence of a lymphoma in the EAC and the thyroid has not been previously described in the literature.

Oncologic outcome in surgical management of jugular paraganglioma and factors influencing outcomes.

BACKGROUND: The purpose of this study was to identify the factors that may influence the management outcome in patients with jugular paragangliomas. METHODS: The surgical records of 121 cases of jugular paraganglioma (Fisch classifications C and D) were reviewed. RESULTS: The average follow-up was 88 months. Intracranial extension (ICE; Fisch classification De and Di) constitutes 55.4% of the cases. Two cases had a malignant jugular paraganglioma. Complete tumor resection was achieved in 81.8% of the cases, and there was evidence of recurrence in 4.0% from this group. Surgical tumor control was achieved in 96% of cases. Perioperative complications consisted mainly of cerebrospinal fluid leakage in 1.6% of the cases. The lower cranial nerve (CN) was preserved in 63% of the patients mainly in the cases without ICE. CONCLUSION: The infratemporal fossa approach type A allows for complete tumor resection with low perioperative morbidity and recurrence rates. The significant influential factors were the severity of ICE and internal carotid artery involvement.

Surgical management of tympanojugular paragangliomas with intradural extension, with a proposed revision of the Fisch classification.

BACKGROUND: Tympanojugular paragangliomas (TJPs) with intradural extension can be successfully treated by a single or staged procedure with low surgical morbidity. OBJECTIVES: To present the clinical findings and treatment methods used for surgically treating TJP with intradural extension, as well as to discuss the complications of treatment and the relative merits of single versus staged surgery by using a comprehensive literature review comparing objective outcome measures. STUDY DESIGN: A retrospective case review of 45 cases of TJP with intradural extension. SETTING: A quaternary skull base and neurotologic center. MATERIALS AND METHODS: The charts of 45 patients with Fisch classification class C or D TJP with intradural extension, who were operated on from April 1988 to April 2010, were analyzed. Clinical findings and preoperative lower cranial nerve (LCN) palsy as well as postoperative totality of resection, postoperative LCN palsy and complications were studied. The types, indications, and distribution of staged procedures were also analyzed. RESULTS: Out of 45 cases, 22 were C3di2. The IX and X cranial nerves were the commonest nerves affected preoperatively. Preoperative internal carotid artery management was performed in 16 cases. Twenty-nine cases had a single procedure and 16 had a staged procedure. The main indication for staged procedures was intradural extension of 2 cm or more. The infratemporal fossa approach (ITFA) type A was the main procedure in all cases. Overall, total resection was achieved in 68.8% of cases with postoperative cerebrospinal fluid leak in 4.4% cases. Postoperative House-Beckmann grade I-III facial nerve status was maintained in 80% of cases, and overall LCN preservation rate was 56.9%. There were no cases requiring tracheostomy, and 3 cases required delayed phonosurgical procedures to improve their voice. CONCLUSIONS: TJP with intradural extension can be successfully managed with the judicious use of staged procedures to reduce the incidence of postoperative cerebrospinal fluid leak. The ITFA did not cause an excessively high rate of facial nerve palsy, and the overall total resection and LCN preservation rate compares very favorably with previously published data.

Rate of recurrent vestibular schwannoma after total removal via different surgical approaches.

OBJECTIVES: The objective of this study was to assess the differences in the recurrence rates of vestibular schwannoma (VS) after total tumor removal through enlarged translabyrinthine (ETL), retrosigmoid (RS), and middle cranial fossa (MCF) approaches. Our results were compared with previously published data, and literature reviews were done to identify the possible causes for the recurrence of VS. METHODS: We performed a retrospective analysis of 2,400 cases of VS that underwent removal at the Gruppo Otologico, Piacenza, Italy, from 1983 until 2010. The minimum postoperative follow-up was 12 months. We also reviewed the previously published data on recurrence rates of VS after ETL, RS, and MCF approaches. RESULTS: Total tumor removal was achieved in 2,252 cases (93.8%). The recurrence rate was 0.05% for the ETL approach, 0.7% for the RS approach, and 1.8% for the MCF approach. Literature reviews of 3 previously published case series utilizing the translabyrinthine approach showed that none of the primary tumors were less than 2.0 cm in size. Recurrences were seen between 1 and 13 years after the initial surgery. CONCLUSIONS: The rate of VS recurrence after total removal is exceptionally low in experienced hands. Undetected microscopic deposits left on crucial points such as the facial nerve, the preserved cochlea nerve, or the fundus of the internal auditory canal could be possible causes for the recurrence. A definite advantage of an ETL approach is the excellent internal auditory canal exposure, resulting in an extremely low rate of VS recurrence. The patients should be followed up to 15 years with gadolinium-enhanced magnetic resonance imaging (with fat suppression sequence in ETL approach cases). Recurrent VS may exhibit a faster growth rate than primary VS.

Effects of early commercial air travel on graft healing rates after tympanoplasty.

