Transoral Excision of an Intracordal Schwannoma: A Case Report and Review.

We discuss a novel approach to resecting a large 1.5 cm intracordal schwannoma via direct laryngoscopy with combined endoscopic and microlaryngoscopic techniques. Removing relatively bulky masses within the vocal cord soft tissue can be challenging secondary to difficult visualization of the operative field during direct laryngoscopy. We describe a case where a bulky atypical spindle cell schwannoma was removed via direct laryngoscopy via combined endoscopic and microlaryngoscopic techniques. The tumor obstructed 40% of the visual field of the laryngoscope. In this case, a 44-year-old female presented to the head and neck surgery clinic with 1.5 years of progressive hoarseness. On fiberoptic laryngoscopy, a mass was noted medializing the right true vocal cord. The patient was taken to surgery and after intubation and suspension with a Dedo laryngoscope, the mass was removed trans-orally through the laryngoscope with visualization using a combination of rigid and flexible endoscopy as well as with a microscope. Although visualization can sometimes be reduced using direct laryngoscopy, surgical excision of relatively large laryngeal masses can be performed in selected cases without the need to approach the masses trans-cervically.

Chondrolaryngoplasty.

Chondrolaryngoplasty is a well-described surgical procedure most commonly performed as part of facial feminization surgery for transgender patients with a diagnosis of gender dysphoria. A complete understanding of relevant neck anatomy and laryngeal function is critical to optimizing surgical outcomes. The overall goal of the procedure is to maximally reduce the thyroid cartilage prominence while preserving laryngeal integrity and minimizing the risk of external scarring. Among available approaches, the bronchoscopic-assisted technique with intraoperative needle localization has been demonstrated to reliably lead to safe and effective surgical outcomes while minimizing the risk of postoperative complications.

Evaluating Patient Benefit From Laryngochondroplasty.

OBJECTIVES/HYPOTHESIS: To elucidate and review current literature on the surgical technique for laryngochondroplasty in male-to-female transgender patients. To determine the degree of benefit afforded to male-to-female transgender patients by laryngochondroplasty using the Glasgow Benefit Inventory (GBI). STUDY DESIGN: Retrospective case series. METHODS: After institutional review board approval was obtained, the GBI survey was given to patients who underwent laryngochondroplasty by the author. Demographic information was analyzed including age, race, wait time to surgery, distance traveled, median zip code income, and concomitant gender-affirming surgeries such as vaginoplasty, breast augmentation, or facial feminization. RESULTS: From April 2016 to April 2020, 209 patients received laryngochondroplasty within the Kaiser Permanente Northern California Medical System. Of those, 91 received laryngochondroplasty with the author and were given the GBI, with 73 patients (80%) responding. Patients were on average 31.4 years old, traveled 45.4 miles to the surgical site, lived in a zip code with a median income of $86,793.61, and waited 95.7 days for surgery. Patients had a statistically significant improvement in all three subscores (general, social, and physical) of the GBI as well as in their overall score. CONCLUSIONS: Laryngochondroplasty is a safe and effective procedure to reduce thyroid cartilage prominence (Adam's apple) in male-to-female transgender patients. There was a statistically significant improvement in the overall score and all subscores of the GBI after laryngochondroplasty LEVEL OF EVIDENCE: 4 Laryngoscope, 130:S1-S14, 2020.

Social Media among Medical Students and Personnel Here to Stay.

Social media is no longer new, even in the professional medical world. It is an established and relatively public medium, and all users would do well to understand the risks associated with it. Medical personnel-whether medical student or staff physician-must familiarize themselves with it to ensure positive outcomes. As with other technologies, best practices will evolve with time, but existing and ongoing research can establish working use guidelines.

The electrolarynx: voice restoration after total laryngectomy.

