The Role of the Parotid-Mastoid Fascia in Identification of the Facial Nerve Trunk During Parotidectomy.

OBJECTIVE: We aim to describe the parotid fascia as a landmark that can help identify the immediately underlying facial nerve trunk. METHODS: Dissection of the parotid fascia and identification of the facial nerve trunk were carried out on 8 fresh cadaveric parotid glands. The attachments and arrangement of the parotid gland and its fascia were evaluated and histologically assessed, with special attention to the fascia overlying the facial nerve trunk. RESULTS: The parotid fascia envelops the posterior aspect of the parotid gland in an open-book fashion. Posteriorly, it connects to the anterior and medial aspect of the mastoid tip. Posterosuperiorly, it attaches to the inferior aspect of the tragal pointer. Directly medial to the fascia lies the facial nerve trunk. CONCLUSION: The parotid fascia, particularly the parotid-mastoid segment overlying the facial nerve trunk, can be utilized as an additional landmark of depth to help identify the facial nerve trunk during a parotidectomy in conjunction with other commonly used standard anatomic landmarks. The parotid fascia sling spans from the mastoid and tragal pointer to the parotid gland and can be easily palpated intraoperatively. Once the fascia is removed, the facial nerve trunk is identified.

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.

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.

Epidemiologic and clinical features of Bell's palsy among children in Northern California.

BACKGROUND: Bell's palsy (BP) is an acute, idiopathic, and usually unilateral paralysis of the facial nerve. Large population-based studies of BP among children are lacking. We determined epidemiologic and clinical features of BP among children enrolled in a large integrated health care delivery system. METHODS: From 2001 through 2006, all children ≤18 years of age diagnosed with BP within the population of Kaiser Permanente Northern California were identified using the International Classification of Diseases, 9th Revision, code 351.0. All cases were adjudicated by an otolaryngologist and categorized as definite, probable, or rejected. Using chart abstraction forms, epidemiologic and clinical features of BP were determined. RESULTS: Of a total of 977 cases initially identified, 822 (84.1%) were adjudicated as a definite or probable case. The overall incidence rate of BP during the study period was 18.8 (95% CI 17.6-20.2) per 100,000 person-years. The incidence rate increased by age and was higher in females than males across all age strata. There was no evidence for a seasonal pattern in the occurrence of BP (p for trend = 0.81). CONCLUSIONS: BP among children may be more common than previously recognized.

Immunization and Bell's palsy in children: a case-centered analysis.

Bell's palsy (BP) is an acute and idiopathic paralysis of the facial nerve, with an estimated incidence ranging from 11.5 per 100,000 person-years to 53.3 per 100,000 person-years in different populations. BP has been reported following immunization with inactivated trivalent influenza vaccine (TIV) and hepatitis B virus (HBV) vaccine. Epidemiologic studies examining this association among children are lacking. From 2001 through 2006, all children aged ≤18 years diagnosed with BP within the Kaiser Permanente Northern California population were identified using International Classification of Diseases, Ninth Revision, code 351.0. All electronically identified cases were reviewed and adjudicated by an otolaryngologist (n = 233). Using a case-centered approach, the authors examined the risk of BP during 3 risk intervals. Immunization with TIV (odds ratio (OR) = 0.7, 95% confidence interval (CI): 0.2, 2.8), HBV vaccine (OR = 0.8, 95% CI: 0.2, 2.4), or any vaccine (treating all vaccines combined; OR = 0.9, 95% CI: 0.6, 1.4) was not associated with increased risk of BP 1-28 days after immunization. Similarly, no association was found between vaccines and BP during the periods 1-14 and 29-56 days following immunization. Results of this study suggest that there is no association between immunization and BP in children.

Tympanostomy tubes for otitis media: quality-of-life improvement for children and parents.

We measured quality of life issues for both children and their parents on the premise that parental quality of life should be an aspect of cost-effectiveness in otitis media treatment. The patients were less than 18 years of age and had had myringotomy with tube insertion at the head and neck surgery department of a large health maintenance organization. Quality of life for patients, parents, and caregivers was evaluated by telephone survey of parents or caregivers and by retrospective chart review of the number of pre- and postoperative healthcare visits and antibiotic usage. Chart review showed a significant postoperative reduction in the number of clinic visits and in use of antibiotic drugs after insertion of tympanostomy tubes. Improved postoperative hearing was noted, and tympanostomy tube insertion was shown to be safe. The chart-review cost analysis showed that tympanostomy tube insertion is a cost-effective treatment for otitis media in children, and the telephone survey results showed that it improves quality of life for children and their parents or other caregivers.

