A case report of a multi-arterial dural arteriovenous fistula.

Dural arteriovenous fistulas are rare intracranial vascular malformations with a propensity for hemorrhage. The Cognard classification system is the most widespread classification system wherein type IIB through V must be promptly treated to avoid the risk of hemorrhage. The case presented herein reports a 71-year-old male presenting with vague non-hemorrhagic neurologic deficits found to have a Cognard type III dural arteriovenous fistula with multiple arterial feeders. Although quite obvious in retrospect, a DAVF can be missed even by an astute radiologist. This should be considered a "never miss" diagnosis as it carries a risk of intracranial hemorrhage and death.

A massive retroperitoneal mature teratoma from a "burned-out" testicular teratoma and seminoma.

Germ cell tumors are the most common nonhematologic malignancy of young men which often present with metastasis to the retroperitoneum, however a primary retroperitoneal mass should also be considered. The case presented herein reports a 42-year-old male presenting with a massive heterogenous retroperitoneal mass determined to be a mature cystic teratoma. Further investigation revealed a multifocal right testicular mass containing both a viable pure seminoma and a fibrous scar demonstrating germ cell neoplasia in situ thus representing the rare phenomenon of a "burned-out" mixed germ cell testicular tumor. When the radiologist is faced with a large retroperitoneal fat-containing mass, the differential includes a renal angiomyolipoma, liposarcoma, or germ cell tumor (whether primary or secondary). If pathology reveals a germ cell tumor, it is imperative to perform a thorough evaluation of the gonads, as it is much more common for a retroperitoneal germ cell tumor to be a metastasis from the gonads, rather than primary in origin.

A curious case of T2-FLAIR mismatch in H3K27M mutant glioma.

Diffuse midline gliomas are a rare relatively new classification of primary central nervous system tumors which include astrocytomas, oligodendrogliomas, and glioblastomas. The T2-FLAIR mismatch sign is regarded as a highly specific imaging feature of IDH-mutant, 1p/19q non-codeleted astrocytomas. The case presented herein demonstrates this sign, however, in a non-IDH mutated diffuse midline glioma with a H3K27M mutation, a World Health Organization Grade IV neoplasm. Although preoperative diagnosis can provide important treatment and prognostic information, it is often quite difficult particularly in primary central nervous system tumors.

Esophageal Food Impaction.

Esophageal foreign body impaction requires urgent or emergent removal depending on clinical symptoms. Radiographic evaluation is extremely valuable in guiding management, although not required. The case presented herein describes a 66-year-old male presenting with epigastric pain and globus sensation for three days, inability to tolerate both foods and liquids, and regurgitation. Fluoroscopic evaluation revealed a food impaction in the distal esophagus. Urgent endoscopy confirmed the diagnosis and revealed a peptic stricture secondary to Barrett's esophagus. Although computed tomography has largely replaced the fluoroscopic examination, it can still provide a definitive diagnosis in many cases.

Ovarian Torsion: Presentation and Management in a Pediatric Patient.

Background: Adnexal torsion is the fifth most common gynecologic emergency accounting for approximately 20 to 30% of ovarian surgeries in pediatric patients. Case: The patient is a ten-year-old female who presented to the emergency room for severe left lower quadrant abdominal pain. On presentation, she was hemodynamically stable with an acute abdomen. A transabdominal ultrasound showed a predominantly anechoic structure measuring up to 5.6 cm without definitive Doppler flow, concerning for a large cyst causing ovarian torsion. Gynecology was consulted, and the patient underwent a diagnostic laparoscopy, aspiration of the left ovarian cyst, and left ovarian detorsion. Pathology results were consistent with benign cystic contents. Conclusion: Appropriate diagnosis and timely surgical gynecological intervention allowed this pediatric patient to salvage and preserve ovarian function.

The Effect of Marijuana on the Voice: A Pilot Study.

