Brandon L. Prendes

Therapeutic Sialendoscopy for the Management of Radioiodine Sialadenitis

OBJECTIVE To describe our experience with therapeutic sialendoscopy for radioiodine (iodine 131 [(131)I]) sialadenitis. DESIGN Retrospective medical chart review. SETTING Academic tertiary referral center. PATIENTS The study included 11 patients who underwent therapeutic sialendoscopy for the treatment of (131)I sialadenitis after failing medical management. INTERVENTIONS Therapeutic sialendoscopy with dilation and irrigation of the ductal system was performed in all patients. MAIN OUTCOME MEASURES Patient-reported frequency and severity of symptoms. RESULTS Our series included 9 women and 2 men (mean age, 51 years; age range, 35-65 years). A total of 23 parotid glands and 5 submandibular glands were treated. Sialendoscopy was possible in all patients, except one in whom the Stensen duct could not be cannulated. Typical endoscopic findings included pale ductal mucosa, thick mucous plugs, ductal debris, and stenosis of the duct. Most patients (91%) reported improvement of symptoms after a single procedure. Complete resolution of symptoms, with sustained benefit, was reported by 6 patients (54%) at a mean follow-up of 18 months. Partial improvement of symptoms, with some persistent intermittent episodes of pain or swelling, was reported by 4 patients (36%). One patient reported no subjective symptomatic improvement after 2 procedures and subsequently underwent a parotidectomy. CONCLUSIONS Sialendoscopy is useful for the improvement of symptoms due to radioiodine-induced sialadenitis in patients who are refractory to conservative medical therapy. Therapeutic sialendoscopy appears to provide effective and sustained symptom improvement in most patients in our experience.

Long-Term Effects of Injection Laryngoplasty With a Temporary Agent on Voice Quality and Vocal Fold Position

Patients with unilateral vocal fold paralysis (UVFP) treated with temporary injection laryngoplasty (IL) have a decreased rate of permanent medialization laryngoplasty (ML) compared to UVFP patients initially treated by observation. The aim of this study was to determine whether the lower rate of ML corresponded with improved quantifiable measures.

Transoral robotic‐assisted surgical excision of a retropharyngeal parathyroid adenoma: A case report

Transoral robotic surgery has been used with increasing frequency for oropharyngeal malignancies. We present the first known case of a transoral robotic‐assisted parathyroidectomy.

Oral human papillomavirus infection in men who have sex with men with anal squamous intraepithelial lesions

Little is known about the association between oral and anogenital human papillomavirus (HPV) infections.

Erosive cholesterol granuloma.

A 66-year-old woman developed asymmetric hearing loss, left poorer than right, and disequilibrium 7 years ago. Over the next several years, hearing in the left ear deteriorated dramatically. More recently, balance disturbance has caused her to stumble under low lighting conditions. Other neurologic symptoms, such as facial numbness or weakness, headaches, and vision changes were absent. An audiogram at presentation documented left complete deafness and right mild hearing loss. Fukuda step testing elicited rotation to the left by 50 degrees. Otoscopy using the office microscope showed translucent, normal-appearing eardrums, and clear middle ear clefts. The facial nerves were entirely normal. Temporal bone CT revealed an erosive lesion of the left petrous apex and internal auditory canal (Fig. 1A). MRI demonstrated a left petrous apex cystic lesion that measured 2.5 1.9 2.2 cm (anteroposterior transverse craniocaudad). A T1-weighted sequence showed a cyst with 2 compartments: 1) a smaller anterosuperior partition that was high in signal intensity, enveloping a band of isointense (without gadolinium) soft tissue within its interior (Fig. 1B); and 2) a larger posteroinferior partition that was moderately high in signal intensity. The lesion did not enhance with gadolinium. A T2-weighted sequence demonstrated both compartments to have high signal intensity (Fig. 1C). The constellation of findings pointed to an erosive cholesterol granuloma (CG). In consideration of the patient’s confirmed left anacusis and the benefits of wide access to the CG, a translabyrinthine approach was performed. At the level of the otic capsule, a cystic lesion with a bluish hue was encountered (Fig. 2A). Following removal of the horizontal and posterior semicircular canals, more of the cyst wall was exposed. After the cyst was punctured, fluid that resembled crankcase oil (Fig. 2B) was released. The remaining superior semicircular canal was exenterated. Fibrous septations and a band of thickened vascular tissue within the lesion’s anterosuperior compartment were divided. The procedure created a widely open CG cavity (Fig. 2C) in communication with the mastoid. The diagnosis of a petrous apex lesion can often be secured by combining imaging features found on highresolution temporal bone CT and MRI with and without gadolinium. Those 2 imagingmodalities are complementary. Whereas CT provides exquisite information on pattern of bone erosion (aggressive versus nonaggressive), extent of osseous involvement, and relationship to otic and vascular structures, magnetic resonance (MR) delivers superior soft tissue contrast, detail of proximate intracranial contents, and capacity for tissue signal differentiation based on T1weighted with and without gadolinium and T2-weighted sequences (1). Typically, CG on CT appears as a bone-eroding expansile mass that has interrupted the trabecular architecture of its internal confines and thinned the external margins of its bony perimeter. The smoothly marginated appearance is nonaggressive, but there may be a break in the continuity of the osseous envelope as the CG becomes large (1). CG on MRI is hyperintense on both T1and T2-weighted sequences and does not enhance with gadolinium. Although small lesions tend to have homogeneous MR signal intensity from blood products and proteinaceous debris, large lesions can exhibit heterogeneous signal intensity from hemosiderin deposition (2). Those imaging attributes differentiate CG from other petrous apex entities and their characteristic findings, including cholesteatoma (hypointense on T1 and restricted diffusion), petrous apicitis (hypointense on T1 with postgadolinium peripheral enhancement), bone marrow asymmetry (hypointense on T2 and signal suppression with fat saturation sequence), neoplasms (hypointense on T1 with post-gadolinium diffuse enhancement; aggressive bony destruction), and carotid aneurysms (hyperintense on T1 with postgadolinium Address correspondence and reprint requests to Steven W. Cheung, M.D., Otology, Neurotology, and Skull Base Surgery, University of California, San Francisco, 2233 Post Street, 3rd Floor, San Francisco, CA 94115; E-mail: scheung@ohns.ucsf.edu This study was supported by the Coleman Memorial and Khatib unrestricted research endowment funds at the University of California, San Francisco. The authors disclose no conflicts of interest. Otology & Neurotology 34:e26Ye27 2013, Otology & Neurotology, Inc.