Odontoma of the middle ear: case report with 25-year follow-up.

We report the 25-year follow-up on the first reported case of odontoma in the middle ear. Diagnosis of odontoma had been made on the basis of radiography films that showed a middle ear mass with multiple toothlike areas of radiopacity. No clinical intervention was recommended. At 25-year follow-up, audiometry showed progressive mixed hearing loss on the affected side and mild ipsilateral sensorineural hearing loss. Computed tomography better characterized the discrete mass, which was shaped similar to a dental crown. To avoid jeopardizing cochlear and facial nerve function, no surgical intervention was pursued, and we recommended use of a BiCROS (bilateral contralateral routing of signal) hearing aid.

Lymphatic mapping for staging of head and neck cancer.

Lymphatic mapping with sentinel lymph node (SLN) biopsy can accurately stage the nodal basins in patients with melanoma of the trunk and extremities and has become a routine, well-accepted diagnostic method for melanoma at these anatomic locations. Melanoma of the head and neck (16% of all cases of melanoma) is complex and difficult to manage because of the rich abundant interlacing lymphatic drainage patterns, as well as watershed areas, which can lead to unusual and unexpected drainage patterns. Radioguided surgery in combination with blue dye facilitates localization of the SLN in the head and neck; however, this type of radioguided surgery is an evolving technique of some difficulty and thus requires careful coordination among the surgeon, nuclear medicine physician, and pathologist. Applications of this technique to other sites in the head and neck are currently being investigated for conditions including squamous cell carcinoma (SCC) of the oral cavity, thyroid cancer, and Merkel cell cancer. More studies of patients with head and neck cancer are needed--and technical issues must be resolved--before radioguided surgery can be recommended as the standard of care for these patients.

Dermatofibrosarcoma protuberans of the head and neck: treatment with Mohs surgery using inverted horizontal paraffin sections.

OBJECTIVE: To describe results of treating dermatofibrosarcoma protuberans of the head and neck with a Mohs surgical technique in which tumor margins were evaluated with inverted horizontal paraffin sections to identify the margin of resection necessary to achieve tumor-free borders. STUDY DESIGN: Retrospective case study of nine patients. METHODS: In each case, Mohs surgery using inverted horizontal frozen-section analysis was continued until tumor-free margins were achieved. The tumor-free specimens collected during this procedure were immediately reprocessed by using inverted horizontal paraffin sectioning, and the histological results of the two techniques were compared. To identify the margins of resection needed to achieve tumor-free margins, preoperative lesion size was compared with postoperative defect size. RESULTS: Paraffin section analysis showed persistent tumor in seven of the nine patients in whom the frozen-section technique was used to clear the tumor. Tumor-free margins were achieved in all patients by using one additional excision. The tumor had spread extensively beyond clinical margins and required a mean minimum margin of 3.7 cm around the gross area of tumor (margin range, 2.5-6.0 cm). Patients treated by this technique showed no local, regional, or distant recurrence at follow-up performed at a mean time of 43 months postoperatively (range, 19-74 mo). CONCLUSIONS: Dermatofibrosarcoma protuberans of the head and neck is a tumor that shows extensive infiltration beyond gross margins. Wide local excision with 2- to 3-cm margins results in an unacceptably high recurrence rate; larger excisional margins are necessary to remove all disease. Accurate margin identification achieved by using Mohs surgery with rush paraffin section analysis results in complete tumor removal and excellent control rates. This method should be preferred for treatment of dermatofibrosarcoma protuberans of the head and neck.

Lipoblastomatosis of the neck causing hemiparesis: a case report and review of the literature.