Marijuana is derived from the cannabis sativa plant originating in central and southeast Asia. In recent years, there was increasing popularity and use of marijuana in addition to the legalization of its recreational use in eleven states. However, the effect of marijuana on the voice is still unclear. OBJECTIVES: The purpose of this study was to determine the perceived impacts marijuana has on voice by surveying patients from a voice center. The inquiry included smoking, vaping, edible marijuana, and cannabidiol (CBD) oil. METHODS AND MATERIALS: An anonymous, web-based questionnaire was sent to adult voice center patients. The survey was distributed using The Research Electronic Data Capture (RED-Cap) tool, hosted by Drexel University. The survey was designed to collect relevant demographic data, past laryngeal history, marijuana use history, and beliefs about effects of marijuana on voice. RESULTS: The survey was sent to 434 voice patients, 42 patients responded to the survey (response rate 9.68%). The average age of respondents was 45.7 (13 were male, 27 were female, and 2 were transgender). Of all, 88.10% reported having never used tobacco, 9.52% were former tobacco users, and 2.38% were current tobacco users. Of all, 75.61% of the respondents reported having tried some form of marijuana during their lifetime (16.13% reported medical use, 45.16% reported recreational use). Out of all, 21.43% were frequent (monthly) users, and 39.29% were infrequent (yearly) marijuana smokers. They reported symptoms that they attributed to marijuana use, including hoarseness, breathiness, and weakness. CONCLUSION: Marijuana may have negative effects on the voice.

Effects of Particle Size of Inhaled Corticosteroid on the Voice.

OBJECTIVES: The purpose of this study was to determine if inhaled corticosteroid (ICS) particle size influences the development of laryngitis including candida laryngitis, dysphonia, or vocalis muscle atrophy in asthmatic patients. STUDY DESIGN: Retrospective analysis. METHODS: Medical records of patients from a quaternary care laryngology practice who have asthma were reviewed retrospectively. Subjects were divided into two groups determined by the particle size of their ICS, small or standard. Each patient only used one type of inhaler. All subjects had been seen in the office for dysphonia evaluation. Statistical analysis was performed on the collected data using χ2 analysis with Yate's Correction for categorical data and a student t-test for means. A P value of less than 0.05 was considered significant. RESULTS: There was a significant difference in vocal fold atrophy rate between groups. CONCLUSION: Routine use of standard particle size ICS is associated with more atrophy than small size ICS.

Tongue Edema Secondary to Suspension Laryngoscopy.

OBJECTIVES: Suspension microlaryngoscopy (SML) is generally a safe, same-day procedure. Complications have been linked to prolonged operative time and substantial force applied to the tongue. This report of two cases describes marked tongue edema following SML, a complication not yet reported in the literature. METHODS: This is a retrospective review of two cases of severe tongue edema following SML. We reviewed the literature for similar reports and proposed treatment plans. RESULTS: Two patients, age 67 and 75, underwent SML for an interval of 247 minutes and 224 minutes for patient 1 and patient 2 respectively. Both developed severe tongue edema requiring inpatient monitoring and steroids. In both patients, the edema improved over several days and returned to baseline. There are no reported cases of this complication in the literature. CONCLUSION: Prolonged SML can lead to tongue edema requiring close airway monitoring. The edema was self-limited and resolved with steroids and close monitoring.

Diagnostic Value of Acoustic and Aerodynamic Measurements in Vocal Fold Movement Disorders and their Correlation with Laryngeal Electromyography and Voice Handicap Index.

OBJECTIVES: Investigate the relationships between the Voice Handicap Index, laryngeal electromyography, and objective acoustic voice testing in order to determine the utility of these measures in the management of vocal fold movement disorders. METHODS: A retrospective review of patients who had completed a Voice Handicap Index-10 (VHI-10) questionnaire, laryngeal electromyography (LEMG), and objective acoustic measurements (including jitter, relative average perturbation, shimmer, noise-to-harmonic ratio, and standard deviation of fundamental frequency). All three tests had been completed within 30 days of the initial evaluation. All patients' results for acoustic measures were recorded as standard deviations from the norm. LEMG results were converted to grade of paresis (mild, moderate, severe) based on the muscle with the lowest recruitment. Spearman correlation coefficients were calculated to determine the relationship between these three parameters. RESULTS: A total of 313 subjects were included in the analysis. VHI-10, LEMG (grade of paresis), and objective acoustic measures were, at best, weakly correlated. VHI-10 was better correlated than LEMG to each acoustic parameter including the average acoustic scores; however, the highest correlation observed only reached ρ = 0.349 (P < 0.001). The acoustic variables that correlated best with VHI-10 and LEMG were the standard deviation of the fundamental frequency (ρ = 0.349, P < 0.001) and shimmer (ρ = 0.207, P < 0.001), respectively. CONCLUSION: This study demonstrates that these measures are, at best, weakly associated. VHI-10 correlated better than LEMG (grade of paresis) to each acoustic voice analysis parameter. However, the maximum correlation coefficient observed was 0.349. Therefore, VHI-10 scores and objective voice acoustic measurements are not useful for predicting the severity of vocal fold movement disorders. Moreover, a given severity of paresis can have different effects on voice handicap and acoustic output in different individuals.

