Amanda L. Silver

Surgical outcomes following the endoscopic modified Lothrop procedure.

Objective: We performed a systematic review of 97 patients in whom an entirely endoscopic modified Lothrop procedure (EMLP) was performed. We studied the safety, efficacy, need for revision surgery, and rate of complication following an EMLP.

Cine Magnetic Resonance Imaging With Simultaneous Audio to Evaluate Pediatric Velopharyngeal Insufficiency

OBJECTIVE To develop a protocol linking cine magnetic resonance (MR) imaging to simultaneously acquired audio recordings of specific phonatory tasks to evaluate velopharyngeal insufficiency (VPI) in children. DESIGN Institutional review board-approved development and application of a novel dynamic cine MR imaging protocol linked to simultaneously recorded audio. SETTING A tertiary care multidisciplinary pediatric airway center. PARTICIPANTS Three healthy adult volunteers and 5 pediatric volunteers (age range, 9.3-18.9 years; mean age, 12.4 years) from the multidisciplinary pediatric airway center with VPI who previously had undergone nasopharyngoscopy, videofluoroscopy, or both. INTERVENTIONS Cine MR imaging with simultaneously acquired audio files was performed in 3 adult volunteers to optimize the protocol and then in 5 pediatric volunteers meeting the inclusion criteria. MAIN OUTCOME MEASURES High-resolution cine MR images with clear intelligible audio recordings of specific phonatory tasks. RESULTS Using 3 healthy adult volunteers, a cine MR imaging VPI protocol was developed that links simultaneously acquired cine MR images to audio recordings of specific validated phonatory tasks. Five school-aged children with VPI from our multidisciplinary pediatric airway center were then enrolled and underwent cine MR imaging using this protocol. The cine MR images and audio recordings acquired were of sufficient diagnostic quality to evaluate VPI closure patterns in school-aged children with VPI. CONCLUSION Cine MR imaging linked to audio is a quick, safe, and well-tolerated dynamic diagnostic imaging tool that may eventually have the potential to guide more precisely the selection and application of surgical techniques for VPI.

Follicular dendritic cell sarcoma presenting in the submandibular region in an 11 year-old.

Follicular Dendritic Cell Sarcomas (FDCS), formerly known as follicular dendritic cell tumors (FDCT), are rare and likely under-diagnosed malignancies arising in the dendritic reticulum cells of lymph nodes. Extranodal cases are rare, with fewer than 70 cases reported in the head and neck.1 The tonsils are the most common extranodal site in the head and neck;2 other sites include the nasopharynx, parapharyngeal space, maxillary alveolar ridge, hard and soft palate.1 FDCS typically affects young or middle aged patients and there may be a slight female predominance.3,4 We present the case of an 11 year-old patient with FDCS involving the right submandibular region. To our knowledge, this is the third reported case of FDCS in the head and neck in a patient under the age of 16.

MRI with synchronized audio to evaluate velopharyngeal insufficiency.

Objective To demonstrate the feasibility of simultaneous-acquired magnetic resonance imaging (MRI) and high-quality synchronized audio recording for evaluating velopharyngeal closure. Design Institutional Review Board–approved case series. Setting Tertiary care hospital. Patients Three healthy adult volunteers with a normal speech pattern. Interventions MRI with simultaneous recorded audio files evaluating velopharyngeal closure. Main outcome measure Precise imaging and audio coordination of specific phonatory tasks. Results Synchronization of MRI and audio in all three adults. Conclusion Our novel imaging and audio protocol provides simultaneous acquired MRI with synchronized high quality audio for evaluating velopharyngeal closure. This technique may provide the opportunity to improve diagnosis and surgical planning in patients with velopharyngeal insufficiency.

Dexmedetomidine Use in Pediatric Airway Reconstruction

Objective. Assess the postoperative use of dexmedetomidine (Precedex) in pediatric patients following airway reconstruction. Study Design. Historical cohort study. Setting. Tertiary medical center. Subjects and Methods. A retrospective review of 24 children undergoing laryngotracheal reconstruction (LTR) or laryngeal cleft repair (LCR) was conducted. Twelve children were treated with standard sedation protocols where dexmedetomidine was administered in lieu of propofol (Diprivan); 12 age-, gender-, and procedure-matched controls were selected. Subjects were divided into groups based on duration of postoperative intubation for cross-comparison; group 1 was intubated <24 hours, group 2 was intubated 2 to 6 days, and group 3 was intubated 7 days or longer. Baseline heart rate and blood pressure measurements were compared to hourly measurements for the first 6 hours following initiation of dexmedetomidine or mechanical ventilation in the control group. Number of supportive respiratory interventions, adverse events, self-extubations, premature termination of dexmedetomidine, amount of muscle relaxants, agents to treat withdrawal, and length of stay were evaluated. Results. Ten patients undergoing LTR and 2 patients undergoing LCR receiving dexmedetomidine were compared to 10 LTR and 2 LCR control patients. Overall, dexmedetomidine was well tolerated and without significant adverse effects, particularly in cases of short-term intubation or as a bridge to extubation. Conclusion. In cases requiring short-term intubation following airway reconstruction, dexmedetomidine may offer a safe alternative to propofol by providing readily reversible sedation during the periextubation period. Further studies are needed to determine the safety, efficacy, dosing, and potential complications of longer term dexmedetomidine administration in pediatric airway reconstruction.

Optic neuropathy caused by naso-orbital mass in chronic intranasal cocaine abuse.

