Firas Alzoubi

Cutaneous Cysts of the Head and Neck

PURPOSE A retrospective study on the features of cutaneous cysts of the head and neck as seen in a North Jordanian population. PATIENTS AND METHODS The records of the Department of Pathology at Jordan University of Science and Technology were reviewed for patients with cutaneous cysts of the head and neck during the 12-year period extending between 1991 and 2002. Applicable records were retrieved, reviewed, and analyzed. Primary analysis outcome measures included patient age, gender, location of the cyst, type, clinical presentation, and treatment. The records of 488 patients were available for analysis. RESULTS Epidermoid cyst was the most frequent lesion (49%) followed by pilar cysts (27%), and dermoid cysts (22%). The site affected most frequently was the scalp (34%), predominantly with pilar cysts (96%). Epidermoid cyst was the most frequent lesion in the neck (68%), cheeks (77%), periauricular area (70%), and the nasal area (55%). Dermoid cyst was the most frequent lesion in the periorbital area (52%). Females represented 51% of the patients and males accounted for 49%. The peak of age distribution for patients with dermoid cysts was at the first decade, and both of epidermoid and pilar cysts peaked at the third decade. Infection presented in 2.5% of cases. All cysts were enucleated surgically. CONCLUSION Maxillofacial surgeons often encounter cutaneous cysts of the head and neck, and they must be familiar with the clinicopathologic characteristics of these lesions.

Revision Surgery for Residual or Recurrent Vestibular Schwannoma

Objective: Assess the requirement for and describe the complication rates of revision surgery for vestibular schwannoma. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: Patients undergoing surgery for vestibular schwannoma by the Manchester Neurotology Service between 1978 and 2004. Intervention: Surgery. Main Outcome Measure(s): The presence of recurrent or residual tumor; necessity for further treatment; complications from revision surgery. Results: Primary surgery was undertaken on 1,037 tumors, with 866 total (19 recurred), 128 near-total, and 43 subtotal removals. Further treatment was performed for 4 recurrent, 2 near-total, and 11 subtotal excised tumors. Thirty-five revision operations resulted in 14 total (1 recurred), 8 near-total, and 13 subtotal removals. Further treatment was required for 3 near-total and 6 subtotal excisions. Poor preoperative facial function (House-Brackmann Grades 4-6) was present in 9 of the 35 patients. A further 10 deteriorated by at least 3 grades by 1 year postoperatively. Other complications of revision surgery included 3 patients with cerebrospinal fluid leaks, a postoperative hematoma requiring evacuation, 2 cerebrovascular accidents, and 2 patients with new cranial nerve deficits. Conclusion: Most residual tumors after primary surgery are successfully managed with watch and rescan. Tumor fragment size is the greatest determinant of revision treatment. After revision surgery, tumor regrowth is much less predictable. Revision surgery is usually considerably more difficult than primary surgery, with a higher complication rate, particularly with regard to the facial nerve. Changing the approach for revision surgery may confer an advantage to facial nerve function.

The role of preoperative CT scan in patients with chronic otitis media

Chronic otitis media may be due to chronic mucosal disease or cholesteatoma. Differentiating the two is usually achieved by clinical examination. The computed tomography (CT) scan is the standard imaging technique for the temporal bone, but its exact role in the preoperative assessment of patients with chronic otitis media is controversial. In this retrospective study we compared preoperative CT results with operative findings in 50 patients who had scan between January 2003 and December 2007. We analyzed the clinical presentation and checked if CT scan confirmed or excluded the presence of cholesteatoma and if this was affected by previous surgery. We concluded that CT scan could not be relied on to differentiate cholesteatoma from chronic mucosal disease. It should be used selectively in the preoperative preparation only if complications of the disease suspected.

A videofluoroscopic study of the emphatic consonants in Jordanian Arabic.

In order to identify the nature of the emphatic consonants and the articulatory features accompanying their production, 384 videofluoroscopic images of 2 male and 2 female Jordanian speakers were analyzed. Analysis focused on the differences between nonemphatic and emphatic consonants in the pharyngeal length and width, the hyoid bone elevation and larynx raising. Results show that males and females produce emphatics as pharyngealized sounds with the tongue root retracting into the oropharynx and the hyoid bone elevating and the larynx raising as a result.

Improved Construction of Auricular Prosthesis by Digital Technologies.

