Gary D. Josephson

Subcutaneous Cervicofacial and Mediastinal Emphysema after Dental Instrumentation

Subcutaneous cervicofacial emphysema and pneumomediastinum are uncommon manifestations often associated with head and neck trauma. The otolaryngologist may be challenged when confronted with a patient who presents with subcutaneous emphysema without a clear trauma history. The astute clinician may be able to obtain the cause by pursuing an investigative role when obtaining a thorough history. Numerous reports of cervicofacial emphysema and pneumomediastinum as a complication of dental and oral surgery procedures are well documented in the literature,1-3 however, the otolaryngology literature offers little information regarding this complication. In the majority of cases, the emphysema remains in the subcutaneous connective tissues of the head and neck. However, if enough air is driven into the subcutaneous tissues it may track into the thorax and mediastinum. These are rare but life-threatening complications. A case of subcutaneous cervicofacial emphysema and pneumomediastinum in a 15-year-old boy is presented. As the otolaryngologist is often consulted to evaluate and manage patients with cervicofacial emphysema and/or pneumomediastinum, he or she must be aware that recent dental work is a possible cause. A brief review of this entity, diagnostic considerations and management are discussed. CASE REPORT

Focal myositis of the sternocleidomastoid muscle: A case report and review of the literature

The otolaryngologist is often confronted with the challenge to diagnose and treat neck masses in the adult population. The differential diagnosis includes both inflammatory and neoplastic diseases. History, physical examination, fine needle aspiration, and computed axial tomography (CAT) scanning are among the tests frequently performed to assist the clinician in making the diagnosis. Despite performing these tests, uncommon diseases often masquerade as common diseases and may make correct clinical diagnosis difficult. The clinician must be aware of unusual diseases that may present in this fashion. We present an unusual case of focal myositis (of Heffner) in the sternocleidomastoid muscle. This inflammatory pseudotumor of skeletal muscle most commonly affects the calf and thigh musculature. We believe we add to the medical literature a fourth case of focal myositis affecting the sternocleidomastoid muscle. This is only the second report of this diagnosis in an adult patient. We present clinical and pathological features of this benign pseudotumor of the head and neck. This will better familiarize the otolaryngologist when confronted with this rare inflammatory mass.

The role of endoscopic sinus surgery in Patients with acquired immune deficiency syndrome

PURPOSEnIncreasingly, otolaryngologists are treating patients with acquired immunodeficiency syndrome (AIDS) who suffer from associated sinusitis refractory to medical therapy. Despite this trend, few reports in the literature detail the mode of surgical therapy, pathogens, and outcome in this patient population. Our aim in this study was to describe our experience in treating these patients, with particular attention to surgical outcome and pathogens.nnnPATIENTS AND METHODSnWe reviewed our experience with performing sinus surgery in 33 AIDS patients. Endoscopic sinus procedures were performed in 24 patients, while the remaining nine patients underwent nasal antral windows and/or Caldwell-Luc operations. Follow-up information was obtained in 16 of the 24 patients who underwent endoscopic sinus surgery.nnnRESULTSnAt an average follow-up time of 16 months, 14 of the endoscopic sinus surgery patients reported improvement from their preoperative condition. Thirty-seven pathogens were identified in 23 patients. A larger percentage of nontraditional pathogens was found in these patients, which suggests a larger role for microbiologic diagnosis and treatment versus empiric therapy.nnnCONCLUSIONnPatients with AIDS and chronic sinusitis may benefit from endoscopic sinus procedures.

Agenesis of the Trachea

Respiratory distress in the newborn requires emergent treatment. Many times, the physician can simply intubate the neonate, gaining airway control, and then proceed to find a cause for the distress among a differential diagnosis. Other times, emergent tracheotomy is performed because intubation is unsuccessful. We present a patient with agenesis of the trachea, a rare anomaly of the respiratory tract that is uniformly fatal, despite attempts at intervention.