BACKGROUND: Lipoblastoma and lipoblastomatosis are rare pediatric adipose tumors that sometimes affect the neck or spinal cord. This case is the third report of lipoblastoma extending into the spinal canal, the first report of intradural tumor extension, and the first report of hemiparesis resulting from lipoblastoma compressing the spinal cord. METHODS: A 13-month-old boy was seen by a pediatrician for a firm, supraclavicular neck mass on the left side. After being evaluated by CT and MRI scanning, the tumor was partially resected. RESULTS: Postoperative microscopic examination of the tumor showed adipose cells with mature nuclei and well-formed fat vacuoles interspersed with fibrovascular septa, a finding consistent with maturing lipoblastoma. CONCLUSIONS: Although lipoblastomatous tumors are treated with complete surgical resection when possible, location of these tumors in the neck may dictate partial resection to avoid intraoperative injury to the spinal cord.

Submandibular gland squamous metaplasia mimicking recurrent squamous cell carcinoma: diagnostic dilemma.

New masses in the head and neck region of previously treated patients with cancer are considered suggestive of potential recurrence. Fine-needle aspiration is an excellent primary tool for evaluating these masses but may show atypical squamous cells that mislead clinicians to pursue aggressive treatment. We describe 3 patients in whom submandibular gland masses developed after radiation therapy for squamous cell carcinoma and for whom subsequent excisional biopsy findings showed benign squamous metaplasia. We review distinguishing clinical and histopathologic features that may allow these lesions to be identified. We also propose a treatment algorithm for this uncommon clinical scenario.

Radiographic comparison of three methods for nasal saline irrigation.

OBJECTIVE: To compare intranasal distribution of saline solution delivered by three popular methods for nasal saline irrigation. STUDY DESIGN: Prospective, controlled comparison. METHODS: Eight healthy adult volunteers received nasal irrigation with 40 mL of isotonic, nonionic contrast material immediately before having coronal computed tomography to visualize distribution of solution in the paranasal sinuses. For each study subject, three methods of irrigation were used: irrigation using positive-pressure irrigation, irrigation using negative-pressure irrigation, and irrigation using a nebulizer. For each subject, three-dimensional computer reconstructions of the irrigated paranasal sinus airspaces were used to compare contrast solution volume and distribution achieved by the three methods. RESULTS: Of the three methods used, two methods, positive-pressure and negative-pressure irrigation, distributed contrast solution widely to ethmoid and maxillary sinuses, but distribution of contrast solution was more uniform using positive-pressure irrigation than using negative-pressure irrigation. The nebulization method distributed contrast solution poorly and resulted in a significantly lower volume of retained contrast solution (P <.05). CONCLUSION: Judged solely on the basis of solution distribution in the nasal sinuses, nasal irrigation is effective when either positive-pressure or negative-pressure irrigation is used but is ineffective when a nebulizer is used.

Telephone appointment visits for head and neck surgery follow-up care.

OBJECTIVES/HYPOTHESIS: To test the hypothesis that patients with a variety of otolaryngologic diagnoses using telephone appointment visits would be equally as satisfied as patients receiving physician office visits, the study compared telephone appointment visits with physician office visits for health maintenance organization patients who needed routine follow-up care in a head and neck surgery clinic. STUDY DESIGN: Randomized, nonblinded cross-sectional study. METHODS: After their initial visit to either of two head and neck surgery clinics, new otolaryngology patients were randomly assigned into treatment and control groups. Patients in the treatment group (n = 73) received follow-up care in the form of telephone appointment visits, and patients in the control group (n = 80) received physician office visits for follow-up care. Study data were collected using telephone interviews and physician tracking forms. RESULTS: Patients receiving telephone appointment visits were significantly less satisfied with their visits than patients receiving physician office visits (chi2 = 25.4, P < .005). Patients who had physician office visits were significantly more likely than were patients in the treatment group to agree "somewhat" or "strongly" that 1) the physician addressed their questions and concerns (chi2 = 24.0, P < .005); 2) the physician provided personal care and attention (chi2 = 29.9, P <. 005); and 3) the physician provided high-quality care (chi2 = 34.5, P < .005). CONCLUSIONS: Patients who received telephone appointment visits were statistically significantly less satisfied with all aspects of their follow-up appointment than were patients who had physician office visits. The study findings indicate that telephone appointment visits may not be an ideal type of follow-up visit for all patients. Despite these findings, one third of patients in the treatment group would consider receiving a telephone appointment visit for future routine follow-up care, and 21.9% had no preference, perhaps a factor indicating willingness to receive a telephone appointment for a follow-up visit.