The ability to speak and communicate with one's voice is a unique human characteristic and is fundamental to many activities of daily living, such as talking on the phone and speaking to loved ones. When the larynx is removed during a total laryngectomy (TL), loss of voice can lead to a devastating decrease in a patient's quality of life, and precipitate significant frustration over their inability to communicate with others effectively. Over the past 50 years there have been many advances in techniques of voice restoration after TL. Currently, there are three main methods of voice restoration: the electrolarynx, esophageal speech, and tracheoesophageal speech through a tracheoesophageal puncture (TEP) with voice prosthesis. Although TEP voice is the current gold standard for vocal rehabilitation, a significant minority of patients cannot use or obtain TEP speech for various reasons. As such, the electrolarynx is a viable and useful alternative for these patients. This article will focus on voice restoration using an electrolarynx with the following objectives: 1) To provide an understanding of the importance of voice restoration after total laryngectomy. 2) To discuss how the electrolarynx may be used to restore voice following total laryngectomy. 3) To outline some of the current electrolarynx devices available, including their mechanism of action and limitations. 4) To compare pros and cons of electrolaryngeal speech to TEP and esophageal speech.

Bilateral Basaloid Squamous Cell Carcinoma of the Parotid Gland: A Case Report and Review of the Literature.

INTRODUCTION: We describe the first known case of bilateral basaloid squamous cell carcinoma of the parotid gland, and we review existing literature. CASE PRESENTATION: A previously healthy, 70-year-old white man presented with a 2-cm enlarging mass in the tail of the right parotid gland. Magnetic resonance imaging and computed tomography showed ipsilateral pathologic adenopathy. Results of fine-needle aspiration revealed a high-grade malignancy with squamous features. The patient underwent a right total parotidectomy and modified radical neck dissection. Final pathologic findings revealed a basaloid squamous cell carcinoma. Four years after the initial resection, the patient presented with an enlarging left parotid mass. Findings of fine-needle aspiration and imaging were similar to those 4 years earlier. The patient received a left total parotidectomy and modified radical neck dissection. Postoperative radiation therapy was performed after each surgical intervention. He remains disease free at 4-year follow-up after the second mass was resected. DISCUSSION: Squamous cell carcinoma with basaloid features is a rare and aggressive type of squamous cell carcinoma. To our knowledge, this is the first case report of bilateral parotid basaloid squamous cell carcinoma.

Sclerosing Polycystic Adenosis: A Rare Tumor of the Salivary Glands.

CASE PRESENTATION: A 74-year-old woman presented to the Head and Neck Surgery clinic with a 4-year history of a slowly growing, painful, left-sided neck mass in the tail of the parotid gland. Fine-needle aspiration suggested well-differentiated adenocarcinoma. DISCUSSION AND RESULTS: The patient underwent a superficial parotidectomy and super-selective neck dissection (level 2). Pathology revealed a tumor consistent with sclerosing polycystic adenosis. CONCLUSION: Sclerosing polycystic adenosis is a rare inflammatory process that causes fibrocystic changes in the salivary gland. Apocrine-like metaplasia and epithelial atypia are common pathologic features. To our knowledge, a total of 51 cases have been described in the English-language literature.

Gingival Metastasis: A Case Report and Literature Review.

Secondary oral cavity neoplasms are rare. We describe a case of an indurated, nonulcerating gingival lesion in a 59-year-old nonsmoking man with no family history of lung cancer. The lesion was the presenting symptom of metastatic lung adenocarcinoma. Reviewing the literature, we find that primary lung cancer among men is one of the most common cancers to metastasize to the oral cavity. Renal and cutaneous neoplasms are the next most common neoplasms to metastasize to the oral cavity. Furthermore, the gingiva, a tissue prone to inflammation, is noted to be a common site for secondary oral cavity neoplasms. This rare case highlights that metastases should influence the clinician's differential of oral mucosal lesions.

Onabotulinum toxin A dosage trends over time for adductor spasmodic dysphonia: A 15-year experience.