Airway obstruction: New Modalities in Treatment

The key to successful therapy of airway obstruction is always to first secure the airway. The primary care physician needs to understand the airway anatomy and the causes of airway obstruction. As a team, the primary care physician and the otolaryngologist can evaluate and treat these disorders.

Safety and Efficacy of Balloon Sinus Dilation in Children

Objective The safety and feasibility of balloon catheters to dilate obstructed sinus ostia was established in adults in the CLEAR study. This minimally invasive approach to endoscopic sinus surgery is potentially advantageous for pediatric patients due to possible decrease in scarring, post-operative pain, and need for operative debridement. This is a preliminary report on the safety and efficacy of using balloon sinuplasty instruments. Methods A prospective, multi-center, non-randomized evaluation is currently underway in pediatric patients diagnosed with chronic rhinosinusitis. To date, 35 patients (58 maxillary, 9 sphenoid, and 3 frontal sinuses) have been enrolled at 5 sites. Safety was assessed by rate of adverse events. Effectiveness was assessed through measurement of patient sinus symptoms. Patients age 12 and older completed the Sino-Nasal Outcome Test (SNOT 20). Parent/guardians completed the SN-5 Questionnaire for patients under age 12. Results No unanticipated adverse effects were noted in any patients. Patient symptoms improved on the SN-5 from average scores of 4.7 at baseline (n=24) to 2.7 at 12 weeks post-surgery (n=11)(p = 0.0001). Patient symptoms improved on the SNOT-20 from 1.7 at baseline (n=10) to 0.9 at 12 weeks post-surgery (n=5)(p = 0.33). Twelve week follow-up data for the entire cohort is anticipated by June 2008 and the abstract will be updated accordingly. Conclusions Preliminary results indicate that when patients are appropriately selected, sinus ostial dilation using balloon catheters in children has an excellent safety profile and may be an effective minimally invasive treatment option to relieve sinus ostial obstruction.

Magnetic resonance imaging to diagnose subglottic cysts of infancy

Magnetic Resonance Imaging to Diagnose Subglottic Cysts of Infancy STEVEN R MOBLEY MD; GARY D JOSEPHSON MD FAAP; ESPERANZA PACHECO MD; Miami FL Objectives: Subglottic cysts may be a cause of stridor and respiratory distress in the infant. The diagnosis is often confirmed during direct laryngoscopy and bronchoscopy; however, the astute clinician must be able to differentiate this from other lesions found in the subglottic region. We present a case of a 6-month-old infant with stridor in whom the diagnosis of subglottic cyst was confirmed on MRI. This allowed for appropriate surgical planning and counseling for the parents on expectations of the surgical outcome. We review and present the current literature on the diagnosis and treatment of subglottic cysts as well as present the novel approach of the use of MR1 in the diagnosis of this lesion. Methods: The study involved a case report and a literature review through MEDLINE of the English language literature. Results: A total of 63 cases of subglottic cysts were identified in the literature from 1968 to present. Most cases were diagnosed by direct laryngoscopy and bronchoscopy. We believe our case to be the first reported case diagnosed using MRI scanning. Treatments included direct rupture, cupped forceps excision, and laser ablation. Recurrence rates reported in the literature were low. Our case was successfuUy treated with laser ablation. Conclusion: The relative incidence of subglottic cysts in the newborn population has increased. This may be due to better identification and reportage and/or the advances in neonatology that have led to increased survival of intubated premature infants. Proper management of subglottic cysts requires early recognition, accurate diagnosis, and directed treatment. The majority of these lesions can be accurately diagnosed and treated during laryngoscopy and bronchoscopy. The use of MR/scanning has not been previously described to assist in the diagnosis of subglottic cysts. We advocate its use in selected cases as it assists in confirming the diagnosis preoperatively, allows a more definitive surgical plan, and allows directed parental counseling on expectations and outcomes from the surgical procedure.