Benjamin D. Liess

The Difficult Airway

Securing the airway in a dyspneic patient is a challenging task because of the myriad causes and presentations. Initial assessment may demonstrate factors indicative of upper airway abnormalities; however, they may not be specific nor sensitive enough to accurately predict difficult intubation. A well-equipped airway cart must be immediately available. A standardized escalating approach to secure the airway in a difficult situation begins with a rapid sequence of attempts at standard intubation, followed by attempted tube introduction over a bougie or using a flexible endoscope or laryngeal mask, and finally surgical interventions including cricothyrotomy or tracheotomy.

Schwannoma of the hard palate

Schwannomas are rare, benign neoplasms that can arise from any cranial, peripheral, or autonomic nerve that contains Schwann cells. Approximately 25% to 45% of all schwannomas occur in the head and neck. They occur most commonly in the eighth cranial nerve, but it has been reported that 20% to 58% arise in the oral cavity, with approximately 10% of these located on the hard palate. We report a case of schwannoma of the hard palate, present important pathologic considerations for diagnosis, and provide a review of the literature regarding extracranial schwannomas.

Congenital Central Alveolar Hypoventilation Syndrome (Ondine's Curse) With Survival Into Adulthood

Ondines curse or central alveolar hypoventilation (CCAH) syndrome is a disorder of the autonomic nervous system resulting in respiratory dysregulation. The clinical outcome is typically poor, with few individuals living into adulthood and even fewer surviving to adulthood with normal neurological function. Our patient initially presented following an uncomplicated delivery with hypotonia, poor respiratory effort, and hypoxemia that required ventilatory support. Laboratory workup, radiographic evaluation, and ancillary testing ruled out brain stem lesions, neuromuscular diseases, cardiovascular and pulmonary disease, and metabolic disorders, resulting in a diagnosis of CCAH syndrome. The patient underwent tracheotomy and chronic ventilatory support. Close long-term management and appropriate treatment modifications have provided for an excellent outcome and good quality of life. The patient is currently 22 years old and is earning her teaching degree for K-12 art education. A combination of early recognition and a multidisciplinary approach may lead to a successful outcome in patients with CCAH syndrome.

Extranodal nasal-type natural killer/T-cell lymphoma masquerading as recalcitrant sinusitis.

Extranodal nasal‐type natural killer (NK)/T‐cell lymphoma is a very uncommon disease process often mimicking refractory sinusitis. The diagnosis may be discovered after an extensive exclusion process. Careful immunohistochemical evaluation is crucial to differentiate NK/T‐cell lymphoma from other malignancies.

Transoral endoscopic removal of a bullet from the infratemporal fossa

The use of endoscopy has expanded into many areas of otolaryngology. Endoscopes allow surgeons to access the human body with smaller surgical exposure, resulting in less tissue disruption. Endoscopic techniques provide reduced patient morbidity in comparison to an open approach by reducing surgical dissection. We present a patient who underwent endoscopic removal of a bullet in the infratemporal fossa (ITF) near the left temporal mandibular joint with an intraoral approach. This approach applies a minimally invasive solution that would otherwise necessitate a more extensive procedure. A 33year-old man presented to the trauma center after being shot in the face. An entrance wound was present in his right cheek, and soft-tissue trauma was noted on the soft palate. The patient experienced trismus as well as difficulty with occlusion. He was otherwise hemodynamically stable and without neurovascular compromise. A CT scan showed a metallic foreign body in the ITF medial to the left condylar head (Fig 1). Under general anesthesia, an oral incision along the anterior border of the left ascending ramus was performed down to the cortex. Subperiosteal elevation was performed past the sigmoid notch and along the ascending condylar neck. Visualization was achieved by using a 4-mm zerodegree sinus endoscope within the dissection cavity. Because the bullet was lodged more medially within the soft tissue of the ITF, careful blunt dissection through the periosteum was performed. Fluoroscopy was used to aid in spatial localization of the bullet. The projectile was visualized and extracted (Fig 2). The patient was lost to follow up. The institutional review board approved this study.

Carcinosarcoma of the parotid gland : Report of a case with immunohistochemical findings

Objectives: Carcinosarcoma (true malignant mixed tumor) of the parotid gland is an extremely uncommon tumor composed of both carcinomatous and sarcomatous components. An understanding of this manifestation is crucial to guide management and treatment of this disease. Methods: A patient who presented with facial nerve weakness and a painful mass of the parotid gland underwent fine needle aspiration, laboratory testing, and computed tomography of the neck that demonstrated a large parotid malignancy. The patient underwent surgical treatment followed by radiotherapy. Histologic and immunohistochemical examination of the specimen was performed. Results: This report of a slow-growing parotid mass with otalgia and facial nerve weakness was treated with radical parotidectomy, supraomohyoid neck dissection, and cable graft repair of the excised facial nerve, which was completely encircled by tumor. Postoperative radiotherapy was administered. Histologic and immunohistochemical evaluation demonstrated carcinosarcoma. Conclusions: Carcinosarcoma is an unusual tumor of the parotid gland. Treatment generally involves surgery with subsequent radiotherapy. Long-term close follow-up is recommended, for this tumor has a high propensity for both local and regional recurrence and metastasis.