The Utility of Strap Muscle in Complex Type I Thyroplasties.

INTRODUCTION: Type I thyroplasty is a common procedure used to improve dysphonia secondary to glottic insufficiency caused by vocal fold paralysis, paresis, or bowing. Revision often involves more complex procedures that can be complicated by mucosal violation, hemorrhage, infection, and shifted or extruded implants. Intraoperative challenges can be managed successfully using autologous strap muscle rotation flaps. OBJECTIVES: Review vocal fold medialization with strap muscle as a viable option for thyroplasty, particularly operations with inadvertent mucosal disruption. METHODS: All operative records of the senior author's 30-year experience were queried for modified, complex, or revision type I thyroplasties. Each of these was reviewed, and only those utilizing autologous strap muscle rotation flaps for vocal fold medialization were included. Changes in voice quality were assessed using strobovideolaryngoscopic assessment of glottic closure and Voice Handicap Index-10 (VHI-10) scores when available. RESULTS: Seven patients were found to have undergone eight type I thyroplasty using autologous strap muscle flaps. Improved glottic closure was seen in all patients except one. This patient, complicated by a laryngeal fracture of unknown origin discovered at the time of surgery, had worse voice with strap muscle implantation intraoperatively; therefore, the patient's fracture was reduced, and medialization was postponed. All other patients reported improved voice quality both intra- and postoperatively. Pre- and postoperative VHI-10 scores were available for two of the seven cases with successfully implanted strap muscles. A decrease in VHI-10 was observed in both cases (mean = 11). No postoperative complications occurred in any patient. CONCLUSION: Although revision thyroplasties are relatively rare, they can be challenging. The seven cases presented herein illustrate the successful and safe use of autologous strap muscle rotation flaps for complex, revision type I thyroplasty procedures. They are particularly helpful in cases requiring additional soft tissue between the thyroid cartilage and mucosa in preparation for possible future medialization after Gore-Tex or Silastic implants, and for inadvertent mucosal disruption in which using a foreign implant might pose a risk of infection. Future studies should be performed with larger populations and longer follow-up to confirm the efficacy and safety of this procedure.

Role of Peri- and Postoperative Antibiotics in Microscopic Laryngeal Surgery.

