David C. Bloom

Management of lymphatic malformations.

Purpose of reviewInnovative otolaryngologists, plastic surgeons, craniofacial surgeons, pediatric surgeons, radiologists, anesthesiologists, neonatologists, obstetricians, and scientists have continued to advance our understanding of the etiology, diagnosis, and treatment of lymphatic malformations. This article reviews the publications over the past 2 years with respect to these advances. Recent findingsFast-sequence MRI limits motion artifacts and allows prenatal MR to be used as a complementary study to ultrasound in the evaluation of large congenital neck masses. Three-dimensional ultrasonography may also be helpful in evaluating prenatal lymphatic malformations. Fluorescence in situ hybridization techniques can be used to evaluate lymphatic malformations for prenatal chromosomal analysis with emphasis on chromosomes 13, 18, 21, X, and Y. The sclerosing agent OK-432 is effective for macrocystic lymphatic malformations but showed less promise for microcystic lesions, mixed lesions, and lesions outside the head and neck region. Somnoplasty shows promise for reduction of tongue lymphatic malformations. Surgical excision, staged when necessary, continues to be integral to management in many cases. SummaryBasic science research has furthered understanding of lymphatic malformations. Clinical research has expanded and refined our diagnostic and therapeutic options for patients with these lesions. Further identification of genes selectively expressed by lymphatic endothelium should facilitate identification of usable vascular markers that can enable analysis of the underlying biology, physiology, pathology, and treatment of the lymphatic system and its malformations.

Imaging and surgical approach of nasal dermoids

OBJECTIVE Determine the most accurate and cost effective radiographic evaluation for nasal dermoids. Determine the best surgical approach for excision of nasal dermoids. DESIGN Retrospective chart review. SETTING Division of Pediatric Otolaryngology, Childrens Hospital and Health Center, San Diego, California. PARTICIPANTS All patients with nasal dermoids evaluated and treated from 1990 to 2000. INTERVENTION Preoperative radiographic evaluation and surgical excision. OUTCOME MEASURES Accuracy of CT and MRI correlated with surgical findings and results. RESULTS Ten patients were identified with the diagnosis of nasal dermoid. The age at diagnosis ranged from 0 to 24 months, with a mean of 3 months. Six children presented with masses located at the glabella, three patients presented with masses located at the nasal dorsum and one presented with a mass at the nasal tip. Six children underwent a computed tomogram with contrast of the head. Seven children underwent a MRI study of the head. Three children underwent an initial CT followed by MRI. Twenty percent of children were found to have intracranial extension. CT scan accurately diagnosed intracranial extension in one case, was indeterminate in a second case and falsely positive in a third case. MRI correctly diagnosed intracranial extension in two cases and had no false positive or false negative results. No children were found to have associated intracranial anomalies. In the early years of the review, a simple excision was made over the mass with blunt and sharp dissection for removal. (An external rhinoplasty incision is now used with better exposure and improved cosmetic results.) In cases with intracranial communication, a combined approach of external rhinoplasty and craniotomy was used. CONCLUSIONS MRI alone is the most cost effective and accurate means of evaluating nasal dermoids and is essential for preoperative planning. The surgical approach of choice is external rhinoplasty for both cosmetic reasons and exposure of nasal dermoids with and without intracranial extension.

Anticoagulation and spontaneous retropharyngeal hematoma.

A 57-year-old man treated with Coumadin for an episode of paroxysmal atrial fibrillation presented to the Emergency Department with progressive dysphagia and odynophagia. Physical examination revealed a large right-sided lateral and posterior pharyngeal wall mass. Laboratory studies were significant for an international normalized ratio (INR) of 5.4 with a white blood cell count of 11,600/muL and a hematocrit of 33.2%. A lateral soft tissue radiograph and computed tomography (CT) scan of the neck demonstrated a retropharyngeal hematoma compromising the airway. Rapid reversal of the coagulopathy was achieved with fresh frozen plasma and vitamin K. Patients with space-occupying retropharyngeal masses present a significant management dilemma. The choice between observation, intubation, or a surgical airway intervention must rely upon knowledge of the natural course and high rate of airway occlusion when faced with a patient who presents with a retropharyngeal hematoma. Once symptoms of airway compromise manifest, the airway must be expeditiously secured before complete obstruction occurs. This diagnosis should be sought when an anticoagulated patient presents with upper airway symptoms.