A 48-year-old woman with a history of chronic intranasal cocaine abuse presented with unilateral proptosis associated with severe visual loss from optic neuropathy in the right eye. Imaging showed extensive bone and soft tissue destruction in the paranasal region and an orbital mass. Initial biopsies suggested a low-grade neoplasm. The correct diagnosis was established only on repeat biopsy, which revealed marked pleomorphism and nonspecific chronic inflammation with irregular collagen bundles containing thick-walled blood vessels. This case emphasizes that intranasal cocaine abuse may clinically, radiographically, and histopathologically mimic a neoplasm or a necrotizing vasculitis.

Rosai‐Dorfman disease presenting in the oropharynx

We report a case of Rosai‐Dorfman disease (RDD) presenting as an oropharyngeal mass, and we provide a detailed discussion of this rare clinical entity.

Pathology quiz case 1. Diffuse large B-cell lymphoma (DLBCL).

A 58-YEAR-OLD MAN PRESENTED WITH A 1-month history of an expanding mass in the left side of his neck and neurologic symptoms. His left-sided otalgia, headache, andodynophagiawere initially treated as a temporomandibular joint disorder. He developed hoarseness, a dry cough, left-sided facial numbness, and a rapidly expanding mass in the left side of his neck (4.3 3.4 cm on a computed tomographic [CT] scan) and then leftsided ptosis and diplopia. Positron emission tomography (PET) revealed multiple systemic foci of intense tracer uptake. The findings of fine-needle aspiration of the neck node at an outside institution were nondiagnostic; flow cytometry was not performed. The results of a bone marrow biopsy and a lumbar puncture were normal. Subsequent CT and magnetic resonance imaging (MRI) demonstrated a left nasopharyngeal mass with involvement of the masticator space, sphenoid sinus, cavernous sinus, pterygopalatine fossa, Meckel cave, vidian canal, foramen rotundum, and ovale. T1-weighted MRI demonstrated replacement of the normal high signal of the marrow as the lesion infiltrated the skull base (Figure 1). A separate large mass on the left side of the neck demonstrated associated lymphadenopathy of levels I through VI. The patient underwent an emergent, uncomplicated transnasal endoscopic biopsy of the nasopharyngeal mass. Tissue was sent fresh for analysis of frozen and permanent sections. Hematoxylin-eosin staining showed a diffuse infiltrate of large discohesive cells with vesicular, irregular nuclei and moderate amounts of pale cytoplasm admixed with scattered small lymphocytes (Figure 2). Immunohistochemical stains showed large cells that were positive for CD20 (Figure 3) and PAX5 but negative for CD3 (Figure 4). The small lymphocytes were positive for CD3. What is your diagnosis?

High Grade Lymphoma Mimicking Advanced Nasopharyngeal Carcinoma

Nasopharyngeal carcinoma represents the most common malignancy of the nasopharynx and central skull base, but the differential diagnosis of a nasopharyngeal mass should be broad. Diffuse large B-cell lymphoma (DLBCL) is the most common type of lymphoma, accounting for 30-40% of the 55,000 new cases of adult NHL diagnosed each year.1,2,3 Common head and neck sites of DLBCL include: Waldeyer’s ring, the nasal cavity, the paranasal sinuses, the thyroid and salivary glands, and the orbit while bone marrow involvement is a late finding.4 Typically lymphoma presents as a rapidly enlarging symptomatic mass at a single lymph node, however 10% of patients with NHL present with extranodal disease in the head and neck region.5 Lymphoma therefore must be considered in cases of extranodal or extralymphatic disease, even in the absence of nodal disease. In all, there are fewer than 30 reported cases of lymphoma presenting with isolated diffuse infiltration of the skull base.6,7,8 The peak incidence of DLBCL is in the seventh decade of life, but the process can occur at any age.4 Currently, there exists no effective screening modalities and patients are diagnosed only after they present with associated symptoms, such as lymphadenopathy. A CT scan in addition to a PET scan should be obtained to aid in staging and prognosis.9 Immunohistological staining is typically positive for CD 19, CD 20, CD 22, CD 45, and CD 79a, but negative for CD 3 and CD 5. Molecular rearrangements involving bcl-2 and bcl-6 are often seen in DLBCL.3,10 Analysis of gene expression profiles has enabled the identification of two molecularly distinct forms of DLBCL: germinal center B cell-like DLBCL, associated with significantly higher survival and activated B cell-like DLBCL (ABClike).3,11 A lesser studied third subgroup, Type III, serves to unify cases that do not express genes characteristic of either of the two more studied groups.3 Untreated, diffuse B-cell lymphoma is rapidly fatal (on the order of months) because of its aggressive progression. Surgical biopsy is imperative for diagnosis and is favored over fine-needle aspiration or large bore-needle biopsies because of the quantity of tissue needed for proper diagnosis.9 R-CHOP or cyclophosphamide, hydroxydaunomycin (doxorubicin), vincristine (Oncovin) and prednisone (CHOP) combined with rituximab, is the most commonly administered chemotherapy for DLBCL.1,2,9 Radiation therapy is adjunctive in cases of limited-stage disease.9 Prompt diagnosis and initiation of treatment often can reverse the cranial nerve palsies associated with primary lymphoma of the skull base and can be life saving. This case demonstrates the importance a broad differential diagnosis and thorough evaluation of the nasopharyangeal mass. Expeditious and accurate tissue diagnosis of a mass mimicking advanced nasopharyngeal carcinoma can be achieved safely in a minimally invasive endoscopic manner, as shown by this case. Although relatively uncommon, the nasopharyngeal mass requires a thorough evaluation. In an adult, the differential diagnosis is broad. Expeditious and accurate diagnostic studies and tissue diagnosis can have critical prognostic implications. We present the case of a man with high-grade lymphoma mimicking advanced nasopharyngeal carcinoma. The presentation, diagnosis and management of diffuse large B-cell lymphoma (DLBCL) in the head and neck are reviewed along with recent literature pertaining to the diagnosis and treatment of this aggressive lymphoma. INTRODUCTION