Abstract Implant-retained auricular prostheses are a successful prosthetic treatment option for patients who are missing their ear(s) due to trauma, oncology, or birth defects. The prosthetic ear is aesthetically pleasing, composed of natural looking anatomical contours, shape, and texture along with good color that blends with surrounding existing skin. These outcomes can be optimized by the integration of digital technologies in the construction process. This report describes a sequential process of reconstructing a missing left ear by digital technologies. Two implants were planned for placement in the left mastoid region utilizing specialist biomedical software (Materialise, Belgium). The implant positions were determined underneath the thickest portion (of anti-helix area) left ear that is virtually simulated by means of mirror imaging of the right ear. A surgical stent recording the implant positions was constructed and used in implant fixtures placement. Implants were left for eight weeks, after which they were loaded with abutments and an irreversible silicone impression was taken to record their positions. The right existing ear was virtually segmented using the patient CT scan and then mirror imaged to produce a left ear, which was then printed using 3D printer (Z Corp, USA). The left ear was then duplicated in wax which was fitted over the defect side. Then, it was conventionally flasked. Skin color was digitalized using spectromatch skin color system (London, UK). The resultant silicone color was mixed as prescribed and then packed into the mold. The silicone was cured conventionally. Ear was trimmed and fitted and there was no need for any extrinsic coloring. The prosthetic ear was an exact match to the existing right ear in shape, skin color, and orientation due to the great advantages of technologies employed. Additionally, these technologies saved time and provided a base for reproducible results regardless of operator.

No evidence of linkage between 7q33-36 locus (OTSC2) and otosclerosis in seven British Caucasian pedigrees.

BACKGROUND The aetiology of otosclerosis is complex, and probably involves an interaction between genes and environmental factors. Previous studies have revealed genetic linkage with a number of chromosome regions, including position 7q33-36. AIM To confirm whether linkage exists between otosclerosis and chromosome region 7q33-36. MATERIALS AND METHODS Seven multiply affected families were ascertained. Deoxyribonucleic acid from members of these families was extracted, and six markers were genotyped to cover a 16 cM region at 7q33-36. Both parametric and non-parametric multipoint linkage analyses were performed. RESULTS Parametric multipoint linkage analysis excluded any linkage at 7q33-36 (logarithm of odds score <-4.0). Non-parametric linkage analysis also failed to confirm any linkage (non-parametric linkage < 1.66). When tested individually, pedigree four was the only one to show a significant non-parametric linkage score between D7s684 and D7s2513 (non-parametric linkage = 1.96). CONCLUSION No linkage was detected between otosclerosis and the 7q33-36 region. This could be explained by the studys lack of power, due to the limited number of families available.

Facial nerve management in jugular paraganglioma surgery: a literature review

OBJECTIVE This literature review analysed facial nerve management strategies in jugular paraganglioma surgery and discusses the tumour resection rate and the facial nerve outcome associated with each technique. METHODS A retrospective review of PubMed and Medline articles on the surgical treatments for jugular paraganglioma was performed. Tumour resection rates and post-operative facial nerve function after non-rerouting, short anterior rerouting and long anterior rerouting approaches were evaluated for each article. RESULTS A total of 15 studies involving a total of 688 patients were included. Post-operative facial nerve function was similar after non-rerouting and short anterior rerouting approaches (p = 0.169); however, both of these techniques had significantly better post-operative facial nerve outcomes compared with long anterior rerouting (p < 0.001 and p = 0.001, respectively). The total tumour removal rate was significantly higher for long anterior rerouting than with the non-rerouting approach (p = 0.016). There was no difference in total tumour removal rate between the long and short anterior rerouting approaches (p = 0.067) and between the short anterior rerouting and non-rerouting approaches (p = 0.867). CONCLUSION No strict guidelines for facial nerve management in jugular paraganglioma resection are available. Although long anterior rerouting provides the best tumour exposure along with a low morbidity rate, case-by-case selection of the surgical approach is recommended.

TLR2, TLR4 and CD86 gene polymorphisms in recurrent aphthous stomatitis

BACKGROUND Recurrent aphthous stomatitis (RAS) is an inflammatory disease induced by genetic and environmental factors. Toll-like receptor (TLR) and CD86 are essential components for innate immunity and cellular immune response. We aimed to determine whether inheritance of specific TLR2, TLR4and CD86 gene polymorphisms are associated with RAS. METHODS Ninety-six patients with RAS and 153 controls were studied. Eight SNPs were genotyped using PCR-RFLP technique; four in TLR2 gene: rs4696480, rs3804100, rs121917864, rs5743708; three in TLR4 gene: rs10759931, rs4986790 rs1927911; and one in CD86 gene rs17281995. Association was assessed by logistic regression analysis. Linkage disequilibrium (LD) was assessed using the Haploview program. RESULTS Significant increase in inheritance of A allele (OR = 1.6, P = 0.01) and AA genotype (OR = 3.89, P = 0.01) of TLR4 rs10759931 was observed in cases. TLR4rs1927911 C allele and CC genotype were also increased (OR = 1.60 and 2.78 respectively); however, this was not statistically significant (P = 0.02 and 0.03 respectively). TLR2 and CD86 did not show association with RAS. CONCLUSIONS This is the first study to investigate the association of TLR and CD86 with RAS. We found a significant association between TLR4 rs10759931 polymorphism and RAS. Confirmatory studies in other populations and functional investigations are needed to determine the role of TLR4 in RAS.