OBJECTIVES/HYPOTHESIS: Although onabotulinum neurotoxin A (BoNTA) has been used for over three decades for the treatment of adductor spasmodic dysphonia, no study has been performed to look at the trend of BoNTA dosages across time. The goal of this study is to evaluate the dosage trends to determine if the dosage necessary for voice improvement in patients increases over time. STUDY DESIGN: Charts were reviewed for patients with 15 years or more of experience. METHODS: Linear regression analysis was performed to determine correlation coefficients and trends. RESULTS: Fifty-five patients receiving BoNTA injections by the senior author (a.b.) for over 15 years were evaluated. Thirty-nine patients (82% female) met inclusion criteria. Patients received injections over an average of 18.6 years ± 1.36 years, with the longest follow-up of 21.5 years. Of 39 patients, 16 (41%) had a negative correlation coefficient (Pearson's r) suggesting a decrease over time, whereas 23 (59%) had a positive correlation coefficient suggesting an increase over time. The mean correlation coefficient was 0.139 ± 0.534 and P < 0.05 in 19 patients and P > 0.05 in 20 patients. R(2) for all patients were less than 0.75. CONCLUSIONS: Onabotulinum neurotoxin A injection dosage trends vary depending on the individual over time. Overall, the dose range appears to be stable in the majority of patients, suggesting that tolerance does not play a significant part in dose variation over time. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:678-681, 2016.

Voice Restoration After Total Laryngectomy.

The ability to speak and communicate vocally is a unique human characteristic that is often taken for granted but is fundamental to many activities of daily living. Loss of voice after total laryngectomy can lead to a serious decrease in quality of life and can precipitate significant frustration over the inability to communicate effectively. There are 3 main methods of voice restoration: esophageal speech, usage of the electrolarynx, and tracheal-esophageal puncture for tracheal-esophageal speech, which can be performed primarily or secondarily. Although all 3 methods have potential benefits, the gold standard is tracheal-esophageal speech.

Glottic myxoma presenting as chronic dysphonia: a case report and review of the literature.

Myxomas of the vocal fold are rare benign tumors often presenting with chronic dysphonia and less frequently with airway obstruction. The current consensus is that all laryngeal myxomas should be totally excised with clear margins to prevent recurrences. The recommendation for complete excision, however, has to be balanced with consideration of preserving vocal fold phonatory and sphincteric function. We report a case of vocal fold myxoma recurring twice after subtotal excision via two surgical approaches. This case illustrates a benign lesion with potential for recurrence and the need for a balanced treatment approach.

The coccidioidomycosis conundrum: a rare parotid mass.

A man, age 62 years, presented to the clinic with a 2-week history of increased nontender, nonerythematous, indurated right-sided parotid swelling. A 4 × 6-cm firm, well-circumscribed mass was palpated in the right parotid gland. A fine-needle aspiration biopsy was performed on the parotid mass with aspiration of 0.5 cc of purulent fluid with some blood. Cultures from the aspirate revealed Coccidioides immitis confirmed by DNA probe. Pathology slides revealed fungal spores. The patient was treated with 800 mg of fluconazole every day for 3 months with resolution of the parotid swelling. However, persistent cervical adenopathy remains.Although this is a rare case of acute parotid swelling, Coccidioides immitis should be considered in the differential diagnosis of parotid masses in a patient with previous coccidioidomycosis. There may be a potential for an increase in frequency and variety of atypical extrapulmonary manifestations of coccidioidomycosis that parallels the increase in coccidioidomycotic pulmonary infections. Long-term antifungal therapy appears essential for control.

Manual dexterity aptitude testing: a soap carving study.