OBJECTIVES: There are no widely accepted guidelines for the use of peri- and postoperative antibiotics for microdirect laryngoscopy (MDL) to prevent postoperative surgical site infection (SSI). This study examines the incidence of not only SSI, but also respiratory and oropharyngeal infections among patients who underwent MDL. STUDY DESIGN: Retrospective cohort. METHODS: Medical records from a quaternary laryngology practice were reviewed retrospectively for patients who underwent MDL between October 2015 and December 2018. Adults who underwent MDL with excision of nonmalignant masses, vocal fold (VF) reconstruction with buccal graft, superficial VF injection, VF injection augmentation, use of carbon dioxide (CO2) or potassium titanyl phosphate (KTP) laser, and laryngeal dilation were included. Subjects were divided into three groups based on the use of antibiotics during the peri- or postoperative period. Group 1 did not receive peri- or postoperative antibiotics. Group 2 received perioperative antibiotics without postoperative antibiotics. Group 3 received both peri- and postoperative antibiotics. Antibiotic use was determined by surgeon policy, which changed over time, not by patient risk factors. Other data collected include demographics, medical comorbidities, surgical procedure, operative time, American Society of Anesthesiology class, incidence of SSI, respiratory or oropharyngeal infection, and postoperative antibiotic and steroid prescriptions for complications. RESULTS: 190 surgeries met inclusion criteria. Groups 1, 2, and 3 consisted of 113, 57, and 20 subjects, respectively. No SSI were reported. Baseline characteristics of median age, American Society of Anesthesiology, wound class, and gender did not differ between groups. Groups were found to have differed in type of procedure performed, with a predominance of vocal fold excision and superficial injection in Group 1, injection laryngoplasty using autologous fat graft and laryngeal reconstruction in Group 3, and a combination of procedure types in Group 2. Laser treatment with CO2 and/or KTP was utilized in 35% of procedures. The mean operative times (total time in which the laryngoscope remained in the oral cavity) for Groups 1, 2, and 3 were 29 (SD = 13), 42 (SD = 23), and 73 minutes (SD = 78), respectively; this was significantly different among the three groups (P < 0.0001). By logistic regression models, operative time was not significantly associated with the overall use of antibiotics (Χ2 = 1.81, P = 0.18) or corticosteroid (Χ2 = .05, P = .82) prescriptions during follow-up. In Groups 1, 2, and 3, 11%, 14%, and 10% of patients, respectively, required a follow-up antibiotic prescription for non-SSI and 11%, 12%, and 0% of patients, respectively, required a follow-up corticosteroid prescription within 30 days postoperatively. There was no significant difference in patients with diabetes or pulmonary comorbidity and patients without comorbidity in use of postoperative antibiotic (P = .45) or corticosteroid (P > .99) prescription. Within 30 days of follow-up, patients in Group 1 experienced VF hemorrhage (defined as any subepithelial blood in the area of excision) at an incidence of 19%. Complications within 30 days of follow-up showed an incidence of substantial pain ranging between 2%-4% and respiratory or oropharyngeal infection between 10%-12%. Two patients in Group 2 reported emergency department visits for dyspnea. One patient in Group 3 was admitted for tongue and floor of mouth swelling secondary to prolonged suspension. CONCLUSION: There were no incidents of SSI in this cohort. The need for follow-up antibiotic and/or corticosteroid prescription did not differ in relation to use or non-use of perioperative antibiotics, and neither did the incidence of respiratory or oropharyngeal infection. Longer operative time was associated with both peri- and postoperative antibiotic use, but there is no evidence yet that antibiotic use was necessary. These findings suggest that avoidance of routine perioperative and/or postoperative antibiotics may be appropriate; and further research should be encouraged.

Incidence of and Risk Factors Associated With Vocal Fold Hemorrhage Following Type I Thyroplasty With Gore-Tex Implant.

OBJECTIVES: The objectives of this study were to determine the rate of hemorrhage following type I thyroplasty performed exclusively with Gore-Tex implant and to define whether age, comorbidities, anticoagulation therapy, presence of vocal fold ectasia, and operative technique are associated with increased incidence of hemorrhage. METHODS: Medical charts of 86 patients who underwent type I thyroplasty with Gore-Tex implant between the years 2013 and 2019 were reviewed retrospectively and divided into two groups based on presence or absence of postoperative vocal fold hemorrhage. Patients were examined on the day following surgery. Hemorrhage was defined as any submucosal erythema on the vocal fold even when isolated to the superior surface. Age, sex, medical comorbidities, preoperative medications with specific attention to anticoagulation therapy, American Society of Anesthesiology score (all procedures were performed under local anesthesia with sedation), operative notes, and pre- and poststroboscopy exams were compared between groups. Statistical analyses were done using Chi-Square (χ 2) Analysis and Student's t test. P values were considered statistically significant at the P < 0.05 level. RESULTS: The rate of hemorrhage was 22.3%. There was a statistically significant difference in incidence of hemorrhage associated with a vocal fold varix on preoperative stroboscopic exam and history of discontinued anticoagulation therapy (1-week preoperatively). No difference was found for the other parameters studied. CONCLUSION: Presence of vocal fold varix or ectasia and preoperative use of anticoagulation or antiplatelet therapy are associated with an increased risk of hemorrhage following type I Thyroplasty with Gore-Tex implant.

Cannabis & ENT: State certification-An expanding yet unregulated system.