Comparison between transtympanic and elevation of tympanomeatal flap approaches in tympanoplasty.

Objective: Transtympanic tympanoplasty is an easy way of introducing a graft through the tympanic membrane to repair a perforation. The aim of our study is to compare the transtympanic technique with the usual method of elevating a tympanomeatal flap. Study Design: Prospective randomized trial. Setting: Tertiary referral teaching hospital. Patients: Patients undergoing surgery for tympanic membrane perforations by the ENT team of King Abdullah University hospital between April 2004 and June 2009. Interventions: Surgery. Main Outcome Measures: Perforations were stratified according to their sizes. Hearing was assessed preoperatively and postoperatively. The success rates defined as perforation closure and hearing improvement were compared between the 2 groups. Results: A total number of 61 patients were enrolled in this study; 29 patients underwent the transtympanic approach, and 32 patients had a tympanomeatal flap elevated under general anesthesia. There was no statistical difference in the success rate between the 2 groups for all perforation sizes, although the tympanomeatal flap elevation technique was more effective in large perforations. There was a statistically significant average of 9 minutes saved in the transtympanic approach. There was a significant advantage in hearing improvement at 1 kHz favoring the transtympanic method. Conclusion: Transtympanic tympanoplasty is a simple technique with comparable success rate to the tympanomeatal flap technique in tympanic membrane closure and hearing results. We recommend it for small- and medium-sized perforations.

The vagal nerve stimulation outcome, and laryngeal effect: Otolaryngologists roles and perspective

INTRODUCTION Epilepsy is one of the most common neurologic disorders. Vagus nerve stimulation (VNS), first investigated in 1938 and subsequently studied as a potential therapy for epilepsy. The FDA approved the use of VNS in 1997 as an adjunctive non-pharmacologic symptomatic treatment option for refractory epilepsy for adults and adolescents over 12years. VNS can cause laryngeal and voice side effects that can be managed by otolaryngologists safely and effectively. OBJECTIVES This study is to review the outcomes of vagal nerve stimulator (VNS) implantation in terms of the surgical procedures, complications, seizure frequency, and the clinical effect on larynx and vocal folds motion. METHODS Series of thirty consecutive patients who had VNS implantation between 2007 and 2014 were recruited. Seizure-frequency outcome, surgical complications and device adverse effects of VNS were retrospectively reviewed. Additional evaluation included use of the Voice Handicap Index and Maximum Phonation Time (MPT) were conducted before and after the implantation. Videolaryngoscopy was used to evaluate the vocal fold mobility before and after the VNS implantation. RESULTS Seizure frequency reduction over a minimum of 2years of follow up demonstrated: 100% in seizure frequency reduction in 1 patient, drastic reduction in seizure frequency (70-90%) in 9 patients, a good reduction in terms of seizure frequency (50%) in 8 patients, a 30% reduction in 5 patients, no response in 6 patients, and 1 patient had increased frequency. The most commonly reported adverse effects after VNS activation were coughing and voice changes with pitch breaks, as well as mild intermittent shortness of breath in 33% of patients. For those patients secondary supraglottic muscle tension and hyper function with reduced left vocal fold mobility were noticed on videolaryngoscopy, though none had aspiration problems. Surgical complications included a wound dehiscence in one patient (3%) which was surgically managed, minor intra-operative bleeding 3%; a superficial wound infection in one patient (3%) which was treated conservatively, none of the complications necessitated VNS removal. CONCLUSIONS VNS appears to be an effective non-pharmacologic adjuvant therapy in patients with medically refractory seizures. With the favorable adverse-effect profile previously described, VNS is generally well tolerated and of a great benefit to such patients. Laryngeal side effects, of which hoarseness being of the greatest repetition, are the most common after the VNS implantation. VNS can affect the voice and reduced vocal cord motion on the implantation side with secondary supraglottic muscle tension. Otolaryngologists are not only capable of performing VNS implantation, but can also manage surgical complications, assess laryngeal side effects and treat them as needed.