Multicenter Interrater and Intrarater Reliability in the Endoscopic Evaluation of Velopharyngeal Insufficiency

OBJECTIVE To explore interrater and intrarater reliability (R (inter) and R (intra), respectively) of a standardized scale applied to nasoendoscopic assessment of velopharyngeal (VP) function, across multiple centers. DESIGN Multicenter blinded R (inter) and R (intra) study. SETTING Eight academic tertiary care centers. PARTICIPANTS Sixteen otolaryngologists from 8 centers. MAIN OUTCOME MEASURES Raters estimated lateral pharyngeal and palatal movement on nasoendoscopic tapes from 50 different patients. Raters were asked to (1) estimate gap size during phonation and (2) note the presence of the Passavant ridge, a midline palatal notch on the nasal surface of the soft palate, and aberrant pulsations. Primary outcome measures were R (inter) and R (intra) coefficients for estimated gap size, lateral wall, and palatal movement; kappa coefficients for the Passavant ridge, a midline palatal notch on the nasal soft palate, and aberrant pulsations were also calculated. RESULTS The R (inter) coefficients were 0.63 for estimated gap size, 0.41 for lateral wall movement, and 0.43 for palate movement; corresponding R (intra) coefficients were 0.86, 0.79, and 0.83, respectively. Interrater kappa values for qualitative features were 0.10 for the Passavant ridge; 0.48 for a notch on the nasal surface of the soft palate, 0.56 for aberrant pulsations, and 0.39 for estimation of gap size. CONCLUSIONS In these data, there was good R (intra) and fair R (inter) when using the Golding-Kushner scale for rating VP function based on nasoendoscopy. Estimates of VP gap size demonstrate higher reliability coefficients than total lateral wall, mean palate estimates, and categorical estimate of gap size. The reliability of rating qualitative characteristics (ie, the presence of the Passavant ridge, aberrant pulsations, and notch on the nasal surface of the soft palate) is variable.

Histologic review of cidofovir-treated recurrent respiratory papillomatosis

Objectives Recurrent respiratory papillomatosis is currently the most common lesion of the larynx in children. The course of the disease is variable and often requires repetitive surgical interventions to maintain the airway. The predominant concern for disease progression is the possibility of spread to the tracheobronchial tree, as this increases the rates of morbidity and mortality. Cidofovir is an antiviral drug with activity against members of the DNA virus family. Development of local malignant change secondary to use of cidofovir has been a concern. The histopathologic findings from biopsy specimens from children treated with cidofovir have not been previously reported. Methods We performed a retrospective review of pediatric operative histologic biopsies and charts of patients treated with intralesional cidofovir and untreated study controls from January 1, 1995, through November 1, 2001. Results Ninety-six specimens were evaluated by 2 blinded pathologists. No cases of dysplasia were identified. The most commonly identified finding was an increased nucleus-to-cytoplasm ratio in 8 of 95 cases (8.4%). No cases of abnormal mitoses, prominent nucleoli, or cellular or nuclear enlargement were found. Conclusions This is the first report of pathologically evaluated recurrent respiratory papillomatosis specimens taken before and after treatment with intralesional cidofovir. No dysplasia was identified, and there were no significant dysplastic changes in the specimens analyzed.