OBJECTIVES: We sought to determine whether commercial air travel soon after tympanoplasty significantly affects graft healing rates. METHODS: We performed a retrospective analysis of 169 patients who underwent tympanoplasty from 1993 to 2009, comparing two groups of patients: 69 patients who flew 1 day after surgery and 100 who did not. The confounding factors analyzed were side of surgery, size of perforation, surgical approach, graft material, and grafting technique. The primary outcome measure analyzed was successful closure of the perforation at the first follow-up visit, at 4 weeks, evidenced by direct otoendoscopic examination. RESULTS: There was no significant difference in the confounding variables between the two groups. There was no significant difference in the primary outcome measure of graft healing rates between the two groups (p = 0.494). Additionally, the overall graft healing rates compared favorably with previously published data from other authors. CONCLUSIONS: Early commercial air travel after tympanoplasty does not significantly affect graft healing rates and should be considered a relatively safe option.

Vertebral artery involvement by tympanojugular paragangliomas: management and outcomes with a proposed addition to the fisch classification.

OBJECTIVES: To present the management and outcomes of cases of tympanojugular paraganglioma (TJP) with vertebral artery (VA) involvement, and to propose the addition of the new 'V' category to the Fisch classification. MATERIALS AND METHODS: Retrospective analysis of data from a quaternary neuro-otologic and skull base referral center. We studied 230 TJP patients to identify the cases with VA involvement and present their management, surgical findings and outcome. RESULTS: Out of 230 patients, 8 patients were found to have VA involvement by TJP. The extradural artery was involved in 1 patient and the intradural VA was involved in 6 patients. The intradural and extradural VA were simultaneously involved in 1 patient. Seven of the 8 patients underwent surgery. In 2 patients, preoperative occlusion was performed (1 with balloon, 1 with coils). In 5 of these 7 patients, the tumor was successfully separated from the VA by microdissection with or without endovascular intervention. In another patient, the tumor together with the involved VA was removed. Of 7 patients who had surgery, 1 patient did not undergo endovascular intervention and had subtotal tumor removal from the VA. There were no serious complications in removing the tumor from around the VA. CONCLUSION: Although uncommon, the intradural or extradural VA can be involved by TJP. To avoid vascular accidents, the VA should be thoroughly evaluated at the planning stage. We advocate that the addition of a 'V' category would help to identify patients who need individualized VA management as part of a complete surgical evaluation.

Management of vagal paragangliomas including application of internal carotid artery stenting.

BACKGROUND: The primary treatment of vagal paraganglioma (VP) includes 'wait and scan', surgery and radiotherapy. OBJECTIVES: To present the clinical findings, surgical treatment including application of internal carotid artery (ICA) stenting to facilitate surgery, and complications, as well as to review the literature and to discuss the decision-making process in the management of VP cases based on our experience and the literature. DESIGN: A retrospective case review of 22 cases with VP. SETTING: Quaternary neurotologic and skull base referral center. MATERIAL AND METHODS: The retrospective chart review identified 22 patients presenting with VP. Our indication for surgery was VP in younger patients, irrespective of the existence of vocal cord paralysis. Preoperative endovascular management of the ICA included permanent balloon occlusion (PBO) and stenting. The transcervical approach and the infratemporal fossa approach type A (ITFA) were used. RESULTS: Fifteen cases had multicentric paragangliomas, 5 cases bilateral tumors, 3 cases a genetic mutation, and 2 cases a positive family history. The most common symptoms were hoarseness, tinnitus and hearing loss. The surgical approaches commonly employed for excision were the transcervical approach (9 cases) and the ITFA (12 cases), whereas 1 case did not have surgery. Three cases had PBO and 7 had intracarotid stent insertion. Gross total removal was achieved in 19 cases, and 1 case had a recurrence. Eighteen cases had no dysphagia or were well compensated after surgery. There were no significant complications noted in our series. CONCLUSIONS: In younger patients with VP, surgery should be recommended. The proper preoperative endovascular intervention and surgical approach facilitates gross total tumor removal. In the management of bilateral or familial paragangliomas, careful and appropriate decision making is essential.

Management of complex tympanojugular paragangliomas including endovascular intervention.

OBJECTIVES/HYPOTHESIS: To identify complex cases of tympanojugular paraganglioma (TJP) and to analyze their management and surgical outcome. To present strategy and guidelines on how to deal with the perioperative complicating factors. STUDY DESIGN: Retrospective analysis. METHODS: We retrospectively studied 212 TJP patients to identify the complex cases and analyzed their management and surgical outcome. The criteria for complex TJP are: 1) very large size; 2) large intradural extension (IDE); 3) extension to the cavernous sinus, foramen magnum, and clivus; 4) significant involvement of the internal carotid artery (ICA); 5) a solitary ICA on the lesion side; 6) involvement of the vertebral artery; 7) dominant or unilateral sigmoid sinus on the lesion side; 8) bilateral or multiple paragangliomas; and 9) recurrence. RESULTS: Sixty patients were classified as complex. Forty-five patients had tumors with IDE. Twenty patients with tumor involving ICA underwent preoperative endovascular intervention. Two patients had a solitary ICA and two others unilateral sigmoid sinus on the lesion side. Thirteen patients had multicentric tumors, and three patients had bilateral ones. The main procedure was the infratemporal fossa approach type A. Total removal was achieved in 46 patients, and five of them experienced recurrence. CONCLUSIONS: It is essential to carefully investigate the hemodynamics of the brain in planning surgery. A proper preoperative endovascular intervention facilitates gross total tumor removal. In bilateral paragangliomas, lower cranial nerves' function should be preserved at least unilaterally. Staged removal is recommended for a tumor with a large intradural component.