OBJECTIVES: 1) Ascertain the status of cannabis legalization by state, 2) Explore the process required to obtain cannabis credentials for both the patient and the physician, 3) Determine the level of interest of otolaryngologists in the medicinal cannabis, and 4) Explore possible research directions into efficacy and potential complications. STUDY DESIGN: Descriptive study. METHODS: Internet searches were conducted to identify each state's Medical Cannabis Program website. The qualifying conditions, list of approved-practitioners, process required for both practitioners and patients for approval were noted. Lists of approved practitioners were analyzed to determine the prevalence of board-certified otolaryngologists. RESULTS: Of the 33 states that authorize medicinal cannabis, eight provide lists of approved-practitioners, six of which provide specialty information. A total of 24 Otolaryngologists can be found of the 5944 physicians on these six lists. All otolaryngologists were located in highly-populated metropolitan areas with a mean number of 29.9 years in practice. Significant variations exist between each state including legal definitions and qualifying conditions. CONCLUSIONS: Lack of consistent regulation across the country drives uncertainty regarding the adoption of medicinal cannabis. Very few otolaryngologists in the country are registered to certify patients for medical cannabis. While the medicinal use of cannabis may currently have limited applications within otolaryngology, many areas that have yet to be explored.

In RRP, serologic response to HPV is frequently absent and slow to develop.

BACKGROUND: Recurrent respiratory papillomatosis (RRP) is characterized by repeated formation of papillomas in the respiratory tract and is caused by human papillomavirus (HPV) types 6 and 11. Women with genital HPV infection are slow to develop weak humoral immunity, but respond robustly to the HPV vaccine. We wondered if people with RRP had a similar immune response. METHODS: A convenience cross-sectional sample of patients with RRP were recruited into one of four groups: 1) adults and adolescents with active RRP, 2) children with active RRP, 3) RRP patients who had undergone HPV vaccination prior to enrollment and, 4) people with RRP who were in remission. Anti-HPV6 and HPV11 serology was determined by cLIA on a single blood draw. RESULTS: Of the 70 subjects enrolled, 36, 16, 8, and 10, were in groups 1, 2, 3, and 4, respectively. 47% of participants aged >11 years and 81% aged ≤11 years possessed no antibodies against HPV6 or HPV11 (ie. double seronegative). 61% of patients in remission were double seronegative. All participants who had received HPV vaccine previously were seropositive to at least one of these low risk HPV types (ie none of them were double seronegative). Among patients who had active RRP and never had HPV vaccination (n = 52) there was an association between duration of symptoms and seropositivity. Of those who were seropositive, the geometric mean duration of symptoms was 11 years compared to 4.7 years for those who were seronegative (p = 0.001). CONCLUSION: People with RRP are capable of developing a humoral response to HPV6 and HPV11. That response appears to be robust when initiated by the HPV vaccine, but either nonexistent or slow to develop in response to infection. Most in remission do not have demonstrable antibody levels against HPV6 or HPV11.

Role of Postoperative Antibiotics in Patients Undergoing Type I Thyroplasty with Gore-Tex Implant.

OBJECTIVES: The purpose of this study was to determine the need for postoperative antibiotic administration in patients undergoing type I thyroplasty performed with Gore-Tex implant. STUDY DESIGN: Retrospective analysis. METHODS: Medical records of patients from a quaternary care laryngology practice who underwent type I thyroplasty for glottic insufficiency using Gore-Tex (W.L. Gore, Newark, Delaware) implant between the years 2013 and 2019 were reviewed retrospectively. Subjects were divided into two groups determined by those who did or did not receive routine postoperative antibiotics. All patients received two grams of cefazolin IV (for the standard 70-kilogram patient), and 10 mg of dexamethasone as a one-time dose given 10 minutes prior to incision. Patients allergic to cefazoline who received a single preoperative dose of 600 mg of clindamycin IV. All subjects were seen in the office at least three times after the procedure: one day, one week, and approximately six weeks following surgery. Statistical analysis was performed on the collected data using χ2 analysis for categorical data and a student t test for means. A P value of less than 0.01 was considered significant. RESULTS: There was no significant difference in infection rate or other complications between groups. CONCLUSION: Routine use of antibiotics following type I thyroplasty with Gore-Tex (W.L. Gore, Newark, Delaware) appears unnecessary.