Daniel W. Karakla

Analysis of transnasal endoscopic versus transseptal microscopic approach for excision of pituitary tumors

Background The traditional method of pituitary tumor excision is transseptal microscopic excision; however, the transnasal transsphenoidal endoscopic approach has shown comparable results with the transseptal microscopic approach at some institutions. The objective of this study is to compare the two types of sellar and parasellar mass resection: transnasal transsphenoidal endoscopic excision versus transseptal microscopic excision. Methods A retrospective cohort analysis was performed on subjects who were referred to a tertiary hospital for surgical management of sellar or parasellar masses. The two groups of patients either underwent a transnasal endoscopic approach with endoscopic excision or transseptal microscopic excision. Demographics, tumor characteristics, operative details, length of hospital stay, intraoperative and postoperative complications, level of postoperative pain, recurrence rate, use of computed tomography (CT) image guidance, and length of follow-up were gathered. The data between the two groups were then compared. Results The analysis included 19 subjects who underwent endoscopic excision and 29 subjects who underwent transseptal microscopic excision. Null macroadenoma was the most common sellar mass followed by prolactinoma. There were no statistical differences in rates of perioperative complications and suprasellar or cavernous sinus invasion. Patients who underwent an endoscopic approach had shorter operative times, lower estimated blood loss, less lumbar drain use, less pain, and a shorter postoperative hospital stay (p < 0.05). Conclusion The two approaches show similar intraoperative characteristics and immediate complication rates. Transnasal transsphenoidal endoscopic excision is a reasonable alternative to the traditional method of sellar mass excision.

Stridor and Dysphagia in Diffuse Idiopathic Skeletal Hyperostosis (DISH)

As otolaryngologists, we are the first consulted for stridor and dysphagia. One must consider both extrinsic and intrinsic etiologies in the differential diagnosis of these symptoms. We report a series of patients with diffuse idiopathic skeletal hyperostosis (DISH) who presented with stridor or dysphagia. We describe the initial presenting symptoms, physical examination/radiographic findings, and discuss the management options. Traditional teaching is that surgery is rarely indicated for DISH of the cervical spine. Recommendations regarding the role of surgery as well as a review of our surgical experience are discussed.

Effectiveness of surgeon interpretation of technetium tc 99m sestamibi scans in localizing parathyroid adenomas.

OBJECTIVES To evaluate the ability of surgeons to predict the laterality of parathyroid adenomas from technetium Tc 99m sestamibi scans and compare their results with the radiologic interpretations. DESIGN Retrospective medical record review with single- blinded review of sestamibi scans. SETTING Tertiary care academic medical center PATIENTS The study population included 110 consecutive parathyroidectomy cases from January 2001 to June 2004. Inclusion criteria were biochemically proven primary hyperparathyroidism, with documented serum hypercalcemia and elevated parathyroid hormone levels. Only cases due to a single adenoma that were cured with a single surgical procedure were included. INTERVENTION All patients underwent resection of a parathyroid adenoma following a preoperative sestamibi localization study and serum calcium and parathyroid hormone level analysis. MAIN OUTCOME MEASURE Adenoma location was determined from a review of operative and pathological reports. Two head and neck surgeons performed a blinded review of all scans, and their findings were compared with the radiology reports. RESULTS Of 82 adenomas, 51 (62%) were correctly lateralized in the radiology report, while the other 31 were interpreted as normal scans. The sensitivity and specificity of the radiologic interpretations for parathyroid adenomas in all patients with primary hyperparathyroidism were 62% and 83%, respectively. The scan interpretation of the 2 surgeons produced accurate lateralization of 91% and 91% of these single adenomas. Of the 31 single adenoma scans read as normal by the radiologist, the surgeons correctly lateralized 22 of 29 (76%) and 21 of 28 (75%) of the adenomas. CONCLUSION The review of sestamibi scans by surgeons allows accurate localization of parathyroid adenomas that may not be identified by standard radiologic interpretations.

Fetal rhabdomyoma of the posterior cervical triangle.

Rhabdomyoma is an uncommon benign tumor, with the majority arising from cardiac muscle. Seventy to 90% of extracardiac rhabdomyomas are found in the head and neck region, usually within the upper aerodigestive tract. The case of a 7-month-old boy with an enlarging posterior triangle neck mass found to be fetal rhabdomyoma is presented. This location is quite rare for benign rhabdomyoma, with previous literature search showing overwhelming predilection for the upper aerodigestive tract.

Percutaneous endoscopic gastrostomy tube dependence following chemoradiation in head and neck cancer patients

Compare long‐term percutaneous endoscopic gastrostomy (PEG) tube dependence, stricture rate, and weight loss in patients receiving a prophylactic gastrostomy tube with those who initially rely on oral intake during chemoradiation for head and neck cancer. Also, to determine what other patient and treatment characteristics influence development of long‐term severe dysphagia.

Role and extent of neck dissection for persistent nodal disease following chemo-radiotherapy for locally advanced head and neck cancer: how much is enough?

Purpose. Neck dissection (ND) is routinely performed for persistent nodal disease after definitive chemo-radiotherapy (CRT) for locally advanced head and neck cancer. This study analyzes the role and extent of ND necessary after CRT based on pathologic outcome. Patients and methods. The study is based on 42 patients undergoing 48 NDs for persistent nodal disease after CRT. Patients were treated to a median radiation dose of 70.4 Gy at 1.8–2 Gy per fraction concurrently with platinum based chemotherapy. Patients with documented residual disease in neck, based on clinical or radiological examination underwent ND at a median interval of 59 days after completion of CRT. Results. Of the 42 patients undergoing ND, 11 (26%) had positive findings on pathologic evaluation. The clinical and treatment characteristics were similar for node negative and positive patients. The involved nodal level(s) were always confined within the clinically documented persistent disease. The median percentage of positive nodes to total nodes removed was 10%. Almost 50% of positive nodes removed had only microscopic or minute viable cancer pathologically. The outcome was better for pathologically node negative patients in comparison to node positive patients. Conclusion. The results of this study suggest that standard ND appears to be an excessive treatment for persistent nodal disease after CRT. Limited ND or even gross nodal resection confined to involved nodal level(s) as identified clinically or radiologically should be tested in a prospective randomized trial for reducing treatment related morbidity while maintaining excellent loco-regional control.

Focal parotid necrosis in systemic lupus erythematosus: Case report and review of the literature

Systemic lupus erythematosus (SLE) is a disease that may affect a number of organ systems, particularly the joints, skin, kidneys, heart, lungs, and immune system. Salivary gland involvement is usually associated with Sjögrens syndrome, in which lymphocytic acinar infiltrates predominate histologically. We present the case of a 29-year-old woman with SLE who developed bilateral parotid enlargement with a unilateral focus of parotid necrosis that was consistent with a cystic mass on computerized tomography. A biopsy of this lesion was histologically similar to a cervical lymph node biopsy in the same patient, with both specimens showing loss of architecture and foci of necrosis consisting of nuclear dust, histiocytes, and scattered plasma cells without formation of granulomata or presence of multinucleated giant cells; these findings are classic for SLE lymphadenopathy. We believe this to be the first reported case of focal necrosis in the parotid gland directly associated with SLE.