Pulsatile tinnitus: A harbinger of a greater ill?

Pulsatile tinnitus is an uncommon otologic symptom, which may be the presenting complaint of a potentially devastating pathology. Understanding this manifestation as a possible symptom of a significant vascular abnormality is crucial to guide management and treatment.

Double-Doyle Intranasal Airway Splint Technique

Objective: Present a novel technique utilized by the senior author for support of unstable, comminuted nasal bone fractures and its adaptation to rhinoplasty and septal surgery to provide greater stabilization of the nasal septum and bones. Illustrate safe and adequate results with this technique. Method: Retrospective chart review of the senior author’s past surgical procedures since 2001 utilizing this Double-Doyle intranasal airway splint technique. Patient demographics, diagnoses, surgical procedure, stenting duration, and complications were identified. This technique involves 2 modified Doyle II intranasal airway splints (Medtronic) to provide greater intranasal support. Results: Eighty-seven cases involving the Double-Doyle intranasal airway splint technique performed for closed nasal reduction, selected cases of open rhinoplasty, and septal procedures revealed overall that this intranasal splint modification was safe, tolerated well by patients, and presented minimal morbidity. All but one patient experienced a successful cosmetic and functional outcome as described by the senior author. Six overall possible complications were noted; 3c cases of minor nasal mucosa damage and 3c cases of possible infection that resolved after removal of the splint and treatment with antibiotics. Conclusion: We present a safe technique that provides prolonged nasal dorsal support in severely comminuted nasal bone fractures without the need for external suspension devices or additional incisions. Additionally, this technique may be applied to rhinoplasty and septal procedures involving significant septal correction to allow greater stabilization of the septum postoperatively.

Metastatic neuroblastoma to the mandible: an unusual presentation.

Neuroblastoma is an uncommon cause of a mandibular mass. We describe an 8-month-old child who presented with loosening of his dentition, poor oral intake, and a large mandibular mass. Thorough radiographic study and subsequent biopsy of the oral lesion revealed the diagnoses of metastatic neuroblastoma. Ultimately, he was successfully treated with surgery and chemotherapy. The unusual presentation and pathophysiology of this malignancy will be reviewed. Neuroblastoma presenting as a mandible mass associated with natal teeth is rare, but it should be considered in the differential diagnosis of pediatric mandibular lesions.

Metastatic esophageal adenocarcinoma presenting as an external auditory canal mass

Metastatic tumors to the external auditory canal (EAC) are exceedingly rare. In the vast majority of cases, these metastases occur in the latter stages of the disease process. To the best of our knowledge there has been only one case report of metastatic esophageal adenocarcinoma to the EAC. We present the first reported case of an EAC mass as the initial presenting symptom of a metastatic esophageal adenocarcinoma. Institutional review board approval was obtained. A 60-year-old African American man presented with a four-week history of swelling in his right EAC. He noted some mild hearing loss in the right ear but denied any otalgia, otorrhea, tinnitus, or vertigo. Physical examination revealed a well circumscribed, nontender mass with a broad base originating from the anterior-inferior aspect of the canal wall (Fig 1). The remainder of the head and neck examination was unremarkable. Medical and surgical history was negative. A review of systems was positive for a 40 pack-year history of tobacco use and one pint of alcohol per weekend. Incisional biopsy specimens from the mass demonstrated a dermal neoplasm with islands of basaloid cells (Fig 2). Higher-power examination of the tumor nests revealed areas of central necrosis, duct-like formations, and a high number of mitoses. Additional immunohistochemical stains were positive for carcinoembryonic antigen, cytokeratin 7, cytokeratin 20, and caudal-related homeobox 2. The diagnosis of metastatic, moderately differentiated adenocarcinoma was made. Further evaluation with upper gastrointestinal endoscopy revealed a 2.5-cm fungating mass partially occluding the esophagus at 35 cm. Biopsies revealed a poorly differentiated large cell carcinoma histologically similar to the EAC mass. Lower endoscopy was negative. A positron emission tomography/computed tomography scan demonstrated Ffluorodeoxyglucose-avid masses in the left maxillary sinus, mediastinum, liver, prevertebral space, and supraclavicular nodes. Later, the patient developed biopsy-proven subcutaneous metastases, and magnetic resonance imaging revealed brain metastases. The patient was treated with FOLFOX-6 plus bevacizumab chemotherapy and stereotactic radiation to the brain. Unfortunately, his condition continued to worsen and he was placed on hospice. The patient died eight months after initial presentation.