Head and Neck Manifestations of Disseminated Coccidioidomycosis

Objectives/Hypothesis Coccidioidomycosis is a fungal disease endemic to semiarid regions in the southwestern United States, northern Mexico, and parts of South America. Although this is primarily a pulmonary disease, approximately 0.5% to 1.0% of infected individuals develop disseminated disease affecting skin, subcutaneous tissue, bone, joints, and meninges. The objectives of the study were to present three cases of head and neck manifestations of disseminated coccidioidomycosis and to review the literature of head and neck presentations, diagnosis, and treatment of this potentially life‐threatening disease.

Management of lymphatic malformations and macroglossia: results of a national treatment survey.

OBJECTIVE To determine current trends among American Society of Pediatric Otolaryngology members on the treatment of various stages of lymphatic malformation (LM) with an emphasis on tongue management. METHODS We queried the members on practice demographics, number of LMs and LM-Mac treated, preferred treatment of different stages of LM and Lm-Mac, indications for LM-Mac tongue treatment, preferred method of surgical tongue reduction, and medical management of acutely enlarging LMs and LM-Mac. RESULTS 39/329 (12%) American Society of Pediatric Otolaryngology members responded to the survey. Airway obstruction or obstructive sleep apnea (27/39, 69%) followed by recurrent tongue trauma with bleeding, pain or mucosal changes (11/39, 28%) were the most common indications for tongue management. 16/37 (43%) of respondents preferred staged tongue reduction followed by neck dissection (cervical approach to the LM), 8/37 (22%) preferred staged neck dissection followed by tongue reduction, and 13/37 (35%) preferred simultaneous treatment of the tongue and neck. The preferred methods of tongue reduction were superficial laser ablation (17/38, 45%) and surgical excision (14/39, 36%). The preferred methods of surgical tongue reduction were anterior wedge (18/38, 47%) and midline keyhole reduction (13/38, 34%). For rapidly enlarging lymphatic malformations involving the tongue, the majority of respondents indicated that they would admit and observe (34/38, 89%), give steroids (34/37, 92%) and administer antibiotics (35/38, 92%). CONCLUSIONS While providing insight into treatment patterns, this survey also helps to elucidate the need for multicenter trials for treatment of LM to develop a standard of care that can be recommended based on evidence based medicine rather.

Posterior ankyloglossia: A case report

Ankyloglossia, or tongue-tie, refers to an abnormally short lingual frenulum. Ankyloglossia is a recognized but poorly defined condition and has been reported to cause feeding difficulties, dysarthria, dyspnea, and social or mechanical problems. In infants, the most concerning symptoms are feeding difficulties and inability to breastfeed. While a recent trend toward breastfeeding has brought frenulectomy back into favor, the literature regarding treatment remains inconclusive. We report a case of posterior ankyloglossia with anterior mucosal hooding and a simple, safe, and effective way to treat it to improve breastfeeding.

Orbital paraffinoma as a complication of endoscopic sinus surgery

Paraffin is a mineral oil that consists of straightchain saturated hydrocarbons. It was first discovered in 1830 and has been used medically since the 1880s. The injection of paraffin into tissues may cause a paraffinoma, characterized as a granulomatous foreign body tissue reaction.1 The body reacts to the nondigested hydrocarbon chains classically found in paraffin, Vaseline, and mineral oil. We report a patient with central postseptal upper lid paraffinoma after nasal septoplasty and endoscopic sinus surgery.

The percutaneous columellar strut.

Background Understanding tip support mechanisms is essential for nasal surgery, especially for preservation or augmentation of tip projection. Methods Support of the nasal tip often is improved by the use of struts placed between the medial crura. The percutaneous columellar strut is a technique that provides additional tip support during septoplasty and closed rhinoplasty. The strut is placed via a small vertical columellar incision. Results The advantage of easy and simple insertion outweighs the minor potential disadvantage of a small, visible vertical columellar scar. It is useful in addressing tip ptosis when trauma, surgery, or aging has reduced the contribution of the septum to tip support. Conclusion A detailed description of the percutaneous columellar strut technique and results of its application are presented.