A spheroid weighted-axis converter of vestibular schwannoma size: maximum diameter and cisternal volume.

Objectives To evaluate spheroid models of vestibular schwannoma (VS) size for bidirectional conversion of maximum diameter in the cistern and 3-dimensional volume. Study Design Methodological study. Setting Academic tertiary referral center. Subjects and Methods Magnetic resonance imaging studies from 91 patients with VS from 2003 to 2011 were analyzed. Linear measurements defining meatal and cisternal components were extracted. Geometrically based conformal models of tumor volume were compared with measured tumor volume using a semiautomated computerized tracing method. Models were inverted to predict maximum axial cisternal length at the level of the internal auditory canal (IAC). Results A spheroid-weighted axis converter (SWC) of VS size was identified by minimizing input measurement parameters while maximizing output prediction performance. Computation steps of tumor volumes were (1) meatal—measure tumor lengths along the IAC and at the porus acusticus and take the average of a cone and cylinder and (2) cisternal—measure maximum tumor length in the axial IAC plane, use the median major:minor axis ratio of 1.26:1 to estimate minor axis length, take the geometric mean of axial dimensions to estimate axis length in the coronal plane, and apply input lengths to a spheroid. Performance error of this SWC had interquartile ranges of 33% for volume and 2 to 3 mm for maximum cisternal length. Conclusion Reporting variability of VS tumor size has made it difficult to reconcile outcomes studies. We propose an accessible tool for bidirectional conversion of volumetric and linear indices of tumor size to unlock potential for meta-analyses of disparate data sets.

Elective Lymphadenectomy during Salvage for Locally Recurrent Head and Neck Squamous Cell Carcinoma after Radiation

Objective This study aimed to assess the rate of occult metastases in patients with head and neck mucosal squamous cell carcinoma who have undergone therapeutic neck radiation, and then develop primary site recurrence, without clinical evidence of recurrent neck disease. Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods Head and neck mucosal squamous cell carcinoma patients with N+ necks treated with primary radiation who developed primary site recurrence with radiologically resolved neck lymphadenopathy, treated with salvage primary-site surgery with or without elective cervical lymphadenectomy (ECL). Main outcome measures were rate of occult nodal metastases, complication rates, and disease-free survival. Results Sixteen patients met inclusion criteria. Of 18 neck sides that underwent either ECL or observation for a mean follow-up of 26 months, 4 (22.2%) were found to have positive occult cervical metastases, all on the ipsilateral side of preradiation neck disease. Patients with advanced T-stage and/or free flap reconstruction were more likely to undergo cervical lymphadenectomy. Patients with persistent (as opposed to recurrent) primary site tumors had the highest rate of occult cervical metastases. Conclusion The risk of occult nodal metastases of 22.2%, in this study, may be too high to justify routinely omitting elective cervical lymphadenectomy in this patient population. Lymphadenectomy should especially be considered in patients with persistent tumors, with advanced recurrent T-stage, and undergoing free flap reconstruction.

A Novel Volumetric Model of Vestibular Schwannomas

Objective: Evaluate an ellipsoid model of vestibular schwannoma (VS) tumor volume based on linear dimensions. Method: MRI scans from 97 patients with VS from 2003 to 2011 were analyzed. Linear measurements of major axes defining an ellipsoid within the cistern and a cone within the internal meatus were made. From those dimensions, geometrically based conformational models of tumor volume were evaluated. Results: Model estimates of tumor volume were compared to measurements made using software utility in Brainlab. Seventy-two MRI scans were used for model optimization and 25 scans to validate model predictions and performance. Optimal model selection was determined based on the best trade-off between time required to obtain measurements and the model’s ability to capture volumetric variance. Analyses showed the optimal tumor model as one where the cisternal component was modeled as an ellipsoid and the canalicular portion was modeled as a cylinder (r = 0.96, P < .001). This model was robust for a broad range of tumor sizes. Conclusion: Expected outcomes following treatment of vestibular schwannomas are dependent on tumor size, which has been variably described throughout the literature both by tumor volume and linear dimension of canalicular and cisternal components. Our model can be used to invert volumetric data to linear indices of volume. This tool will enable meta-analysis of disparate data sets.

Pilomatricoma masquerading as metastatic squamous cell carcinoma

We present a case of a 58-year-old woman with a posterior neck mass who underwent fine-needle aspiration of the lesion, with initial cytopathologic evaluation being consistent with metastatic squamous cell carcinoma. However, following excisional biopsy of the tumor, histopathologic evaluation revealed a pilomatricoma. Appreciation of the difficulty in cytologic classification of this benign tumor and its propensity for confusion with more aggressive tumors may help prevent unintended and unnecessary invasive procedures as a result of erroneous diagnoses.