IMPORTANCE: Currently there are few validated metrics for predicting surgical skill among otolaryngology residency applicants. OBJECTIVE: To determine whether manual dexterity aptitude testing in the form of soap carving during otolaryngology residency interviews at Kaiser Permanente Medical Center Oakland predicts surgical skill at the time of graduation from otolaryngology residency programs. DESIGN, SETTING, AND PARTICIPANTS: This study was conducted to determine how applicants with the best and worst soap carvings compared at the time of graduation with respect to various metrics including visuospatial ability and manual dexterity. Over the last 25 years, applicants to the residency program at Kaiser Permanente Oakland were required to carve soap during their residency interview. The 3 best and 3 worst soap carvings from 1990 through 2006 were determined. Of the individuals who carved those soaps, 62 qualified for the study and matriculated into otolaryngology residency programs. INTERVENTIONS: Surveys were sent to the 62 individuals' residency programs to evaluate those individuals on a 5-point Likert scale in various categories as well as to rank those individuals as being in the top 50% or bottom 50% of their graduating class. MAIN OUTCOMES AND MEASURES: All else being equal, we hypothesized that applicants who had the manual dexterity and visuospatial skills to accurately carve a bar of soap would more likely possess the skills necessary to become a good surgeon. RESULTS: There was no difference between individuals with the best soap carvings and those with the worst soap carvings in all categories: cognitive knowledge, visuospatial ability, manual dexterity, decision making, and overall score (P > .10 for all categories). There was a 95% response rate, with 35 of 37 residency programs responding and 59 of 62 surveys returned. CONCLUSIONS AND RELEVANCE: Manual dexterity aptitude testing in the form of soap carving does not appear to correlate with surgical skill at the time of graduation. Further studies need to be conducted to determine the role of manual dexterity and visuospatial aptitude testing in the otolaryngology application process.

Lymphoepithelial carcinoma: a case of a rare parotid gland tumor.

A 29-year-old woman presented from another hospital with a 10-month history of an enlarging left-sided facial mass. Computed tomographic scan revealed a mass in the superficial lobe of the left parotid gland with left-sided cervical lymphadenopathy. The patient received a total left parotidectomy and a selective neck dissection. Histopathologic slides revealed lymphoepithelial carcinoma (LEC) that stained positive for cytokeratin, as well as Epstein-Barr virus (EBV). An LEC of the parotid is a rare salivary gland tumor accounting for less than 1% of all salivary gland tumors. As reaffirmed in our case, LEC is more common in women, occurs primarily in the parotid gland, and has an ethnic predilection. Histologic analysis reveals an infiltrative, poorly differentiated tumor nestled in a lymphoid stroma, with near 100% positivity for EBV in endemic areas. Complete resection of this poorly differentiated carcinoma followed by postoperative radiation is essential for local control.

Disease relapse after segmental resection and free flap reconstruction for mandibular osteoradionecrosis.

OBJECTIVE: The objective of this study was to assess the outcomes, complications, and incidence of disease recurrence of mandibular osteoradionecrosis (ORN) after resection and microvascular free flap reconstruction. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: Retrospective patient data review of 40 patients with mandibular ORN who were treated by segmental mandibulectomy and microvascular reconstruction between 1995 and 2009. All patients received radiation therapy for previous head and neck cancer, and 12 of 40 patients received concurrent chemotherapy. All patients failed to respond to conservative management. There were 26 males and 14 females, with a median age of 62 years. Median follow-up was 17.4 months. RESULTS: There were no free flap failures. The incidence of wound-related complications was 55 percent. Median time to complication was 10.6 months. Ten (25%) patients developed symptoms of residual or recurrent ORN, with 70 percent of the recurrences arising in unresected condyles that were adjacent to the segmental mandibulectomy. Statistical analysis revealed that current smokers were at reduced risk to develop residual or recurrent ORN. CONCLUSION: This present study confirms that microvascular free flaps are reliable for treatment of advanced mandibular ORN. Nevertheless, there remains a 55 percent incidence of wound-healing complications. The lack of objective clinical criteria to judge the appropriate amount of mandible resection in patients with ORN remains an unresolved issue that resulted in the development of recurrent ORN in 25 percent of patients. Further investigations are needed to better understand the pathophysiology of ORN to prevent postoperative wound complications and disease recurrence.